Policy briefing

Treat delirium as a medical emergency

Delirium is among the most common medical emergencies and risk reduction should be considered throughout a patient’s care, new guidance says

Delirium is among the most common medical emergencies and risk reduction should be considered throughout a patient’s care, new guidance says

Patients at risk of delirium should have their hearing aids. Picture: iStock

Essential facts

Delirium is among the most common of medical emergencies, according to the national clinical guideline organisation the Scottish Intercollegiate Guidelines Network (SIGN).

Delirium is an acute deterioration in mental functioning arising over hours or days that is triggered mainly by acute medical illness, surgery, trauma or drugs. Prevalence is around 20% in adult acute general medical patients. It affects up to 50% of those who have hip fractures and up to 75% of those in intensive care. Risk factors include older age, dementia, frailty, the presence of multiple co-morbidities, being male, sensory impairments, a history of depression, a history of delirium and alcohol misuse.

What’s new?

Risk reduction for delirium should be considered throughout a patient’s care, according to new guidance.

The SIGN guideline on reducing risk and managing delirium states the focus should be on non-pharmacological approaches.

Patients at risk of delirium should receive a package of care including pain control, early mobilisation, optimal hydration and nutrition, and should keep their glasses and hearing aids with them.

The guideline also calls for the promotion of good sleep, prevention and treatment of post-operative complications, regulation of bladder and bowel function and supplementary oxygen if necessary.

The 4AT test for delirium should be used to identify patients with probable delirium in emergency department and acute hospital settings. Delirium is often missed in routine clinical care and lack of detection is associated with poor outcomes.

The 4AT tool, which assesses arousal, attention, abbreviated mental test and acute change, requires no training and is quick and easy to use, the guideline states.

When delirium is diagnosed, established pathways of good care are required.

Healthcare professionals should first consider acute, life-threatening causes of delirium, including low oxygen level, low blood pressure, low glucose level and drug intoxication or withdrawal. Potential causes should be systematically identified and treated, noting that multiple causes are common.

To promote brain recovery, healthcare professionals should optimise physiology, manage concurrent conditions and reduce noise in the environment.

Nurses should specifically detect, assess causes and treat agitation or distress, using non-pharmacological means only if possible.

Implications for nurses

  • Delirium is often multifactorial. Prevention may merge with treatment when non-pharmacological practices are used. Risk reduction should be considered throughout the patient’s care.
  • All patients at risk of delirium should have their medication reviewed by an experienced healthcare professional.
  • Communicate a diagnosis of delirium 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 ulcers, dehydration, malnourishment and isolation.
  • Monitor for recovery and consider specialist referral if not recovering.

Expert comment

NHS Ayrshire and Arran delirium nurse Vicky MacRaeVicky MacRae, delirium nurse at NHS Ayrshire and Arran

‘Delirium affects all age groups and crosses all specialties. It is associated with poor outcomes, particularly for older people, in terms of increased length of hospital stay, falls, loss of independence and cognitive decline.

‘Nurses must know to treat it as a medical emergency. Early detection and risk reduction are key to tackling delirium, with fundamental high-quality care being at the heart of this.

‘Nurses can improve care by using a validated screening tool such as 4AT. If undertaken at the earliest opportunity it can prompt a more accurate diagnosis and encourage early consideration of the underlying causes of delirium.

‘Non-pharmacological management of a patient with a delirium is the key message of this guidance. In Ayrshire and Arran we use a comprehensive pathway incorporating the triggers, investigate, manage, engage (TIME) care bundle to provide good delirium care.’

Erin Dean is a health journalist

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