Diagnosis and Management of Delirium Guideline

Diagnosis and Management of Delirium. Guideline

Reference Number TWCG20(14) Version 3 Issue Date: 23/07/2019 of 22

It is your responsibility to check on the intranet that this printed copy is the latest version

Diagnosis and Management of Delirium Guideline

Lead Author: Alexander Thomson Consultant Physician, Ageing and Complex

Medicine Directorate

Additional author(s) Ross Overshott, Emma Vardy (led update)

Division/ Department:: Integrated Care Division (ICD) Elderly Care

Applies to: (Please delete) Salford Care Organisation

Approving Committee Clinical Effectiveness Committee, Document Approval Meeting

Date approved: 11/07/2019

Expiry date: July 2022

Contents

Contents

Section Page

Document summary sheet

1 Overview 3

2 Scope & Associated Documents 3

3 Background 3

4 What is new in this version? 4

5 Guideline 4

5.1 Standards 5

Definition and characteristics of delirium 5

Definition 5

Characteristics of delirium 5

Delirium subtypes 5

5.2 Causes, risk factors and prevention of delirium 6

Causes of delirium 6

Risk factors 6

Delirium prevention 6

5.3 Detection of delirium 6

Screening tools for delirium

6

Detection of delirium as part of the NEWS2 7

The 4AT 7

The Confusion Assessment Method (CAM) 8

Group arrangements:

Salford Royal NHS Foundation Trust (SRFT)

Pennine Acute Hospitals NHS Trust (PAT)




The CAM-ICU 8

Application of assessment tools 8

5.4 Assessment 8

History 8

Examination 8

Investigations 8

Role of neuroimaging 9

Role of urinalysis in the investigation of delirium 9

Role of EEG 9

Role of lumbar puncture 9

5.5 Management 10

Medical management 10

Nursing management 11

Management of agitation 11

General approaches to agitation management 11

Non-pharmacological methods of agitation management 12

Pharmacological methods of agitation management 12

Principles of pharmacological treatment of the agitated patient with delirium 12

Choice of agent 13

Management of persistent distressing symptoms in delirium 14

Management of insomnia 14

5.6 Recovery from delirium 15

6 Roles and responsibilities 16

7 Monitoring document effectiveness 16

8 Abbreviations and definitions 16

9 References 16

10 Appendices 18

Appendix 1: Delirium Pathway 18

Appendix 2: Medications commonly implicated in delirium 19

11 Document Control Information 20

12 Equality Impact Assessment (EqIA) screening tool 22




1. Overview (What is this guideline about?) The objectives of this document are to provide advice to clinical staff of different disciplines about delirium. Key Practice Points covered by the document are:

Core information on the causes, assessment, investigation, management and prognosis

of delirium.

A patient care pathway summarising the management of a patient with delirium.

Guidance on the pharmacological and non-pharmacological management of agitation

and aggression in patients with delirium.

2. Scope (Where will this document be used?)

This guideline provides practical advice for doctors, nurses and allied health

professionals involved in clinical adult services at Salford Care Organisation.

The guidance covers the assessment, identification, diagnosis and management of

patients with delirium.

The guidance does not cover patients <18 years of age or specific alcohol withdrawal

management (see policy 185TD(P)66).

The Intensive Care Unit has a separate guideline for delirium. Please refer to

GSCcrit01(15) on the Intranet.

Associated Documents

Delirium in Critical Care Patients Management guidelines GSCcrit01(15)

Delirium, published online by Royal College of Psychiatrists Med43(15)

Critical Care Unit Delirium – Information for Families and Patients

Mental capacity policy RM3(09)

3. Background (Why is this document important?)

Delirium is a common and serious medical problem both in hospital and community-dwelling adults. The prevalence of delirium in patients in hospital is 10-31% (Siddiqi et al 2006). Incidence and prevalence rates of delirium are higher in older adults and those undergoing surgery (Robinson and Eisman 2008). Awareness, recognition and management of delirium should be a priority for all healthcare organisations in the UK, and are supported by national guidelines (NICE 2010, BGS/RCP 2006). It is essential to have good systems and processes in place to identify and treat delirium due to its strong association with adverse outcomes. Patients with delirium are at greater risk of




complications, prolonged length of stay, institutionalisation, dementia and higher risk of death (Witlox et al 2010). This guideline aims to support staff in the management of patients with delirium, improving the quality of care to this vulnerable patient group and reducing the impact of this condition on morbidity, mortality and quality of life.

4. What is new in this version?

This is a revised document TWCG20(14). There is a new section on management of insomnia in delirium. The guidance reflects development of the Electronic Health Record. It is also in line Greater Manchester standards for delirium which are anticipated to be published in 2019.

5. Guideline This document is a delirium policy for Salford Care Organisation

5.1 Standards

5.1 Definition and characteristics of delirium 5.1.1 Definition Delirium is defined as “a disturbance of consciousness that is accompanied by a change in cognition that cannot be better accounted for by a pre-existing or evolving dementia” (DSM IV). 5.1.2 Characteristics of delirium As defined by the DSM V criteria, delirium is characterised by: • Disturbance in attention (reduced ability to direct, focus, sustain, and shift attention) and

awareness. • The disturbance develops over a short period of time (usually hours to days), represents

a change from baseline, and tends to fluctuate during the course of the day. • An additional disturbance in cognition (memory deficit, disorientation, language,

visuospatial ability, or perception) • The disturbances are not better explained by another pre-existing, evolving or

established neurocognitive disorder, and do not occur in the context of a severely reduced level of arousal, such as coma

• There is evidence from the history, physical examination, or laboratory findings that the

disturbance is caused by a medical condition, substance intoxication or withdrawal, or medication side effect.




These cardinal characteristics may be used as part of delirium screening tools such as the Confusion Assessment Method (CAM) or 4AT. See section 5.3. Additional features that may accompany delirium and confusion include: • Psychomotor behavioural disturbances such as hypoactivity, hyperactivity with increased

sympathetic activity, and impairment in sleep duration and architecture. • Variable emotional disturbances, including fear, depression, euphoria, or perplexity. 5.1.3 Delirium subtypes Delirium has been classified into subtypes depending on the changes is level of consciousness: • Hyperactive (restlessness, agitation, non-purposeful walking, insomnia) • Hypoactive (drowsiness, somnolence, withdrawn) • Mixed: alternating hyperactive and hypoactive subtypes This distinction is important. Hypoactive delirium is more easily missed and associated with worse outcomes (O’Keeffe and Lavin 1999).

5.2 Causes, risk factors and prevention of delirium

5.2.1 Causes of delirium A variety of medical problems may cause, contribute to or prolong delirium. Major reasons include infection, metabolic disorders including dehydration, pain, neurological problems and drugs, including drug withdrawal. Other common reasons include urinary catheterisation, faecal impaction/constipation, urinary retention, post-operatively, response to trauma/injury, change in environment, sleep deprivation/long haul flights, post-ictal state/non-convulsive status. The mnemonic PINCH-ME may be used by staff as a checklist to consider possible causes of a patient’s delirium: • P pain • I infection/intoxication • N nutrition • C constipation • H hydration/hypoxia • M medication • E environmental In many cases, patients may have more than one cause for their delirium. This is particularly true in older people where careful assessment and evaluation for more than one cause is essential. In a significant proportion of cases, despite careful investigation, no specific cause of delirium will be found.




5.2.2 Risk factors Some patients are at higher risk of developing delirium than others. This concept highlights the importance of screening for delirium in high risk groups (see section 5.3) and adopting delirium prevention strategies in these patients (section 5.2.2) The main risk factors for delirium include: • Advancing age • Dementia • Hip fracture • Previous history of delirium • Multiple co-morbidities • Polypharmacy 5.2.3 Delirium prevention In high risk groups, such as those mentioned , it is important to take steps to both prevent delirium developing in the first place or reducing its duration. These are the basic tenants of essential nursing care and include: • Pain management • Management of constipation • Bladder care, including avoidance or urinary catheters • Support with nutrition and hydration • Promoting sleep hygiene • Medication review and stewardship eg avoiding use of benzodiazepines other than for

management of alcohol withdrawal or acute seizure management, titrating opiates to manage pain but minimise side effects and use laxatives as necessary.

• Provision of sensory aids (glasses and hearing aids) • Early mobilisation • Environmental considerations e.g. noise, consistent staffing • Avoid unnecessary ward moves, where possible • Where possible involving relatives and carers in delivering care For those at risk of developing delirium patients and carers should be warned of the risk of developing delirium to alleviate distress and help with management if it does occur.

5.3 Detection of delirium

5.3.1 Screening tools for delirium In certain higher-risk groups of patients or in those where there may be a suspicion of delirium, it is appropriate to screen for this condition. Screening tools should be used to raise suspicion of a diagnosis of delirium, but are no replacement for wider clinical judgement. There are a number of validated screening tools for delirium available and selection should take into consideration time required and ease of use. For the purposes of intentional rounding the SQiD (Single Question in Delirium) is most suitable for identification and monitoring. To further




assess for delirium of those described in the literature, this guideline recommends the use of the 4AT (Bellelli et al 2014, www.the4at.com) or the Confusion Assessment Method (CAM) (Inouye et al, 1990). Both tools are used widely across the UK. It is important to be aware that delirium may still occur in the absence of a positive tests result because the condition fluctuates. 5.3.2 Detection of delirium as part of the NEWS2 The NEWS2 has an additional category not previously available within the NEWS. The item ‘new confusion’ scores 3. New confusion should be identified using the SQiD, single question to identify delirium (Sands et al, 2010). That is ‘Do you think (the patient) has been more confused in lately’. If the answer is yes it should prompt further assessment as below. 5.3.3 The 4AT The 4AT is recommended for use for identification of patients with probable delirium in the Emergency Department at Salford Royal Hospital, in the Emergency Assessment Unit (EAU) and in the ward setting. It requires little training and is quick and easy to use (Appendix 2). • A score of 4 or above suggests delirium +/- underlying dementia • A score of 1-3 suggests possible cognitive impairment (unspecified) • A score of 0 suggests cognitive impairment is unlikely to be present 5.3.4 The Confusion Assessment Method (CAM) The CAM is also quick to use, but usually requires more training and experience. It suggests delirium is likely to be present if the following criteria are met: 1. The presence of acute confusion, with fluctuation AND 2. Inattention (difficulty concentrating) AND EITHER 3. Disorganised thinking OR 4. Altered level of consciousness (either heightened arousal/agitation or drowsy). Further information on how to use the CAM in clinical practice is detailed in Appendix 3. 5.3.5 The CAM-ICU Delirium is a common phenomenon in patients in intensive care unit (ICU) settings. A tool with good sensitivity and excellent specificity for screening for delirium in this patient group, has also been developed; the CAM-ICU (Gusmao-Flores et al 2012). The identification of delirium rests on meeting similar diagnostic criteria to the CAM with some specific caveats for ICU patients. These are demonstrated in the following video: https://www.youtube.com/watch?v=6WyJ0zL7VkI




The Intensive Care Unit has a separate guideline for delirium. Please refer to GSCcrit01(15) on the Intranet. 5.3.6 Application of assessment tools All those over 65 years of age, or under 65 and at risk, admitted to hospital as an emergency ie non-elective should be assessed for possible delirium using the 4AT. Any patients admitted to hospital who develop new confusion as detected by the NEWS2 should have a 4AT to assess for delirium. Once delirium has been diagnosed they should be assessed daily for resolution. On confirmation of delirium the TIME bundle is available electronically to guide investigation and management. Diagnosis of delirium should be added to health issues, and can be performed as part of an automated aspect of the digitised 4AT.

5.4 Assessment

5.4.1 History History taking should focus on identifying clinical features of delirium and possible causes. Establishing a cognitive baseline is essential, and should involve speaking to family members or caregivers. Look for recent changes to medications, particularly those which may be associated with withdrawal reactions. Take an alcohol history and consider alcohol withdrawal as a cause (see Appendix 2). A functional and social history is mandatory, particularly in older adults with delirium. 5.4.2 Examination Physical examination should be completed in every patient. Particular focus should be placed on neurological examination and cognitive assessments including screening assessments for delirium (section 5.3). Patients should be examined for signs of sepsis, and digital rectal examination undertaken to exclude faecal impaction. They should also be assessed for urinary retention. Bedside plasma glucose testing should also be completed before any other diagnostics. 5.4.3 Investigations The following investigations are mandatory in the investigation of a patient with delirium: • plasma glucose • full blood count • urea & electrolytes, liver function tests, thyroid function and bone profile • C-reactive protein • ECG • Chest x-ray The following investigations may be indicated according to the findings from the history or physical examination, but may not be necessary in every patient: • urinalysis (see section 5.4.5 for limitations of use) • blood, urine or sputum culture • arterial blood gas • neuroimaging (see section 5.4.4)




• lumbar puncture • EEG 5.4.4 Role of neuroimaging Neuroimaging is not necessary in every patient with delirium. However, it is indicated immediately if a patient has developed new focal neurological signs including reduced level of consciousness, after head injury, presenting after a fall or if they are taking anticoagulant treatment. A CT brain scan should be performed in the first instance, unless the history or examination suggests a MR brain would be more helpful. If a delirium is failing to resolve as anticipated and/or no cause has been identified, neuroimaging should be considered. 5.4.5 Role of urinalysis in the investigation of delirium Diagnosis of urinary tract infection (UTI) should not be made on the basis of urinalysis alone. The sensitivity and specificity of urine dipstick testing in the diagnosis of urinary tract infection is low. The incidence of asymptomatic bacteriuria in older adults (>65 years) is high, and unnecessary antibiotic treatment may be harmful in this group. Do not do urine dipstick testing of catheter urine specimens as it will invariably be positive, even without infection. If considering a diagnosis of UTI as a cause or a contributor to delirium, this should be supported by the history (frequency, dysuria, new incontinence), examination (fever, suprapubic pain, urinary retention) and diagnostics (cloudy urine on inspection, raised inflammatory markers). If UTI is considered as a differential diagnosis, a mid-stream or catheter specimen of urine should be sent for culture. 5.4.6 Role of EEG EEG should be considered when there is suspicion of epileptic activity or non-convulsive status epilepticus as a cause of patient’s delirium. 5.4.7 Role of lumbar puncture SIGN guidelines do not recommend use of lumbar puncture in patients presenting with delirium.

5.5 Management

5.5.1 Medical management • Management of delirium should begin with the treatment of the underlying cause or

causes. During treatment, other complications may arise which may exacerbate the delirium or relapse an improving delirium. Medical staff should be vigilant for this.

• Robust medicines management, including a medication review of all patients and

antibiotic stewardship is also mandatory. Do not suddenly stop long-term treatment with benzodiazepines or other psychotropic medications (see Appendix 2).




• In those patients who are drowsy and sleepy with hypoactive delirium particular attention needs to be paid to pressure area relief, nutrition and hydration and vigilance for hypostatic pneumonia.

• New confusion detected as part of the NEWS2 should prompt the use of screening tools

such as the 4AT and confirmation of diagnosis. • The trajectory of the delirium should be monitored and recorded. • Early explanation with family members and caregivers about the diagnosis, cause,

investigation, management and prognosis of delirium should be undertaken by an experienced clinician. Written information should also be provided (see Delirium, published online by Royal College of Psychiatrists Med43(15), this can also be accessed as part of completion of the TIME management bundle. A separate information leaflet for relatives and patients on ICU is also available on the Intranet (CS35(18) - G18043001W)

• Detect, assess and treat causes of agitation and/or distress by treating the underlying

cause and using non-pharmacological means if possible. • Symptoms such as paranoia/hallucinations, problems with delivery of nutrition and

hydration, and legal and ethical complications may need the input of specialist staff to support the parent medical and nursing team. In these circumstances, advice should be sought from the Mental Health Liaison team or a Geriatrician.

• Monitor recovery and consider specialist referral to a geriatrician or mental health liaison

if not recovering. • Aim to prevent the complications of delirium such as immobility, falls, pressure sores,

dehydration, malnourishment, isolation. 5.5.2 Nursing management It is essential that patients with delirium are nursed with a proactive, and anticipatory approach, using the principles of least restrictive practice. Interventions should be opportunistic. If the patient declines this may include offering several times, or another member of staff offering the intervention. Anticipate Care Needs by: • Monitoring and reviewing prescribed medication for adverse or unwanted side effects • Assessing for pain, and providing analgesia, use Abbey Pain Scale if needed • Promoting hydration • Providing orientation • Encouraging mobility • Providing sensory aids, including ensuring that hearing aids are working • Completing hospital passport with patient and/or carer To provide a therapeutic environment: • Reduce noise • Provide adequate light in day, and dim lights in evening/nights




• Avoid relocating the patient where possible including to other areas of the same ward. • Encourage sleep, use relaxation/calming environment in the evenings • Consider use of behaviour monitoring chart if the patient has challenging behaviour.

When ‘as-required’ medication is used the nurse administering the medication should ensure clear documentation supporting the indication and use for treatment.

5.5.3 Management of agitation 5.5.3.1 General approaches to agitation management • Always re-assess the patient and look for factors which may be responsible for the

episode of agitation e.g. pain, urinary retention, alcohol withdrawal, substance misuse. • Consider the use of pharmacological treatment in any circumstances to be a last resort

and always consider non-pharmacological management steps in the first instance (section 5.5.3.2).

• When addressing management of agitation always consider the risks to the patient, other

patients and members of healthcare staff. Pharmacological treatment should ONLY be used if the patient is at risk of harming themselves or others, or if they have very distressing symptoms such as hallucinations.

• Ensure that all documentation, particularly if pharmacological management is used, is

clear and detailed. This should reflect the proportionality of the steps taken to address an episode of agitation and the principles of managing the patient in their best interests. Mental capacity assessment and best interest decision should also be documented.

• Consider early contact with either the Mental Health Liaison Team for advice and

support. Mental health support can be obtained out of hours by contacting the mental health liaison team via switchboard.

• Consider whether Deprivation of Liberty Safeguarding (DOLS) assessment may be

necessary if the patient is deemed to lack capacity in terms of their stay in hospital and treatment. The Safeguarding Team may be contacted for advice about this.

5.5.3.2 Non-pharmacological methods of agitation management These methods should always be attempted before pharmacological treatment considered. They include: • Leaving the patient in a safe environment, disengaging and observing from a distance. • Distraction by engaging in an activity • Music or television • Asking friends, relatives or care-givers to attend. This can be a particularly effective

technique and one which most families would be keen to support.




5.3.3 Pharmacological methods of agitation management Before medication is considered, non-pharmacological methods should have been attempted and maintained throughout. In this situation an assessment of capacity is required and should be documented, including the rationale for sedation, it’s proportionality and the judgement that it be in that patient’s best interests. These may, however be unsuccessful. Treatment using pharmacological treatments may be considered in the following circumstances: • To prevent the patient endangering themselves or others • To allow staff to carry out essential investigations or treatment • To relieve distress in highly agitated patients, particularly those with paranoia or

hallucinations In this situation an assessment of capacity is required and should be documented, including the rationale for medication and medication choice, it’s proportionality and the judgement that it be in that patient’s best interests. This guidance is specifically for the management of symptoms associated with delirium. Management of behavioural and psychological symptoms of dementia has different management, 5.3.3.1 Principles of pharmacological treatment of the agitated patient with delirium 1. Aim to offer oral medication in the first instance. 2. If an oral route is not possible due to the patient’s agitation, consider parenteral

administration routes. 3. Start with a single agent at low dose. Only prescribe as a single stat dose, and not regular

use, until further specialist advice has been sought. 4. Re-assess the patient following treatment. Determine if referral to the Mental Health

Liaison Team is required. 5.3.3.2 Choice of agent The evidence for pharmacological treatment is insufficient to support a recommendation, however expert opinion from the NHS Scotland SIGN delirium guidelines supports a role for medication in specific situations such as inpatient in intractable distress, and where the safety of the patients and others is compromised. This guideline would recommend the following: 1. Offer oral medication first in the smallest dosage




2. If the oral route is declined by the patient or they are unable to take it for other reasons, this can be given by intramuscular injection. The reason for choosing the intramuscular route must be documented as described above

3. When a patient is given sedative medication intramuscularly without their consent then

the following must be clearly documented in the patient’s notes to legally justify the

administering of the rapid tranquilization:

- the patient lacks capacity to consent to taking the medication

- the details of the reasoning/assessment of the capacity assessment (e.g. the patient is

very agitated and aroused and unable to weigh up information given to them)

- it is in the patient’s best interests to receive medication to reduce the risk of harm to the

patient and that non-pharmacological measures has been taken and have not been

successful

- the patient has been offered oral medication but has refused

- proportionate measures to the likelihood of harm, and the seriousness of harm, have

been taken to administer the medication and the least restrictive option has been taken

- if there is time, the decision to give sedative medication intramuscularly should be

discussed with family members of the patient and their agreement recorded

Medications that may be considered are listed in the table below:

Medication Single starting dose Maximum dose in 24 hours*

Cautions/Contraindications

Haloperidol 0.5mg orally 0.5mg im

2mg orally 2mg im

Prolonged QTc interval in ECG Signs of parkinsonism or lewy body dementia When used with any medication that prolongs QT interval this is off-license

Risperidone 0.25mg orally 1mg in divided doses

Signs of parkinsonism or lewy body dementia Not licensed in delirium

Lorazepam if antipsychotics are contraindicated

0.5mg orally 0.5mg-1mg im

2mg orally 2mg im

Caution in renal impairment Not licensed in delirium

*unless on the specific advice of a specialist eg mental health liaison Lorazepam is no longer recommended first line as there is a single trial of the use of lorazepam in delirium in the hospital setting which found no benefit and treatment was stopped early due to intolerable side effects. As per the SIGN guidelines recommendations within this guideline are based on the best clinical evidence. Some recommendations may be for medicines prescribed out with the marketing authorisation (MA) also known as product licence. This is known as ‘off-label’ use.’ Haloperidol




is only licensed when used without other drugs that prolong the QT interval (SIGN guidelines, NICE 2018 surveillance of delirium guideline). If in doubt about pharmacological management of agitation seek advice from the on-call Mental Health Liaison Team, a Geriatrician or the on-call psychiatrist via switchboard. 5.3.3.3 Management of persistent distressing symptoms in delirium • Ensure that non-pharmacological management measures are being maintained. • If further pharmacological management is necessary, the patient should be referred to

the Mental Health Liaison Team unless the parent team has specialist expertise in this area (e.g. Ageing and Complex Medicine).

5.5.4 Management of insomnia • Sleep may be impaired when a person has a delirium. Non-pharmacological measures

should be implemented first-line. These should include good sleep hygiene measures such as avoidance of caffeinated drinks in the evening, keeping environmental noise to a minimum, adherence to usual sleep routines, and avoidance of stimulation such as watching television late into the evening.

• Other associated contributory factors should be identified, for example the presence of any hallucinations or pain. If sleep deprivation is felt to be contributing to delirium, and sleep hygiene measures have been attempted, pharmacological measures should be a last resort. There is no evidence for the use of night sedation to treat insomnia in delirium. There are no licensed hypnotics, anxiolytics or antidepressants to treat insomnia in the context of delirium. Where medication is being considered, specialist advice should be sought.

5.6 Recovery from delirium

Following recovery from an episode of delirium, the following issues should be considered:

Add the diagnosis of delirium to the Health Issues section of the Electronic Patient Record.

Highlight the presence of delirium in the related section of the discharge summary.

During the period of recovery, steps should be taken to avoid a relapse of the delirium (see section 5.2 Delirium prevention).

Part of preventing delirium includes minimising ward moves. Moving patients who have a delirium from one bed area to another will exacerbate the delirium, increasing complications, morbidity, mortality and length of stay.

Similarly, even when a patient has recovered from delirium, unnecessary ward moves may result in a delirium relapse with the associated consequences and risks of patient harm (Goldberg et al 2015).

Patient who either have delirium or have had delirium during their in-patient stay should not be moved unnecessarily between wards.




At the time of discharge review all medications. If the patient remains on antipsychotic or sedative medication consider whether this is necessary to continue. If the patient is discharged on an antipsychotic medication ask their GP to review this within 28 days.

Consider whether the patient requires further cognitive testing in the community. This is particularly important if there are any concerns about pre-morbid chronic cognitive decline (i.e. dementia). Any underlying medical causative factors may also require follow-up. Further cognitive assessments could be considered by referral to the Memory Service in the community by those with referral access (eg Mental Health Liaison Team, Ageing and Complex Medicine, Neurology). If direct referral access is not available, please refer to the MHLT during the admission. Alternatively ask the GP to reassess post-discharge.

6. Roles & responsibilities

This policy will be held on the Trust Intranet

The policy will be promoted by the matrons, lead nurses, department managers, clinicians, the Lead Nurse for Dementia and the Mental Health Liaison team

Managers and clinicians will ensure that all staff will have had appropriate training to comply with the protocol and will monitor practise

The Lead Nurse for Dementia will be responsible for the dissemination of the policy. It will be circulated via email to all clinical leads, lead nurses and ward managers/ward matrons

It will be discussed at the Dementia/Delirium Link Nurse Meetings which will be held monthly

Ward Managers will be responsible for ensuring the 4AT document is completed in the Nursing Admission Assessment Document

Ward Managers/Lead Nurses to ensure staff have attended the Dementia Care Training to ensure staff are up to date

7. Monitoring document effectiveness

The policy will be monitored by the Dementia Steering Group and any complaints, AIRS/SIARCS reviewed along with feedback from staff and patients. The dementia steering group will provide updates to the Clinical effectiveness Committee for approval

8. Abbreviations and definitions

Terms explained in document




9. References

American Psychiatric Association, Diagnostic and Statistical Manual, 5th ed, APA Press, Washington, DC 2013. Bellelli G, Morandi A, Davis DH, et al. Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age & Ageing. 2014;43:496-502 Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR Goldberg A, Straus SE, Hamid JS, et al. Room transfers and the risk of delirium incidence amongst hospitalized elderly medical patients: a case–control study. BMC Geriatrics 2015 15:69 Gusmao-Flores D, Salluh JIF, Chalhub RA, and Quarantini LC. The confusion assessment method for the intensive care unit (CAM-ICU) and intensive care delirium screening checklist (ICDSC) for the diagnosis of delirium: a systematic review and meta-analysis of clinical studies. Critical Care. 2012; 16(4): R115. Inouye SK, van Dyck CH, Alessi CA et al. Clarifying confusion: The confusion assessment method. A new method for detection of delirium. Annals of Internal Medicine. 1990; 113(12):941-8 NICE Guideline 103. July 2010. Delirium diagnosis, prevention and management. NICE 2018 surveillance of delirium:prevention, diagnosis and management (NICE guideline CG103)https://www.nice.org.uk/guidance/cg103/resources/2018-surveillance-of-delirium-prevention-diagnosis-and-management-nice-guideline-cg103-pdf-8546233843141 O'Keeffe ST, Lavan JN. Clinical significance of delirium subtypes in older people. Age Ageing. 1999 Mar;28(2):115-9. RCP & BGS joint publication. June 2006. The prevention, diagnosis and management of delirium in older people.

Sands MB, Dantoc BP, Hartshorn A, Ryan CJ, Lujic S. Single Question in Delirium (SQiD):

testing its efficacy against psychiatrist interview, the Confusion Assessment Method and the

Memorial Delirium Assessment Scale. Palliative Medicine. 2010. 24(6):561-5

Siddiqi N House A, Holmes J. Occurrence and outcome of delirium in medical in-patients: a systemic literature review. Age & Ageing 2006.;35:350-364 SIGN157 Risk reduction and management of delirium. A national clinical guideline. March 2019. NHS Scotland (NICE has accredited the process used by the Scottish Intercollegiate Guidelines Network) Thomas N Robinson and Ben Eiseman. Postoperative delirium in the elderly: diagnosis and management. Clin Interv Aging. 2008 Jun; 3(2): 351–355. Witlox J, Eurelings LSM, et al. JAMA.. 2010;304(4):443–51

https://www.nice.org.uk/guidance/cg103/resources/2018-surveillance-of-delirium-prevention-diagnosis-and-management-nice-guideline-cg103-pdf-8546233843141

https://www.nice.org.uk/guidance/cg103/resources/2018-surveillance-of-delirium-prevention-diagnosis-and-management-nice-guideline-cg103-pdf-8546233843141

https://www.ncbi.nlm.nih.gov/pubmed/?term=Dantoc%20BP%5BAuthor%5D&cauthor=true&cauthor_uid=20837733

https://www.ncbi.nlm.nih.gov/pubmed/?term=Hartshorn%20A%5BAuthor%5D&cauthor=true&cauthor_uid=20837733

https://www.ncbi.nlm.nih.gov/pubmed/?term=Ryan%20CJ%5BAuthor%5D&cauthor=true&cauthor_uid=20837733

https://www.ncbi.nlm.nih.gov/pubmed/?term=Lujic%20S%5BAuthor%5D&cauthor=true&cauthor_uid=20837733




10. Appendices

Appendix 1

Delirium Pathway 4AT on admission or completed after new confusion identified on NEWS2

Delirium suspected or identified

by screening tool e.g. 4AT/CAM

History History of dementia or previous delirium

Onset and progression of confusion Alcohol and other drug use

Medications – any recent changes, withdrawal, alcohol Social and functional history

Examination

Full physical examination, including detailed neurological examination

Consider rectal examination for faecal impaction Check bedside plasma glucose

Management 1. Treat underlying cause/s 2. Medication review 3. Map trajectory of delirium/recovery 4. Communicate with relatives 5. Takes steps to promote recovery/avoid relapse e.g. pain, nutrition, hydration, bladder, bowels, environment, sensory 6. Monitor for complications e.g. pressure sores, secondary infection 7. Manage agitation 8. Robust documentation

Investigations Essential: FBC, U&E, LFTs, Ca, CRP, ECG, CXR

Consider: neuroimaging, blood & urine cultures, LP, EEG, ABG

Recovery Consider cognitive follow-up e.g. dementia assessment Explanation to patient Update health issues and note on discharge summary

Consider indication for Deprivation of Liberty Safeguarding assessment

For help and advice contact Mental Health Liaison on-call staff 24/7




Appendix 2

Medications commonly implicated in delirium

Consider agents with high anticholinergic burden. Eg amitriptyline, oxybutynin,

chlorpheniramine, fesoterodine, paroxetine, solifenacin, tolterodine, trospium

Refer to the ACB score system http://www.agingbraincare.org/uploads/products/ACB_scale_-_legal_size.pdf

Consider opiates including codeine, tramadol, morphine and oxycodone

Consider withdrawal of medications including opiates, benzodiazepines and alcohol.

http://www.agingbraincare.org/uploads/products/ACB_scale_-_legal_size.pdf




11. Document Control Information

All sections must be completed by the author prior to submission for approval

Lead Author: Alexander Thomson Consultant Physician Elderly Care Directorate Emma Vardy, Clinical dementia lead led update

Lead author contact details:

0161 206 2110 [email protected]

Consultation List the persons or groups who have contributed to this guideline. (please state which Care Organisation)

Name of person or group Role / Department / Committee (Care Org) Date

Dementia steering group Salford Care Organisation 12/3/19

MCA/DOLS team Salford City Council 26/6/19

Liz Lamerton Principal Clinical Pharmacist, Salford

Care Organisation 3/5/19

Endorsement List the persons or groups who have seen given their support to this guideline. (please state which Care Organisation)

Name of person or group

Role / Department / Committee (Care Org)

Date

Dementia steering group Salford Care Organisation 25/6/19 and 10/7/19

Sara Barton, Clinical Director for Clinical

Effectiveness Salford Care Organisation 4/7/19

Keywords / phrases: Delirium, Sedation, Confusion, Agitation

Communication plan:

This policy will be held on the Trust Intranet

The policy will be promoted by the matrons, lead nurses, department managers, clinicians, the Lead Nurse for Dementia and the Mental Health Liaison team

Managers and clinicians will ensure that all staff will have had appropriate training to comply with the protocol and will monitor practise

The Lead Nurse for Dementia will be responsible for the dissemination of the policy. It will be circulated via email to all clinical leads, lead nurses and ward managers/ward matrons

It will be discussed at the Dementia/Delirium Link Nurse Meetings which will be held monthly

Ward Managers will be responsible for ensuring the 4AT document is completed in the Nursing Admission Assessment Document

Ward Managers/Lead Nurses to ensure staff have attended the Dementia Care Training to ensure staff are up to date




Document review arrangements:

This document will be reviewed by the author, or a nominated person, at least once every three years or earlier should a change in legislation, best practice or other change in circumstance dictate.

This section will be completed following committee approval

Guideline Approval: Name of Approving Committee: Clinical Effectiveness Committee, Document Approval Meeting

Chairperson: Dr Sara Barton

Approval date: 11/07/2019

Formal Committee decision (tick) Chairperson’s approval X




12. Equality Impact Assessment (EqIA) screening tool Legislation requires that our documents consider the potential to affect groups differently, and eliminate or minimise this where possible. This process helps to reduce health inequalities by identifying where steps can be taken to ensure the same access, experience and outcomes are achieved across all groups of people. This may require you to do things differently for some groups to reduce any potential differences.

1a) Have you undertaken any consultation/

involvement with service users, staff or other

groups in relation to this document?

No

Please state:

1b) Have any amendments been made as a

result?

No

Please Comment:

2) Does this guideline have the potential to affect any of the groups below differently or

negatively? This may be linked to access, how the process/procedure is experienced, and/or

intended outcomes. Prompts for consideration are provided, but are not an exhaustive list.

Protected Group Yes No Unsure Reasons for decision

Age (e.g. are specific age groups excluded? Would the same

process affect age groups in different ways?) N

Sex (e.g. is gender neutral language used in the way the

guideline or information leaflet is written?) N

Race (e.g. any specific needs identified for certain groups such

as dress, diet, individual care needs? Are interpretation and translation services required and do staff know how to book these?)

N

Religion & Belief (e.g. Jehovah Witness stance on blood

transfusions; dietary needs that may conflict with medication offered.)

N

Sexual orientation (e.g. is inclusive language used? Are

there different access/prevalence rates?) N

Pregnancy & Maternity (e.g. are procedures suitable for

pregnant and/or breastfeeding women?) N

Marital status/civil partnership (e.g. would there be any

difference because the individual is/is not married/in a civil partnership?)

N

Gender Reassignment (e.g. are there particular tests related

to gender? Is confidentiality of the patient or staff member maintained?)

N

Human Rights (e.g. does it uphold the principles of Fairness,

Respect, Equality, Dignity and Autonomy?) N

Carers (e.g. is sufficient notice built in so can take time off work

to attend appointment?) N

Socio/economic (e.g. would there be any requirement or

expectation that may not be able to be met by those on low or limited income, such as costs incurred?)

N

Disability (e.g. are information/questionnaires/consent forms

available in different formats upon request? Are waiting areas suitable?) Includes hearing and/or visual impairments, physical disability, neurodevelopmental impairments e.g. autism, mental

N




health conditions, and long term conditions e.g. cancer.

Are there any adjustments that need to be made to ensure that people with disabilities have the same access to and outcomes from the service or employment activities as those without disabilities? (e.g. allow extra time for appointments, allow advocates to be

present in the room, having access to visual aids, removing requirement to wait in unsuitable environments, etc.)

N

3) Where you have identified that there are potential differences, what steps have you taken to mitigate these? N/A

4) Where you have identified adjustments would need to be made for those with disabilities, what action has been taken?N/A

5) Where the policy, procedure, guidelines, patient information leaflet or project impacts on patients how have you ensured that you have met the Accessible Information Standard – please state below: ……………………………………………………………………………………………………………… EDI Team/Champion only: does the above ensure compliance with Accessible Information Standard

o Yes

o No

If no what additional mitigation is required:

Will this guideline require a full impact assessment? No Please state your rationale for the decision: (a full impact assessment will be required if you are unsure of the potential to affect a group differently, or

if you believe there is a potential for it to affect a group differently and do not know how to mitigate

against this - Please contact the Inclusion and Equality team for advice on [email protected]) Author: Type/sign: Emma Vardy Date: 10/7/19 Sign off from Equality Champion: Date:

mailto:[email protected]

Diagnosis and Management of Delirium Guideline

Documents

Transcript of Diagnosis and Management of Delirium Guideline