The Role of Dysregulation of Glucocortoids in the onset, Course and outcome of Delirium in the older people

Lead Research Organisation: University of Edinburgh
Department Name: School of Clinical Sciences

Abstract

Acute confusion commonly occurs in older people, and especially in patients with dementia, with acute illness and after operations. Until recently, doctors thought that acute confusion was unimportant. Thus, few specific treatments are available, and almost nothing is known about the causes. However, acute confusion is now known to be potentially serious, being linked with longer stays in hospital, other illnesses, and long-term permanent memory problems. Because of this, urgent research is now needed.

Experimental studies have shown that high levels of the hormone cortisol can cause confusion. Cortisol goes up in illness and after surgery. In old age it often stays high for too long, and therefore possibly causing confusion.

In this study, 200 older people awaiting surgery will have tests of cortisol and memory, and will have brain scans. After surgery we expect that about 40 people will become confused, and we will test to see if this is linked with high cortisol, using memory tests and repeat brain scans.

If high cortisol is linked with acute confusion, new treatments, such as anti-cortisol drugs, will be developed. Because thousands of older people become acutely confused every year in the UK, any new treatments would be of great benefit.

Technical Summary

AIMS: Delirium (acute confusional state) is a highly prevalent, serious, and poorly understood acute condition, occurring mainly in older people. The main cognitive deficit is in attention. Associated with acute illness, trauma, or certain drugs, delirium is an independent predictor of increased length of stay, morbidity, institutionalisation, and mortality. Moreover, episodes of delirium may be a marker of brain pathology, or cause brain damage, because in patients matched for cognitive function, those suffering an episode of delirium have a higher risk of dementia 1-2 years later.
The mechanisms are poorly understood, but one important hypothesis is that pathologically sustained high glucocorticoid (GC) levels occurring in the context of acute physiological stress is involved in delirium. Supporting evidence includes the observation that ageing is associated with failure to suppress cortisol levels after a stressor because of defective feedback regulation. Therefore, some older people will show inappropriately sustained high glucocorticoids (GCs) in the context of stress (acute illness, surgery, etc.). Also, sustained high GCs cause attentional deficits, probably related to prefrontal cortical dysfunction; deficits in declarative memory and hippocampal dysfunction are also consequences of high GCs.
OBJECTIVES: (1) determine if higher cortisol levels after a pre-operative dexamethasone suppression test predict a higher risk of delirium; (2) determine if delirium in association with high GCs is associated with (a) permanent decrements in cognitive function, and (b) permanent structural and biochemical alterations in the brain.
DESIGN: Prospective natural history study of 200 patients aged over 70 undergoing elective orthopaedic surgery.
METHODOLOGY: 200 patients undergoing major elective orthopaedic surgery will have pre-operative (1-2 months) detailed measurements of GC levels, including post-dexamethasone cortisol; cognitive assessment; detailed neuroimaging, including subregional volumes (prefrontal cortex, hippocampus, etc.), diffusion tensor imaging, and magnetic resonance spectroscopy. Peri-operatively patients will be assessed for delirium and GC levels will be measured. Three months post-operatively, cognitive assessment will be performed in all patients, and neuroimaging in 25 patients who have had delirium, and 25 controls.
SCIENTIFIC AND MEDICAL OPPORTUNITIES: Delirium imposes an enormous human and socioeconomic burden, and is a major unmet medical need. It has been subjected to strikingly little mechanistic research. Should impaired regulation of glucocorticoid levels be a major mechanism of delirium, this will open the door to further focused mechanistic research, and medically, preventive and treatment (eg. anti-glucocorticoids) strategies. Reductions of even a few percent in the incidence, severity, or duration of delirium would have large health and economic benefits.

Publications

10 25 50
 
Description 4AT test for delirium is mentioned in advice for clinicians in multiple documents and websites
Geographic Reach Multiple continents/international 
Policy Influence Type Citation in other policy documents
Impact The 4AT is now being used in many UK sites (eg. London, Birmingham, Inverness, Glasgow) as well as international sites. It is included in many local guidelines as well as the Scottish Government's Healthcare Improvement Scotland care package for delirium. The 4AT is the standard tool for delirium assessment in Scotland, and likely the most widely-used in the UK. The 4AT was included in the Australian Commission on Safety and Quality in Healthcare Delirium Care Standards. It was also recently included in the Best Practice Tariff for Hip Fracture Care in the NHS in England in 2017. The outcome is that there is are increased rates of delirium detection and therefore the quality of delirium care in the UK and internationally.
URL http://www.va.gov/GERIATRICS/Guide/LongTermCare/Delirium_professionals.asp#
 
Description Chair of Royal College of Physicans Map of Medicine panel on delirium
Geographic Reach National 
Policy Influence Type Membership of a guideline committee
Impact National guideline available to most UK hospitals via Map of Medicine scheme (sponsored by Royal College of Physicians (London))
 
Description Chair of Scottish Intercollegiate Guidelines Network - Delirium Guideline. Guidelines published on 13 March 2019.
Geographic Reach Multiple continents/international 
Policy Influence Type Membership of a guideline committee
URL https://www.sign.ac.uk/
 
Description Chair of regional group: 'Delirium and dementia implementation group' (Lothian Health Board)
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Influenced training of practitioners or researchers
Impact Regional group which is responsible for implementing improvements in the detection, management and follow-up of delirium and dementia in the acute general hospitals in my region. This involves multiple educational activities alongside audit.
 
Description Citation in systematic review
Geographic Reach Multiple continents/international 
Policy Influence Type Citation in systematic reviews
Impact The 4AT delirium assessment tool was included in this systematic review and this has led to increased dissemination and use of the 4AT in clinical practice.
 
Description Co-founded Scottish Delirium Association
Geographic Reach National 
Policy Influence Type Influenced training of practitioners or researchers
Impact The Scottish Delirium Association (SDA) is a group of healthcare professionals that meet quarterly to create and disseminate resources aimed at improving delirium care. The SDA has worked with Healhcare Improvement Scotland (HIS) to produce tools such as the TIME bundle and two delirium care pathways. These tools are now used in clinical practice in Scotland and beyond. There is agreement that this work in collaboration with the government has created a step shift in delirium care in Scotland.
URL http://www.scottishdeliriumassociation.com
 
Description Delirium adviser on Scottish Govt 'Reshaping Care for Older People' programme
Geographic Reach National 
Policy Influence Type Gave evidence to a government review
 
Description European Delirium Association website
Geographic Reach Multiple continents/international 
Policy Influence Type Influenced training of practitioners or researchers
Impact I set up and was the main author of the European Delirium Association website until 2012, and I have continued to contribute as an adviser since. This has multiple sources of educational material.
URL http://www.europeandeliriumassociation.com
 
Description Founded European Delirium Association
Geographic Reach Multiple continents/international 
Policy Influence Type Influenced training of practitioners or researchers
Impact The EDA is the world's first international organisation focused on delirium. It now has >500 members and has held 12 international conferences. We have developed standards for research which have influenced many researchers, and also have clinical guidelines and educational materials on our website which have been downloaded by users in many different countries. The EDA holds the largest research conferences in the world on delirium. The EDA directly stimulated the creation of the American Delirium Society in 2011, and the Australasian Delirium Association in 2012. Both of these organisations run major international conferences and influence policy.
URL http://www.europeandeliriumassociation.com
 
Description Influenced delirium detection practice in various national and international locations
Geographic Reach Multiple continents/international 
Policy Influence Type Influenced training of practitioners or researchers
Impact The delirium detection tool the 4AT (www.the4AT.com) continues to be increasingly implemented clinically in several international sites. Multiple UK sites including Guy's and St Thomas's, Aberdeen Royal Infirmary, and internationally, eg. hospitals in Houston, and Johns Hopkins. The 4AT is now a mandatory part of the NHS England Best Practice Tariff for all hip fracture care - that is, delirium must be screened for, and the 4AT is the recommended tool. There are translations into French, German, Thai, Italian, Russian, German, Dutch, Norwegian, etc. The 4AT has likely become the most-used delirium screening tool in the UK, and is likely used >100 000 times a year now. This estimate comes from the hip fracture mandate (50 000 patients per year alone), and known use as a routine tool in Sunderland (>14 000 documented uses over 2-3 years), Salford, in many Scottish centres, and other sites across the UK. This widespread use of the 4AT increases the rates of detection of delirium, with likely impacts on duration and severity of delirium (because care occurs earlier), on the quality of the patient experience (because lack of detection means that adequate communication with patients and carers cannot occur), and also on healthcare costs, because delirium is common (15% of hospital inpatients) and increases length of stay and rates of new institutionalisation in care homes. The main way the 4AT is disseminated is my website www.the4AT.com, which I set up independently in 2011.
URL http://www.the4AT.com
 
Description BBSRC funding (Targetted Priority Studentships Programme)
Amount £245,000 (GBP)
Organisation Biotechnology and Biological Sciences Research Council (BBSRC) 
Sector Public
Country United Kingdom
Start 08/2008 
End 09/2012
 
Description CSO Research Grant
Amount £193,181 (GBP)
Organisation Chief Scientist Office 
Sector Public
Country United Kingdom
Start 02/2009 
End 05/2012
 
Description Clinical Research Fellowship
Amount £245,168 (GBP)
Organisation Age UK 
Department Research into Ageing Fund (RiAF)
Sector Charity/Non Profit
Country United Kingdom
Start 05/2009 
End 01/2015
 
Description Clinical Research Fellowship
Amount £220,000 (GBP)
Organisation Age UK 
Sector Charity/Non Profit
Country United Kingdom
Start 09/2012 
End 08/2016
 
Description Dunhill Medical Trust Clinical Research Fellowship
Amount £200,000 (GBP)
Organisation The Dunhill Medical Trust 
Sector Charity/Non Profit
Country United Kingdom
Start 08/2012 
End 12/2015
 
Description HTA
Amount £1,900,000 (GBP)
Organisation National Institute for Health Research 
Department Health Technology Assessment Programme (HTA)
Sector Public
Country United Kingdom
Start 01/2013 
End 12/2018
 
Description HTA
Amount £819,726 (GBP)
Funding ID 11/143/01 
Organisation National Institute for Health Research 
Sector Public
Country United Kingdom
Start 02/2014 
End 11/2016
 
Description MRC DPFS/DCS
Amount £1,007,984 (GBP)
Funding ID MR/L023210/1 
Organisation Medical Research Council (MRC) 
Sector Academic/University
Country United Kingdom
Start 10/2014 
End 03/2017
 
Description MRC Developmental Pathway Funding Scheme (DPFS)
Amount £190,000 (GBP)
Funding ID E-007 
Organisation Medical Research Council (MRC) 
Sector Academic/University
Country United Kingdom
Start 04/2010 
End 06/2012
 
Description NHS Education for Scotland funding
Amount £18,000 (GBP)
Organisation NHS Health Scotland 
Sector Public
Country United Kingdom
Start 08/2012 
End 01/2015
 
Description Project grant
Amount £185,751 (GBP)
Funding ID R484/0516 
Organisation The Dunhill Medical Trust 
Sector Charity/Non Profit
Country United Kingdom
Start 02/2017 
End 01/2020
 
Description Project grant
Amount £260,000 (GBP)
Funding ID ARUK-PG2016B-12 
Organisation Alzheimer's Research UK 
Sector Charity/Non Profit
Country United Kingdom
Start 11/2016 
End 10/2018
 
Title 4AT delirium assessment tool 
Description The 4AT assessment tool is now in common use in research studies, eg. see https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-016-0649-8 and https://www.ncbi.nlm.nih.gov/pubmed/30091294 
Type Of Material Physiological assessment or outcome measure 
Year Produced 2011 
Provided To Others? Yes  
Impact The 4AT has become a standard tool for delirium detection and has been used to detect delirium in many published and ongoing studies (10 validation studies with a total of around 2500 patients). 
URL http://www.the4AT.com
 
Title 4AT screening instrument for delirium and cognitive impairment 
Description A very brief screening instrument for delirium and cognitive impairment primarily aimed to be used in clinical practice but also usable as a research tool. 
Type Of Material Physiological assessment or outcome measure 
Year Produced 2011 
Provided To Others? Yes  
Impact The 4AT is being used in local research projects as well as in routine clinical practice. It has been incorporated into the regional 'Unitary Patient Record' for all emergency adult medical admissions. One impact has been that the rates of the term 'delirium' appearing in electronic discharge summaries has increased from 0.6% to 1.7% between Jan 2010 and Sep 2011. The 4AT has now been adopted by several London hospitals as the standard screening tool for delirium used in the CQUIN dementia screening programme. It is also a mandatory part of the best practice tariff for acute hip fracture care in England. IN 2013 the 4AT has been adopted by an increasing number of healthcare organisations. 
URL http://www.the4AT.com
 
Title New computerised instrument for the assessment of attentional deficits in delirium 
Description A new computerised, programmable, battery-powered small device with new neuropsychological test protocols for delirium assessment in hospital inpatients. Validated. 
Type Of Material Technology assay or reagent 
Year Produced 2009 
Provided To Others? Yes  
Impact £150,000 grant from the MRC DPFS scheme to develop commercially-viable device, then £1M grant also from the MRC DPFS scheme (ongoing). 
 
Description Cerebrospinal fluid analyses in delirium: University of Amsterdam 
Organisation Academic Medical Center
Department Department of Internal Medicine
Country Netherlands 
Sector Academic/University 
PI Contribution We are the leaders of the project.
Collaborator Contribution We have shared protocols and we analysed cerebrospinal fluid in patients with delirium collected in the Netherlands. We have presented the work at the European Delirium Association and are about to submit two papers on this.
Impact Two abstracts at the European Delirium Association meeting, Nov 2010 (both oral presentations). One paper published in the Journal of the American Geriatrics Society. Adoption of the CSF sampling during spinal anaesthesia by several other groups.
Start Year 2009
 
Description Cerebrospinal fluid analyses in delirium: University of Oslo 
Organisation Oslo University Hospital
Department Department of Geriatric Medicine
Country Norway 
Sector Hospitals 
PI Contribution We initiated this collaboration, to share samples and analyses. We contributed information about methodology.
Collaborator Contribution We have received and sent cerebrospinal fluid samples from each other's cohorts and performed different sets of analyses on these samples.
Impact Poster presentations in the American Delirium Society meeting in Indianapolis in June 2011. One poster presentation in the European Delirium Association meeting in Nov 2011. The collaboration is multidisciplinary, involving basic laboratory science and clinical geriatric medicine. Additional findings were presented at the American Delirium Society meeting in June 2012, and the European Delirium Society in Oct 2012. Several papers have now been published as a result of this collaboration (papers with authors Watne, Hall, MacLullich, and others).
Start Year 2010
 
Description Delirium epidemiology 
Organisation University of Cambridge
Department Cambridge Institute of Public Health
Country United Kingdom 
Sector Academic/University 
PI Contribution I have contributed to the generation of the idea to study delirium's impact on cognitive trajectories, interpretation of data, study design and writing of the manuscript
Collaborator Contribution Added knowledge on how delirium alters trajectories of cognitive decline and neuropathological findings.
Impact The main paper from the first set of analyses has been published in the journal Brain. The work directly led to the main author Daniel Davis gaining a Wellcome Trust Intermediate Fellowship. He is now based at the MRC Unit for Lifelong Health and Ageing in UCL. I maintain a very active collaboration - eg. as the senior author on Dr Davis's recent protocol paper describing the main study in his Wellcome Trust award.
Start Year 2010
 
Description Delirium epidemiology - Dr Daniel Davis 
Organisation University College London
Department MRC Unit for Lifelong Health and Ageing
Country United Kingdom 
Sector Public 
PI Contribution I worked closely with Daniel Davis to develop his application to the Wellcome Trust for an Intermediate Fellowship. He was successful in gaining this and has now taken up a position as WT IF at the MRC Unit for Lifelong Health and Ageing. I have contributed substantially to the ongoing conduct of Dr Davis's study including in study design, delirium ascertainment methods, and staff training (including on-site training in Edinburgh).
Collaborator Contribution Dr Davis is the lead scientist on this work and runs the study with involvement of a wider team.
Impact To date only the protocol paper has been published.
Start Year 2015
 
Description Development of a new animal model of delirium based on the spontaneously hypertensive rat 
Organisation Trinity College Dublin
Country Ireland 
Sector Academic/University 
PI Contribution I initiated this work. It involves several University of Edinburgh collaborators, from basic science to neuroimaging.
Collaborator Contribution Dr Colm Cunningham (Wellcome Trust Senior Research Fellow) has provided training and advice for members of the team, and has contributed to the experimental design.
Impact None yet.
Start Year 2010
 
Description Development of a new brief clinical screening tool for delirium and cognitive impairment: the 4AT 
Organisation Mayo Clinic
Department Emergency Medicine
Country United States 
Sector Hospitals 
PI Contribution I initiated this project, by first writing the 4AT with two colleagues (Tracy Ryan and Helen Cash) and then forming a network of collaborators to test the properties of the instrument.
Collaborator Contribution Expertise in liaison psychiatry, eg. delirium diagnosis, and design of tool evaluation procedures.Statistical support and access to volunteer and patient cohorts. Three-site study now running.
Impact We have written a new test called the 4AT. This instrument is now in clinical use in several clinical settings in NHS Lothian and elsewhere in the UK, and internationally. The test is available at this website: www.the4AT.com. A grant validating the 4AT was awarded by the NIHR and studies are ongoing. The first part of the study has yielded valuable information on implementation of the detection tool.
Start Year 2010
 
Description Development of a new brief clinical screening tool for delirium and cognitive impairment: the 4AT 
Organisation NHS Bradford City CCG
Country United Kingdom 
Sector Public 
PI Contribution I initiated this project, by first writing the 4AT with two colleagues (Tracy Ryan and Helen Cash) and then forming a network of collaborators to test the properties of the instrument.
Collaborator Contribution Expertise in liaison psychiatry, eg. delirium diagnosis, and design of tool evaluation procedures.Statistical support and access to volunteer and patient cohorts. Three-site study now running.
Impact We have written a new test called the 4AT. This instrument is now in clinical use in several clinical settings in NHS Lothian and elsewhere in the UK, and internationally. The test is available at this website: www.the4AT.com. A grant validating the 4AT was awarded by the NIHR and studies are ongoing. The first part of the study has yielded valuable information on implementation of the detection tool.
Start Year 2010
 
Description Development of a new brief clinical screening tool for delirium and cognitive impairment: the 4AT 
Organisation NHS Lothian
Department Department of Liaison Psychiatry
Country United Kingdom 
Sector Hospitals 
PI Contribution I initiated this project, by first writing the 4AT with two colleagues (Tracy Ryan and Helen Cash) and then forming a network of collaborators to test the properties of the instrument.
Collaborator Contribution Expertise in liaison psychiatry, eg. delirium diagnosis, and design of tool evaluation procedures.Statistical support and access to volunteer and patient cohorts. Three-site study now running.
Impact We have written a new test called the 4AT. This instrument is now in clinical use in several clinical settings in NHS Lothian and elsewhere in the UK, and internationally. The test is available at this website: www.the4AT.com. A grant validating the 4AT was awarded by the NIHR and studies are ongoing. The first part of the study has yielded valuable information on implementation of the detection tool.
Start Year 2010
 
Description Development of a new brief clinical screening tool for delirium and cognitive impairment: the 4AT 
Organisation NHS Sheffield CCG
Country United Kingdom 
Sector Public 
PI Contribution I initiated this project, by first writing the 4AT with two colleagues (Tracy Ryan and Helen Cash) and then forming a network of collaborators to test the properties of the instrument.
Collaborator Contribution Expertise in liaison psychiatry, eg. delirium diagnosis, and design of tool evaluation procedures.Statistical support and access to volunteer and patient cohorts. Three-site study now running.
Impact We have written a new test called the 4AT. This instrument is now in clinical use in several clinical settings in NHS Lothian and elsewhere in the UK, and internationally. The test is available at this website: www.the4AT.com. A grant validating the 4AT was awarded by the NIHR and studies are ongoing. The first part of the study has yielded valuable information on implementation of the detection tool.
Start Year 2010
 
Description Development of a new brief clinical screening tool for delirium and cognitive impairment: the 4AT 
Organisation University of Bradford
Country United Kingdom 
Sector Academic/University 
PI Contribution I initiated this project, by first writing the 4AT with two colleagues (Tracy Ryan and Helen Cash) and then forming a network of collaborators to test the properties of the instrument.
Collaborator Contribution Expertise in liaison psychiatry, eg. delirium diagnosis, and design of tool evaluation procedures.Statistical support and access to volunteer and patient cohorts. Three-site study now running.
Impact We have written a new test called the 4AT. This instrument is now in clinical use in several clinical settings in NHS Lothian and elsewhere in the UK, and internationally. The test is available at this website: www.the4AT.com. A grant validating the 4AT was awarded by the NIHR and studies are ongoing. The first part of the study has yielded valuable information on implementation of the detection tool.
Start Year 2010
 
Description Development of a new brief clinical screening tool for delirium and cognitive impairment: the 4AT 
Organisation University of Edinburgh
Department MRC Centre for Cognitive Ageing and Cognitive Epidemiology
Country United Kingdom 
Sector Public 
PI Contribution I initiated this project, by first writing the 4AT with two colleagues (Tracy Ryan and Helen Cash) and then forming a network of collaborators to test the properties of the instrument.
Collaborator Contribution Expertise in liaison psychiatry, eg. delirium diagnosis, and design of tool evaluation procedures.Statistical support and access to volunteer and patient cohorts. Three-site study now running.
Impact We have written a new test called the 4AT. This instrument is now in clinical use in several clinical settings in NHS Lothian and elsewhere in the UK, and internationally. The test is available at this website: www.the4AT.com. A grant validating the 4AT was awarded by the NIHR and studies are ongoing. The first part of the study has yielded valuable information on implementation of the detection tool.
Start Year 2010
 
Description LUCID study 
Organisation University of Oslo
Country Norway 
Sector Academic/University 
PI Contribution I participated in the study design of 'The Oslo Study of Clonidine in Elderly Patients with Delirium; LUCID'. This involved a visit to Oslo and correspondence after that regarding the protocol.
Collaborator Contribution Extensive involvement in developing the concept (partly stimulated by the results of our work on stress and delirium), the measurement of delirium, and other aspects of the protocol.
Impact Protocol for the study has been submitted for publication and now returned for revision with expected acceptance for publication. The study completed in 2017 and a manuscript will be submitted before May 2018
Start Year 2012
 
Description Neuropsychological testing in delirium 
Organisation University of Edinburgh
Department Psychology
Country United Kingdom 
Sector Academic/University 
PI Contribution Experimental design in neuropsychology of delirium projects
Collaborator Contribution Involvement in neuropsychology of delirium projects; consultation on cognitive test design, recruitment of dementia patients, statistical analyses
Impact New grant: 'Development of a new neuropsychological instrument for the diagnosis and monitoring of delirium'. This has led to new grants (£150,000 from the MRC Development Pathway Funding Scheme, then a further £1.06M from the same scheme). The device is known as the Delbox, and a software version called the DelApp. The project has so far multiple papers at international conferences and research papers. The DelBox and DelApp are being used in our own studies but also in other studies, eg. the LUCID study in Oslo, and a study in John Hopkins.
Start Year 2008
 
Title A new computerised instrument for detection of attentional deficits in delirium 
Description A new computerised neuropsychological testing device with novel cognitive testing procedures for the assessment of attentional deficits in delirium. 
IP Reference EP2485645 
Protection Patent granted
Year Protection Granted 2012
Licensed No
Impact A grant (£150,000) from the MRC DPFS scheme to commercialise the device.
 
Title 4AT screening test for delirium and cognitive impairment 
Description A brief screening instrument for delirium and cognitive impairment for clinical use. Available on this website: www.the4AT.com NIHR project grant completed with report submitted in Dec 2017. 
Type Diagnostic Tool - Non-Imaging
Current Stage Of Development Wide-scale adoption
Year Development Stage Completed 2017
Development Status Under active development/distribution
Clinical Trial? Yes
Impact The 4AT has become a standard tool for delirium assessment in the UK and in many other countries. Eg. it is mandated for all hip fracture patients in the UK - see the National Hip Fracture Database report https://www.nhfd.co.uk/docs/reports2018 The 4AT has had a large international impact on routine clinical care. Certainly the most-used in the UK (likely >1 million uses), and likely the most-used in Australia and New Zealand, with rapid growth in other countries. 
URL http://www.the4AT.com
 
Description 4AT website 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact I set up the website www.the4AT.com in 2011. This website allows for the dissemination of the delirium detection the 4 "A"s Test (4AT) that I wrote (with two colleagues) in 2011. It also provides some background information on the 4AT.

Since 2011, the 4AT website has had increasing visits: 2015 - 16,320 users/42,964 page views; 2016: 22,953 users/57,615 page views, 2017: 33,857 users/67,066 page views; 2018: 47,018 users/90, 289 page views. Users are global, with most visit from the UK, Australia, Canada, Ireland and the USA. The scale of these visits, plus the inclusion of the 4AT in many pathways, other websites, and articles for clinical audiences means that the tool has likely had millions of uses with patients, which represents substantial clinical impact.
Year(s) Of Engagement Activity 2011,2012,2013,2014,2015
URL http://www.the4AT.com
 
Description Audio podcast on delirium detection for the BMJ Group (posted Nov 14 2011) 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact The podcast is on a public website. It was posted on 14 Nov. By 2 Dec it had had 450 downloads.

Unknown at this stage.
Year(s) Of Engagement Activity 2011
 
Description British Council invited talk, Spain 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? Yes
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact I gave a talk in Seville on Nov 6th 2009 sponsored by the British Council, the Instituto Tomas Pascal and the Fundacion de Ciencias de la Salud, entitled, "Delirium and dementia: recent advances and future developments". The audience was primarily lay.

The impacts were some reports in the Spanish press. I also did an associated radio interview for 'Radio Exterior de España' which will be broadcast in the next few weeks.
Year(s) Of Engagement Activity 2009
 
Description Dissemination of information on new 4AT screening instrument for delirium and cognitive impairment: incorporation into NHS Education for Scotland dementia education 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? Yes
Geographic Reach National
Primary Audience Health professionals
Results and Impact The 4AT is included in national educational materials in this website: http://www.nes.scot.nhs.uk/media/350872/acute_dementia_interactive_2011.pdf

The 4AT is also part of Healthcare Improvement Scotland's 'Delirium Toolkit': http://www.healthcareimprovementscotland.org/our_work/person-centred_care/opac_improvement_programme/delirium_toolkit.aspx

The 4AT is a new screening instrument for delirium and cognitive impairment which is being used in various NHS settings across the UK.
Year(s) Of Engagement Activity 2011,2012,2013,2014
URL http://www.the4AT.com
 
Description Health Improvement Scotland - ongoing meetings and changes to clinical practice recommendations 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? Yes
Type Of Presentation Keynote/Invited Speaker
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact I have an ongoing partnership with Healthcare Improvement Scotland (Scottish Government Health Department) which involves producing materials related to delirium detection (4AT: www.the4AT.com), delirium treatment (the TIME bundle and the summary and comprehensive delirium management pathways), and a new initiative related to delirium prevention.

The impacts have been extensive, with this partnership producing materials now in wide clinical use in dozens of UK hospitals, and also used internationally (eg. in 5 hospitals in Houston, Texas).

I received several requests for my presentation slides. These slides will also be made available on NHS websites.

The talk also generated publicity for the Scottish Delirium Association (www.scottishdeliriumassociation.com) which I co-founded in 2010 to provide a forum for sharing of pathways, teaching resources, research findings, audit methodologies, etc.
Year(s) Of Engagement Activity 2012,2013,2014,2015,2016
URL http://www.scottishdeliriumassociation.com
 
Description Multiple lectures on the 4AT to clinical audiences 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Multiple lectures locally, nationally and internationally to clinical audiences on the 4AT. Several thousand attendees. Active website which now has >4000 hits per month. 4AT now implemented as a routine clinical for delirium detection in multiple UK hospitals, and several international sites. The 4AT is recommended in many pathways and several guidelines, and will be recommended in the forthcoming Scottish SIGN guidelines on delirium.

The 4AT is implemented on several wards locally and is being trialled in sites around the UK and elsewhere.
Year(s) Of Engagement Activity 2011,2012,2013,2014,2015
URL http://www.the4AT.com
 
Description RCPE talk 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? Yes
Type Of Presentation Keynote/Invited Speaker
Geographic Reach National
Primary Audience Health professionals
Results and Impact I received several requests for my talk slides.

The event was on 30 October 2012.

This talk contributed to the increasing interest in delirium, and specifically in exposure of the screening instrument the 4AT.
Year(s) Of Engagement Activity 2012
 
Description TV interviews: BBC Scotland and STV 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact I contributed to a press release and was interviewed by BBC Scotland and STV relating to a 'Hot Topics Symposium' on 'The Confused Patient in the Acute Hospital' that I initiated and organised at the Royal College of Physicians of Edinburgh. The TV interviews appeared on the evening news and the TV station websites, and the press release was widely cited in the Scottish press.

I was invited by a BBC Scotland reporter to get in contact about a possible longer piece on delirium.
Year(s) Of Engagement Activity 2012
 
Description Talk on delirium to UK Brussels Office 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact I spoke on delirium research at a meeting of UK regional health offices on ageing issues in health which was hosted by the the UK Brussels Office. This was on Jun 5 2009

Ongoing contacts with policymakers
Year(s) Of Engagement Activity 2009