Delirium Management (Secondary Care) (Guidelines)

• 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.
• Is the person at risk of developing delirium, and how will I reduce that risk?
• 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.

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 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.

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

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
• Is this person at risk of developing delirium, and how will I reduce that risk?

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:

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.

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

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

• AWI: See Scottish Government Section 47 certificate of incapacity
• EDC: See the Mental Welfare Commission for Scotland Good Practice Guide: The Mental Health Act in general hospitals

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.

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 and "consider specialist referral".  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.

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 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.

• Local Rapid tranquilisation (Guidelines), available on TAM
• See the HIS ‘Think Delirium’ page for delirium documentation and advice.
• See the SDA comprehensive management pathway for further detailed management.
• See the SIGN 157 guide for evidence and further information on delirium.
• Further resource regarding Stress and distress in dementia, on TAM
• See NICE https://cks.nice.org.uk/topics/delirium/prescribing-information/haloperidol/ -lower dose haloperidol
• Haloperidol Monitor for adverse effects - see MHRA
• SQID - Single Question in Delirium: “Is this patient more confused than before?"
• TIME bundle: part of NHS Highland nursing documentation