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Overview

This guideline summary provides recommendations based on current evidence for best practice in the detection, assessment, treatment, and follow up of adults with delirium, as well as reducing the risk of delirium. The guideline excludes delirium secondary solely to alcohol and illicit substance use. It also excludes delirium in children.

Recommendations are marked up with an [R] and good-practice points are marked up with a [✓].

Detecting delirium

Tools for detection and assessment

  • Use of the 4AT tool (The 4 As Test [Arousal, Attention, Abbreviated Mental Test 4, Acute change]) could be considered for use in community or other settings for identifying patients with probable delirium. It does not require specific training, is brief and easy to use and has wide applicability in various clinical settings [R]
  • A formal assessment and diagnosis must be made by a suitably trained clinician whenever patients with probable delirium are identified [✓]
  • Where delirium is detected, patients and their family/carers should be informed of the diagnosis (see Provision of information[✓]
  • Where delirium is detected, the diagnosis of delirium should be clearly documented to aid transfers of care (e.g. handover notes, referral and discharge letters) [✓]

Tools for measuring severity of delirium

  • Monitoring patients diagnosed with delirium for changes in severity or response to treatment may help predict the full clinical impact
  • Table 1 lists tools that assess severity. Selection of a tool should take into consideration time required and ease of use. The 13-item DOS, mRASS, MMSE, DRS-R-98 and ICDSC can be considered as tools for the purpose of monitoring severity of delirium in suitable clinical areas (see Table 1)
Table 1: Overview of delirium assessment tools
ToolTime taken (min)Training requiredStaffSettingsReported sensitivity %Reported specificity %Delirium severity ratingSuitable for monitoringSuitable for detecting DSD

4AT

<2

No

Any

Multiple

86–100

65–82

No

No

Yes

AMT

2

No

Any

Medical

75–87

61–64

No

No

No

CAM and variants

3–10

Yes

Any

Multiple

46–94

63–100

No[B]

No

Yes

CAM-ICU

<5

Yes

Any

ICU

28–100

53–99

No

Yes

No

DOS (13-item)[A]

5

Minimal

Any

Multiple

89–100

87–97

Yes

Yes

No

DRS- R-98

20

Yes

Psychiatry

Multiple

57–93

82–98

Yes

No

Yes

ICDSC

7–10

Minimal

Any

ICU

73–97

69–97

Yes

Yes

No

MMSE

5

Minimal

Any

Multiple

76–91

51–84

Yes

No

No

Nu-DESC

<5

No

Any

Multiple

32–96

69–92

No

No

No

RADAR

<1

No

Any

Multiple

43–84

64–78

No

Yes

No

mRASS

1

No

Any

Multiple

65–75

82–90

Yes

Yes

Yes

SQiD

<1

No

Any

Medical

77–91

56–71

No

Yes

No

Suitability for monitoring refers to the use of a tool daily or more for screening for incident delirium.

[A] DOS requires assessment over three shifts so time to detection is three days. It is geared towards assessment of hyperactive delirium

[B] with the exception of CAM-S

AMT=Abbreviated Mental Test; CAM=Confusion Assessment Method; DSD=delirium superimposed on dementia; DRS-98-R=Delirium Rating Scale; DOS=Delirium Observation Screening Scale; ICDSC=Intensive Care Delirium Screening Checklist; ICU=Intensive Care Unit; Nu-DESC=Nursing Delirium Screening Scale; MMSE=Mini Mental State Examination; RADAR=Recognising Acute Delirium As part of your Routine; mRASS=Modified Richmond Agitation-Sedation Scale; SQiD=Single Question to Identify Delirium

Non-pharmacological risk reduction

  • The following components should be considered as part of a package of care for patients at risk of developing delirium: [R]
    • 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
  • Where possible, assistance should be sought from a patient’s relatives and carers to deliver care to reduce the risk of delirium developing [✓]

Pharmacological risk reduction

  • All patients at risk of delirium should have a medication review conducted by an experienced healthcare professional. For more information on pharmacological risk reduction, see the full guideline [R]

Non-pharmacological treatment

  • Healthcare professionals should follow established pathways of good care to manage patients with delirium [R]
    • first consider acute, life-threatening causes of delirium, including low oxygen level, low blood pressure, low glucose level, and drug intoxication or withdrawal
    • systematically identify and treat potential causes (medications, acute illness, etc), noting that multiple causes are common
    • optimise physiology, management of concurrent conditions, environment (reduce noise), medications, and natural sleep, to promote brain recovery
    • specifically detect, assess causes of, and treat agitation and/or distress, using non-pharmacological means only if possible
    • communicate the diagnosis to patients and carers, encourage involvement of carers, and provide ongoing engagement and support
    • aim to prevent complications of delirium such as immobility, falls, pressure sores, dehydration, malnourishment, isolation
    • monitor for recovery and consider specialist referral if not recovering
    • consider follow up
  • Promote cognitive engagement, mobilisation, and other rehabilitation strategies [✓]

Pharmacological treatment

  • There is insufficient evidence on the efficacy and safety of pharmacological treatments to support a recommendation for their use. Expert opinion supports a role for medication only in specific situations, such as in patients in intractable distress, and where the safety of the patient and others is compromised. For more information on pharmacological treatment, see the full guideline

Follow up

  • Healthcare professionals should be aware that older people may have pre-existing cognitive impairment which may have been undetected, or exacerbated in the context of delirium. Appropriate cognitive and functional assessment should be considered. Timing of this assessment must take into account persistent delirium [R]
  • In patients who have experienced delirium in intensive care, consideration should be given to follow up for psychological sequelae, including cognitive impairment [R]
  • Patient records should be coded to highlight a previous episode of delirium so that hospital staff are aware of the increased risk on readmission [✓]
  • All patients who have had delirium should be reviewed by the primary care team [✓]

Provision of information

If a patient is at risk of delirium

  • Identify the family and/or main carer of the patient
    • ensure that the patient’s contact details are on file. If the patient lacks capacity, ascertain whether a family member or carer has Power of Attorney/Guardianship over welfare
  • Explain to the patient and the family/carer about delirium:
    • delirium is common amongst hospitalised patients especially following an operation
    • acute triggers of delirium include:
      • infection, dehydration, severe constipation, urinary retention, and pain
      • critical illness
      • surgery especially heart and hip operations
      • side effects of new medicines or medicines withdrawal
    • those most at risk are:
      • older people
      • older people on multiple medicines
      • people with dementia, Parkinson’s disease, stroke or pre-existing cognitive impairment
      • people who are hearing or visually impaired
  • Ask family/carers to alert medical staff if they notice any change to their relative’s normal behaviour
  • Ask the patient and family/carers to complete a ‘Getting to know me’ form, or similar, to help healthcare staff to take care of the person’s specific needs
  • Ask family/carers to help, if they feel able to do so, to reduce the risk of delirium developing by doing the following:
    • ensure hearing aids, glasses and dentures are available at all times
    • talk to and keep the patient informed in short, simple sentences
    • check that the patient has understood you and be prepared to repeat if necessary
    • keep a calendar and/or clock within view
    • bring in some familiar objects from home to the hospital to keep next to the bed side
    • if required, encourage the patient to eat and drink

If a patient develops delirium

  • Explain to the patient and family/carers that delirium is a change in mental state that often starts suddenly but usually improves when the physical condition improves and the underlying cause gets better
  • Discuss treatment options and possible side effects with the patient and/or carer
  • Provide the family/carer with appropriate information leaflets
  • It is important for carers and relatives to participate and work together with the clinical team in hospital or home to clear delirium and give the affected person the best chance of getting back to good health
  • Explain that the person affected with delirium may show many different types of change. The patient may:
    • be less aware of their surroundings
    • be unable to speak clearly or follow conversations
    • have dreams which can sometimes be frightening and can carry on when they wake up
    • hear voices or noises which may not be present (auditory hallucinations)
    • see objects or people that are not present or in different context (visual hallucinations)
    • get upset that other people are trying to harm them
    • be agitated or restless, unable to sit still, and have an increased risk of having a fall
    • be sleepy and slow to move and respond
    • be reluctant to eat or drink
    • have a temporary change in personality
    • have all or some of the above and that could quickly change
    • have worse symptoms in the evenings or overnight
  • Suggest completing a diary so that if the person with delirium cannot remember what has happened the carer can fill in the blanks and help make sense of the experience once the person is starting to feel better

Let the family/carer know how to help someone with delirium

  • They can help by reassuring and reorienting the patient, e.g.:
    • ensure hearing aids, glasses and dentures are available at all times
    • have a gentle and friendly approach, smiling and providing reassurance
    • talk and keep the patient informed in short, simple sentences
    • check that the patient has understood you and be prepared to repeat if necessary
    • familiarity helps, so try to make sure that someone the patient knows well is with them
    • try not to agree with any incorrect ideas but disagree with tact and change the subject
    • keep a calendar and/or clock within view and give reminders of the surroundings
    • bring in some familiar objects from home to the hospital to keep next to the bed side
    • remind the patient to eat and drink and assist if required
  • The key is to remain calm and help the affected person feel calm and in control
  • For information on investigations for underlying causes of delirium, and to view the Scottish Delirium Association delirium management pathway, see the full guideline

Scottish Intercollegiate Guidelines Network (SIGN). Risk reduction and management of delirium. Edinburgh: SIGN, 2019 (SIGN publication no. 157).

Available from: sign.ac.uk/sign-157-delirium

The copyright of Scottish Intercollegiate Guidelines Network (SIGN) guidelines is retained by SIGN. Subject to copyright statement (see www.sign.ac.uk/copyright-statement.html). All SIGN guidelines are subject to regular review and may be updated or withdrawn. SIGN accepts no responsibility for the use of its content in this product/publication.

Published date: March 2019.