Delirium Pathway

NHS Grampian

Delirium Overall Pathway

Prevention

Identification

Management

Discharge Planning

Screening

Screening

At risk for delirium

Age ≥75

Dementia

Current hip fractureSevere illness

AMT <8

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Prevention

Prevention

Screen for clinical factors

Manage clinical factors

Avoid inappropriate

transfers

Ensure familiarity

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Prevention – Clinical FactorsClinical factor Preventive intervention

Cognitive impairment/disorientation Adequate lighting, signage, clock, calendar, re-orientation, regular visits from family & friends

Dehydration or constipation Encourage fluid intake, maintain fluid balance & seek advice if necessary

Hypoxia Optimise oxygen saturation

Immobility/limited mobility Physiotherapy input, walking aids, encourage mobilisation & exercises

Infection Treat, avoid unnecessary catheterisation

Multiple medication Medication review & seek advice if necessary

Pain Screen for pain, look for non-verbal signs, treat

Poor nutrition Address, seek dietetics & other specialist help if necessary

Sensory impairment Ear wax, hearing aids, visual aids

Sleep disturbance Reduce noise & activity level in the ward during sleeping hours

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Ensuring familiarity

• Involve family member(s) or usual carer(s), if possible, in routine care; they know the person better

• Use personal items in the bed side (photos of family members, etc.)

• Same member(s) of staff caring for the person during the shift

• Any other measures as applicable individually

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IdentificationIs the person disoriented in time/place, agitated, drowsy or has AMT < 8?

Yes

Is this worse than usual?

Yes

Likely Delirium

Follow Delirium management guidelines

No

No

Does the person have capacity to consent to treatment?

Yes

Obtain informed consent

No

Use AWI Section 47 form & treatment plan

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Management

Management of delirium

General management

Identification & management of underlying causes

Management of behaviour that challenges

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General Management

• Offer opt-in for Butterfly scheme; inform the treating team of the diagnosis

• Effective communication & re-orientation– Introduce yourself clearly, repeatedly, if necessary– Explain where the person is & why they are in hospital

• Ensure familiarity• Encourage visits from friends/family• Stimulation level in the environment to be tailored to

the needs of the person• Avoid transfers

General management (Contd.)

• Correct sensory impairment – Ensure wearing spectacles/hearing aids– Look for ear wax if deaf/hard of hearing

• Day-time routine– Find out usual routine from family/carers & adhere to this as closely as possible– Encourage patient to get up & sit out of bed– Dress in their daytime clothes– Early mobilisation to toilet/dayroom– Early involvement of Physio/OT

• Night-time routine– Find out usual routine from family/carers & adhere to this as closely as possible;

Clarify what normal sleep times are for the patient– Ensure the ward area/room is quiet– Ensure appropriate level of lighting as used routinely by the person (some

persons may not like complete darkness)Back to overall pathwayBack to management pathway

Identification & management of underlying causes

• Infection• Constipation• Urinary retention• Dehydration• Medication (

polypharmacy)• Pain

• Head injury• Stroke• Endocrine disorders• Alcohol withdrawal

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Please note that delirium is often caused by many factors; the list here is not exhaustive; specific investigations including neuro-

imaging may be needed in some cases

Infection

• Pyrexial? Raised WCC/CRP?– Urine symptoms?.......... Dipstick (+/-) MSU

(+/-)– Chest symptoms?.......... CXR Sputum culture– Skin Site…………………….. Risk factors……………………– Other Specify…………………………………………………………..

• Treat according to NHSG antimicrobial guidelines

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Constipation

• PR exam? ..............(If impacted, consider enema)• Stop/reduce contributory drugs if able (opiates,

iron, calcium channel blockers, amitriptyline)• Laxatives – Initially Movicol 1 sachet twice daily + Senna 2

tablets at night– Once bowels cleared, stop movicol and consider

senna +/- other laxative

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Urinary Retention

• Check abdomen for distended bladder• Particular attention if– not passing urine; – passing frequent small amounts of urine;– renal failure on bloods

• NB: Often co-exists with constipation and/or UTI

• Management:

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Dehydration

• Clinically dehydrated?• Biochemically dehydrated? Urea>Creat;

Na ( = severe)• Push oral fluids: Maintain & monitor fluid

intake chart • Intravenous fluids if severely dehydrated

(clinically/biochemically) or if poor oral intake

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Medication

• Review drug chart & attempt to stop/reduce drugs that may precipitate or worsen delirium

• Common offenders include– Bladder stabilisers (Oxybutynin, Tolterodine, Solifenacin)– Tricyclic antidepressants (Amitriptyline, Imipramine)*– Anticholinergics (Hyoscine/Buscopan, atropine eyedrops)– Benzodiazepines (diazepam, lorazepam, Zopiclone)*– Antihistamines (particularly sedative antihistamines)– Digoxin (check blood levels)– Lithium (check blood levels)– Opiates (morphine, codeine, Tramadol)*– High dose Steroids* (*may be dangerous to withdraw abruptly)

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Alcohol withdrawal

• Usual onset within 24-72 hours of last drink• Agitation, restlessness, tremors,

visual/auditory hallucinations, autonomic dysfunction, paranoid ideation usual features

• Longer acting benzodiazepines drug of choice eg. Chlordiazepoxide; symptom triggered flexible dosing schedule to be used

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Pain

• Often patients with delirium/dementia will not be able to say that they are in pain

• Be alert to the possibility of pain• Regular analgesics would be more beneficial

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Management of behaviour that challenges

• Talk to the patient calmly, reassure and de-escalate the situation– Delirium is a scary experience for the patient: remember, they may not know

• where they are• who you are or that you’re trying to help

• Don’t be confrontational• Try to distract & change the topic rather than challenging abnormal

beliefs– Talk about something that will be of interest to the patient; you may be able to get this from

“This is me” document or by speaking to the family/carers

• Sit with the patient, they may require one-to-one nursing for a period of time (delirium fluctuates, so they will settle eventually)

• Ensure personal safety of the person with delirium and those around them including yourself

• Identify any causes of upset– e.g. pain, needing the toilet, wanting a cigarette

Management of behaviour that challenges (contd.)

• Drugs should only be used:– To relieve patient distress– To prevent patient endangering themselves or

others– To allow essential investigation/intervention

• Ensure you complete an Adults with Incapacity (Scotland) Act 2000 Section 47 form & treatment plan if appropriate

Management of behaviour that challenges (contd.)

• Antipsychotic drugs are first preference if needed– Start low, go slow; oral if possible– Haloperidol 0.5-1mg, max 2 mg/24hr initially (total, including oral & parenteral)– If consistent evening agitation, consider regular antipsychotic in early evening

(1800h)– Caution: Parkinsonian symptoms, QTc prolongation, Dementia in Lewy Body

Disease• Avoid benzodiazepines (diazepam/lorazepam), unless:

– Alcohol withdrawal (use diazepam withdrawal regime)– Parkinsonism (Parkinson’s disease or Lewy Body Dementia; even then, consider

reduction in dopaminergic agents)– If needed, use lorazepam 0.5mg (oral/parenteral), max 2 mg/24 hours– Caution: Falls, respiratory depression (Flumazenil should be available), sedation,

paradoxical agitation • Link to NHS Grampian Rapid Tranquilisation policy

Management of behaviour that challenges (contd.)

• Discuss with the Liaison Psychiatry team during in-hours or with the duty Psychiatry team out-of-hours regarding use of Mental Health (Care & Treatment) (Scotland) Act 2003– If the person needs more than one dose of

parenteral antipsychotic/benzodiazepine for their behaviour

– If the person is refusing to stay in hospital for their treatment

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Discharge Planning

• Make sure that Delirium is recorded as a diagnosis in the discharge summary

• Inform the GP of delirium• May need follow-up from GP in 3-6 months to

review cognitive function (delirium may be a marker for underlying undiagnosed dementia)

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