Aims
Method
Acknowledgements
Key recommendations
Introduction
Prevention
Assessment
Management
Service Organisation
References
Appendices

Summary of Guidelines to prevent and treat delirium in hospital

Step 1:
Identify all older patients (over 65 years) with cognitive impairment using the AMT or MMSE on admission

Step 2:
Consider Delirium in all patients with cognitive impairment and at high risk (severe illness, dementia, fracture neck of femur, visual and hearing impairment). Use the CAM screening instrument.

Step 3:
Identify the cause of delirium if present from the history, examination and investigations, and treat underlying cause or causes - commonly drugs or drug withdrawal, infection, electrolyte disturbance, dehydration or constipation.

Step 4:
In patients with delirium and patients at high risk of delirium:-  

Do

• provide environmental and personal orientation
  ensure continuity of care

• encourage mobility
• reduce medication but ensure adequate analgesia
• ensure hearing aids and spectacles are available and in good working order
• avoid constipation
• maintain a good sleep pattern
• maintain good fluid intake
• involve relatives and carers (carers leaflet)
• avoid complications (immobility, malnutrition, pressure sores, oversedation, falls, incontinence)
• liaise with Old Age Psychiatry Service

Do not

• catheterise
• use restraint
• sedate routinely
• argue with the patient

Step 5:
Ensure a safe discharge and consider follow up with Old Age Psychiatry Team. Provide family/carer education and support

Aim 

To update the guideline: “Guidelines for the diagnosis and management of delirium in the elderly” 1997 compiled by Dr Lesley Young and Dr Jim George based on the work of the multi-disciplinary working party on “Confusion in Crises”, Royal College of Physicians, 1995.

Method 

The update was overseen by a multi-professional guideline development group including representatives from nursing, care of the elderly, and old age psychiatry. [appendix 1].

Ms Karen Reid, Library Information Service, Royal College of Physicians, supported by Dr Jim George and Dr John Holmes carried out a literature search using the following databases: Medline, Embase, Cochrane Library, PsychINFO, BNI. HMIC, CINAHL

Dr Jim George and Dr John Holmes appraised the literature. All abstracts were reviewed. Abstracts were excluded if they related to letters, case reports, editorials, palliative care or related to the paediatric literature.

The Library Information Service at the Royal College of Physicians holds a database of the literature identified and the papers appraised.

Grading of evidence during literature appraisal and grading of recommendations in the guideline has followed the principles used by the Scottish Intercollegiate Guideline Network [SIGN] and the National Institute of Clinical Excellence [NICE] as indicated in the Appendix 2.

The Guideline Development Group reviewed the evidence and recommendations. The draft update was circulated to a multi-professional expert panel for peer review. The Guideline Development Group considered the comments of the expert panel and produced a final version.

The Clinical Practice and Evaluation Committee and the Policy Committee of the British Geriatrics Society have endorsed the update.

Acknowledgements

The Guideline development group would like to thank and acknowledge the support received from the expert panel which reviewed the draft update.

They would also like to thank Annette Guerda-Fischer and Jo Gough for their administrative help in organising the Guideline Development Groups activities.

Key Recommendations

Aids to diagnosis

• Cognitive testing should be carried out on all elderly patients admitted to hospital .
• Serial measurements in patients at risk may help detect the new development of delirium or its resolution (Grade B).
• A history from a relative or carer of the onset and course of the confusion is essential to help distinguish between delirium and dementia. (Grade C).
• The diagnosis of delirium can be made by non psychiatrically trained clinicians quickly and accurately using the Confusion Assessment Method ( CAM ) screening instrument (Grade B)

Prevention

Patients at high risk should be identified at admission and prevention strategies incorporated into their care plan (Grade A).

History

Many patients with delirium are unable to provide an accurate history. Where ever possible corroboration should be sought from the carer, general practitioner or any source that knows them well (Grade C ).

Management

• The most important approach to the management of delirium is the identification and treatment of the underlying cause (Grade C).
• The patient should be nursed in a good sensory environment and with a reality orientation approach, and with involvement of the multi-disciplinary team (Grade C)
• The use of sedatives and major tranquillisers should be kept to a minimum (Grade C)
• It is preferable to use one drug only, starting at the lowest possible dose and increasing in increments if necessary after an interval of two hours (Grade D).
• All medication should be reviewed every 24 hours, at least (Grade D).
• One to one care of the patient is often required and should be provided while the dose of neuroleptic medication is titrated upward in a controlled and safe manner. (Grade D)

Staff Training, Education Audit

• Senior doctors and nurses should ensure that doctors in training and nurses are able to recognise and treat delirium (Grade C).
• Regular audit should be undertaken to assess the processes and outcomes of care of patients with delirium e.g. use of cognitive scores, ward moves, length of stay, complications and mortality. (Good Practice Point)
• The results of audit should be used as feedback on the performance of doctors and nurses in order to target educational programmes. (Good Practice Point)

Guidelines for the prevention, diagnosis and management of delirium

Definition

Delirium (acute confusional state) is a common condition in the elderly affecting up to 30% of all elderly medical patients. Patients who develop delirium have high mortality, institutionalisation and complication rates, and have longer lengths of stay than non-delirious patients [1]. Delirium is often not recognised by clinicians [2], and is often poorly managed. Delirium may be prevented in up to a third of older patients [3,4]. The aim of these guidelines is to aid recognition of delirium and to provide guidance on how to manage these complex and challenging patients.

Diagnosis

Delirium is characterised by a disturbance of consciousness and a change in cognition that develop over a short period of time. The disorder has a tendency to fluctuate during the course of the day, and there is evidence from the history, examination or investigations that the delirium is a direct consequence of a general medical condition, drug withdrawal or intoxication (DSM IV) [5].

In order to make a diagnosis of delirium, a patient must show each of the features 1-4 listed below:

1. Disturbance of consciousness (i.e. reduced clarity of awareness of the environment) with reduced ability to focus, sustain or shift attention.
2. A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a pre- existing or evolving dementia.
3. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.
4. There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition, substance intoxication or substance withdrawal.

Delirium may have more than one causal factor (i.e. multiple aetiologies). A diagnosis of delirium can also be made when there is insufficient evidence to support criterion 4, if the clinical, presentation is consistent with delirium, and the clinical features can not be attributed to any other diagnosis, for example delirium due to sensory deprivation.

INTRODUCTION

Prevalence of delirium

Some older people arrive at hospital with delirium (prevalent) while others develop during their hospital stay (incident). Hospital prevalence rates for delirium vary widely because of different patient characteristics in the different studies – the highest rates are seen in older patients in critical care settings. The average prevalence of delirium in older people in general hospitals is 20% (range 7 – 61%) [6]. Post fracture neck of femur the prevalence varies from 10% to 50% [7].

Prognosis of delirium

Patients with delirium have increased length of stay, increased mortality and increased risk of institutional placement [8,9,10]. Hospital mortality rates of patients with delirium range from 6% to 18% and are twice that of matched controls [10,11]. Patients with delirium are also three times more likely to develop dementia. Delirium appears to be an important marker of risk for dementia or death, even in older people without prior cognitive or functional impairment [11].

PREVENTION

Patients at high risk should be identified at admission and prevention strategies incorporated into their care plan (Grade A).

Up to a third of delirium is preventable [3,4].Early attention to possible precipitants of delirium and adopting the approaches detailed under "management of confusion" in those patients at increased risk of delirium may prevent the development of delirium and improve the outcome in those who go on to develop it [4,12, 13, 14]. Delirium is more common in those with a pre-existing organic brain syndrome [7] or dementia [15-22], and may co-exist with disorders such as depression, which are also common in the elderly [15, 23,24]. Patients with dementia are five times more likely to develop delirium [6]. Risk factors for the development of delirium [7,21,23] are shown in Table 1, Precipitating factors [20,25] are shown in Table 2.

Table 1. Risk factors for developing delirium

Old age [26]
Severe illness [20]
Dementia [20]
Physical frailty [27]
Admission with infection or dehydration [20,26]
Visual impairment [20]
Polypharmacy [23,26,28]
Surgery e.g. fracture neck of femur
Alcohol excess [21]
Renal impairment

Table 2. Precipitating factors for delirium

Immobility
Use of physical restraint
Use of bladder catheter
Iatrogenic events
Malnutrition
Psychoactive medications
Intercurrent illness
Dehydration

ASSESSMENT

Aids to diagnosis

• Cognitive testing should be carried out on all elderly patients admitted to hospital (Grade C ).
• Serial measurements in patients at risk may help detect the new development of delirium or its resolution (Grade B).
• A history from a relative or carer of the onset and course of the confusion is essential to help distinguish between delirium and dementia. (Grade C).
• The diagnosis of delirium can be made by non psychiatrically trained clinicians quickly and accurately using the Confusion Assessment Method ( CAM ) screening instrument [29,30,31]. [see appendix 3] (Grade B)

An initial assessment of the cognitive function of all patients should be made and recorded. When confusion is suspected the use of cognitive screening tools (such as the Abbreviated Mental Test (AMT) score [32] and Mini Mental State Examination (MMSE) [33]) may increase recognition of delirium present on admission. [see appendix 3]. However by themselves these tools cannot distinguish between delirium and other causes of cognitive impairment.

Delirium is frequently a complication of dementia. Care is needed therefore to distinguish between the two. The most helpful factor is an account of the patient’s pre-admission state from a relative or carer. Use of the Confusion Assessment Method [29] or serial measurements of cognition can help to differentiate delirium from dementia or detect its onset during a hospital admission [34].

Delirium can be subdivided into hypoactive, hyperactive and mixed subtypes [35]. It is important to recognise that hypoactive and quiet delirium is the commonest type. Health staff should always be alert to the possibility of confusion when communicating with patients. Hyperactive delirium is characterised by increased motor activity with agitation, hallucinations and inappropriate behaviour. Hypoactive delirium in contrast is characterised by reduced motor activity and lethargy and has a poorer prognosis. Delirium may be unrecognised by doctors and nurses in up to two-thirds of cases [36].

Differential diagnosis

The differential diagnosis of delirium includes:

• Dementia
• Depression
• Hysteria
• Mania
• Schizophrenia
• Dysphasia
• Non convulsive epilepsy/ temporal lobe epilepsy

Clinical Assessment

The underlying cause of delirium is often multi-factorial. Common contributory medical causes of delirium include : [37,38,39,40,41]

• Infection (e.g. pneumonia, UTI)
• Cardiological (eg myocardial infarction, heart failure)
• Respiratory (eg pulmonary embolus, hypoxia)
• Electrolyte imbalance (eg dehydration, renal failure, hyponatraemia)
• Endocrine & metabolic (eg cachexia, thiamine deficiency, thyroid dysfunction)
• Drugs [41] (particularly: those with anticholinergic side effects, eg tricyclic antidepressants, antiparkinsonian drugs, opiates, analgesics, steroids)
• Drug (especially benzodiazepine) and alcohol withdrawal.
• Urinary retention
• Faecal impaction
• Severe pain
• Neurological (e.g. stroke, subdural haematoma, epilepsy, encephalitis)
• Multiple contributing causes

History

Many patients with delirium are unable to provide an accurate history. Where ever

possible corroboration should be sought from the carer, general practitioner or any source that knows them well (Grade C).

In addition to standard questions in the history, the following information should be specifically sought (Grade D)

• Onset and course of confusion
• Previous intellectual function (eg ability to manage household affairs, pay bills, compliance with medication, use of telephone and transport)
• Full drug history including non-prescribed drugs and recent drug cessation [especially benzodiazepines]
• Alcohol history
• Functional status (eg activities of daily living)
• History of diet and food intake
• History of bladder and bowel voiding
• Previous episodes of acute or chronic confusion
• Symptoms suggestive of underlying cause (eg infection)
• Sensory deficits
• Aids used (eg hearing aid, glasses etc.)
• Pre-admission social circumstances and care package
• Comorbid illness

Communication between staff from different disciplines is essential to avoid unnecessary repetition of information gathering.

Examination

A full physical examination should be carried out including in particular the following areas:

• Conscious level
• Nutritional status
• Evidence of pyrexia
• Search for infection: lungs, urine, abdomen, skin
• Evidence of alcohol abuse or withdrawal (eg tremor)
• Cognitive function using a standardised screening tool eg AMT or MMSE, including tests for attention (eg serial 7`s, WORLD backwards, 20-1 Test)
• Neurological examination (including assessment of speech)
• Rectal examination – if impaction suspected

Investigations

The following investigations are almost always indicated in patients with delirium in order to identify the underlying cause (Grade D):

• Full blood count including C Reactive Protein
• Urea and electrolytes, Calcium
• Liver function tests
• Glucose
• Chest X-ray
• ECG
• Blood cultures
• Pulse oximetry
• Urinalysis

Other investigations may be indicated according to the findings from the history and examination.

These include:

• CT head (see below)
• EEG (see below)
• Thyroid function tests
• B12 and folate
• Arterial blood gases
• Specific cultures eg urine, sputum
• Lumbar puncture (see below)

CT Scan

Although many patients with delirium have an underlying dementia or structural brain lesion (eg previous stroke), CT has been shown to be unhelpful on a routine basis in identifying a cause for delirium [15] and should be reserved for those patients in whom an intracranial lesion is suspected.

• Indications for the use of CT scanning (Grade C):
• Focal neurological signs
• Confusion developing after head injury
• Confusion developing after a fall
• Evidence of raised intracranial pressure

EEG

Although the EEG is frequently abnormal in those with delirium [42,43,44], showing diffuse slowing, its routine use as a diagnostic tool has not been fully evaluated.

EEG may be useful where there is difficulty in the following situations (Grade C):

• Differentiating delirium from dementia
• Differentiating delirium from non-convulsive status epilepticus and temporal lobe epilepsy
• Identifying those patients in whom the delirium is due to a focal intracranial lesion, rather than a global abnormality

Lumbar puncture

Although various abnormalities have been seen in the CSF of patients with delirium [45], routine LP is not helpful [46] in identifying an underlying cause for the delirium (Grade C). It should therefore be reserved for those in whom there is reason to suspect a cause such as meningitis. This might include patients with the following features:

• Meningism
• Headache and fever

Management

Treatment of underlying cause

The most important approach to the management of delirium is the identification and treatment of the underlying cause (Grade C).

• Incriminated drugs should be withdrawn wherever possible. In the cases of opiates causing delirium, it may be possible to reduce the dose or change to an alternative [47].
• Biochemical derangements should be corrected promptly [38].
• Infection is one of the most frequent precipitants of delirium. If there is a high likelihood of infection (eg abnormal urinalysis, abnormal chest examination etc.), appropriate cultures should be taken and antibiotics commenced promptly, selecting a drug to which the likely infective organism will be sensitive.
• Parenteral thiamine should be administered when alcohol abuse or under nutrition is apparent

Management of confusion

In addition to treating the underlying cause, management should also be directed at the relief of the symptoms of delirium.

a. Environment

The patient should be nursed in a good sensory environment and with a reality orientation approach, and with involvement of the multi-disciplinary team [3,4,12,13,14,39,48 - 58] (Grade B).

Ensure

• Lighting levels appropriate for time of day.
• Regular and repeated (at least 3 times daily) cues to improve personal orientation.
• Use of clocks and calendars to improve orientation.
• Hearing aids and spectacles should be available as appropriate and in good working order.
• Continuity of care from nursing staff.
• Encouragement of mobility and engagement in activities and with other people.
• Approach and handle gently.
• Elimination of unexpected and irritating noise (e.g. pump alarms).
• Regular analgesia, for example regular Paracetamol.
• Encouragement of visits from family and friends who may be able to help calm the patient. Explain the cause of the confusion to relatives. Encourage family to bring in familiar objects and pictures from home and participate in rehabilitation.
• Fluid intake to prevent dehydration (use subcutaneous fluids if necessary)[59].
• Good diet, fluid intake and mobility to prevent constipation.
• Adequate CNS oxygen delivery (use supplemental oxygen to keep saturation above 95%).
• Good sleep pattern (use milky drinks at bedtime, exercise during the day).

Avoid:

• Inter and intra ward transfers [60].
• Use of physical restraint [61,62,63,64].
• Constipation.
• Anticholinergic drugs where possible and keep drug treatment to a minimum.
• Catheters where possible.

Depending on the layout and nature of the ward, these measures may be facilitated by nursing the patient in a single room. For example, in a busy, Nightingale ward, a patient with delirium may be better managed in a side room, whereas in a ward with small bays the presence of other patients may have a reassuring influence. Management of delirium is a measure of overall quality of care [65]

b. Wandering

Patients who wander require close observation within a safe and reasonably closed environment. The least restrictive option should always be used when acting in the best interests of the patient to keep them safe from assessed risk [66]. In the first instance attempts should be made to identify and remedy possible cause of agitation - eg pain, thirst, need for toilet. If the cause of the agitation cannot be remedied, the next least restrictive option is to try distracting the agitated wandering patient. Relatives could be encouraged to assist in this kind of management as they will have information about the person which will help when offering meaningful distractions. The use of restraints or sedation should only be used as a final option, once others have been tried, and only if they can be justified as being in the best interests of the patient

This step wise approach should be adopted consistently by the whole team including relatives and other informal carers.

c. Rambling speech

Patients with delirium often exhibit confused and rambling speech, it is usually preferable not to agree with rambling talk, but to adopt one of the following strategies, depending on the circumstance. [67]

(Grade C):

• Tactfully disagree (if the topic is not sensitive).
• Change the subject.
• Acknowledge the feelings expressed – ignore the content.

d. Sedation

The use of sedatives and major tranquillisers should be kept to a minimum (Grade C)

All sedatives may cause delirium, especially those with anticholinergic side effects [68]. Many elderly patients with delirium have hypoactive delirium (quiet delirium) and do not require sedation [35]. Early identification of delirium and prompt treatment of the underlying cause may reduce the severity and duration of delirium [53]. The main aim of drug treatment is to treat distressing or dangerous behavioural disturbance [e.g. agitation and hallucination]

Drug sedation may be necessary in the following circumstances (Grade D)

• in order to carry out essential investigations or treatment
• to prevent patient endangering themselves or others
• to relieve distress in a highly agitated or hallucinating patient

It is preferable to use one drug only, starting at the lowest possible dose and increasing in increments if necessary after an interval of two hours (Grade D).

All medication should be reviewed every 24 hours (Grade D).

The preferred drug is Haloperidol [69,70,71] 0.5 mg. orally which can be given up to two hourly. A maximum dosage of 5 mg [orally or IM] in 24 hours is general guide but may need to be exceeded depending on the severity of distress, severity of the psychotic symptoms, weight and sex. Haloperidol can be given IM, 1 – 2 mg. An alternative in patients with Dementia with Lewy Bodies and those with Parkinson’s Disease is Lorazepam 0.5 mg. to 1 mg. orally which can be given up to two hourly (maximum 3 mg. in 24 hours). If necessary, Lorazepam can be given 0.5 mg. – 1.0 mg. IV or IM (dilute up to 2 mls. with normal saline or water) up to a maximum of 3 mg. in 24 hours.

One to one care of the patient is often required and should be provided while the dose of neuroleptic medication is titrated upward in a controlled and safe manner. (Grade C)

Sedation should only be used in situations as indicated above and should not be used as a form of restraint. If sedatives are prescribed, the prescription should be reviewed regularly and discontinued as soon as possible. The aim should be to tail off any sedation after 24 – 48 hours.

For delirium due to alcohol withdrawal (delirium tremens) a benzodiazepine (eg diazepam or chlordiazepoxide) are preferred in a reducing course. Detailed guidelines for this condition are beyond the scope of these guidelines.

e. Prevention of complications

The main complications of delirium are :

• Falls
• Pressure sores
• Nosocomial infections
• Functional impairment
• Continence problems
• Over sedation
• Malnutrition

Restraints (including cotsides, "geriatric chairs" etc.) have not been shown to prevent falls and may increase the risk of injury [61 ,62,63,64]. It may be preferable to nurse the patient on a low bed or place the mattress directly on the floor. Adoption of the good practices described should make the use of physical restraints unnecessary for the management of confusion (Grade C).

Pressure sores

Patients should have a formal pressure sore risk assessment ( eg Norton score, or Waterlow score), and receive regular pressure area care, including special mattresses where necessary (Grade C). Patients should be mobilised as soon as their illness allows.

Functional impairment

Assessment by a physiotherapist and occupational therapist to maintain and improve functional ability should be considered in all delirious patients (grade D). There is evidence that patients who are managed by a multidisciplinary team do better than those cared for in a traditional way [3, 4,12,14, 39] (Grade B).

Continence

A full continence assessment should be carried out. Regular toileting and prompt treatment of UTI`s may prevent urinary incontinence [39]. Catheters should be avoided where possible because of the increased risks of trauma in confused patients, and the risk of catheter associated infection (Grade C).

Malnutrition

It is often difficult for delirium patients to eat adequately to meet increased metabolic needs. Food alternatives that take into account the patient’s preferences, and the option of finger foods should be considered. Adequate staffing levels should be ensured to support and encourage eating. Oral nutritional supplements can be considered and in severe cases short-term feeding by nasogastric tube may need to be considered [39], although this is rarely a practical option.

Post Delirium Counselling

The literature suggests the delirium is often a very unpleasant experience for patients and that their may be left with unpleasant half-recollection of the events and of the delusions held during delirium. [72] Consideration should be given to provide some support and counselling for patients who have been through the experience.

Service Organisation

Staff Training and Education

Senior doctors and nurses should ensure that doctors in training and nurses are able to recognise and treat delirium (Grade C).

An educational package for the multi-disciplinary team is important. Such education of nurses and doctors has been shown to be effective in recognising and preventing delirium on an acute medical ward [73].

Liaison Psychiatry

Liaison psychiatry services have a valuable role in preventing and managing delirium [6]. In particular help should be sought if there are behavioural problems. Many patients with delirium have an underlying dementia which may be best followed up and managed by an Old Age Psychiatrist.

Discharge

Care must be taken to ensure the delirium has been properly investigated and treated before discharge. As with all elderly patients discharge should be planned in conjunction with all disciplines involved in caring for the patient, both in hospital and in the community (including informal carers). Practical arrangements should be in place prior to discharge for activities such as washing, dressing, medication etc. in accordance with the joint statement of the British Geriatrics Society and the Association Directors of Social Services [74] (Grade C).

• Communication with all parties, including family and carers, involved in the patients care is vital.
• Prior to discharge it is useful to assess the patients cognitive and functional status (eg using standardised tools such as AMT and Barthel Index).
• Discharge summaries should be completed promptly.

Follow up

Delirium is a common first presentation of an underlying dementing process. It may also be a marker of severe illness and comorbidity. It is therefore often appropriate to refer the patient to a Geriatrician, Psychiatrist of Old Age, CPN, Occupational Therapist or Social Worker for the Older People for further assessment and follow up. Patients with delirium may benefit from more intensive support post discharge [75].

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For appendices see Word document including :

1. Members of the Guideline Development Group
2. Grading system from the SIGN methodology
3. Abbreviated Mental Test Score (AMT) and Mini mental state examination and the Confusion Assessment Method