Recognising delirium in the community

When older people develop delirium, it can land them in hospital and set off a cycle of declining health. Identifying and tackling the syndrome early - while people are still at home - is the target of a new RCN campaign.

When older people develop delirium, it can land them in hospital and set off a cycle of declining health. Identifying and tackling the syndrome early – while people are still at home – is the target of a new RCN campaign

Delirium: early action is needed in people's homes. Picture: iStock

Up to 30% of patients on medical wards, up to 50% of surgical patients and around 14% of care home residents are believed to have delirium, but this serious condition remains poorly understood by some nurses. 

Delirium usually develops over one or two days and can often be prevented and symptoms treated if dealt with promptly. Older people, and people with cognitive impairment, dementia, severe illness or a hip fracture, are more at risk. Early recognition is vital as delirium leads to a higher risk of falls, increases the chances of being admitted to hospital and has high mortality rates.

Delirium champions

The RCN is appealing for nurses, particularly those working in the community, such as district nurses and care home nurses, to act as delirium champions. The champions will give other staff the tools to recognise early delirium, develop a local pathway for escalating patients causing concern and emphasise the need to act swiftly to prevent harm.

The initiative focuses on the community to try to catch people at the early stage of the condition and prevent the need for hospital admission. Consultant nurse for older people at University College London Hospitals NHS Foundation Trust Vicki Leah and dementia lead nurse at Imperial College Healthcare NHS Trust Jo James, were prompted to lead the work through the RCN older people’s forum after seeing many older people arrive at emergency departments in very poor health.

‘People come in who are already delirious, and have probably been so for a number of days,’ Ms Leah says. ‘By the time they get to us they are often in a fairly bad way and it tends to be difficult for us to turn them around. With older people who are frail, or have dementia, it often doesn’t take much for them to become delirious. It could just be [prompted by] something like constipation, or an ear or tooth infection. But if delirium is not recognised, they often fall over and come to us having broken a hip, which further compounds the delirium.’

Action needed at home

Awareness of delirium in hospitals has been on the agenda for a while, and the care of those who are delirious in acute settings is improving, Ms Leah says. Now early action is needed in people’s homes.

The National Institute for Health and Care Excellence (NICE) states in its 2014 quality standard to improve delirium care that reporting is poor in the UK, indicating that awareness and procedures need to be improved. Rates could be higher than currently reported, research suggests. The NICE standard recognises the difficulty in diagnosing delirium as the symptoms can be vague and affect people differently. People may become hyperactive and can be restless, agitated and aggressive, but they can also become withdrawn, quiet and sleepy, or have a mixture of both.

Sudden change

It can be difficult to distinguish between delirium and dementia because symptoms overlap, and some people may have both conditions. But dementia tends to develop slowly, whereas delirium is characterised by sudden changes. NICE says if clinical uncertainty exists over the diagnosis, initial management should be for delirium.

NICE recommends checking if a person’s dentures fit well, encouraging visits from friends and family, medication review, looking for and treating infections, and avoiding unnecessary catheterisation to help reduce the risk of delirium.

Ms Leah says the key sign is a person who suddenly seems ‘so different to yesterday’.

The RCN’s package of training for champions to provide to colleagues includes a short animated video showing a district nurse visiting a patient. It shows how small signs from the day before, including the patient having not had breakfast or getting dressed, not being chatty and appearing withdrawn, suggests that they could have delirium.

RCN professional lead for older people and dementia care Dawne Garrett says one of the important jobs of the delirium champions will be confirming, and possibly creating, the escalation route for patients causing concern. While this may be straightforward on a hospital ward, it may not always have been clarified in the community. The resources for the champion role include a template to develop an escalation pathway.

The campaign has prompted huge interest, with more than 500 nurses applying in the first two weeks. This shows there are many nurses who want to improve the care of people with this potentially devastating condition, says Ms Garrett.

 ‘The thing about delirium is that if we spot it in time we can improve people’s outcomes and make a difference to their quality of life and life expectancy,’ she says.

Erin Dean is a freelance journalist

Find out more about becoming an RCN delirium champion here

Signs of delirium 

Signs of delirium can be vague and difficult to identify. Look out for patients who are:

  • More sleepy than usual
  • More active or alert than usual
  • Hard to wake up
  • Poor concentration
  • Slow responses
  • More confused
  • Seeing and/or hearing things
  • Paranoia
  • Less mobility and/or movement
  • Restless/agitated
  • Not eating
  • Refusing to co-operate
  • Withdrawn
  • Change in attitude
  • Change in communication
  • Sleep problems

Source: RCN leaflet Don’t Discount Delirium

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