DELIRIUM

DELIRIUM DIAGNOSIS PREVENTION AND MANAGEMENT

Delirium is a serious disturbance in mental abilities that results in confused thinking and reduced awareness of the environment. The start of is usually rapid — within hours or a few days.

It can often be traced to one or more contributing factors, such as a severe or chronic illness, changes in metabolic balance (such as low sodium), medication, infection, surgery, or alcohol or drug intoxication or withdrawal.

Because symptoms and dementia can be similar, input from a family member or caregiver may be important for a doctor to make an accurate diagnosis.

• It is a clinical syndrome characterised by disturbed consciousness, cognitive function
  or perception, which has an acute onset and fluctuating course

• It is a common but serious and complex clinical syndrome associated with poor outcomes

• Older people, people with dementia, severe illness or a current hip fracture are more at risk

Reduced awareness of the environment

This may result in:

• An inability to stay focused on a topic or to switch topics
• Getting stuck on an idea rather than responding to questions or conversation
• Being easily distracted by unimportant things
• Being withdrawn, with little or no activity or little response to the environment

SCOPE

• Preventing, identifying, diagnosing and treating

• Focuses on preventing in people identified to be at risk

• Covers adults in intermediate care & Bradwell Community Hospital

KEY PRIORITIES FOR IMPLEMENTATION

• Risk factor assessment
• Indicators
• Interventions to prevent
• Diagnosis
• Interventions to treat
• initial management
• distressed people

STEP 1 – RISK FACTOR ASSESSMENT

• Assess the risk in all patients over 65yrs  
• Consider if cognitive impairment and the presence of any of these risk factors:

• Current hip fracture   –   Physically frail
• Dementia                    –  Alcohol excess
• Severe illness               –  Medication
• Visual/hearing impairment
• Dehydration/Sepsis

STEP 2 – DIAGNOSIS

• If indicators are identified, carry out a clinical assessment using short CAM 

• A healthcare professional who is trained and competent in the diagnosis should carry out the assessment

• If there is difficulty distinguishing between the diagnoses , dementia or delirium superimposed on dementia, treat first

   Document the diagnosis

The features 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 

STEP 3 – TREATING : INITIAL MANAGEMENT

For people diagnosed with delirium identify and

manage the possible underlying cause or

combination of causes by:

• History taking

• Physical examination

• Investigations 

STEP 4 –  ACTION PLAN

In addition to treating the underlying cause,

management should be directed at relieving

symptoms :

• Basic observations
• Communication
• Environment
• Nutrition 
• Elimination

• Assess for pain
• Maintain mobility
• Assess sleep pattern
• Capacity

Do Not:

• Catheterise
• Use restraint
• Sedate routinely
• Argue with the patient

STEP 5 – TREATING : DISTRESSED PEOPLE

• If a person is distressed or considered a risk to themselves or others, first use verbal and non-verbal techniques to de-escalate the situation. 
• If these are ineffective or inappropriate, consider giving short-term drug treatment 

• Start at the lowest clinically appropriate dose and titrate cautiously according to symptoms

STEP 6 – DISCHARGE PLANNING

• Discharge checklist

• Review sedation

• Assess cognitive and functional status

• Advice and reassurance 

• Referrals completed

REMEMBER

Addressing these clinical factors in a patient at risk of delirium can prevent delirium:

• cognitive impairment and/or disorientation
• dehydration and/or constipation
• hypoxia
• infection
• immobility or limited mobility
• pain 
• multiple drugs
• poor nutrition
• sensory impairment
• poor sleep patterns and sleep hygiene

Read More about delirium here

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