Delirium Care Pathways
Identify and address the causes of Delirium
In order to identify and address the causes of delirium, a comprehensive initial evaluation should be performed that includes the following components:
(i) Obtain history
- Medication
- recent changes
- include prescription and over-the-counter medications
- Dehydration – diuretics use, hot weather
- Falls
- Infection
- Bladder and bowel function
- Premorbid cognitive and functional status
- Alcohol history
- Past medical history and comorbidities
- Social history
- History of dietary and fluid intake
- Sensory impairments
This information can be obtained from a number of sources such as documented in medical record from previous admissions and consultation with the person with delirium, their general practitioner and/or carer/family members. People with delirium may provide unreliable histories and information should be sought from family members, GP, residential care staff, etc.
(ii) Examination
- Obtain vital signs – temperature, pulse, respirations, blood pressure (lying and standing), and oxygen saturation
- Mental state examination
- Decreased arousal
- Decreased attention
- Disorientation
- Neurological examination
- New signs
- Chest
- Auscultation
- Cough
- Abdomen
- Palpable faeces/faecal impaction
- Palpable bladder/urinary retention
- Skin
- Lesions
- Signs of dehydration
(iii) Investigations
The following investigations are used to screen for common causes of delirium:- Urinalysis and MSU (if urinalysis abnormal)
- Full blood examination
- Urea and electrolytes
- Glucose
- Calcium
- Liver function tests
- Chest x-ray
- Cardiac enzymes
- ECG
- Specific cultures eg blood and sputum (if fever present, cough and/or abnormal chest radiograph)
- Arterial blood gases (if short of breath, cough and/or abnormal chest radiograph)
- CT brain (if history of falls, patient/client on anticoagulant therapy or focal neurological signs present)
- Lumbar puncture (if headache and fever and meningism present)
- EEG (may assist in determining aetiology eg non-convulsive status epilepticus)
- Thyroid function tests
- B12 and folate
Adapted from: Clinical Epidemiology and Health Services Evaluation Unit 2006, Clinical Practice Guidelines for the Management of Delirium in Older People, Victorian Government Department of Human Services, Melbourne, Victoria