Clinical practice guidelines on risk reduction and management of delirium

The Scottish Intercollegiate Guidelines Network (SIGN) has developed guidelines for risk reduction and management of delirium.

Delirium is an acute deterioration in mental functioning arising over hours or days that are triggered mainly by acute medical illness, surgery, trauma, or drugs. Delirium is independently linked with poor outcomes including medical complications, falls, increased the length of hospital stay, new institutionalization, and mortality. It can cause significant patient and carer distress.

This new national guideline on delirium provides a critical focal point for Scotland-wide improvements in delirium care. Because delirium is so common, all healthcare staff having contact with acutely unwell patients need to assume responsibility for detecting and treating it, as well as aiming to reduce the risk of delirium occurring. Those working in the long-term care environment should be able to recognize delirium, reduce risk, and monitor those in their care to resolve delirium.

Detecting Delirium

• Use the 4 As Test (Arousal, Attention, Abbreviated Mental Test 4 [AMT4], Acute change) for identifying patients with probable delirium in emergency and acute hospital settings. This tool may also be used in the community or other settings.


• In the ICU setting, use the Confusion Assessment Method for the ICU (CAM-ICU) or the Intensive Care Delirium Screening Checklist (ICDSC) to identify patients with probable delirium.


• Use CT brain scan in those patients presenting with delirium in the presence of the following:
  
  
  
  • New focal neurological signs
  
  
  • Reduced level of consciousness
  
  
  • A history of falls
  
  
  • Head injury
  
  
  • Anticoagulation therapy
  
  
  
  


• Consider an electroencephalogram when there is suspicion of epileptic activity or non-convulsive status epilepticus.

Reducing Risk of Delirium

• Consider all of the following as part of a package of care for patients at risk for delirium:
  
  
  
  • Ensuring patients have their glasses and hearing aids, if applicable
  
  
  • Promoting sleep hygiene
  
  
  • Early mobilization
  
  
  • Pain control
  
  
  • Prevention, early identification, and treatment of post-operative complications
  
  
  • Maintaining optimal hydration and nutrition
  
  
  • Regulation of bladder and bowel function
  
  
  • Provision of supplementary oxygen, if appropriate
  
  
  
  


• Monitor depth of anesthesia in patients 60 years of age and older undergoing surgery that is expected to last more than 1 hr.

Treating Delirium

• Consider acute, life-threatening causes of delirium. These may include low oxygen level, low blood pressure, low glucose level, and drug intoxication or withdrawal.


• Identify and treat potential causes such as medications and acute illness. Multiple causes are common.


• Optimize physiology, environment, and medications to promote brain recovery.


• Detect and treat agitation or distress with non-pharmacologic means, if possible.


• Communicate diagnosis to patients and caregivers and provide ongoing support.


• Attempt to prevent delirium complications such as immobility, falls, pressure sores, dehydration, malnourishment, and isolation.


• Monitor patient recovery and refer to a specialist if necessary.

For detailed guidelines follow the link: https://www.sign.ac.uk/assets/sign157.pdf