The National Institute of healthcare and excellence has released guidelines to manage, prevent and diagnose delirium in patients with acute illness and hospitalization.
Delirium is an abrupt change in the brain that causes mental confusion and emotional disruption. This usually occurs with people with acute illness and long-term hospitalization making it difficult for them to think, remember, sleep, pay attention, and more. This can have serious consequences (such as increased risk of dementia and/or death) and, for people in the hospital, may increase their length of stay in the hospital and their risk of new admission to long-term care. Keep this in view NICE has released guidelines on managing delirium.
This guideline covers adult patients (18 years and older) in a hospital setting and adults (18 and older) in long-term residential care. The guideline addresses: modifiable risk factors („clinical factors‟) to identify people at risk of developing, diagnosis of delirium in acute, critical and long-term care; as well as pharmacological and non-pharmacological interventions for;
- Reducing the incidence of delirium and its consequences
- To reduce the severity, duration, and consequences of delirium in people who develop the condition.
The guideline is briefly provided below:
1. Risk factor assessment
- When people first present to hospital or long-term care, assess them for the following risk factors. If any of these risk factors is present, the person is at risk of delirium.
- Age 65 years or older.
- Cognitive impairment (past or present) and/or dementia. If cognitive impairment is suspected, confirm it using a standardized and validated cognitive impairment measure.
- Current hip fracture.
- Severe illness (a clinical condition that is deteriorating or is at risk of deterioration)
- Observe people at every opportunity for any changes in the risk factors for delirium.
2. Indicators of delirium: at presentation
- At presentation, assess people at risk for recent (within hours or days) changes or fluctuations in behavior. These may be reported by the person at risk, or a carer or relative. Be particularly vigilant for behavior indicating hypoactive delirium (marked*). These behavior changes may affect:
- Cognitive function: for example, worsened concentration*, slow responses*, confusion.
- Perception: for example, visual or auditory hallucinations.
- Physical function: for example, reduced mobility*, reduced movement*, restlessness, agitation, changes in appetite*, sleep disturbance.
- Social behavior: for example, lack of cooperation with reasonable requests, withdrawal*, or alterations in communication, mood and/or attitude.If any of these behavior changes are present, a healthcare professional who is trained and competent in diagnosing delirium should carry out a clinical assessment to confirm the diagnosis.
3. Interventions to prevent delirium
- Ensure that people at risk of delirium are cared for by a team of healthcare professionals who are familiar to the person at risk. Avoid moving people within and between wards or rooms unless absolutely necessary.
- Give a tailored multicomponent intervention package:
- Within 24 hours of admission, assess people at risk for clinical factors contributing to delirium.
- Based on the results of this assessment, provide a multicomponent intervention tailored to the person’s individual needs and care setting.
- The tailored multicomponent intervention package should be delivered by a multidisciplinary team trained and competent in delirium prevention.
- Address cognitive impairment and/or disorientation by:
- providing appropriate lighting and clear signage; a clock (consider providing a 24-hour clock in critical care) and a calendar should also be easily visible to the person at risk
- talking to the person to reorientate them by explaining where they are, who they are, and what your role is
- introducing cognitively stimulating activities (for example, reminiscence)
- facilitating regular visits from family and friends.
- Address dehydration and/or constipation by:
- ensuring adequate fluid intake to prevent dehydration by encouraging the person to drink – consider offering subcutaneous or intravenous fluids if necessary
- taking advice if necessary when managing fluid balance in people with comorbidities (for example, heart failure or chronic kidney disease).
- Assess for hypoxia and optimize oxygen saturation if necessary, as clinically appropriate.
- Address infection by:
- looking for and treating infection
- avoiding unnecessary catheterization
- implementing infection control procedures in line with the NICE guideline on healthcare-associated infections.
- Address immobility or limited mobility through the following actions:
- Encourage people to:
- mobilize soon after surgery
- walk (provide appropriate walking aids if needed – these should be accessible at all times).
- Encourage all people, including those unable to walk, to carry out active range-of-motion exercises.
- Address pain by:
- assessing for pain
- looking for non-verbal signs of pain, particularly in those with communication difficulties (for example, people with learning difficulties or dementia, or people on a ventilator or who have a tracheostomy)
- starting and reviewing appropriate pain management in any person in whom pain is identified or suspected.
- Carry out a medication review for people taking multiple drugs, taking into account both the type and number of medications. For information on medicines, optimization see the NICE guideline on medicines optimization.
- Address poor nutrition by:
- following the advice is given on nutrition in the NICE guideline on nutrition support for adults
- if people have dentures, ensuring they fit properly.
- Address sensory impairment by:
- resolving any reversible cause of the impairment, such as impacted ear wax
- ensuring hearing and visual aids are available to and used by people who need them, and that they are in good working order.
- Promote good sleep patterns and sleep hygiene by:
- avoiding nursing or medical procedures during sleeping hours, if possible
- scheduling medication rounds to avoid disturbing sleep
- reducing noise to a minimum during sleep periods.
4. Indicators of delirium: daily observations
- Observe, at least daily, all people in the hospital or long-term care for recent (within hours or days) changes or fluctuations in usual behavior. These may be reported by the person at risk, or a carer or relative. If any of these behavior changes are present, a healthcare professional who is trained and competent in the diagnosis of delirium should carry out a clinical assessment to confirm the diagnosis.
5. Diagnosis (specialist clinical assessment)
- If indicators of delirium are identified, carry out a clinical assessment based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria or short Confusion Assessment Method (short CAM) to confirm the diagnosis. In critical care or in the recovery room after surgery, CAM‑ICU should be used. A healthcare professional who is trained and competent in the diagnosis of delirium should carry out the assessment. If there is difficulty distinguishing between the diagnoses of delirium, dementia or delirium superimposed on dementia, treat for delirium first.
- Ensure that the diagnosis of delirium is documented both in the person’s hospital record and in their primary care health record.
6. Treating delirium
- In people diagnosed with delirium, identify and manage the possible underlying cause or combination of causes.
- Ensure effective communication and reorientation (for example explaining where the person is, who they are, and what your role is) and provide reassurance for people diagnosed with delirium. Consider involving family, friends, and carers to help with this. Provide a suitable care environment.
- If a person with delirium is distressed or considered a risk to themselves or others, first use verbal and non-verbal techniques to de-escalate the situation. For more information on de-escalation techniques, see the NICE guideline on violence and aggression. Distress may be less evident in people with hypoactive delirium, who can still become distressed by, for example, psychotic symptoms.
- If a person with delirium is distressed or considered a risk to themselves or others and verbal and non-verbal de-escalation techniques are ineffective or inappropriate, consider giving short-term (usually for 1 week or less) haloperidol. Start at the lowest clinically appropriate dose and titrate cautiously according to symptoms.
- Use antipsychotic drugs with caution or not at all for people with conditions such as Parkinson’s disease or dementia with Lewy bodies.
If delirium does not resolve
- For people in whom delirium does not resolve:
- Re-evaluate for underlying causes.
- Follow up and assess for possible dementia.
7. Information and support
- Offer information to people who are at risk of delirium or who have delirium, and their family and/or carers, which:
- informs them that delirium is common and usually temporary
- describes people’s experience of delirium
- encourages people at risk and their families and/or carers to tell their healthcare team about any sudden changes or fluctuations in behavior
- encourages the person who has had delirium to share their experience of delirium with the healthcare professional during recovery
- advises the person of any support groups.
- Ensure that information provided meets the cultural, cognitive and language needs of the person.
To get more details about the guide line please visit