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Update for nurses on timely assessment of this common condition in acute settings and long-term care, and why it should be treated as a medical emergency
Delirium is a common condition experienced by people in hospitals and long-term care settings. Opportunities to prevent and treat it are often not taken, however, according to the National Institute for Health and Care Excellence (NICE). It has updated its guidance and is urging the NHS and providers of long-term care to do more to meet people’s needs.
Nursing Older People. 35, 2, 6-8. doi: 10.7748/nop.35.2.6.s2
Published: 03 April 2023
Delirium, sometimes called acute confusional state, is characterised by disturbed consciousness, cognitive function or perception – with individuals commonly experiencing hallucinations, false ideas and paranoia. It develops quickly, usually over one or two days, but sometimes it just takes a matter of hours. Medical issues, such as an infection or a high temperature, dehydration, pain, recent surgery and medications can all cause the condition.
There are two subtypes of delirium – hyperactive and hypoactive – and some people will show signs of both.
» Hyperactive delirium Usually causes restlessness and agitation
» Hypoactive delirium Thought to be the most common form, but tends to be more difficult to identify. The person can become withdrawn, quiet and sleepy
» Mixed delirium When the person shows signs of hyperactive and hypoactive delirium, fluctuating between the two
Source: NICE (2023)
About 20-30% of patients on medical wards in hospital will have delirium at some point, with even higher rates among those who have undergone surgery or who are in intensive care, says NICE. In long-term care, the prevalence is thought to be under 20%.
Delirium can cause longer stays in hospital or critical care, lead to more complications like pressure ulcers and increase the risk of death. Northumbria University assistant professor adult nursing Claire Pryor, who has carried out research into delirium, says it is effectively ‘acute brain failure’ and believes it should be treated as seriously as heart or kidney failure.
Dr Pryor says: ‘It’s a medical emergency, but I don’t think we always recognise it as such. That’s partly because of the way it presents itself through changed behaviour – there is not a blood or laboratory diagnostic test for delirium. It is physical, mental and cognitive: we need to think of that triad.’
It is crucial to identify those at risk of delirium as soon as possible, the NICE guidance states. It can be present when the person arrives at hospital or in long-term care, or it can develop. Any of the following is considered a risk factor:
Those judged to be at risk should be monitored carefully for changes, to spot delirium as early as possible. These changes may include:
» Cognitive fluctuation, such as deteriorating concentration, slow responses and confusion.
» Visual or auditory hallucinations.
» Changes in physical function, such as reduced mobility, restlessness and agitation.
» Changes in appetite and sleep disturbance.
» Social difficulties, such as ability to engage with requests; withdrawal; or problems with communication and mood.
If any of these changes are observed, the individual should be assessed using the 4AT screening tool.
Independent nurse consultant Dawne Garrett, a former RCN professional lead for older people, says: ‘It’s important that staff use the 4AT tool – the fact that NICE recommends it should give people the confidence to.
‘The beauty of it is that it is so easy to use. It is not just for nurses – others, such as healthcare assistants and therapists, can use it too. Everyone needs to be on alert for delirium.’
The only exceptions for use of the 4AT tool are in critical care or the recovery room after surgery, where NICE recommends that staff use either the Confusion Assessment Method for Intensive Care Unit (CAM-ICU) or the Intensive Care Delirium Screening Checklist screening tools.
British Association of Critical Care Nurses chair Nicki Credland says these assessments should be carried out routinely.
‘The beauty of the 4AT tool is it is so easy to use. It is not just for nurses – others, such as healthcare assistants and therapists, can use it too. Everyone needs to be on alert for delirium’
Dawne Garrett
‘They should be used on every ICU patient and form part of the daily assessment. Delirium in ICU is common so needs to be one of the daily priorities of care.’
The individual is scored 0-4 in the following categories:
» Alertness Whether the person is drowsy or agitated
» Awareness Ask the individual their age, date of birth, where they are and whether they know the year
» Attention Ask the person if they can name the months of the year backwards
» Acute change or fluctuating symptoms Assess whether the onset of delirium has been sudden or symptoms are fluctuating
An overall score of four or above suggests delirium, but the diagnosis needs to be made formally by a nurse or doctor.
Source: 4AT
The Royal College of Psychiatrists believes one in three cases of delirium could be prevented by managing the risks or through early identification, when delirium is developing.
NICE suggests steps to take if someone is deemed at risk:
» Avoid moving people in and between wards or rooms unless absolutely necessary.
» Provide appropriate lighting, clear signage and a 24-hour clock to reduce disorientation.
» Talk to the person, explaining where they are and who they are.
» Introducestimulating activities and facilitate regular visits from family or friends.
» Ensure hearing aids and/or glasses are available.
» Ensure adequate fluid intake to prevent dehydration.
» Assess for hypoxia and optimise oxygen saturation.
» Assess and manage pain.
» Encourage patients to be mobile, particularly following surgery.
» Look for and treat infection and avoid unnecessary catheterisation.
Dr Pryor says: ‘As nurses, we need to be aware of potential delirium in all patients, irrespective of age, though it is more prevalent in the older population.
‘The skill is recognising the change. One trap staff in acute settings may fall into is thinking they do not know the patient well enough to recognise red flags for delirium.
‘You may hear nurses say “nightshift didn’t tell me this patient behaved like this” or “isn’t this patient acting strange”. They are spotting a red flag for delirium, but may not recognise it. From this point of view, nurses in long-term care settings may be better placed because they will know the individual personally.’
Delirium can cause longer stays in hospital or critical care, lead to more complications such as pressure ulcers and increase the person’s risk of dying.
If delirium is diagnosed, identify and manage the underlying cause. This could include, for example, prescribing antibiotics to treat an infection.
Effective communication and reorientation, such as explaining where the person is and who they are, is essential. Family and friends can help with this if they are available.
If the individual is distressed, de-escalation techniques to calm or distract are important. But if the person is considered a risk to themselves or others and de-escalation techniques have not worked, the use of the antipsychotic medication haloperidol for a week or less should be considered, the NICE guidance states.
Imperial College Healthcare dementia and delirium nurse consultant Joanna James emphasises this should be a last resort though.
‘Delirium can be difficult for staff to deal with. Patients are confused and can refuse IV fluids or antibiotics. Sometimes you have to sedate patients, but ideally you would not do that – it should be a last resort. One of the biggest challenges is getting the brain engaged again.’
She says the use of picture diaries, which are commonly used for patients in the ICU, and scheduled activities can help.
‘We’ve just started a pilot on the neurosurgery ward where staff take a picture of patients with delirium twice a day – it could be when visitors come in or when they are doing something – to help them reconnect with what has been happening.
‘Alongside this we are getting staff and visitors to do activities with the patients. For hyperactive delirium, it is things like reading a paper, doing a crossword or puzzle.
‘For hypoactive delirium, it may be an activity pack, playing catch with a sensory ball or moving the person from bed to a chair.’
Dr Pryor says there needs to be investment in training for nurses. ‘Nurses will learn about delirium during their undergraduate degree and NHS organisations may add it in parallel to dementia training, but I still don’t think it is getting the attention it deserves,’ she says. ‘Delirium and dementia have similarities, but they are different conditions.’
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust has set up a delirium team to provide support in north Cumbrian hospitals.
The Reach Out team identifies those at risk of delirium with the aim of preventing the condition developing, or treating it early. Working seven days a week, the team comprising nurses, doctors and therapists actively seeks out and assesses anyone at risk of delirium who is admitted to hospital. This includes everyone aged over 65, and patients with dementia, a hip fracture or with severe illness.
The team screens 2,000 patients a month and offers support to patients, carers and staff, as needed. If someone has suspected or confirmed delirium, the team will see them twice a day. Members also help coordinate discharge and follow-up support for the person once they leave hospital. Since the team’s introduction in 2017 there has been a 20% reduction in delirium.
She says the RCN’s delirium champions network seems to work well, but she wants to see more projects.
‘We need to emphasise hypoactive delirium, which may be missed because there is a decrease in activity. The temptation is not to wake or engage with quiet or sleepy patients because patients need to rest.’
Dr Garrett agrees extra training would make a difference, particularly in long-term care settings.
‘This is not only an issue in hospitals. I am concerned about the pressure on staff. You can have good awareness of delirium, but the environments they work in makes it harder to spot. If patients are spending hours in corridors it is hard to monitor and observe them and notice changes. If in doubt, assume it is delirium. After all, you’re not going to harm patients by taking the steps to prevent or treat them for delirium.’
See Evidence & Practice, page 22
This is an abridged version of an article at rcni.com/delirium-older-people
4AT Rapid Clinical Test for Delirium. www.the4at.com
NICE (2023) Delirium: Prevention, Diagnosis and Management in Hospital and Long-Term Care. www.nice.org.uk/guidance/cg103
RCN (2017) Become a Delirium Champion.
