Policy for the Diagnosis, Management and Prevention of Delirium (Acute confusion) in Adults over 18 years

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1 Document type: Policy for the Diagnosis, Management and Prevention of Delirium (Acute confusion) in Adults over 18 years Policy Version: V2.0 Author (name): Author (designation): Susan Cook Ann Lloyd Intermediate Care Pharmacist Consultant Nurse Validated by ICSD Clinical Governance Board Dr A Kallat (Lead Geriatrician) Dementia steering group Medicines safety Group Dr Wild Date validated March 2016 Ratified by: Date ratified: Name of responsible committee/individual: Name of Executive Lead (for policies only) Master Document Controller: Date uploaded to intranet: Key words Review date: Executive Director Dementia Steering Group N/A Gina Riley Delirium May 2019 or in light of new guidance Version control Version Type of Change Date Revisions from previous issues 1 N/A Original document 2 Update May 2016 Addition of medication advice, 4AT, pathway & condensed assessment form, Equality Impact Bolton NHS Foundation Trust strives to ensure equality of opportunity for all service users, local people and the workforce. As an employer and a provider of healthcare Bolton NHS FT aims to ensure that none are placed at a disadvantage as a result of its policies and procedures. This document has therefore been equality impact assessed to ensure fairness and consistency for all those covered by it regardless of their individuality. The results are shown in the Equality Impact Assessment (EIA). of Delirium (Acute confusion) in Adults over 18 years Page 1 of 24

2 Contents Purpose 2 Introduction Overview of process for identification and screening of patients Detailed pathway for the diagnosis and management of delirium Monitoring 13 References 13 Appendices Appendix 1 Differential Diagnosis Appendix 2 Common drug causes of delirium and examples Appendix 3 Assessment documentation for identification of delirium Appendix 4 - Delirium Management Pathway PURPOSE 1. This policy has been written to provide staff with an assessment document for the assessment and management of delirium in an in-patient setting (excluding ICU). This policy is in line with the NICE guidelines for the identification and management of delirium This policy applies to all health Care Professionals who may come into contact with those patients at risk of developing or displaying signs of delirium. It is intended to provide these staff with the tools and information to assess, treat and manage delirium in older people. of Delirium (Acute confusion) in Adults over 18 years Page 2 of 24

3 CONTENT Introduction 3. Delirium (sometimes called acute confusional state ) is a clinical syndrome characterised by disturbed consciousness, cognitive function or perception, which has an acute onset and fluctuating course. It usually develops over 1 2 days. Delirium may be present when a person is admitted to hospital, intermediate care or long-term care or may develop during a stay. 4. Delirium is a common but complex clinical syndrome associated with poor outcomes. However, it can be prevented and treated. Delirium can be hyperactive, hypoactive or both. Fast/loud speech Hyperactive Restlessness Sparse/slow speech Hypoactive Unawareness Anger/irritable Euphoria Apathy Lethargy Impatience Wandering Decreased motor activity Uncooperative Easy startled Staring Laughing Swearing/singing Persistent thoughts Nightmares Decreased alertness Be particularly vigilant for behaviour indicating hypoactive delirium Hyperactive delirium is usually easily recognized Hypoactive and mixed often unrecognized and untreated 5. Be aware that delirium or high risk of delirium may not necessarily imply that a patient is incompetent for the purpose of establishing consent for care and treatment. Consent should always be sought if possible. If patients do not have the capacity to make decisions, healthcare professionals (HCP s) should follow Bolton NHS Foundation Trust advice on consent. of Delirium (Acute confusion) in Adults over 18 years Page 3 of 24

4 Overview of process for identification and screening of patients 1. Identify all patients over 65 years of age with cognitive impairment using the Abbreviated Mental Test (AMT) on admission. Consider delirium in all patients with cognitive impairment and with any of the following risk factors: Severe illness Physically frail Dementia Alcohol excess Fracture neck of femur Medication issues Visual and hearing impairment Dehydration/Sepsis 2. Use the short Confusion Assessment Method (CAM) or 4AT screening instrument to diagnose delirium. 3. Identify the cause of delirium if present from the: History (obtained from patient, relatives or carers) Examination Investigations Treat underlying cause or causes (commonly drugs, infection, electrolyte disturbance, dehydration or constipation) 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 avoid constipation maintain a good sleep pattern maintain good fluid intake involve relatives and carers (carers leaflet) liaise with RAID Do not Use restraint Sedate routinely Argue with the patient Cautions: Avoid unnecessary catheterisation ensure hearing aids and spectacles are available and in good working order/clean avoid complications (immobility, malnutrition, pressure ulcers, over-sedation, falls, and incontinence) 5. If sedation has to be used, use one drug only at the lowest possible dose and increasing in increments if necessary after an interval of two hours. Indication for use of sedation must be documented. Review daily 6. Ensure a safe discharge and consider follow up with old age psychiatry team. Provide family/carer education and support. Ensure any prescribed sedation is discontinued or referred 1. Detailed to GP pathway for review. for Inform the Diagnosis GP of delirium and episode Management of Delirium of Delirium (Acute confusion) in Adults over 18 years Page 4 of 24

5 Every patient older than 65 should be screened when admitted 6. Routine screening is important to allow modification of risk factors which may prevent delirium, and also for early treatment of conditions which may otherwise further complicate care, e.g. dementia or depression. Assess and record baseline cognitive function at admission using AMT tool (Appendix 3) 7. Consider delirium in all patients with cognitive impairment and with any of the following risk factors: Severe illness A clinical condition that is deteriorating or is at risk of deterioration Patients with dementia (Appendix 1) Fracture neck of femur Visual and hearing impairment Dehydration/Sepsis Physically frail Alcohol excess Medication issues (Appendix 2) -Drug induced delirium is very common amongst the elderly. Drugs can be the sole cause of delirium in some e.g. drug toxicity, new medication, withdrawal of drugs 8. Nursing staff should be aware of risk factors and potential early signs and symptoms of delirium. Any concerns should be monitored and documented. Observe patients at every opportunity for any changes in the risk factors for delirium. Patients at high risk should be identified at admission and prevention strategies incorporated into their care plan. 9. Ensure that people at risk of delirium have a care environment that: Avoids unnecessary room changes Maintains a team of healthcare professionals who are familiar to the person at risk Do not assume that any such indications are normal features of aging If indicators of delirium are identified, a Healthcare Professional (HCP) should carry out a clinical assessment using the short Confusion Assessment Method (CAM) or 4AT to confirm the diagnosis (Appendix 3). of Delirium (Acute confusion) in Adults over 18 years Page 5 of 24

6 10. The features of delirium according to Diagnostic and Statistical manual of Mental Disorders (DSM IV) are: Consequences of a general medical condition, substance intoxication or disturbance of consciousness (i.e. reduced clarity of awareness of the environment) with reduced ability to focus, sustain and shift attention 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 The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day There is evidence from history, physical examination or laboratory findings that the disturbance is caused by the direct physiological substance withdrawal 2 In people diagnosed with delirium, identify and manage the possible underlying cause or combination of causes. 11. Always attempt to take a history from the patient, if this is not possible or insufficient, then an additional history from the family or carer may also be undertaken. Previous baseline cognitive function - E.g. ability to manage household affairs, pay bills, compliance with medication, use of telephone and transport Possible underlying causes - E.g. infection, severe pain, dehydration, constipation Previous and current behaviour and personal interactions Assess if fluctuating progression of delirium is present Any previous episodes of delirium Previous sensory impairment - Aids used e.g. hearing aid, glasses Previous psychiatric co-morbidity - e.g. depression or dementia Psychosocial history - e.g. family problems and current family care arrangements Functional status - e.g. activities of daily living should be assessed by an OT or physiotherapist Potential for self-harm or danger to others of Delirium (Acute confusion) in Adults over 18 years Page 6 of 24

7 Drug history - to include non-prescribed drugs (over-the-counter, herbal, complementary medicines) Alcohol or substance abuse (overdose or withdrawal) Delirium that occurs after intoxication can arise within minutes or hours after intoxication. It may occur after one episode or prolonged use of alcohol. Delirium usually resolves as the intoxication ends but may continue for several days Please refer to RBH Guidelines for the Drug Management of Alcohol Detoxification In Adults (excludes Maternity) for further advice 12. Physical examination (This may not be possible in acutely confused or uncooperative patients) Conscious level Nutritional status Evidence of pyrexia Signs of infection Evidence of alcohol abuse or withdrawal Neurological examination (including assessment of speech) Rectal examination (if impaction suspected) 13. Investigations Full blood count including C reactive protein Liver function tests Chest X-ray Blood cultures (if clinically indicated) Urinalysis Thyroid function tests CT head (if a cerebral lesion suspected) Urea and electrolytes Glucose ECG Pulse oximetry Oxygen saturations B 12 and folate Other investigations may be indicated according to the findings from the history and examination of Delirium (Acute confusion) in Adults over 18 years Page 7 of 24

8 14. Medication review Carry out a medication review, taking into account both the type and number of medications. Withdraw any incriminating drugs if possible and monitor requirements of all other medication. Drugs can also cause delirium if withdrawn abruptly ensure the patient is written up for all their regular medication. MANAGEMENT OF DELIRIUM 15. In addition to treating the underlying cause, management should also be directed at relieving symptoms of delirium. Patients at high risk of delirium should also have these strategies incorporated into their care plan. 16. Basic Observations Minimum twice daily until condition improves Temp, BP, Heart Rate, O 2 Saturations, respirations and NEWS score If patient drowsy need to include neurological observations 17. Improve Communication Resolve any reversible cause of the impairment, such as impacted ear wax, ensure hearing and visual aids are available, in good working order and used by patients who need them. Ensure effective communication and regular reorientation (for example, explaining where the person is, who they are, and what your role is) Provide reassurance for people diagnosed with delirium. Consider involving family, friends and carers to help with this Use interpreters where necessary Speak slowly and clearly 18. Environment Ensure the patient s immediate surroundings are appropriately adapted by: a. promoting an awareness of time of day through adequate lighting, clocks, calendars and frequent reminders of the time of day b. encouraging family, friends or carers to bring familiar pictures/objects to reduce sense of disorientation c. encourage family and friends to spend as much time as possible with the patient. Allow open visiting of Delirium (Acute confusion) in Adults over 18 years Page 8 of 24

9 d. noisy surroundings may over stimulate patient so reduce noise in these situations Assess and remove potential hazards in the immediate surroundings e.g. furniture, access to hot water/drinks, equipment Implement Falls Prevention care plan if relevant. o May need low level bed. o Avoid bed rails if possible. o Enable adequate supervision. o Can the patient be moved to a more suitable bed on the ward/unit? Continuity of care from nursing staff. Consider one to one nursing supervision in those with extreme behavioural disturbance to prevent self-harm such as removing IV lines or falls 19. Nutrition Assessment Address through the following actions: Ensure adequate fluid intake to prevent dehydration by encouraging the patient to drink. Offer small amounts at least hourly if patient is reluctant to drink. Consider SC/IV fluids if necessary. Maintain fluid balance chart Take advice where necessary when managing fluid balance in patients with comorbidities (i.e. heart failure, chronic kidney disease) It is often difficult for patients with delirium to eat enough to meet their metabolic needs. Adequate staffing levels are needed to support and encourage to eat; ensuring food is of appropriate consistency and taking into account patients preferences. If people have dentures, ensuring they fit properly. 20. Elimination Good diet, fluid intake and mobility to prevent constipation A full continence assessment should be carried out. Regular toileting and prompt treatment of UTI s may prevent urinary incontinence Catheters should be avoided where possible because of the increased risks of trauma in confused patients and the risk of catheter associated infection of Delirium (Acute confusion) in Adults over 18 years Page 9 of 24

10 21. Assess for Pain Look for non-verbal signs of pain, particularly in those with communication difficulties (for example, people with learning difficulties or dementia, or people on a ventilator or who have a tracheostomy) Start and reviewing appropriate pain management in any person in whom pain is identified or suspected 22. Maintain Mobility Avoid unnecessary bed rest and over sedation Encourage people to walk (provide appropriate walking aids if needed these should be accessible at all times) Encourage all people, including those unable to walk, to carry out active range-ofmotion exercises Wandering may be managed through collusion walk with the patient and invite him/her to return to the unit 23. Assess Sleep Pattern Address problems with sleep disturbance through the following actions: Promote good sleep patterns and sleep hygiene Reduce noise and disturbance to a minimum during sleep periods Low level lighting Avoiding nursing or medical procedures during sleeping hours, if possible Scheduling medication rounds to avoid disturbing sleep 24. Capacity Consider need for capacity assessment and best interest decisions where a patient is non-compliant with interventions Do not: Catheterise Sedate routinely Use restraint Argue with the patient of Delirium (Acute confusion) in Adults over 18 years Page 10 of 24

11 25. Sedation Keep the use of sedatives and major tranquillisers to a minimum. All sedatives may cause delirium, especially those with anticholinergic side effects. Drug treatment must only be used: To enable essential investigations to be carried out To prevent a patient endangering themselves or others To relieve distress in a highly agitated or hallucinating patient If sedation has to be commenced use ONE drug only at the lowest possible dose and increase in increments if necessary after an interval of at least 2 hours. Indications for use of sedation must be documented Review the need for sedation on a daily basis and always prior to discharge Indication Drug Dose Contraindications/Cautions Delirium Haloperidol 0.5mg tablets Delirium in patient with Parkinson s Disease or Lewy body dementia Delirium associated with alcohol/sedative withdrawal or severe anxiety Olanzapine 2.5mg tablets Quetiapine 25mg tablets Lorazepam 0.5mg tablets mg every 2hrs if indicated to a maximum dose of 5mg/24hrs mg orally 2 hourly, daily max 20mg (10mg in elderly) Start at lowest clinically appropriate dose and titrate cautiously REVIEW DAILY 25mg BD (More appropriate than haloperidol to minimise extra pyramidal side effects) REVIEW DAILY 0.5mg 1mg at intervals of no less than 2 hours to a maximum dose of 3mg/24 hours REVIEW DAILY Avoid in severe hepatic failure or alcohol/sedative withdrawal Use with care if prescribed with other drugs that increase the QT interval Caution in cardiovascular disease Use with care if prescribed with other drugs that increase the QT interval Caution in cardiovascular disease and epilepsy Severe hepatic impairment, respiratory depression N.B. Haloperidol and Olanzapine do not have UK marketing authorisation for this indication but is recommended by NICE for this application. of Delirium (Acute confusion) in Adults over 18 years Page 11 of 24

12 26. Discharge Planning Care must be taken to ensure that the delirium has been properly investigated and treated before discharge. Discharge should be planned in conjunction with the multi-disciplinary team involved in caring for this patient. Discharge checklist Ensure any sedation treatments have not been given for at least 48 hours prior to discharge Stop any sedation treatments on discharge or refer to GP for review Prior to discharge assess cognitive and functional status Offer advice and reassurance to family, friends and carers involved in patients care Offer advice re prevention of recurring cause of delirium - E.g. dehydration, infection, visual/hearing problems, alcohol, falls Ensure all appropriate onward referrals are completed of Delirium (Acute confusion) in Adults over 18 years Page 12 of 24

13 Monitoring Compliance Area to be monitored methodology Who Reported to frequency Delirium risk assessment on admission and implementation of delirium care plan. Audit of 20 case notes in medicine & 20 in surgery Consultant Nurse IMC Pharmacy Lead Dementia Specialist Nurse Deputy Director of Nursing and Dementia Steering Group. Annual Use of sedation in patients with delirium Audit IMC Pharmacy Lead/Dementia Specialist Nurse Deputy Director of Nursing and Dementia Steering Group. Medicines safety group. Annual Staff familiarity and use of policy. Survey Consultant Nurse Older people. Dementia Specialist Nurse. Deputy Director of Nursing and Dementia Steering Group. Annual. References: 1. Clinical pathway confusional states in older people. RBH April Delirium: Prevention, diagnosis and management. NICE clinical guideline [CG103] Review decision date: January 2015 no changes 3. Guidelines for the prevention, diagnosis and management of delirium in older people. Concise guidance to good practice series. No 6 London: RCP, Clinical Review. Delirium in older people. John Young, Sharon K Inouye. BMJ 21/04/2007 Vol. 334: Delirium (acute confusional state) management. Map of Medicine 6. Delirium (acute confusional state) suspected. Map of Medicine of Delirium (Acute confusion) in Adults over 18 years Page 13 of 24

14 Appendix 1 Differential Diagnosis Delirium is frequently a complication of dementia and may also co-exist with disorders such as depression. Care is therefore needed to distinguish between these. Feature Delirium Dementia Depression Onset Course Acute/sub-acute Depends on underlying cause, often worse at twilight Short, diurnal fluctuations in symptoms; worse at night in the dark and on awakening Chronic, generally insidious, depends on cause Long, no diurnal effects, symptoms progressive yet relatively stable over time Coincides with life changes, often abrupt Diurnal effects, typically worse in the morning; situational fluctuations but less than delirium Progression Abrupt Slow but even Variable, rapid slow but uneven Duration Hours to less than one month, seldom longer Months to years At least two weeks, but can be several months to years Awareness Reduced Clear Clear Alertness Fluctuates; lethargic or hyper vigilant Generally normal Normal Attention Impaired, fluctuates Generally normal Minimal impairment but is distractible Orientation Fluctuates in severity, generally impaired May be impaired Selective disorientation Memory Recent and immediate impaired Recent and remote impaired Selective or patchy impairment islands of intact memory Thinking Disorganised, distorted, fragmented, slow or accelerated incoherent Difficulty with abstraction, thoughts impoverished, makes poor judgement, words difficult to find Intact but with themes of hopelessness, helplessness or selfdepreciation Perception Distorted; illusions, delusions and hallucinations, difficulty distinguishing between reality and misperceptions Misperceptions often absent Intact; delusions and hallucinations absent except in severe cases of Delirium (Acute confusion) in Adults over 18 years Page 14 of 24

15 Appendix 2 Common drug causes of delirium and examples. PLEASE SEEK PHARMACIST ADVICE BEFORE DISCONTINUING ANY MEDICATION AND GIVE CONSIDERATION TO APPROPRIATE ANALGESIA. Common drug causes of delirium Drug Class Analgesics Antibiotics Antiepileptics Antihistamine Antimanic Antispasmodic Antidepressants (Tricyclic) Antiparkinsonian (dopamine agonists) Antipsychotics Benzodiazepines (including withdrawal of drug) Bronchodilator Cardiac glycosides Diuretics H 2 receptor antagonists Example Opiates (e.g. morphine), NSAID s, tramadol, Aciclovir, Co-trimoxazole Phenytoin, valproate Hydroxyzine, diphenhydramine Lithium citrate/carbonate Alverine citrate Amitriptyline, Dosulepin Levodopa, Selegiline, Benzhexol Chlorpromazine Diazepam, Temazepam, Chlordiazepoxide Theophylline, aminophylline Digoxin Furosemide Cimetidine, ranitidine Drugs can also cause delirium if withdrawn abruptly ensure the patient is written up for all their regular medication. If medications are thought to precipitate delirium consider other comorbidities before discontinuation. This list is not exhaustive please refer to the current BNF for further information. of Delirium (Acute confusion) in Adults over 18 years Page 15 of 24

16 Appendix 3 Assessment documentation for identification of delirium Patient s name: Date of Birth NHS No: Name and role of person conducting assessment: Date of assessment Location Abbreviated Mental Test Score ( AMTS) Scoring: Each correctly answered question scores 1 point. Age How old are you? Time (to nearest hour) I am going to say an address. Say: 42 West St. Ask patient to repeat the address Year - What year is it? Name your home address - Where do you live? Recognition of two persons (e.g. doctor, nurse) Date of birth Year of First World War (1914) Name of present Prime Minister Count backwards from 20-1 TOTAL SCORE COGNITION A SCORE OF LESS THAN 8 SUGGESTS ABNORMAL Consider delirium if ANY of the following risk factors are present: Older patients Visual or hearing impairment Severely ill Fracture neck of femur Dementia Dehydration/Sepsis Physically frail Alcohol excess Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Medication related issues Yes / No Action taken If indicators of delirium are identified from step 1, a HCP should continue to step 2 to confirm diagnosis. of Delirium (Acute confusion) in Adults over 18 years Page 16 of 24

17 Patient s name: Date of birth: NHS No: Name and role of person conducting assessment: Date of assessment Location: Confusion Assessment Method (CAM). The CAM instrument consists of the nine operational criteria including the four cardinal features of acute onset and fluctuation, inattention, disorganised thinking and altered level of consciousness. Scoring- The diagnosis of delirium by CAM requires the presence of features 1 and 2 PLUS either 3 or 4 Tick Yes or No as appropriate Yes No Feature 1 Acute onset and fluctuating course This feature is usually obtained from a family member or nurse and is shown by positive responses to the following questions: Is there evidence of an acute change in mental status from the patient s baseline? Did the (abnormal) behaviour fluctuate during the day, that is, tend to come and go, or increase or decrease in severity? Feature 2 Inattention This feature is usually obtained by interacting with the patient, but may also be reported by family members or staff and is shown by a positive response to the following question: Did the patient have difficulty focusing attention, for example being easily distractible or having difficulty keeping track of what was being said? Feature 3 Disorganised thinking This feature is usually obtained by interacting with the patient, but may also be reported by family members or staff and is shown by a positive response to the following question: Was the patient s thinking disorganised or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? Feature 4 Altered level of consciousness This feature is obtained by observing the patient and is shown by any answer other than alert to the following question Overall, how would you rate this patient s level of consciousness? Alert (normal) Vigilant (hyper alert) Lethargic (drowsy, easily aroused) Stupor (difficult to arouse) Coma (un-rousable) Action taken If delirium identified from CAM identify the cause or causes of Delirium (Acute confusion) in Adults over 18 years Page 17 of 24

18 Patient s name: Date of Birth NHS No: Name and role of person conducting assessment: Date of assessment Location: 4AT - Assessment test for delirium & cognitive impairment Alertness This includes patients who may be markedly drowsy (eg. difficult to rouse and/or obviously sleepy during assessment) or agitated/hyperactive. Observe the patient. If asleep, attempt to wake with speech or gentle touch on shoulder. Ask the patient to state their name and address to assist rating. Normal (fully alert, but not agitated, throughout assessment) Mild sleepiness for <10 seconds after waking, then normal Clearly abnormal AMT4 Age, date of birth, place (name of the hospital or building), current year. No mistakes 1 mistake 2 or more mistakes/untestable Attention Ask the patient: Please tell me the months of the year in backwards order, starting at December. To assist initial understanding one prompt of what is the month before December? is permitted. Circle appropriate score Months of the year backwards : Achieves 7 months or more correctly Starts but scores <7 months / refuses to start Untestable (cannot start because unwell, drowsy, inattentive) Acute Evidence of significant change or fluctuation in: alertness, cognition, other mental fun (eg. paranoia, hallucinations) arising over the last 2 weeks and still evident in last 24hrs 0 No Yes Scoring 4 or above: possible delirium +/- cognitive impairment 1-3: possible cognitive impairment 0: delirium or severe cognitive impairment unlikely (but delirium still possible if [4] information incomplete) AT score of Delirium (Acute confusion) in Adults over 18 years Page 18 of 24

19 GUIDANCE NOTES The 4AT is a screening instrument designed for rapid initial assessment of delirium and cognitive impairment. A score of 4 or more suggests delirium but is not diagnostic: more detailed assessment of mental status may be required to reach a diagnosis. A score of 1-3 suggests cognitive impairment and more detailed cognitive testing and informant historytaking are required. A score of 0 does not definitively exclude delirium or cognitive impairment: more detailed testing may be required depending on the clinical context. Items 1-3 are rated solely on observation of the patient at the time of assessment. Item 4 requires information from one or more source(s), eg. your own knowledge of the patient, other staff who know the patient (eg. ward nurses), GP letter, case notes, carers. The tester should take account of communication difficulties (hearing impairment, dysphasia, lack of common language) when carrying out the test and interpreting the score. Alertness: Altered level of alertness is very likely to be delirium in general hospital settings. If the patient shows significant altered alertness during the bedside assessment, score 4 for this item. AMT4 (Abbreviated Mental Test - 4): This score can be extracted from items in the AMT10 if the latter is done immediately before. Acute Change or Fluctuating Course: Fluctuation can occur without delirium in some cases of dementia, but marked fluctuation usually indicates delirium. To help elicit any hallucinations and/or paranoid thoughts ask the patient questions such as, Are you concerned about anything going on here? ; Do you feel frightened by anything or anyone of Delirium (Acute confusion) in Adults over 18 years Page 19 of 24

20 History taking Always attempt to take a history from the patient. If this is not possible or insufficient, then an additional history From the family or carer may also be undertaken Task Completed Comments Yes/No Previous baseline cognitive function Possible underlying causes Drug history including recent changes Previous/current behaviour Assess if fluctuating progression of delirium is present Any previous episodes of delirium Previous sensory impairment Previous psychiatric co-morbidity such as depression or dementia Psychosocial history (family issues, current care arrangements) Functional status (activities of daily living) Potential for self-harm or danger to others Alcohol or substance abuse Physical examination This may not be possible in acutely confused or uncooperative patients Task Completed Yes/No Comments Conscious level Nutritional status Evidence of pyrexia Signs of infection Evidence of alcohol abuse or withdrawal Neurological examination (including assessment of speech) Rectal examination (if impaction suspected of Delirium (Acute confusion) in Adults over 18 years Page 20 of 24

21 Investigations The following investigations are almost always indicated in patients with delirium in order to identify the underlying cause Task Full blood count including C reactive protein Urea and electrolytes Liver function tests Glucose Chest X-ray ECG Blood cultures Pulse oximetry Urinalysis Oxygen saturations Completed Yes/No Comments Other investigation may be indicated according to the findings from the history and examination See full guideline Please record other investigations carried out: Action Plan for management of patient with delirium: Signature Date of Delirium (Acute confusion) in Adults over 18 years Page 21 of 24

22 Delirium Management Pathway THINK DELIRIUM Delirium can have serious consequences (such as increased risk of dementia and/or death) and may increase the length of stay of people already in hospital and their risk of new admission to longterm care Delirium is frequently undetected Be aware that patients with delirium may have paranoid ideas/delusions Risk assess and manage appropriately History of acute change Think delirium Risk factors for delirium Acute illness Over 65 years of age Fracture neck of femur Physically frail Severe illness Dehydration Sensory impairment Sepsis Dementia Alcohol excess Medication issues Take a full history from patient, family or carer and assess capacity to consent to treatment Yes Assess and record baseline cognitive function using AMT Does patient have cognitive impairment? Yes Screen patient for delirium using CAM or 4AT tool Does patient screen in? Yes No No No This pathway does not relate to alcohol or substance misuse Observe people at every opportunity for any changes in the risk factors for delirium or for change in cognitive function Repeat pathway If risk factors/ change in cognition present repeat screening using CAM/4AT tool If distinguishing between the diagnoses of delirium, dementia or delirium superimposed on dementia is difficult, treat for delirium first History Investigation s Examinations Initial Management Document the diagnosis and treatment in the person's record Identify and manage the underlying cause or combination of cause Ensure effective communication and reorientation and provide reassurance Consider involving family, friends and carer s to help with this. Ensure that people are cared for by a team of HCP s familiar to them. Avoid moving people within and between wards or rooms unless necessary If anti-psychotics are needed. Start at the lowest clinically appropriate dose and titrate cautiously according to symptoms. Review daily Avoid Bed moves Unnecessary Interventions Dehydration Constipation Catheterisation Delirium can persist for weeks or months after the causes are treated Patient improving Reduce and discontinue antipsychotic treatment if used Repeat cognitive assessment Encourage patients to share experience Patient NOT improving Re-evaluate for underlying causes After one week or if severe delirium refer to RAID Delirium resolved Plan for discharge Document diagnosis of delirium on discharge letter to GP Delirium not resolved consider best interest meeting Plan for discharge Consider need for extra support GP to consider referral to memory team Please refer to full guideline for further information of Delirium (Acute confusion) in Adults over 18 years Page 22 of 24

23 Equality Impact Assessment Tool Yes/No Comments 1. Does the document/guidance affect one group less or more favourably than another on the basis of: Race No Ethnic origins (including gypsies and travellers) No Nationality No Gender (including gender reassignment) No Culture No Religion or belief No Sexual orientation No Age Yes Aimed at over 65 s as they are the greater risk group. Disability - learning disabilities, physical disability, sensory impairment and mental health problems 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are there any valid exceptions, legal and/or justifiable? 4. Is the impact of the document/guidance likely to be negative? 5. If so, can the impact be avoided? 6. What alternative is there to achieving the document/guidance without the impact? 7. Can we reduce the impact by taking different action? No Yes No No Aimed at over 65 s as they are the greater risk group. If you have identified a potential discriminatory impact of this procedural document, please refer it to the Equality and Diversity Co-ordinator together with any suggestions as to the action required to avoid/reduce this impact. Document Development Checklist of Delirium (Acute confusion) in Adults over 18 years Page 23 of 24

24 Type of document Lead author: Is this new or does it replace an existing document? What is the rationale/ Primary purpose for the document What evidence/standard is the document based on? Is this document being used anywhere else, locally or nationally? Who will use the document? Is a pilot run of the document required? (optional) Has an evaluation taken place? What are the results? (optional) What is the implementation and dissemination plan? (How will this be shared?) How will the document be reviewed? (When, how and who will be responsible?) Are there any service implications? (How will any change to services be met? Resource implications?) Keywords (Include keywords for the document controller to include to assist searching for the policy on the Intranet) Staff/stakeholders consulted If the document makes reference to a medicine, has the reference been reviewed by the senior divisional pharmacist. Policy Susan Cook & Ann Lloyd Replaces previous document To improve management of Delirium and comply with NICE guidelines. NICE guideline CG103. Delirium: prevention, diagnosis and management Update Clinical staff No Monitoring plan within policy To be included in the dementia strategy Available on Intranet. Reviewed by Lead Authors Three yearly and in light of any new evidence or guidance No Delirium Dementia steering group, Dr Miller, GMW consultant Dr Kallat, Consultant Physician, ICDS Clinical Governance Board, Medicines Safety Group Signature of pharmacist: Susan Cook, Senior IMC Tier Pharmacist EIA Signed and dated By validating officer Signed and dated By ratifying officer of Delirium (Acute confusion) in Adults over 18 years Page 24 of 24