Delirium Management (Secondary Care)

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Delirium is primarily a reflection of the brain being under stress from an acute change in the health of an individual. It can be defined as 'an acute deterioration in mental functioning arising over hours or days that is triggered mainly by acute medical illness, surgery, trauma or drugs’. Fluctuating symptoms with altered alertness and concentration are hallmarks of the condition.

Delirium is a frequently occurring medical issue, prevalent in all surgical, medical and level 2 and 3 areas. It is under-detected, complicated and harmful, but at risk groups can be highlighted to prevent or minimize delirium. It is relevant to all staff, including medical, nursing, allied health professionals and pharmacy, and involves identifying significant health problems, some of which are life-threatening. The combination of effective prevention and management will lead to less distress for patients, carers and staff, along with reduced falls, length of hospital stay and mortality. In up to 30% of patients no cause is identified.

The relevance of delirium is recognized nationally through the Scottish Delirium Association (SDA) see SDA delirium pathway and the development of SIGN 157 “Risk reduction and management of delirium

This guide is particularly aimed at older adults, the most likely population to experience delirium, however the principles of care in all age groups are the same. More robust patients may need higher doses of medication than those described below.

Exclusions

  • Withdrawal from illicit drugs or alcohol: Specific advice on the management of delirium related to alcohol withdrawal is covered under NICE guideline “Alcohol-use disorders overview".
  • The TAM Rapid Tranquilisation guidance has specific advice on when intramuscular (IM) medication is used for severely distressed patients, and the monitoring described should be followed when IM medication is used in delirium.

 

 

Quick reference guide

  • Ensure that new confusion is scored appropriately on the NEWS2 chart when appropriate. This highlights to the whole team that delirium is present, relevant and needs action.
  • Differentiate between confusion and language impairment, i.e. dysphasia
  • Delirium in COVID-19 is a recognized symptom and in vulnerable patients, notably care home residents, can lead to a severe and prolonged delirium
  • Don’t prescribe delirium. Prescribe appropriately, especially in those already at higher risk of delirium
  • Reduce and stop medication prescribed for distress when possible, and, if being used at discharge, ensure clear follow-up advice is in place for its review.
  • Patients may need an explanation of their delirium after it has resolved. Good communication with relatives/carers is important and can reduce distress.  SIGN has produced an information booklet for patients or relatives.  The Royal College of Psychiatrists have developed a shorter leaflet.

Presentation

Delirium can present as:

  • Hypoactive delirium: with drowsiness or showing loss of attention/ concentration
  • Hyperactive delirium: distress/ agitation/ hallucinations/ delusions/ paranoid.
  • A mixed presentation of hypo- and hyper- active delirium

Fluctuating symptoms are frequent and at times an individual may superficially seem close to their normal, this variability and fluctuation should be recognized as supporting the diagnosis of delirium.

Recognizing delirium can be difficult if you are unfamiliar with the patient. It is important to appreciate reports of a change from normal in the person by staff or family/carers who know the person as indications of a potential new, significant illness. Collaborative history taking is essential in highlighting these details.

The change from normal is the important factor to assist in detecting early or subtle delirium; examples of how delirium can be described are: ‘They are a bit vague’, ‘just slept all morning’, ’doesn’t wake up when examined but yesterday was chatty’, ‘not wanting to eat or drink or engage with staff’, ‘thought they were somewhere else’, ‘not concentrating’, ‘seeing things on the curtains and on the wall’.

Picking up on these comments by using the Single Question in Delirium (SQID) and the TIME bundle allows the early detection and management of delirium, and reduces the associated poor outcomes; including increased mortality, length of stay and morbidity.

SQID: Is this patient more confused than before?

TIME bundle: part of NHS Highland nursing documentation. See: HIS Think Delirium

 

Groups at risk of delirium

Groups at risk of delirium are those with:

Acute illness, dementia, age over 70 years, frailty, sensory impairment, polypharmacy, recent anaesthetic/surgery, hip fracture surgery, being catheterised, recent discharge from acute hospital, use of opioids, benzodiazepines, oral anti-cholinergics, restraint, depression, history of alcohol misuse, acute or chronic pain.

Delirium is often driven from pathology out with the brain, but at risk groups often have underlying brain pathology, ie, previous stroke, Parkinson’s Disease.

Reducing the risk of delirium is achievable through:

  • Orientation and ensuring patients have their glasses and hearing aids
  • Promoting sleep hygiene
  • Early mobilisation
  • Pain control
  • Prevention, early identification and treatment of postoperative complications
  • Maintaining optimal hydration and nutrition
  • Regulation of bladder and bowel function
  • Provision of supplementary oxygen, if appropriate.
  • Minimizing ward moves in patients susceptible to delirium

All patients at risk of delirium should have a medication review conducted by an experienced healthcare professional. (SIGN 157)

Management

Management

  • If suspected- complete the 4AT to support diagnosis.
  • Then follow the TIME delirium bundle: (HIS Think Delirium)

Managing delirium requires a comprehensive assessment to direct treatment appropriately as it is often multi-factorial see: SDA delirium pathway. Senior staff should be aware of its presence and their review sought if there are ongoing concerns.

Understand that the person may be frightened and distressed; remaining calm and in control is part of de-escalating stressful situations. Environmental factors and behaviour of staff are crucial to minimizing distress, see: SDA delirium pathway.

Focused advice on managing Stress and Distress in Dementia is available on TAM

Providing information with leaflets, and allowing family or carers to stay with a patient, may help to relieve distress, and help them to understand the situation.

Important conditions may present together. The more common and treatable ones associated with delirium are:

Condition  Management 
Pain 
  • What is the source of pain?
  • What is the appropriate analgesia for this individual 
Urinary retention 
  • Examination, fluid balance chart, bladder scan 
Constipation 
Hypoxia 
  • History and examination
  • Update chest XR 
Hyponatraemia 
  • Check medication, bloods and fluid balance 
Hypoglycaemia 
  • Check BM
  • Query excess medication 
Infection/sepsis 
  • History/ examination Sepsis 6 
  • Do not assume UTI on the basis of dipstick results alone in the over 65s. See: SIGN 160 
Medication intoxication, or withdrawal 
  • Review prescription chart and medication history 
Dehydration or AKI 
  • Check bloods and fluid balance
  • Review medication 
Being in hospital 
  • Consider environmental issues
  • Support family visiting 

The majority of these significant medical issues will not necessarily trigger an elevation in NEWS, so new confusion, which scores 3, can be an early alert to these issues.

Further management should be followed as per the SDA delirium pathway.

Imaging

Brain imaging is not usually part of the first-line assessment, unless there is concern due to anticoagulation, head injury or focal neurological signs.

Legal considerations in delirium

Consider whether Adults with Incapacity (AWI) and/or Emergency Detention Certificates (EDC) are appropriate.

Medication

Unmanageable distress

  • If patients’ symptoms threaten their safety or the safety of others prescribe a low dose of one medication (start low – go slow) and review every 24 hours. Consider capacity to consent to treatment (AWI Section 47)
  • If patient is refusing oral medication repeatedly it may be appropriate to consider administration of medication covertly. The appropriate forms must be completed prior to this (AWI covert medication care plan) and consent sought from welfare attorney/guardian if in place. Method of covert administration must be discussed with pharmacy. See Mental Welfare Commission Covert medicine policy.
  • Local advice reinforces that there is no evidence of any specific antipsychotic having benefit over others.
  • The use of all medications (other than haloperidol) is off-label. Please refer to the Royal College of Psychiatrists guideline: Use of licensed medicines for unlicensed applications in psychiatric practice.
  • In severe cases you may need to exceed the maximum doses below, this should trigger consideration of specialist referral.

Oral antipsychotics: Used in low dose as below

Medication  Starting dose  Max daily dose Minimum interval  Comments 
Risperidone  250 micrograms once or twice daily  1mg  6 hours  Caution in Parkinson's disease or Lewy Body disease 
Olanzapine  2.5mg daily  10mg  12 hours  Caution in Parkinson's disease or Lewy Body disease 
Haloperidol  500 micrograms up to twice daily  2mg  6 hours 

Licensed indication but 

  • Contraindicated in QTC prolonging medication 
  • Pre-treatment ECG required 
  • Contraindicated in Parkinson's disease
  • See recent MHRA warning
Benzodiazepines
Medication Starting dose Max daily dose
(IM + oral)_
Minimum interval Comments 
Lorazepam  500 micrograms to 1mg up to twice daily  2mg  4 hours 
  • Can be used in parkinsons disease, Lewy Body Dementia or if signs of Parkisonism 
  • Consider the potential risk of worsening/prolonging delirium with benzodiazepines 

Intramuscular
Only use if oral route is unachievable. NHS Highland Rapid Tranquilisation guidance must be followed, including patient monitoring requirements

Medication  Starting dose  Max single dose  Minimum dose interval  Max daily dose
(IM plus oral) 
Comments 
Haloperidol  500 micrograms daily  500 micrograms 6 hours  2mg 

Licensed indication but 

  • Contraindicated with QT prolonging drugs 
  • Pre-treatment ECG required 
  • Contraindicated in Parkinson's disease
  • See recent MHRA warning.
Lorazepam  500 micrograms daily  500 micrograms to 1mg  4 hours  2mg 

Consider the potential risk of worsening/prolonging delirium with benzodiazepines 

Younger or more robust patients may need higher doses of medication.

After 72 hours of unmanageable agitation/distress, review the potential causes for delirium again. It may be appropriate to prescribe a regular low dose of a medication and an extra ‘as required’ dose on the prescription chart.

If different routes of a medication are prescribed, these may need to be prescribed separately taking, into account the different doses that can be given via different routes.

Discharge advice

Delirium as a diagnosis and any recognized triggers should be highlighted on the discharge letter.  Follow up after discharge should be undertaken if the delirium has not resolved fully during the inpatient stay. If there is ongoing concern regarding the potential for dementia, then cognitive screening should take place once delirium has fully resolved, followed by referral to Older Adult Psychiatry services. See SDA delirium pathway

Referral to Older Adult Psychiatry

Referral criteria

  • There is some doubt about diagnosis and a primary psychiatric condition is a possibility.
  • There is difficult to manage behaviour persisting despite utilising the non-pharmacological and pharmacological guidance in this document, or there are side effects to psychotropic medication.
  • Advice is required for a pre-morbid psychiatric condition.
  • Advice is required regarding detention under the mental health act, or as soon as possible after the patient has been detained on an Emergency Detention Certificate.

Health Care Professional Resources

Last reviewed: 06 September 2022

Next review: 31 July 2025

Version: 1

Approved By: TAM Subgroup of the ADTC

Reviewer Name(s): Duncan Gray, Associate Specialist Medicine for Elderly

Document Id: TAM528

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