222 TOWARDS A DELIRIUM FRIENDLY EMERGENCY DEPARTMENT

Background

Delirium affects approx. 10-30 % of patients over the age of 65. Up to 70% of cases are missed in the Emergency Department (ED). Delirium results in increased morbidity, mortality, increased length of stay and decreased functional status with increased discharges to residential care centres. Delirium in the ED is an independent predictor of death within 6 months.

Methods

We completed an audit which showed 40% of those > 65 years of age in the ED were delirious and 60% of those had dementia. None of these had been identified as delirious prior to review. We have approx. 5,000 patients >75 years of age attending our ED annually (1/7th of presentations). This audit was used as a catalyst for our quality improvement project. We established a steering group with a small quality improvement sub-committee. We combed the literature, identified areas for improvement and costed our project. We also looked at reliance on 1:1 carers for those with delirium and potential benefits to patient, staff and management.

Results

We used the SPARK ignite programme as a means to gain momentum and also educate ourselves on business management and change management. We competed in the finals with our “delirium package” – focussing on orientation, stimulation, safety and education. These 4 pillars of delirium care have been shown to prevent delirium, reduce hospital stay for those with delirium and also augment their delirium cycle. Competing and winning a prize highlighted the importance of delirium care and brought our project to a bigger stage.

Conclusion

Due to our multi-disciplinary team composed of non-consultant hospital doctors, advanced nurse practitioners and occupational therapists, we have been able to introduce the national dementia programme for early identification of delirium in the emergency department. We now have a space for managing those with delirium and have received funding to put our package in place. This can be replicated in hospitals around the country highlighting the non-pharmacological treatments for delirium.

Intranuclear Coccidiosis in Tortoises: Nine Cases

Chelonian intranuclear coccidiosis has been reported once, in two radiated tortoises ( Geochelone radiata), and is apparently rare. We describe intranuclear coccidiosis diagnosed histologically in two radiated tortoises, three Travancore tortoises ( Indotestudo forstenii), two leopard tortoises ( Geochelone pardalis), one bowsprit tortoise ( Chersina angulata), and one impressed tortoise ( Manouria impressa). Infection was systemic and involved alimentary, urogenital, respiratory, lymphoid, endocrine, and integumentary systems. Trophozoites, meronts, merozoites, macrogametocytes, microgametocytes, and nonsporulated oocysts were seen histologically or by electron microscopy. intracytoplasmic and extracellular stages of parasite development also were identified histologically. Sequencing of a coccidial 18S rRNA consensus polymerase chain reaction (PCR) product revealed a novel sequence that provided phylogenetic information and may be useful for further diagnostic test design. intranuclear coccidiosis was associated with variable degrees of inflammation in all cases, was considered the cause of death in six tortoises, and was a substantial contributing factor to the cause of death in two tortoises.

The content of suicide notes written by those using different methods for suicide

In a sample of 40 suicide notes from West Berlin, those using hanging seemed to be angrier and to blame others more than those using poisoning.

Joseph Richman's signs for distinguishing genuine from simulated suicide notes

Scores from two independent judges indicated that criteria derived from the clinical experience of a suicidologist were successful in differentiating genuine from simulated suicide notes.

Sex differences in suicide notes

In a sample of 40 German suicide notes, men and women did not differ in the presence of motives of disrupted interpersonal relationships or of work/career/financial crises.

Content differences in suicide notes by gender and age: serendipitous findings

In a sample of 40 German suicide notes, no gender differences were identified. Suicide notes of older people had fewer feelings of inadequacy and more indications of illness and grief over widowhood.

[Anorectic reactions in low intelligence]

Six female in-patients suffering from anorectic reaction are described. Difficulties in diagnosis and differences between these patients and anorectic patients of normal intelligence are discussed. The main finding is that in all six cases there was an extremely close and symbiotic mother-child relationship and a weak or absent father. Relevant life events in the nuclear family (new partner for the mother, illness in the father) then triggered the eating disorder.