Practice question

How do I manage the care of an older person with delirium?

Delirium can have devastating effects on an older person, increasing the risk of dementia and mortality. National guidelines recommend prompt detection by screening older people for delirium on admission to hospital
Nurse attending to an older patient who is experiencing and needs hydration

Delirium can have devastating effects on an older person, increasing the risk of dementia and mortality. National guidelines recommend prompt detection by screening older people for delirium on admission to hospital

Delirium is a condition that causes an acute confusional state and 96% of cases in the hospital setting are experienced by older people ( Royal College of Nursing 2020 ). As a result of delirium, many older people spend longer in hospital and require complex care during their stay, and some require ongoing care in the community.

View RCNis delirium resources

A person may

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Delirium can have devastating effects on an older person, increasing the risk of dementia and mortality. National guidelines recommend prompt detection by screening older people for delirium on admission to hospital


Dehydration is a common and treatable cause of delirium. Picture: Andrew Hasson​​​​​​

Delirium is a condition that causes an acute confusional state and 96% of cases in the hospital setting are experienced by older people (Royal College of Nursing 2020). As a result of delirium, many older people spend longer in hospital and require complex care during their stay, and some require ongoing care in the community.

View RCNi’s delirium resources

A person may have developed delirium before they present to hospital or it may develop during an admission. Older people living with dementia or long-term conditions are at greater risk of developing delirium (Healthcare Improvement Scotland (HIS) 2019). Delirium can have devastating effects on an older person with increased risk of developing dementia and an increase in mortality (National Institute for Health and Care Excellence (NICE) 2010).

Identifying delirium

Prompt detection of delirium improves outcomes and national guidelines recommend that older people should be screened for delirium on admission to hospital (NICE 2010, HIS 2019), but many studies suggest that delirium is widely under-diagnosed. Delirium should be suspected when someone has a new onset of confusion and other medical diagnoses have been ruled out.

However, it can be difficult to make that decision based on experience alone. Therefore, the use of a delirium screening tool can be helpful. A growing number of screening tools are available and there is strong evidence that using any validated tool improves identification and subsequent treatment of delirium (British Geriatrics Society 2019).

Free download of the 4AT rapid clinical tool for delirium

4AT is a rapid clinical test for delirium that is free to download and use (MacLullich et al 2014). It has performed well in multiple evaluation studies and is one of the most recognised screening tools for delirium. It is also recommended for identifying delirium in an acute hospital setting (HIS 2019). This tool considers four areas for assessment (MacLullich et al 2014):

  • Alertness.
  • Abbreviated mental test 4 (AMT4).
  • Attention.
  • Acute change or fluctuating course.

Based on the person’s answers a score is recorded that may indicate a possible delirium.

Treating delirium

The mnemonic PINCH ME (Let’s Respect 2014) has been helpful for identifying some of the common causes of delirium. PINCH ME stands for:

  • P =Pain.
  • In = Infection.
  • C = Constipation.
  • H = deHydration.
  • M = Medication.
  • E = Environment.

These are all treatable causes of delirium and it is vital that nurses consider these potential causes to provide quick interventions and treatments. There are clear guidelines for intervening when an older person has been identified with delirium (NICE 2010). These include minimising, where possible, the effect of the environment and promoting sleep. These aspects can be difficult in an inpatient setting but making efforts to reduce patient movements and not waking patients for routine care are just two of the positive interventions nurses can make when advocating for the patient.

Nurses’ crucial role in identifying sudden changes in an older person’s cognition

Ensuring adequate hydration, assessing for pain and constipation as well as ensuring rapid assessment and treatment for infections are also crucial. This can be achieved through the care plans and assessment tools available to nurses in clinical settings (Dixon 2018).

Nurses have a crucial role in identifying sudden changes in an older person’s cognition. However, they must also provide interventions to hasten speedy recovery and minimise the deleterious effects of delirium on older people. It is therefore important to ensure that knowledge on this common condition is fully understood and applied to daily clinical nursing practice.


References


Clifford Kilgore is a nurse consultant in intermediate care and older people, Dorset HealthCare University NHS Foundation Trust, Poole, Dorset, England

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