Case Study: Delirium in Elderly and Healthcare Services, Public Health

This essay presents a comprehensive analysis of delirium in elderly individuals, using the case of Mr. Alec Novak to illustrate key concepts. It begins with an introduction to healthy aging and the challenges of delirium, a common neuropsychiatric condition characterized by cognitive and attentional deficits. The essay then delves into the analysis of Mr. Novak's case, considering his age, hearing impairment, psychological stress, and the loss of his wife as contributing factors. It explores assessment services, including the Aged Care Assessment Team (ACAT) and various Australian Government-funded support services, as well as the benefits of peer support groups like CHOPS. The essay further examines health promotion strategies, emphasizing the importance of evidence-based guidelines for delirium management, including identifying causes, pharmacological and non-pharmacological interventions, and creating a supportive care environment. Finally, it discusses effective communication strategies with both the patient and family members, highlighting the need for reality orientation, validation, and reassurance. The essay concludes by emphasizing the importance of quality of life and the right to healthy living for all individuals, regardless of age.

HEALTHCARE
AGEING IN SOCIETY

Contents
Introduction................................................................................................................................2
Analysis of health issue of Delirium..........................................................................................2
Assessment and Services............................................................................................................3
Health Promotion.......................................................................................................................4
Communication..........................................................................................................................6
Conclusion..................................................................................................................................6
References..................................................................................................................................8

Introduction
Getting older is a natural phenomenon of life. As proposed by the World Health
Organization (WHO), different terms such as healthy aging, successful aging, and lately
active aging, are used to describe an aging process where there is a delay in the associated
negative consequences. Over the years, greater attention has been paid on the promotion of
longevity, dignity, together with a better quality of life, for the elderly age group. The
concept of healthy ageing is not only limited to the mere absence of diseases, but also
involves the efficient adaptations to the changes in life while maintaining the physical,
mental, and social wellbeing. Thus, the term healthy ageing is comprised of satisfactory old
age and the identification of the factors that lead towards the same. The following work
would shed light on the various aspects of delirium in the ageing phase of human beings. The
various facets such as issue, support services, health promotion strategies and the role of the
communication are elaborated taking the case study of Mr Novak as the central point of the
work.
Analysis of health issue of Delirium
Delirium is referred to as the common yet serious acute neuropsychiatric condition.
The syndrome is stated to be a brief and generally reversible cause of mental dysfunction.
The issue is recognised clinically characterised by numerous neuropsychiatric abnormalities.
The condition occurs usually in the patients who are elderly but is not limited to the said age
group and can also occur in individuals who have a previously compromised mental status.
The sense of decreased attention and awareness, together with a change in the baseline
cognition are stated to be the clinical hallmarks of the above condition (Alagiakrishnan,
2019). There are additionally associated wide range of triggering factors such as trauma,
acute illness, surgery, and drugs. The five core domains of delirium are stated to be cognitive
deficits, attentional deficits, circadian rhythm dysregulation, emotional dysregulation and
psychomotor dysregulation (Maldonado, 2017). In order to diagnose the syndrome a formal
cognitive assessment, together with the evaluation of the history of acute onset of symptoms
is necessary.
It is significant to note that though one factor can lead to the delirium, the occurrence
of the syndrome is multifactorial in elderly people. The development of the delirium can be
characterised by the complex inter-relationships between numerous predisposing factors or

precipitating factors and the vulnerable patients. The predisposing factors range from
dementia, cognitive impairment, visual impairment, hearing impairment, functional
impairment, depression, alcohol misuse, comorbidity or the severity of illness, alcohol misuse
and the older age (Inouye, Westendorp & Saczynski, 2014). Besides, the precipitating factors
range from drugs such as psychoactive drugs, sedatives; surgery, use of physical restraints,
infections, coma, any iatrogenic event or trauma (Inouye, Westendorp & Saczynski, 2014).
The above factors lead to permanent damages to the various components of the nervous
system such as neurons, receptors, dendrites, and microglia, making the elderly more
susceptible to the delirium syndrome.
The possible contributing factors that influenced the delirium of Novak as per the
listed circumstances in the given case study are listed as follows. Firstly, Mr Alec Novak is
aged 79 years and the older age is one of the contributing factors. Secondly, Mr Novak had
suffered hearing impairment being the part of the Yugoslav war. The war and the following
immigration to a new country would have resulted in psychological stress. The said stress
combined with the hearing impairment is another contributing precipitating factor. Thirdly,
Mr Novak’s wife died and the fact that he is living independently would have resulted in
depression, thereby leading to the cause of delirium.
Assessment and Services
Aged Care Assessment Team (ACAT) are the teams of professionals from the
discipline of medical, nursing and allied health issues. These professionals are engaged in the
assessment of the various needs that are physical, medical, psychological, social, restorative,
and the cultural needs of elderly people and thus facilitate them and their carers with the
appropriate levels of support (HealthyWA, 2019). The assessment may lead to the conclusion
that the older patient may be able to remain at home. However, if the assessment shows
otherwise, the team of professionals would aid in the access of the residential aged care
facilities to the elderly or their caregivers. It is significant to note that there is various kind of
Australian Government-funded services recommended by the ACAT as listed below. These
are both low and high levels of home care packages to assist people to be able to remain at
home. This is followed by the residential respite services including both the low and high
levels of care and the residential aged care services. Lastly, transition care is also
recommended to those older patients who are undergoing a transition from hospital to
permanent residential care or their home.

The Peer support groups refer to the interjection of the valuable services and
resources that creates a bridge between the people affected by similar concern. The groups
are aimed at better understanding each other’s situation in the light of having similar
experiences, exploring resolutions to overcome common challenges, and feeling supported by
others (WHO, 2017). Thus, the unique relationships are formed that were not possible
otherwise.
One of the Peer Support Group that could benefit Mr Novak is Care of Confused
Hospitalised Older Persons (CHOPs). The program is a collaboration between the NHMRC
Cognitive Decline Partnership Centre (CDPC) and the NSW Agency for Clinical
Innovation (ACI). The group is in the form of a speciality society that is comprised of
medical practitioners, consultant physicians, psychogeriatricians, academics, and other
voluntarily associated individuals who are engaged in the care of older people. The following
purposes are laid down by the program in the form of their key 7 principles. The program is
engaged in the screening of the cognitive changes, measurement of risk of delirium, assessing
the older people with confusion, management of older people with confusion, encouraging
the communication, educating the staff and building a supportive care environment (CHOPS,
2019). The CHOPS program is currently being rolled out in 12 sites across NSW and the
interested facilities therein (The University of Sydney, 2019).
A care facility implementing the CHOPS program can be beneficial for Mr Novak can
help him establish a daily routine of activities and assist him in the same, engage him in
group activities; apart from undertaking the required medical attention. The facility can
further coordinate with the niece of Mr Novak for reduction of agitation, sadness, feeling of
depression and improved emotional well-being.
Health Promotion
A well-designed implementation plan is crucial for the successful implementation of
treatment and change in clinical practice in order to address the issues like Delirium,
Dementia and others in the older people (Travers, Graham, Henderson & Beattie, 2017). In
the Australian context, evidence-based delirium care has been comprehensively addressed in
the “Clinical Practice Guidelines for the Management of Delirium in Older People,” as

developed in the year 2006 (State of Victoria, 2018). The evidence-based management
guidelines for delirium include the following steps.
The first step involves the identification of the cause of delirium which must be done
with the aid of a comprehensive initial evaluation. The evaluation is comprised of techniques
like obtaining the history of the patient, examination of the physical vital signs and the
investigation of the causes of delirium. The second step involves the Multicomponent
management of delirium symptoms with the aid of the pharmacological and pharmacological
interventions. The non-pharmacological strategies are similar to that of the preventive
measures of the syndrome and additionally include the use of a support person to care for the
patient, and nursing by staff on one on one basis. These also include involving family
members and allowing them to stay with the patients, provision of relaxation strategies and
encouraging the same staff members to care for the patients during the day as well as the
night shifts. The pharmacological interventions include administering the Antipsychotic
medications and extending the low doses of haloperidol. The limited use of the second-
generation antipsychotic medications is suggested for the said group of the patients because
of the potential side effects. The next step involves the provision of a supportive care
environment characterised by educating the client and their carers/family members. The
provision of providing adequate sensory, physical, and psychological support is crucial for
the management of the syndrome in the said patients. Education part includes providing the
information regarding the diagnosis of delirium, causes when identified and the future
management plan.
Apart from the education of the family members and the caregivers, the education of
the staff is also an important aspect. The medical staff on the intervention ward must be
provided with the written management guidelines about the code of conduct in the context of
the behaviour, must be provided with the training with the aid of the formal presentations,
and should be engaged in the group discussions and collaborative workshops. The follow-up
sessions to reinforce the earlier learnings are also crucial. The guidelines are essential which
includes the proper documentation of the various aspects related to a case. The nurses of the
intervention unit must be provided with training on how to follow the protocols regarding the
administration of the Orientation-Memory Concentration (OMC) test for the identification
and efficient management of delirium. Another important aspect of the management of the
delirium involves the role of the settings, which means in case of the patients with the mild
symptoms of emotional and behavioural disturbances, the patients can be managed at the

residential care settings. The residential care units offer efficient services under the joint
management of the general practitioner and nursing staff as against the noisy hospital settings
and the sleep disturbance in the patients is quite common in hospitals.
Hence, it can be stated that it is imperative to identify the underlying cause of the
delirium syndrome and the precipitating factors contributing towards it. The non -
pharmacological strategies are a better pick and must be incorporated after customising the
same as per the need of the individuals. The delirium can be best managed by involving a
multidisciplinary team including the clinicians with expertise in delirium management.
Communication
As stated in the previous section, communication about the syndrome with the patient
and the family members is an important aspect of the management of the delirium. It has
been suggested that the staff caring for Mr Novak must develop a communication strategy
that must include both the elements of reality orientation and the validation. In the context of
reality orientation, Mr Novak must be reminded of the time of the day, their location, and
other useful current aspects. Also, in the validation context, Mr Novak must be encouraged to
share his feelings and experiences of anxiety, fear, loneliness, or such and the management
team must provide counselling. The important issue that must be communicated to Mr Novak
is the reassurance that counselling and the present clinical management strategies have
benefitted to the people suffering from delirium.
In the context of the communication with family members, the niece of Mr Novak must be
communicated about the medical condition of Mr Novak together with the causes that led to
the same. Further, counselling communication is necessary here, to communicate the role of
the family members in the effective management and the prevention of syndrome. A
consumer brochure must be used for the said communications.
Conclusion
The discussions in the previous part enable to conclude that every individual has a right to
quality and healthy life in the context of physical, emotional and mental aspects, irrespective
of the age. It has been identified that the issue of delirium is common in the elderly people
because of several cognitive and other factors, and the same has been discussed in detail
involving the comprehensive evaluation of underlying causes, the role of assessment services
and the evidence-based clinical practices, taking the case study of Mr Novak. The role of

communication has also been explored. A range of measures has been suggested in the
management section for the elderly. Hence, it can be concluded that an overall study of the
issues and well-crafted strategy, together with the support of the family members is crucial
for the efficient management of delirium.

References
Alagiakrishnan, K. (2019). Delirium. Retrieved from:
https://emedicine.medscape.com/article/288890-overview
Care of Confused Hospitalised Older Persons. (2019). About. Retrieved from:
https://www.aci.health.nsw.gov.au/chops/about
HealthyWA (2019). Aged Care Assessment Team (ACAT). Retrieved from:
https://healthywa.wa.gov.au/Articles/A_E/Aged-Care-Assessment-Team-ACAT
Inouye, S. K., Westendorp, R. G., & Saczynski, J. S. (2014). Delirium in elderly people. The
Lancet, 383(9920), 911-922.
Maldonado, J. R. (2017). Delirium pathophysiology: An updated hypothesis of the etiology
of acute brain failure. International journal of geriatric psychiatry, 33(11), 1428-
1457.
State of Victoria (2018). Clinical Practice Guidelines for the Management of Delirium in
Older People - October 2006. Retrieved from:
ttps://www2.health.vic.gov.au/about/publications/policiesandguidelines/Clinical-
Practice-Guidelines-for-the-Management-of-Delirium-in-Older-People---October-
2006
The University of Sydney. (2019). Improving the experience of the confused patient.
Retrieved from:
http://sydney.edu.au/medicine/cdpc/news-events-participation/CHOPs.php
Travers, C., Graham, F., Henderson, A., & Beattie, E. (2017). CogChamps – a model of
implementing evidence-based care in hospitals: study protocol. BMC Health Services
Research, 17(1). doi:10.1186/s12913-017-2136-0
World Health Organization. (2017). Creating peer support groups in mental health and
related areas. Retrieved from:
https://apps.who.int/iris/bitstream/handle/10665/254813/WHO-MSD-MHP-17.13-
eng.pdf