3.2 Delirium assessment

Assessment and diagnosis

Delirium assessment

Introduction

Delirium is an acute confusional state or episode characterised by a sudden onset of impaired cognition that results in a reduced ability to focus, sustain or shift attention. It is a serious medical problem that is often not recognised by health professionals. Delirium is associated with high levels of mortality and gradual deterioration of physical and cognitive function.

Delirium can be difficult to recognise as the symptoms vary. Symptoms include decreased attention span, disorganised thought, rambling speech, and hallucinations and delusions may also develop. Confusion may fluctuate throughout the day, often with a disturbed sleep wake cycle. It has a rapid onset and family and carers may notice a sudden change in level of confusion and general wellbeing. Level of consciousness may also vary, and the person may be hyperalert, with agitation and high levels of arousal, or conversely hypoalert, lethargic and non-responsive. Delirium may often be missed in older people who remain quiet and unobtrusive while their functional decline continues.

Delirium is different to dementia, although people with dementia are prone to episodes of delirium and both conditions may co-exist. Dementia is a progressive condition that has an onset of months to years. The person with dementia is generally alert and their confusion does not appear to change throughout the day. It is important for families and carers to note a sudden change in cognition and function as this may be due to delirium.

Certain older people appear to be at greater risk of developing delirium:

• Those with dementia
• Aged over 70 years
• With depression
• With visual impairment
• Taking three or more medications
• Who use an indwelling catheter
• Who are restrained
• Who live in residential care.

Delirium can be caused by acute illness or infection, surgery, medications, metabolic abnormalities, cardiopulmonary disorders, a change in environment, constipation, or pain. If symptoms of delirium develop it is important to identify and treat possible contributing factors as soon as possible. This may involve blood and urine tests, x-rays, electrocardiograms and blood gases if required. Pain, hydration level, and presence of constipation should be assessed and monitored. Glasses, if worn, should be available and earwax should be attended to. A significant contribution to the management of delirium involves attending to the person’s environment. Use orientation strategies (for example, clock and calendar in room), discourage daytime sleeping, try to diminish surrounding noise and avoid the use of restraints. Good communication strategies are required, including the use of interpreters if necessary. If these measures fail and the person with delirium is severely distressed, or experiencing significant psychotic features, and putting him or herself at risk, medication may be required. Low dose antipsychotics such as Haloperidol or Risperidone may be administered. Escalating doses should be avoided and medications should be frequently reviewed. If there are parkinsonian features, atypical antipsychotics such as Oanzepine or Qietapine may be required.

The experience of delirium may be frightening for all concerned. It is important for families and carers to be educated about delirium. Families and carers can provide invaluable assistance consoling the person experiencing delirium by providing orientating cues or supplying personal items that may calm or soothe the person. The person experiencing delirium may require counselling following the event, as the symptoms of delirium may be recalled and cause distress.

Evidence indicates that delirium can be prevented in acute hospitals. Approximately 10-15% of people admitted to hospital have delirium, and a further 5-40% are thought to develop delirium once in hospital. Preventative strategies may lower the likelihood of delirium developing. Such strategies include limited use of indwelling catheters and restraints, attention to hydration, strategies to assist sleep, visual and hearing aids, and early mobilisation and exercise.
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Recommendations

• People with dementia are prone to experience episodes of delirium
• Delirium is a common and serious medical condition that is often unrecognised and has high morbidity and mortality
• Delirium is usually caused by an underlying acute health condition that needs to be identified and treated
• Certain medications may cause confusion, particularly if many are taken. It is important to discuss concerns with your doctor or a health professional as soon as possible
• Prevention of delirium is possible in those at risk by attending to non-medication strategies such as orientation, mobility, visual and hearing impairment, hydration, sleep, and avoidance of restraints
• Non-medication strategies should be the first line of management once an underlying cause has been adequately treated
• Only if the person with delirium is at risk of harm or develops distressing psychotic features, should medication be trialled
• People who have experienced delirium may recall some of the unpleasant features. Education and psychological support are important
• People who have experienced one episode of delirium are more likely to experience another and families and carers should utilise preventative strategies
• Symptoms of dementia, delirium and depression may be similar so an accurate diagnosis is important. (Refer to Depression assessment).

Summary

Depression and delirium may have symptoms similar to those of dementia and accurate diagnosis is important. Delirium is an acute medical condition that should be treated immediately. It is important for families, carers and health professionals to be educated and know how to respond when the condition occurs.
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Assessment and diagnosis

Delirium assessment

Recommended resources

Name of resource and where it is available	Brief description and type of resource	Target setting
Clinical Epidemiology and Health Service Unit, Melbourne Health. (2006). Clinical practice guidelines for the management of delirium in older people. www.health.vic.gov.au [ > Aged care > Acute aged care interface]	Guidelines. A comprehensive outline of delirium, including detection and diagnosis, risk factors, prevention and management. Includes a quick guide summary of the guidelines for easy reference.
Harding, S. (2006). For Australian Government Department of Health and Ageing. Delirium in older people. www.health.gov.au	Booklet. Designed for health professionals who work with older people. Includes an overview of delirium, issues involved in assessment and management and tools that may be useful in identifying delirium.
Registered Nurses Association of Ontario. (2004). Caregiving strategies for older adults with delirium, dementia and depression. Toronto: Registered Nurses Association of Ontario. www.rnao.org [ > Nursing best practice guidelines > Clinical practice guidelines program > Guidelines & factsheets > Cognitive impairment]	Guidelines. A comprehensive document providing resources necessary for the support of evidence-based nursing practice. Nurses, healthcare professionals and administrators may find the document useful for the development of policies, procedures, protocols, education programs, assessment, and documentation tools. Includes a summary of the recommendations for easy reference.
Registered Nurses Association of Ontario. (2003). Screening for delirium, dementia and depression in older adults. Toronto: Registered Nurses Association of Ontario. www.rnao.org [ > Nursing best practice guidelines > Clinical practice guidelines program > Guidelines & factsheets > Cognitive impairment]	Guidelines. Designed for nurses and health professionals to guide practice regarding assessment and screening for delirium, dementia, and depression in older adults. Also includes recommendations for education of nurses and organisational policies and procedures to support best practice.

Symbol	Explanation
	Hospital Setting
	Residential Care Setting
	Light reading
	Medium level resource
	In depth, detailed resource
Underlined text	Refer to glossary for definition

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