Policy and Practice Update

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1 DOI: /j x Policy and Practice Update Blackwell Publishing Asia Clinical practice guidelines for the management of delirium in older people in Australia Joanne Tropea, Jo-Anne Slee and Caroline A Brand Clinical Epidemiology and Health Service Evaluation Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia Len Gray Academic Unit in Geriatric Medicine, The University of Queensland, Brisbane, Queensland, Australia Tony Snell Clinical Governance Directorate, Royal Melbourne Hospital, Parkville, Victoria, Australia Delirium is a common and serious condition which is often overlooked or misdiagnosed in older people. In 2006, the first set of national clinical practice guidelines for the management of delirium in older people were developed. This paper provides an abbreviated version of the guideline document which includes recommendations for the detection of delirium (diagnosis and screening), assessment and prediction of risk factors for delirium, prevention of delirium and interventions to manage people with delirium. The guidelines reflect the available evidence base and highlight the limited high level research in delirium care, particularly in the areas of symptom management and screening for delirium. Key words: aged, Australia, delirium, guideline. Background information This paper provides a synopsis of the Clinical Practice Guidelines for the Management of Delirium in Older People, which was commissioned on behalf of the Australian Health Ministers Advisory Council (AHMAC), by the AHMAC Health Care of Older Australians Standing Committee. Although delirium guidelines have been developed in some local health settings (especially hospitals), these guidelines are the first set of comprehensive national clinical practice guidelines for the management of delirium in older people specifically developed for the Australian health-care environment across the acute, subacute, residential care and community care settings. The full guideline document is available at Development of the guidelines was undertaken by a multidisciplinary expert working group of clinicians, academics and consumer representation. The guidelines are based on a comprehensive and structured review of the evidence to questions regarding the detection, prevention, management and risk Correspondence to: Ms Joanne Tropea, Clinical Epidemiology and Health Service Evaluation Unit, Royal Melbourne Hospital. Joanne.Tropea@mh.org.au factor assessment of delirium in older people. The recommendations have been summarised using the National Health and Medical Research Council pilot program additional levels of evidence and grades for recommendations for developers of guidelines [1]. An external review of the draft guidelines was conducted involving 22 national and international reviewers. Epidemiology of delirium Delirium is a common and serious condition among older people. Studies show that delirium prevalence and incidence varies across patient populations and health-care settings. Some of the variation is explained by study methods, such as patient age group, inclusion of cognitively impaired patients, length of patient follow up, and methods for defining and diagnosing delirium. Table 1 collates some of the available data on delirium incidence and prevalence rates in different settings; however, there are very few Australian-based epidemiological studies. Given that older people are at increased risk of delirium, we can expect an increase in the burden of delirium associated with the ageing population. Delirium in older people is associated with significant mortality and morbidity [12]; increased length of hospital stay [13]; and increased risk of cognitive decline, functional decline and nursing home placement [14,15]. The cost of delirium to the health-care system is substantial. Research in the USA indicates that hospital stays complicated by delirium account for approximately 1.5 million inpatient days [16], and $US6.9 billion in Medicare expenditure each year [17]. Several other US studies suggest that delirium prevention would reduce both acute and long-term care costs [18]. However, no such cost data exist for the Australian health-care system [19]. Aetiology and risk factors Delirium aetiology is complex and multifactorial (see Fig. 1), involving an interaction between predisposing patient factors (or vulnerabilities) and precipitating factors (or insults) [20]. Although there are many potential causes of delirium, the more common include severe illness, infection, and medication and alcohol use/withdrawal. In most cases, the cause of delirium can be identified [21], and in older people, multiple causes can coexist [20,22]. There is high level evidence that older age; cognitive impairment; visual impairment; depression; abnormal serum sodium; use of indwelling catheter; use of physical restraint; and the addition of three or more medications are risk factors for the development 150 Australasian Journal on Ageing, Vol 27 No 3 September 2008,

2 Australian delirium guidelines Table 1: Delirium incidence and prevalence in different patient populations Patient group Delirium incidence or prevalence data and references Surgery % incidence in hip fracture surgery patients 60 years and older [2,3] 14.7% incidence in elective hip surgery patients 60 years and over without severe dementia [2] 32% incidence in patients, aged 65 years or older, who have undergone CABG surgery [4] General medical 15 20% prevalence at time of admission to ward [5] 18% prevalence of patients 65 years and older within 72 hours of admission, and a further 2% incident delirium up to 1 week following admission [6] Emergency departments 5 10% prevalence rates [5] Intensive care units 70% prevalence of delirium of all patients 65 years or older, during their ICU stay and up to 7 days postdischarge [7] Long-term care 40.5% 14-day period prevalence from US state minimum dataset [8] 52.6% of older hospitalised patients from long-term care experienced delirium during their hospital admission [9] Hospital admission 10 15% of older patients had prevalent delirium on hospital admission [10] 21.6% of hospital older community-dwelling patients experienced delirium during their hospital admission [9] CABG surgery, coronary artery bypass graft surgery; ICU, intensive care unit. Figure 1: The interrelationship between level of vulnerability and level of precipitating insult. Box 1: Diagnostic and Statistical Manual of Mental Disorders-IV criteria for delirium [11] A Disturbance of consciousness (ie reduced clarity of awareness of the environment) with reduced ability to focus, sustain or shift attention. B 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, established or evolving dementia. C The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day. D 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; or the symptoms of criteria A and B developed during substance intoxication; or medication use is aetiologically related to the disturbance; or the symptoms of criteria A and B developed during, or shortly after, a withdrawal syndrome; or the delirium has more than one aetiology (eg more than one aetiological general medical condition, a general medical condition plus medication side effect); or a clinical presentation of delirium that is suspected to be caused by a general medical condition or substance use but for which there is insufficient evidence to establish a specific aetiology; or delirium because of causes not listed in this section (eg sensory deprivation) of delirium. However, the evidence is mainly derived from studies that were both hospital-based and conducted outside of Australia, making generalisation to other settings difficult. Detection and diagnosis of delirium The definition of delirium and its differentiation from dementia was first outlined by the American Psychiatric Association (APA) in Box 1 contains the diagnostic criteria for Australasian Journal on Ageing, Vol 27 No 3 September 2008,

3 Tropea J, Slee J-A, Gray L et al. Box 2: Recommendations for the detection and diagnosis of delirium in all health-care settings A structured process to screen for and diagnose delirium should be established in all health-care settings (expert opinion). A formal cognitive function assessment should be performed on all older people as part of the routine admission process to all health-care settings (expert opinion). Each of the tools recommended for screening and diagnosis of delirium require specific training (expert opinion). delirium according to the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV text revised edition, APA). Diagnostic tools Delirium is a syndrome that can involve a complex diagnostic process, and is often missed by clinicians. A number of tools have been developed to enable clinicians other than medical specialists, and even lay people to diagnose delirium. The Confusion Assessment Method (CAM) and the Delirium Rating Scale (DRS) were designed to be used by clinicians, while the Delirium Symptom Interview (DSI) was designed for use by non-clinicians. The CAM-ICU has been developed and validated specifically for use in intensive care. Each of the abovementioned tools is based on DSM criteria for delirium, but the expertise required to administer and interpret the tools differs and limited training materials or guidance is available. In addition, none of the tools have been validated in the Australian setting. Screening for delirium Underrecognition is a major issue in the diagnosis of delirium [23], yet there is some evidence to suggest that early detection improves outcomes such as duration of delirium and length of hospital stay [5,24]. Implementing a formalised process for the screening of delirium may improve detection rates [25,26]. Delirium screening could involve use of a validated cognitive assessment tool (such as Mini-Mental State Exam, Abbreviated Mental Test) to obtain a measure of baseline cognitive assessment. The application of routine repeated cognitive assessment could be considered for patients at high risk of developing delirium, such as orthopaedic surgery. In low-risk settings, a sudden change or deterioration in behaviour, cognition or functional status indicates the need for further assessment. Box 2 summarises recommendations for the detection and diagnosis of delirium in all health-care settings. Prevention of delirium Prevention of delirium refers to implementation of strategies that can reduce the incidence of delirium in older people who have predisposing risk/s for delirium. A small number of delirium prevention studies have been reported in the literature, the majority of which feature a multicomponent prevention approach [27,28]. These studies have focused on addressing modifiable risk factors for delirium, with primary outcome measures being reduction in the number and/or the severity of risk factors (see Table 2). The Yale Delirium Prevention Trial [28] was the first clinical controlled trial to show that delirium could be prevented in older hospitalised people by utilising a non-pharmacological regimen to normalise sleep patterns; cognitively stimulating activities; limiting catheter and restraint use; encouraging mobilisation and exercises; reorientation; correction of dehydration; and use of vision and hearing aids. The intervention has since become embedded in the Hospital Elder Life Program (HELP) a model of care aimed at preventing cognitive and functional decline in older hospitalised people. It is implemented by an interdisciplinary team and a highly trained and supervised group of volunteers. Table 2: Delirium prevention strategies Environmental strategies Lighting appropriate to time of day Quiet environment especially at rest times Provision of clearly visible clock and calendar Encourage family/carer involvement in care Encourage family/carer to bring in personal and familiar objects Avoid room changes Clinical practice strategies Encourage/assist with eating and drinking to ensure adequate intake Ensure that those who usually wear hearing and visual aids are assisted to use them Regulation of bowel function Encourage and assist with regular mobilisation Encourage independence in basic activities of daily living Medication review Promote relaxation and sufficient sleep Manage discomfort or pain Provide orienting information Minimise use of indwelling catheters Avoid use of physical restraints Avoid psychoactive drugs Use of interpreters and other communication aids for CALD patients/clients Use of ATSI liaison officer for ATSI populations ATSI, Aboriginal and Torres Strait Islander; CALD, culturally and linguistically diverse. 152 Australasian Journal on Ageing, Vol 27 No 3 September 2008,

4 Australian delirium guidelines Box 3: Recommendations for the prevention of delirium All settings Preventative environmental and clinical practice strategies outlined in Table 2 should be incorporated into the care plan of all older people, across all health-care settings, to reduce their risk of developing delirium (expert opinion). Hospital settings Older orthopaedic surgery patients should be reviewed by a geriatrician preoperatively or within 24 hours after surgery, and then postoperatively on a daily basis for 5 days (grade B, [27]). Where resources are available, older surgical patients should be reviewed by a geriatrician at least preoperatively and postoperatively (expert opinion). Multicomponent delirium prevention strategies targeting: (i) cognitive impairment; (ii) sleep deprivation; (iii) immobilisation; (iv) vision impairment; (v) hearing impairment; and (vi) dehydration; as implemented by trained volunteers under the supervision of medical and/or nursing geriatric specialists, may be considered for use with older hospitalised patients (grade C, [28]). Training should be provided to assist health-care workers, who care for older people, to implement multicomponent delirium prevention strategies targeting (i) cognitive impairment; (ii) sleep deprivation; (iii) immobilisation; (iv) vision impairment; (v) hearing impairment; and (vi) dehydration (expert opinion). A modified version of HELP was recently tested in Australia [29]. This before-and-after study utilised trained volunteers but omitted the sleep and mobilisation protocols. Authors reported a reduced incidence and severity of delirium among intervention patients. However, there are a number of methodological limitations with the study including the small sample size (n = 37). In addition there are distinct differences between the USA and Australia with respect to the availability and use of volunteers in the health sector, and further Australian research is required to determine the sustainability of a program which is reliant on a volunteer workforce. Box 3 summarises recommendations for the prevention of delirium. Management of delirium Delirium management entails a multifaceted approach, comprising the following elements: Investigate and address the cause of delirium Manage the symptoms of delirium Prevent complications Educate the patient/client and their carers/family Management of delirium symptoms is largely nursing care based, and focuses on the non-pharmacological strategies outlined in the section on delirium prevention (Table 2). While there is general agreement that this approach is beneficial, there is little evidence to support it and further research is needed to establish the effectiveness of such practices. Management of severe behavioural disturbance Most episodes of delirium can be managed with nonpharmacological interventions. Antipsychotic medication is indicated when behavioural or emotional disturbance is causing significant distress to the person with delirium; is placing them or others at risk; or is interfering with essential investigations or treatment; and the symptoms cannot be managed using non-pharmacological methods [17,30]. It is essential that a clear and structured approach to monitoring, review and documentation of patient status is followed when prescribing antipsychotic medications (see Fig. 2). Box 4 summarises recommendations for the management of delirium. Limitations While there is general agreement that delirium is a major contributor to morbidity and mortality in older populations, there is extremely limited research data to guide clinical practice. Most of the available information emanates from international settings which further raises concerns about the relevance of context-specific interventions and their generalisability to Australian settings. In addition, there is a virtual absence of costeffectiveness data to guide informed development of evidencebased health policy. Although the target population for the guidelines included Aboriginal and Torres Strait Islander populations, there was no evidence to guide culturally specific recommendations, a major gap in our knowledge and understanding of the burden of this condition in Australia s indigenous population. One of the limitations in delirium research relates to the difficulties inherent in identifying prevalent and incident delirium within a system that currently does not provide a structured approach to screening and diagnostic assessment, and in which patient length of stay is reducing. Such research studies are therefore highly resource-intensive and costly. The guideline working group strongly recommends that funding bodies respond to this gap in knowledge in order to contribute to improved health outcomes for our ageing population. Implementation The challenge for health-care organisations will be the practical implementation of the guidelines. It will necessitate organisations to consider the prevalence of delirium in their patient population, as well as risk of incident delirium, in order to design systems that will efficiently meet the needs of their population. Such systems will need to integrate processes for the prevention and early intervention of delirium, as well as the detection and monitoring within usual care processes. Complex health service changes may be required, and considerable planning is essential to develop robust implementation and evaluation frameworks [34]. Despite all these limitations the guidelines provide a structured approach for implementation Australasian Journal on Ageing, Vol 27 No 3 September 2008,

5 Tropea J, Slee J-A, Gray L et al. Figure 2: Pharmacological management of the delirious patient with severe behavioural or emotional disturbance. 154 Australasian Journal on Ageing, Vol 27 No 3 September 2008,

6 Australian delirium guidelines Box 4: Recommendations for the management of delirium identify cause, manage symptoms and prevent complications Investigation and treatment of delirium cause The underlying cause of delirium should be investigated and precipitating factors treated (expert opinion). Management of symptoms in all people with delirium Non-pharmacological strategies should be incorporated into the care plan of all older persons with delirium across all health settings; and should always be utilised as a first-line strategy to manage the symptoms of delirium (expert opinion). Delirium is best managed by clinicians with expertise in delirium management, and in most cases should involve a multidisciplinary team (expert opinion). Management of severe behavioural and/or emotional symptoms In addition to non-pharmacological strategies, the following reorientation and reassurance strategies should be considered for people with severe behavioural and/or emotional symptoms: one-on-one nursing or the use of a trained support person; opportunity for family member/carer to remain with the patient at all times (including overnight); consistency of staff members caring for the person; and provision of relaxation strategies to assist with sleep (expert opinion). Specialised delirium rooms should be considered for delirium patients with severe behavioural and/or emotional disturbance (expert opinion). Expert psychiatric consultation should be considered for people with severe behavioural and/or emotional symptoms (expert opinion). Caution should be exercised in prescribing antipsychotic medications to older people with delirium (expert opinion). Antipsychotic medications, for the management of delirium in older people, should be reserved for those cases where the person experiences severe behavioural and/or emotional disturbance (expert opinion). When antipsychotic medications are indicated the following processes should be incorporated into the patient care plan: The indication(s) for its use must be documented and reviewed regularly Commencement of the antipsychotic should be accompanied by documented recommendations about: (i) the dosage of medication; (ii) the mode of medication delivery; and (iii) the frequency with which patient status is to be reviewed by a medical physician. Frequency of medical review will vary according to patient status. For example, a patient with significant agitation may require 4 hourly medical review, and a patient with less significant agitation may require 8 hourly medical review. Titration must commence from a low dose typically the equivalence of mg of haloperidol; olanzapine 2.5 mg orally; or risperidone 0.25 mg orally Close monitoring by nursing and medical staff is required. The dosage and frequency of antipsychotic medication should be titrated carefully against the level of patient agitation at each review. It is important that nursing staff caring for patients on antipsychotic medication are able to consult regularly with medical staff. Discharge planning and follow up Information about delirium should be made available to people who have experienced delirium and their family/carers (expert opinion). Discharge planning for people who have experienced delirium should include follow up, professional monitoring and treatment (expert opinion). Postdelirium counselling should be considered for people who have experienced delirium (expert opinion). Staff education Staff education strategies aimed at increasing knowledge and awareness about delirium in older people should be considered in all health-care settings (hospital settings grade D, [31,32]; all other settings expert opinion). Delirium management should be part of the basic curricula of medical, nursing and allied health university training, and be included in training of other care workers and ongoing professional development programs (expert opinion). Implementation of delirium management guidelines accompanied by education and reinforcement should be considered in all health-care settings (hospital settings grade D, [33]; all other settings expert opinion). planning and guide organisations in assessment of their contextual needs as well as offer a basis for prioritising areas for intervention. Summary In summary, we have developed evidence-based guidelines for the detection, prevention and management of delirium in older people. Despite the limited evidence on which these recommendations are based, they provide a framework for guiding current management and highlight important gaps for targeting future research. Project expert working panel: Angela Crombie, Peteris Darzins, Nicole Doran, Diana Frew, Alex Holmes, Brendan Kay, Jonathon Knott, Dawn Kroemer, Dina Lo Giudice, Robert Malon, David Russell, Debra Parnell, Mark Santini, Vijaya Sundararajan Project technical staff: Jo Slee, Jo Tropea Delirium Consultancy Steering Group Ian Hender, Nicole Doran, Michael Murray, Deborah Law, Lisa Clinnick, Carol Gillam We would also like to thank those who assisted in the external review process. Acknowledgements The project to develop Clinical Practice Guidelines for the Management of Delirium in Older People was an initiative of the Australian Health Ministers Advisory Committee s Care of Older Australians Working Group (COAWG), now Health Care of Older Australian Standing Committee (HCOASC), and the Australian Department of Health and Ageing. Delirium Clinical Guidelines Expert Working Group Project directors: Caroline Brand, Tony Snell, Len Gray Key Point Delirium in older people is often overlooked or misdiagnosed. This paper presents an abbreviated version of the first nationally developed clinical practice guidelines for the detection, risk factor assessment, prevention, and management of delirium in older people. Australasian Journal on Ageing, Vol 27 No 3 September 2008,

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