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• To understand the relationship between delirium and falls
• To enhance your knowledge of the signs and symptoms of delirium
• To learn about some of the validated delirium screening tools that can be incorporated into a multifactorial falls risk assessment
Delirium, which may present as acute fluctuation in arousal and attention and changes in a person’s behaviours, can increase the risk of falls, while a fall can increase the risk of developing delirium. There is, therefore, a fundamental relationship between delirium and falls. This article describes the main types of delirium and the challenges associated with recognition of the condition and discusses the relationship between delirium and falls. The article also describes some of the validated tools used to screen patients for delirium and includes two brief case studies to illustrate this in practice.
Nursing Older People. doi: 10.7748/nop.2023.e1418
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Leah V, Ngwu L (2023) Identifying the relationship between delirium and falls. Nursing Older People. doi: 10.7748/nop.2023.e1418
Published online: 22 February 2023
Delirium has been described as a diagnosed state of critical change in a person’s mental and attention status (Doherty et al 2014). The condition is associated with suboptimal patient outcomes, including prolonged hospital stay, increased mortality, long-term cognitive impairment, institutionalisation and dependency (Pendlebury et al 2015, Goldberg et al 2020, Tsui et al 2022). It is also associated with injurious harm from falls (Tieges et al 2021).
Falls are common adverse events associated with older people that can lead to serious injury and premature admission to long-term care, as well as distress, pain, loss of confidence and independence, and reduced ability to take part in social activities (National Institute for Health and Care Excellence (NICE) 2013, Martins et al 2019). Falls are also associated with the development of delirium (Lakatos et al 2009, Babine et al 2017, Sillner et al 2019).
This article discusses the relationship between delirium and falls and outlines some of the challenges associated with recognising and diagnosing delirium. The article also includes a description of some validated delirium screening tools and uses two fictional case studies to illustrate screening in practice.
Delirium presents as an acute fluctuation in arousal and attention and global cognitive impairment, and can be distressing for patients (Partridge et al 2013, Day and Higgins 2015), their families and the professionals caring for them (Gibb et al 2020). The acute fluctuation in arousal and attention, alongside changes in the person’s behaviour, mood, feelings, attitudes and perception, makes recognition of delirium challenging (Babine et al 2017). However, early identification of delirium is important as there is generally an underlying cause or combination of causes that must be identified and managed (NICE 2023).
Delirium has been found to affect one in four older patients (aged ≥70 years) in acute medical inpatient settings (Gibb et al 2020), however its prevalence in community settings is less well documented. One systematic review found the prevalence of delirium in the general population was 1% to 2% in people aged ≥65 years and 10% in those aged ≥85 years (de Lange et al 2013). In long-term care settings such as nursing homes, prevalence of delirium may be up to 60% (British Geriatrics Society 2019). NICE (2014, 2023) guidelines recommend that all adults aged ≥65 years are screened for delirium on admission to hospital or a long-term care setting and that this diagnosis should be communicated on transfer of care to other settings.
People who have developed delirium have reported experiencing visual hallucinations, anger, fatigue, depression, fear (Morandi et al 2011, Grover et al 2015), panic and insecurity, as well as difficulty interacting with hospital staff (Sörensen Duppils and Wikblad 2007). Other experiences reported by patients include feeling neglected by family members and hospital caregivers, which has resulted in them refusing care or seeking ways to flee from what they considered a frightening situation (Bélanger and Ducharme 2011, Pollard et al 2015). Patients have also reported that once the episode had resolved they felt a sense of remorse and guilt (Pollard et al 2015, Van Rompaey et al 2016).
There are three main subtypes of delirium – hyperactive, hypoactive and mixed (Rahman 2020). The symptoms associated with hyperactive, hypoactive and mixed delirium are shown in Table 1. Hyperactive delirium is easier to identify than hypoactive delirium; for example, symptoms in people with hypoactive delirium may be inaccurately attributed to tiredness due to advanced age, side effects of medicines or illness (Rahman 2020).
(Adapted from Rahman 2020)
The variations in presentation in people with delirium can hinder recognition and may be one reason why the condition is often misdiagnosed and undertreated (Babine et al 2017). Hyperactive delirium may be misdiagnosed as dementia, for example, while hypoactive delirium can be misdiagnosed as depression; both misdiagnoses may have negative effects on patient outcomes (Lakatos et al 2009).
• Delirium may present as acute fluctuation in arousal and attention and global cognitive impairment, and can be distressing for patients, their families and the professionals caring for them
• Falls are common adverse events associated with older people and can lead to serious injury and premature admission to long-term care
• Cognitive impairment in older people has been shown to significantly increase the risk of falls
• Using a validated delirium screening tool can trigger further assessment, ongoing monitoring and care planning, and completion of a falls risk assessment and prevention plan
• Inclusion of delirium screening as an element of a falls risk assessment can improve recognition of the condition and enhance the falls prevention plan
Cognitive impairment in older people has been shown to significantly increase their risk of falls compared with those who do not have cognitive impairment (Li and Harmer 2020). Despite investment in falls prevention programmes (NICE 2013, NHS England 2020, Office for Health Improvement and Disparities 2022), the number of people sustaining a fall remains high. In England and Wales more than 250,000 hospital falls are recorded annually, with an average of 6.63 falls per 1,000 occupied bed days (Morris and O’Riordan 2017). In care homes, in which the population is at higher risk of falls than the general population, around 25% of falls account for serious injury while 40% of admissions from care homes to hospitals are related to falls (Logan et al 2021).
The authors of this article suggest that this is in part due to a lack of understanding among nurses and other healthcare professionals of the relationship between falls and delirium and inadequate recognition of delirium in healthcare settings. This is supported by a prospective study which concluded that recognition of delirium by emergency department nurses and physicians was suboptimal (Lee et al 2022).
The risk factors for falls are similar to those for the development of delirium (Babine et al 2017, Ferguson et al 2018, Sillner et al 2019). In a retrospective case-control comparative study of delirium markers in older people who had experienced falls, Doherty et al (2014) identified altered levels of awareness and inattention to the environment as risk factors for falls. Altered levels of awareness and inattention are also seen in patients with delirium (Babine et al 2017). For example, a common scenario in which a person falls is when they have attempted to go to the toilet at night. The impaired attention associated with delirium can reduce the person’s ability to notice environmental hazards, such as inadequate lighting or loose carpeting (Hshieh et al 2015), which may then result in a fall.
Disorientation, lack of strength and stability and reduced ability to undertake dual activities that are seen in some older people with cognitive impairment further emphasises the relationship between delirium and falls. Frailty, vision and hearing impairment, acute illness or exacerbation of existing long-term conditions, dehydration, malnutrition, side effects of medicines, electrolyte imbalance, infection and change in environment, such as transfer of care to hospital or a care home, are all associated with increased risk of both falls and delirium (Fong et al 2015).
Lack of recognition of delirium could result in an underestimation of the person’s risk of falls. All healthcare settings in the UK should have a falls assessment and prevention programme in place (NICE 2013, Scottish Government 2019). Falls assessments, which are recommended for those aged ≥65 years (and those aged 50 to 64 years if considered at high risk) (NICE 2013), aim to identify an individual’s risk factors and initiate development of a multifactorial intervention plan with the person and family at the centre. NICE (2013) guidelines recommend inclusion of a cognitive assessment in falls risk assessment, while the Royal College of Physicians (RCP) (2015) recommends inclusion of delirium screening. Inclusion of delirium screening as an element of a falls risk assessment can improve recognition of the condition and enhance the falls prevention plan (Babine et al 2016).
All healthcare professionals should take responsibility for recognising delirium; however, it can be challenging to synthesise and articulate the multiple clinical symptoms associated with the condition. Person-centred care is central to effective detection and management of delirium and risk of falling because the fluctuating symptoms of delirium mean that some clinical features can be missed. Therefore, knowledge of the person’s usual level of function and behaviours, which may require involvement of the family and/or other health and social care professionals, alongside the use of a validated delirium screening tool is required to support early detection, prevention and management (Babine et al 2017).
Screening for delirium has a dual purpose: first, to identify the condition on initial presentation; and second, to ensure continuous monitoring to identify new onset delirium. There are a number of screening tools available that can be incorporated into a multifactorial falls risk assessment.
The Single Question in Delirium (SQiD) tool, which asks ‘Do you think [person’s name] has been more confused lately?’ can be used for early detection of delirium (Rosgen et al 2018). This simple question can be posed to the person, their family or carers as part of a falls risk assessment. It is an effective tool for use as part of daily handovers in care settings where staff know the residents well. However, if the person is experiencing hypoactive delirium, diagnosis could be missed due to symptoms such as reduced psychomotor activities and sleepiness, therefore it is important that nurses use their clinical judgement and do not rely only on the SQiD. The tool can be used regularly to identify changes in the person’s condition. If changes are noted this should trigger use of the 4 ‘A’s test (4AT) (MacLullich et al 2019).
The 4AT is a validated, four-item (alertness, Abbreviated Mental Test 4 (AMT4), attention, acute change) bedside screening tool used for identification of delirium (MacLullich et al 2019). It can be accessed online at: www.the4at.com/4atguide The tool is recommended in the Scottish Intercollegiate Guidelines Network guidelines on delirium and has been widely implemented as it is quick, easy to use, does not require training and can be used in many settings (Healthcare Improvement Scotland 2019). It is intended to guide healthcare professionals rather than confirm or refute a diagnosis.
The 4AT is scored from 0-12 across the four items (MacLullich et al 2019):
• A score of ≥4 indicates possible delirium +/- cognitive impairment.
• A score of 1-3 suggests possible cognitive impairment.
• A score of 0 does not exclude delirium and the person may require more detailed assessment.
• A summary of the 4AT scoring method is shown in Table 2.
| Item 1: Alertness | Item 2: Abbreviated Mental Test 4 (AMT4) | Item 3: Attention | Item 4: Acute change (or fluctuating course) |
|---|---|---|---|
| |||
| Scoring: | Scoring: | Scoring: | Scoring: |
|
|
(Adapted from MacLullich et al 2019)
The Confusion Assessment Method (CAM) has been extensively validated for use in clinical and research settings (Inouye et al 1990). The CAM has nine features – acute onset, inattention, disorganised thinking, altered level of consciousness, disorientation, memory impairment, perceptual disturbance, psychomotor agitation and altered sleep-wake cycle – which reflect the Diagnostic and Statistical Manual of Mental Disorders diagnostic criteria for delirium (American Psychiatric Association 2013). Acute onset (with fluctuating course) and inattention with either disorganised thinking or altered level of consciousness indicates a diagnosis of delirium (Inouye et al 1990). It should be noted that use of the CAM requires training, and the tool comes with a 19-page training document, therefore it may not be practical for use in some settings.
Greater Manchester Community Delirium Toolkit
dementia-united.org.uk/delirium-community-toolkit/
Let’s talk delirium
Confusion Assessment Method (CAM)
The Observational Scale of Level of Arousal, originally designed for research use to characterise the abnormalities of level of arousal associated with delirium, can be used to assess the person’s level of arousal in non-intensive care unit delirium based on four elements (eye opening, eye contact, posture and movement) (Hall et al 2020).
Two tools developed for use by nurses are the Delirium Observation Screening Scale, which supports early recognition of delirium based on nurses’ observations during regular care (Schuurmans et al 2003), and the Stanford Proxy test for Delirium, which is completed by nurses at the end of their shift based on their knowledge of the patient acquired during a full shift of nurse-patient interaction (Maldonado et al 2015). However, these two tools have weak sensitivity and/or specificity compared with the 4AT and CAM and take longer to administer (Rahman 2020).
In January 2023, NICE updated its guidelines on prevention, diagnosis and management of delirium in hospital and long-term care. The updated guidelines recommend that if there is suspicion of delirium a competent health or social care practitioner should carry out an assessment of the person using the 4AT. However, in critical care settings, for example recovery post-surgery or intensive care, the guidelines recommend use of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) (Barr et al 2013) or the Intensive Care Delirium Screening Checklist (ICDSC) (Bergeron et al 2001) instead of the 4AT (NICE 2023).
The addition of ‘new onset of confusion’ to the level of consciousness item in the National Early Warning Score 2 (NEWS2), the widely used tool that aims to improve the detection of and response to clinical deterioration in adult patients, has provided a method of continuous assessment of delirium (RCP 2020). Supplementary guidance to support best practice when assessing new onset of confusion includes the recommendation to assume that confusion is new until confirmed otherwise (Vardy et al 2022). In practice, this means that if a person is assessed as having new onset of confusion the previous day, this must still be regarded and documented as new onset of confusion the following day if symptoms continue. If new onset of confusion is identified via the NEWS2, the patient should be further assessed using the 4AT (MacLullich et al 2019, Vardy et al 2022), apart from in critical care settings (NICE 2023) as noted above.
In settings where the NEWS2 is not part of routine observations, the SQiD should form part of the daily handover and if changes are noted a 4AT should be undertaken. If the 4AT suggests the person may be experiencing delirium an appropriately qualified clinician should be requested to confirm the diagnosis, record this in the patient’s notes, escalate the situation in line with the plan of care and inform the family.
In all settings a validated delirium screening tool score that suggests the person may be experiencing delirium should trigger a falls risk assessment and/or review. In addition to falls prevention interventions that may already be in place, other interventions specific to the individual’s presenting symptoms of delirium should be added to the care plan. Where appropriate, the patient’s family should be involved in this aspect of care planning.
The fictional case studies (Case study 1 and 2) detail the use of the 4AT.
A 78-year-old man presents to the emergency department (ED) following a fall at home. He is accompanied by his wife who tells the nurse that his memory has been poor for the past six months and that he has recently been diagnosed with Alzheimer’s disease. He usually looks after himself and likes to potter in the garden in good weather.
On observation, the nurse notices that the patient’s eyes are closed. When the nurse says his name, he tries to open his eyes and speak, but is unable to respond.
The nurse undertakes the 4 ‘A’s test (4AT) (see Table 2) and scores the patient as follows:
• Alertness=4 (clearly abnormal)
• Abbreviated Mental Test 4 (AMT4)=2 (untestable)
• Attention=2 (untestable)
• Acute change/fluctuating course=4 (evidence from the patient’s wife)
The total score of 12 suggests the patient may be experiencing hypoactive delirium and therefore requires a formal assessment by an appropriately trained clinician. The patient is also at high risk of falls. The nurse therefore completes a falls risk assessment which is included in the handover to staff on the receiving ward when the patient is transferred.
An 81-year-old woman presents to the ED with a gangrenous left foot. She had been commenced on antibiotics in the community but with no improvement. She is admitted to a ward and given intravenous antibiotics and opioids for pain. Two days after admission she appears to be unhappy, is suspicious of the nurses and says there was a party during the night and that her water has been poisoned.
The nurse undertakes the 4AT and scores the patient as follows:
• Alertness=0 (normal)
• AMT4=0 (all answers correct)
• Attention=0 (accurately recites months of the year backwards)
• Acute change/fluctuating course=4 (evidence of change in behaviours from ward nurses and presumed to be experiencing acute, new onset paranoia)
The total score of 4 indicates possible hyperactive delirium, based on behaviour changes alone, therefore a formal assessment by an appropriately trained clinician is required. The patient is also at high risk of falls. Therefore, the nurse reviews the falls risk assessment and prevention plan already in place and includes additional prevention strategies relevant to the patient’s presenting symptoms of delirium.
Delirium is a distressing condition for patients, families and healthcare staff and increases the risk of falls. Recognition of delirium can be challenging due to the variation in presenting symptoms. However, using a validated screening tool, such as the SQiD, 4AT or CAM, can provide evidence of the possibility of the condition and trigger further assessment, ongoing monitoring and care planning, including a falls risk assessment. The ability to recognise possible delirium in patients in all settings should result in improved falls prevention planning and thus reduce the incidence of falls and increase patient safety.
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