Investigating inequalities in delirium detection and outcomes for people with severe mental illness: understanding current practice, clinical challenges and opportunities for change
A quarter of all adults in general hospitals develop delirium, yet people with severe mental illness (SMI) are far less likely to have it spotted because doctors mistake their confusion for their existing psychiatric condition. This matters because delirium is a medical emergency—a sign that physical illness is stressing the brain. When it goes undetected, the underlying cause, such as infection or organ failure, goes untreated, leading to worse outcomes including higher death rates. The problem is well known but poorly understood. This project will use linked health records from Scotland to measure exactly how often delirium is missed in people with SMI, and whether they face longer hospital stays, more readmissions, or higher mortality as a result. If the research confirms these inequalities, it will directly inform the next revision of NICE delirium guidelines. The practical change would be better screening protocols and staff training, so that acute confusion in someone with SMI triggers a check for physical illness rather than being dismissed. That could reduce preventable deaths and improve physical healthcare for an underserved group.
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Background: Delirium is a severe neuropsychiatric syndrome that occurs when physical illness induces acute cerebral stress and subsequent hypometabolism. It affects 1 in 4 adults in general hospitals and has poor outcomes. Despite its high prevalence and poor prognosis, delirium remains under-recognised and treated. Detecting delirium is essential to delivering effective treatment, and morbidity and mortality are worse if recognition and treatment are delayed. Having severe mental illness (SMI) increases the likelihood of delays in delirium diagnosis, as acute changes in mental state are often attributed to the existing psychiatric condition, rather than to delirium. This may lead to physical illness being missed and un-treated. This is an inequality in delirium care that has been highlighted by NICE. Aim: To investigate whether there are inequalities in detection and outcomes of delirium for people with SMI, explore why these differences occur and how this could be improved. Objectives: To synthesise existing evidence on delirium occurrence in people with SMI. To test whether people with SMI have differences in delirium detection on admission to general hospital compared to people without SMI. To test whether people with SMI have differences in length of admission, re-admission and mortality rate after delirium compared to people without SMI. To explore experiences of delirium amongst people with SMI and healthcare professionals. Methods: I will conduct a systematic review to collate studies reporting the prevalence, incidence or occurrence of delirium in people with SMI. I will conduct a cross-sectional study using linked primary and secondary care anonymised datasets in Scotland to examine delirium detection on admission to general hospital. I will use logistic regression to analyse whether there are differences in completion of delirium screening, delirium prevalence, and recording of delirium diagnosis in healthcare records for people with SMI. I will conduct a longitudinal cohort study using this dataset to examine outcomes of delirium. I will use linear regression to test whether there are differences in length of admission with delirium for people with SMI, and time-to-event analysis to test whether there are differences in rates of 30-day re-admission or 1-year mortality for people with SMI. I will conduct qualitative interviews with patient-carer dyads to understand experience and clinical presentation of delirium amongst people with SMI, to inform how we might better detect it. I will conduct focus-groups with healthcare professionals to understand barriers and facilitators to recognising and managing delirium in people with SMI. Timeline for delivery: 0-7: Perform systematic review and submit ethics applications 8-24: Cross-sectional and longitudinal cohort studies 25-34: Qualitative study 35-45: Write up thesis, submit and disseminate Anticipated impact: The evidence generated by this project will inform the next revision of NICE delirium guidelines to address the identified gap in delirium care for people with SMI. Improving this will impact identification and treatment of underlying physical illness in people with SMI and address inequalities in their physical healthcare. It will increase wider understanding of how delirium is poorly detected in under-served groups.
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