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Guidelines for the prevention, diagnosis and management of delirium in older people in hospital

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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).

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