Delirium Diagnosis and Management in Older People in a General Hospital Setting

Guidelines for the diagnosis and Management of Older Peoplewith Delirium

in a general hospital setting

CONTENTS

1. INTRODUCTION

Delirium is common in hospitalised patients with a range between 10 and 50% reported in different studies1,2,3. It occurs most frequently in older people (up to 30% of older inpatients) but also commonly in Intensive Care Unit (ICU) patients4, in the alcohol dependent 5 and in the terminally ill6. It can occur in a wide variety of medical situations.

Delirium is often not recognised by clinicians (missed in up to 2/3 of cases) and is frequently poorly managed7. Lack of recognition is important and may occur for a number of reasons including the fluctuating nature of it, overlap with dementia, lack of formal cognitive assessments being used, failure to appreciate the clinical consequences and failure to consider the diagnosis important7.

It is vital that delirium is recognised and appropriately managed because patients who develop delirium have high mortality (twice as likely to die), institutionalisation and complication rates, and have longer lengths of stay than non-delirious patients (up to 8 days has been described)8. There is potential to prevent the onset of delirium in up to 30% of older in-patients9, 10. The National Service Framework for Older People (DOH 2001)11 identifies a fundamental requirement for the NHS to ensure the good and effective management of patients with mental health needs wherever they are being cared for.

This document has been designed to assist clinicians in the achievement of this standard. The guidance contained within this document has been developed in line with the Guidelines for the Prevention, Diagnosis and Management of Delirium in Older People, Royal College of Physicians, 200612, and also draws on the guidelines from the Isle of Wight health care trust 200513.

Note: Clinician is used in reference to Doctors, Nurses and all members of the Multi-disciplinary team (MDT)

2.PURPOSE

The following guideline aims to provide support for clinicians in the recognition, diagnosis and management of older people presenting with the symptoms of Delirium within the acute hospital environment, it is important to remember that patients with delirium can be found in all specialties of the hospital These guidelines do not specifically cover the management of withdrawal of alcohol. Appendix II provides quick reference guides to the guideline.

3.SCOPE

This document is intended for the use of all staff involved in the care of patients identified as at risk or with a confirmed diagnosis of Delirium.

The primary focus of the document has been developed around the care of older people, who are particularly prone to developing this condition. However the guidance may also be broadly applied to the treatment of acute confusion in younger patients.

4.DEFINITIONS

Since it’s inclusion in the Diagnostic and Statistical Manuel of Mental Disorder in 1987, Delirium has been the consensus term for the syndrome although it is also known as acute confusion.

Delirium, is a disturbance of consciousness and cognition, with rapid onset (over hours to days usually), fluctuatingcourse due to a cause such as a general medical condition, drug withdrawal or drug intoxication15. It is important to remember that Delirium is dangerous. Delirium can be treated and Delirium may be the only manifestation of severe disease (eg myocardial infarction) in an older person

There are four core features (which should all be present to make the diagnosis, although these may not always be easy to find)

1. Disturbance of consciousness (reduced awareness, reduced ability to focus, sustain or shift attention)
2. Disturbance of cognition such as a memory problem, disorientation or language problem
3. Develops over a short period of time and tends to fluctuate during the course of the day
4. Evidence from history, examination or laboratory results that it is caused by a general medical problem, substance intoxication or withdrawal16.

In practice it is often the disturbance of cognition that is noticed and the other features, although present may not be identified by the clinician. Those with acute confusion should be managed in the same way as those fulfilling all the core features of delirium

There are several subtypes of delirium recognised. These are hyperactive (pulling at clothing, restless, wandering, aggressive);hypoactive (more common, sleepy, difficulty following conversation, behaviourally not difficult and therefore the most common type to be missed) or a mixed picture where the patient may fluctuate between the two types described above17.

It is important to recognise behaviours that can be associated with an underlying delirium which include: illusions/hallucinations, psychomotor disturbances as outlined above, altered sleep wake cycle, disorientation, restlessness, wandering, stripping off clothes, verbal aggression, physical aggression, refusal to eat/drink, inappropriate behaviour including sexual, an inability to co-operate or participate in care17.

5.DUTIES AND RESPONSIBILITIES

Detail the duties, accountabilities and responsibilities (including level) of Directors, individuals, specialist staff, departments and committees.

It is the responsibility of all clinical staff involved in the caring for patients with Delirium to follow the recommendations of this guideline.

It is the responsibility of the Consultants, Matrons and Divisional Nurses to ensure that systems exist to enable staff to receive the training they require.

6.PROCESS

6.1 Causes of Delirium

Up to a third of delirium is preventable9,16. Therefore awareness of risk factors, likely precipitating factors and the appropriate avoidance of these wherever possible are essential to reduce the development of the syndrome. Delirium is usually the result of the complex interaction of multiple conditions and risk factors. There is often a balance between risk factors and precipitating factors. For example, an older person with dementia may only require a relatively minor precipitant to become delirious, whereas in a young and usually fit person a major precipitant, such as severe sepsis, would need to occur before that person developed delirium. Table 118,19, outlines some of the major known risk factors and possible precipitants of delirium. These are not exhaustive lists

Table 1. Risk factors and precipitating factors

(Adapted from Inouye et al 1993 and Inouye 2000)

6.2 Management of a patient with delirium

This should include:-

• Recognition of the condition
• Identification of underlying causes
• Treatment of underlying causes
• Management of the confusion and behaviour associated with delirium

Recognition of the condition

Diagnosing delirium can be difficult, and as previously highlighted, the diagnosis is frequently missed. In view of this the following are suggested12:

• Cognitive testing should be carried out on all older patients on to admission hospital and be entered into the patient’s notes.

• Serial measurements in patients at risk may help detect the new development of delirium or its resolution.

• Information, to include prior cognitive status wherever possible, should be sought from all available sources to include the patient’s carer or supporter, GP or anyone who knows them well.

Clinicians are encouraged to make an initial assessment of the cognitive function by the use of a recognised screening tool such as the: Mini Mental State Examination20 (MMSE, see Appendix II), or the Abbreviated Mental Test score21 (AMTS see Appendix III). Clinicians are encouraged to support the test with information for the patient and their cares in the form of the Mini Mental State Examination (MMSE) - a guide for people with dementia and their carers can be found on the Alzheimer’s Society website (

However cognitive tests by themselves cannot distinguish between delirium and other causes of cognitive impairment. Dementia and delirium frequently occur together and it can be particularly difficult to distinguish between them when a patient presents acutely. It is frequently the situation that underlying confusion from dementia is worsened by an episode of delirium. IT SHOULD BE ASSUMED THAT ALL PATIENTS PRESENTING ACUTELY WITH CONFUSION ARE DELIRIOUS UNTIL PROVEN OTHERWISE TO AVOID TREATABLE CONDITIONS BEING MISSED.

The Confusion Assessment Method (CAM) can be used to formally diagnose delirium (see Appendix VII).

In many cases patients suffering from Delirium will be unable to provide a complete and detailed history. Therefore an exploration of pre-admission state from a relative or carer may prove invaluable and is an essential part of the assessment.

Having established a baseline, further serial measurements should be undertaken as a means to detect any improvement or deterioration in the status of cognitive function (suggested at least twice a week or when there are significant changes in the condition)

Identification of the underlying cause(s)

History

Common causes of delirium include any physical illness, medication (particularly those with anticholinergic side effects) or withdrawal from alcohol or drugs23. See appendix IV for a list of some of the drugs that may precipitate delirium.

Many patients with a confused state are unable to provide the necessary information. Therefore information should always be sought from someone who knows the patient well to contribute to a more comprehensive assessment.

In addition to standard questions in the history, the following information should be specifically sought.

• Full drug history including non prescribed drugs and recent changes
• Alcohol history
• Benzodiazepine use (avoid rapid withdrawal)
• Previous intellectual function (e.g. ability to manage household affairs)
• Functional status (e.g. actives of daily living)
• Onset and course of confusion
• Previous episodes of acute or chronic confusion
• Symptoms suggestive of underlying cause (e.g. infection)
• Sensory impairments
• Bowel habits

Examination

Physical examination can be difficult and may be needed to be completed in stages. Be aware of your approach to the patient (see section 7.4 management of confusion). Full examination should be undertaken with particular reference to the following:

• Neurological examination, level of consciousness
• Nutritional status (clinical evidence plus MUST score)
• Clinical evidence of dehydration
• Evidence of pyrexia or hypothermia (beware that older patients with sepsis do not always mount a pyrexia)
• Evidence of alcohol/ substance use or withdrawal
• PR Examination for constipation should be considered
• Cognitive function using a standardised screening tool e.g AMTS, MMSE

Investigations

The following investigations are almost always indicated in patients with delirium in order to identify the underlying cause:

• Full blood count, C Reactive Protein or ESR, urea and electrolytes, calcium and phosphate, liver function tests, glucose
• Chest Xray and pulse oximetry
• ECG
• Urinalysis
• Thyroid function tests (if not done within the last six months)

Other investigations may be indicated according to the findings from the history and examination.

These include:

• Blood cultures, B12 and folate, Magnesium, Arterial blood gases, Specific cultures eg urine, sputum

• CT head (see below)
• Lumbar puncture (see below)
• EEG (see below)

CT Scan

Although many patients with delirium have an underlying dementia or structural brain lesion (e.g previous stroke), CT has been shown to be unhelpful on a routine basis in identifying a cause for delirium18 and should be reserved for those patients in whom an intracranial lesion is suspected.

Indications for the use of CT scanning should be discussed with a senior clinician (SpR level or Consultant)

• Focal neurological signs
• Confusion developing after head injury
• Confusion developing after a fall
• Evidence of raised intracranial pressure

Lumbar puncture

Routine Lumbar puncture is not helpful in identifying an underlying cause for the delirium24. It should therefore be reserved for those in whom there is reason to suspect a cause such as meningitis or encephalitis. This might include patients with the following features:

• Meningism
• Headache and fever

EEG

Although the EEG is frequently abnormal in those with delirium, showing diffuse slowing25, its routine use as a diagnostic tool has not been fully evaluated. However it can be useful when a medical cause cannot be found; if the EEG is abnormal it will identify the need to carry on looking for a cause

EEG may also be useful where there is difficulty in the following situations (after discussion with an Spr or Consultant):

• Differentiating delirium from nonconvulsive status epilepticus and temporal lobe epilepsy
• Differentiating delirium from dementia
• Identifying those patients in whom delirium is due to a focal intracranial lesion

Treatment of underlying cause

The most important approach to the management of delirium is the identification and treatment of underlying cause(s). It is common for there to be more than one contributing factor. Therefore it is important that all possible causes are actively managed concurrently.

• Incriminating drugs should be withdrawn wherever possible26. Many drugs can precipitate delirium and any recent changes/additions should be considered a possible contributing factor. Appendix IV outlines some of these but is not exhaustive
• Drugs with anticholinergic activity (many drugs in common use, including benzodiazepines, have some anticholinergic effects and it is not always possible to avoid them all and their contribution to delirium should be balanced with their other required effects. Appendix IV outlines some drugs that may precipitate or worsen delirium, many of them through anticholinergic activity
• Correct biochemical abnormalities promptly27
• Treat underlying infection (please refer to the guidelines from Microbiology with regard to potential prescription of antibiotics).
• Avoid Constipation – monitor bowel habit daily
• Avoid Catheters- where possible

Management of Confusion

Non Pharmacological Management

In addition to treating the underlying cause, management should also be directed at the relief of the symptoms of confusion/delirium. The patient should be nursed in a good sensory environment with a multi-disciplinary approach to individualised care7,8,9,16,18,28-33.

This includes:-

Improve communication

Be aware of the person’s life biography – this may give you cues for conversational topics and prevent anxiety

Verbal – Do not confront. Confused people are more likely to become agitated and aggressive if they feel threatened. Communicate clearly, calmly, simply and express your wish to help with their situation to reduce their distress/confusion.

• Introduce and personalise yourself to the person.
• Listen to the person, observe the behaviour and try to interpret the message, emotion and feelings being communicated.
• Try to avoid commands and the words ‘don’t’ and ‘why’.
• Explain to the person what you want them to do – not what not to do.
• Acknowledge their feelings and show concern.
• More than one member of staff talking to the person at the same time will add to the confusion and lose the thread of intervention. It may also serve to make the person feel threatened.
• Try to orientate the person and highlight visual clues for them to acknowledge. If the patient insists they are somewhere else, e.g. show other patients in beds.
• Validate/acknowledge their feelings and do not proceed with reality orientation as this could provoke a confrontation.
• Engage with the person in meaningful interaction offer distraction and diversions
• Explain unfamiliar noises/equipment/personnel to the person to avoid misinterpretation.
• Do not label a person or their behaviour in a negative way to others.

Non-verbal – Open-handed gestures are seen as non-threatening, whereas pointed gestures are invariably seen as aggressive. Offering a handshake will be recognised by a confused person as a friendly gesture. If a person refuses to shake hands, this may indicate to the nurse that hostility and potential aggression are likely.

• Approach the person from the front, slightly off-centre to avoid feelings of confrontation.
• Maintain good eye contact and initial distance of approx. three feet, so as not to invade personal space.
• If the person is in bed or seated, avoid standing over them and, where possible, crouch down to their eye level.
• Non-verbal clues such as facial expression, body posture and eye contact will be taken on board by the patient and will override verbal communication

Favour high-quality sleep

Non pharmacological sleep promotion; noise reduction; use of low level lighting; avoidance of constant lightening; Maintenance of a normal sleep- wake cycle. If liked use milky drinks at bedtime.

Limit sensory underload or overload

Screen for visual and hearing impairment; provision of visual and hearing aids; Lighting level appropriate

for time of day; avoidance of rooms with no windows. Where possible elimination of unexpected and

irritating noise e.g. pump alarms.

Involve and inform significant others

Explain the cause of the confusion to relatives. Encourage family to bring in familiar objects and pictures form home and participate in rehabilitation

Avoid malnutrition and vitamin deficiencies