Delirium Avoid it Recognize it Find the cause of it

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Philip McKinney
5 years ago
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1 Delirium Delirium is acute cognitive dysfunction. It has a 20% - 30 day mortality (usually because of underlying conditions). It is associated with increased lengths of hospital stay, increased disability, unnecessary Nursing Home admissions and significant morbidity. In 30-50% of patients it will leave permanent cognitive harm. For these reasons it is vital that we: Avoid it (Nearly 50% of the physically frail elderly will either have or develop delirium after admission to hospital. It is avoidable with the following simple measures.) 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) Recognize it (studies have shown that both Doctors and Nurses can be very poor at recognizing when someone has delirium). Identify all older patients (over 65 years) with cognitive impairment using the 4 point AMT if abnormal this should prom[t a more detailed cognitive assessment e.g MOCA or Addenbrookes cognitive exam. 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 4AT assessment tool/ screening instrument. Find the cause of it 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.

2 4AT assessment tool for delirium; [1] 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) 0 Mild sleepiness for <10 seconds after waking, then normal 0 Clearly abnormal 4 [2] AMT4 Age, date of birth, place (name of the hospital or building), current year. No mistakes 0 1 mistake 1 2 or more mistakes/untestable 2 [3] 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. Months of the year backwards Achieves 7 months or more correctly 0 Starts but scores < 7 months / refuses to start 1 Untestable (cannot start because unwell, drowsy, inattentive) 2 [4] ACUTE CHANGE OR FLUCTUATING COURSE Evidence of significant change or fluctuation in: alertness, cognition, other mental function (eg. paranoia, hallucinations) arising over the last 2 weeks and still evident in last 24hrs No 0 Yes 4 4 or above: possible delirium +/- cognitive impairment 1-3: possible cognitive impairment 0: delirium or cognitive impairment unlikely (but delirium still possible if [4] information incomplete) Treat it 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 Don t catheterise use restraint

3 sedate routinely argue with the patient Wait till it settles (before for instance making decisions regarding Nursing Home Care). This does not preclude discharge home if someone

4 CHECKLIST FOR CLINICAL GUIDELINE POSTING ON INTERNET (short version) Complete ALL sections CLINICAL GUIDELINE INFORMATION Name of the clinical guideline: Please specify the review date for the clinical guideline: Management of Delirium in older adults ( older peoples services) This MUST be in line with the naming convention: Drug name / Procedure, Condition, Patient Group, (Scope)* Refer for guidance to Key List of Terms (MESH) available on Website *Scope = primary care referral / acute care / specialty or service /general use/specific professional group e.g. :20/02/2016 The review date must not exceed 3 years from date of guideline development 02 Glycaemic Control in Adults with Type 1 Diabetes (acute) Antifungal Agent Selection Guideline for Invasive Fungal Infections in Adult Patients (acute general ward) Methotrexate Administration pathway for Gastroenterology patients (acute day unit) Constipation in Children Guideline for management (paediatric outpatients) Author Name; Monklands Care of Elderly Department Department: Monklands Hospital, Care of Elder;y Department Directorate: Older Peoples Services ; caroline.mcinnes@lanarkshire.scot.nhs.uk ( responsible clinician) Telephone; Work address: Monklands Hospital Page 4 of 7

5 Head of Department Name: Dr Ana Talbot Department: Monklands Hospital, Care of Elderly Department Designation:Lead Clinician Work address: Monklands Hospital Telephone number: Page 5 of 7

6 CLINICAL GUIDELINE CLASSIFICATION (PLEASE TICK ALL THAT APPLY) Please note: The primary search of the NHS Lanarkshire Clinical Guideline Resource will be on the clinical guideline title. To enable easier storage and retrieval of the clinical guideline, please tick all that apply from the classification below. Acute Services Division All Acute HM MK WGH Associated Hospitals Health and Social Care Partnerships Both CHPs / HSCPs North CHP / HSCP South CHP / HSCP THE NAME OF THE SERVICE / SPECIALTY YOU TICK BELOW WILL BE USED AS A KEY SEARCH TERM if the name of your service is not included or you refer to your service using another term ( e.g. care of the elderly you regularly use geriatrics) can you provide the term: Older Peoples Services Service / Specialty Service / Specialty Service / Specialty Service / Specialty Acute Pain Endoscopy Minor Injury & Nurse Treatment Psychiatry Addictions ENT Surgery Neonatology Psychological Services Anaesthetics Gastroenterology Neurology Public Health Medicine Audiology General Medicine Obstetrics Radiology Biochemistry General Surgery Occupational Therapy Renal Medicine Cancer services Genito-urinary Medicine Oncology Respiratory Medicine Cardiology Gynaecology Ophthalmology Rheumatology Medicine Care of the Elderly Haematology - Labs Oral & Maxillofacial Surgery Sexual Health Service Child Protection Haematology - Medicine Orthodontics Smoking Cessation Community Nursing Healthcare Associated Infection Orthoptics Speech & Language Therapy Continence Service High Dependency Out of Hours Stroke Critical Care Infectious Diseases Outpatients Surgical Pre-assessment Day Surgery Intensive Care Paediatrics - Medicine Theatres Page 6 of 7

7 Dental Services - Acute Learning Disabilities Paediatrics - Surgery Tissue Viability Dental Services - Community Long Term Conditions Nursing Palliative Care Transfusion Services Dermatology Mental Health - Adult Pathology Trauma & Orthopaedic Surgery Dietetics & Nutrition Mental Health - Child & Adolescent Pharmacy Urology Emergency Medicine Mental Health - Forensic Services Physiotherapy Vascular Surgery Emergency Receiving Mental Health - Old Age Psychiatry Podiatry Other, specify below Endocrinology & Diabetes Microbiology Prisoner Healthcare SECTION I: SUBMISSION DETAILS Please the following to ClinicalGuidelines@lanarkshire.scot.nhs.uk Clinical guideline (in Microsoft word format if possible) Fully completed checklist If you have any questions regarding this checklist or process, please contact Frances Kinnear via or telephone (I only work Wed and Friday pm) Page 7 of 7

Long-stay patients methodology Published by NHS England and NHS Improvement

Long-stay patients methodology Published by NHS England and NHS Improvement July 2018 1 Document Title: Long-stay patients methodology Version number: 1.0 First published: 9 July 2018 Updated: Prepared