Can You Recognise Delirium?

Delirium

Can you recognise delirium?

Delirium is a change in a person's mental state or consciousness, which is often shown as confusion, difficulties with understanding and memory, or personality changes. There are different kinds of delirium – some people may be agitated and restless or have delusions and hallucinations, others may just become unusually sleepy.

Delirium is a common and serious illness in people in hospital or long-term care (nursing or residential care). However, it can be prevented and treated if dealt with urgently.

It usually develops over 1 or 2 days and is usually temporary. Some people may have delirium when they first come to hospital or long-term care, or it may develop during a hospital stay or long-term care.

People who develop delirium can be at risk of other problems such as falls and pressure sores. People who are already in hospital may need to stay for longer and are more likely to go into long-term care. (NICE guidelines 2010)

Types of delirium

Hyper delirium – Increased confusion, agitated, restless, possible hallucinations, unable to concentrate

Hypo delirium- withdrawn, quiet, sleepy,

Mixed delirium- fluctuate between both

Hypo delirium is more common, frequently missed and undiagnosed.

Anyone any age can get a delirium

Prevention and Monitoring Delirium

For identification of those more at risk and the screening tool, see the risk assessment document. This must be filled in.

Common causes of delirium

Pain- is your patient in pain? What have you done about it? Have you reviewed the pain? How do they take their pain relief? How do they communicate pain? Give the pain relief when it’s prescribed. Are they in a comfortable position?

Infection- has the source of been found? Any other associated symptoms? Symptom management, Pain relief? Give prescribed medication ASAP? Have you thought about the route of meds? Do they have a cannula? Have you sent appropriate samples off for MC&S/Cultures?

Nutrition- Is your patient eating? Are they eating enough? If they are not eating, why? Do they have a choice of food they like? Can they see their food, is it accessible, and are their dentures in? Do they need assistance? Are you monitoring their food intake?

Constipation/Cognition- Have they opened their bowels? What type? Are they eating and drinking properly? Are they taking medications which cause constipation? If laxatives are prescribed, give ASAP and monitor. Monitor bowel function.

Have they got a dementia or other known cognitive impairment putting them at risk of delirium?

Hydration/Hypoxia- Are your patients drinking regularly? How much are they drinking? Have they got what they like to drink? How do you know what they like? Can they see their drink? Do they need assistance? Monitor fluid intake and output. Remember some patients have a fluid allowance, is your patient fluid overloaded? Monitor U&E’s.

Sleep- Is your patient sleeping at night? If they are not, why? What can you do to help someone sleep? Are they comfortable, symptom/pain free? Look at the environment; is there anything you can do to help? Are your wearing soft soled shoes? Are alarms turned onto quiet at night? Are the lights on the ward dimmed or off? Remind colleagues of the same principles. Are we making sure our patients know the difference between day and night? Are patients getting dressed in the day and changed into bed clothes at night? Are patients sleeping during the day? Why?

Medication- Is your patient getting the correct medication and at the correct time? Check contraindications/side effects? Have they had a medication review? Have they had any antipsychotic medications? You must inform the GP to any changes in medication and that they have had antipsychotics in hospital. Has your patient had their medications? Have they taken too much? Polypharmacy? On discharge, are you confident your patient will be able to continue to self-medicate, do they need assistance?

Environment- Are they orientated to their surroundings? Do they have everything at hand? Do they wear glasses, hearing aids, are they in and working? Encourage people to bring things in that are familiar like photos , blankets etc. Do they need assistance within their environment? Have they got their nurse call bell? Do they know how to use it? Be aware of excessive noise, this can be overwhelming for some people? Can they hear you when giving information? What is their mood, how can you help alleviate anxiousness and distress, how can you enhance your environment into a more comfortable space? Have you considered using the ‘My Life’ machine?

By monitoring the above we can PREVENT delirium and monitor those who have delirium using;

NEWS charts for any warning and abnormal scores symptomatic of pain/infection

Intentional rounding/care comfort record, is there a pattern of behaviour/symptoms relating to eating/drinking, bowels, sleep and pain? Do they wear glasses or hearing aids?

DOS, this is a screening tool to help with early diagnosis and monitoring of delirium.

Family- They can help and give you the all-important information about the person you are looking after.

Remember for those patients who have a known diagnosis of a dementia, do not confuse increased confusion with being symptoms of their dementia. You must rule out delirium.

Just because they are deemed medically fit, does not mean they don’t have a delirium, this may be due to the other causes as noted, the environment and ward moves are common causes of delirium, sometimes its multifactorial.

Help and advice

Monday-Friday

Danielle Woods
Lead Nurse for Dementia | Ward 30
Bradford Teaching Hospitals NHS Foundation Trust
T: 01274 38 3562
M: 07947566967

Andrew Clegg
Clinical Senior Lecturer & Honorary Consultant Geriatrician
Deputy Lead, NIHR CLAHRC Older People's Theme
Academic Unit of Elderly Care and Rehabilitation | Bradford Institute for Health Research
Bradford Teaching Hospitals NHS Foundation Trust
T: 01274 38 2096
M: #6650
F: 01274 365252

Older peoples Liaison team – 65 years and over, will see patients younger who have a known diagnosis of a dementia fax referral

( also available alternate weekend days)

Out of Hours

Dementia/Delirium web page on the trusts intranet – look under departments, then under clinical.

First response team for adults up to 65 years of age

You can call the on call Reg for elderly for any advice on Delirium and management/care for people with a dementia.