On this page
- Key messages
- Delirium symptoms develop quickly
- Delirium and ageing
- Risk factors for delirium
- Delirium and discharge planning
- Involve the patient, carers and other professionals
- Document the episode, patient status and medication
- Refer to community health and support services
- Preventing and managing delirium
- Preventing and managing delirium
Key messages
- Delirium is an acute disturbance in a person’s attention, awareness and cognition that can be caused by an acute medical condition or medication changes. Delirium is serious and may be the only sign of a deteriorating patient.
- Delirium should be treated as a medical emergency.
- Delirium is common in older patients, yet it is often overlooked, misdiagnosed and poorly managed. This can lead to the person experiencing falls, incontinence, malnutrition, dehydration, infections and pressure injuries.
- Delirium can often be prevented and can be treated and managed. As clinicians we must listen to the families of our patients when they tell us the person seems confused. If the person does not have family or friends visiting regularly, we need to be extra vigilant to detect changes in a person’s behaviour and investigate promptly. All team members are responsible for this and should feel confident to escalate their concerns.
- In addition to following health service policy and procedures, consider the recommended actions and discuss them with colleagues and managers.
“We must recognise and respond to delirium as we would any other medical emergency…[if we don’t] the outcome is as bad for older patients as if they experienced an acute myocardial infarct” (Geriatrician, Clinical Leadership Group on Care of Older People in Hospital)
Delirium is a serious condition where the person experiences a disturbance in attention, perception, awareness and cognition. Delirium may be caused by general medical conditions (for example, infections, hypoxia), certain medications, intoxicating substances or a combination of these.
Delirium develops quickly and symptoms fluctuate throughout the day. It usually lasts for a few days but may persist for weeks or even months in vulnerable older adults1,2. Delirium may be the only sign of medical illness or a rapidly deteriorating patient.
Delirium can be hyperactive, hypoactive (‘quiet’ delirium) or mixed. Hyperactive delirium is characterised by increased motor activity, restlessness, agitation, aggression, wandering, hyper alertness, hallucinations and delusions, and inappropriate behaviour. Hypoactive delirium is characterised by reduced motor activity, lethargy, withdrawal, drowsiness and staring into space. It is the most common delirium in older people. ‘Mixed’ delirium is where people have features of hyperactive and hypoactive delirium.
Delirium symptoms develop quickly
Delirium develops quickly, over hours or days, and symptoms fluctuate throughout the day and are often worse at night.
Symptoms include:
- difficulty directing, focusing, sustaining or shifting attention
- confusion
- fluctuating or reduced consciousness
- disorientation to time and place (particularly time)
- disturbance of the sleep-wake cycle, for example, agitated or restless at night and drowsy during the day
- impaired recent memory
- speech or language disturbances, for example, rambling speech
- increased or decreased psychomotor activity
- emotional disturbances, for example, fearfulness, irritability, anger, sadness
- hallucinations and delusions
- lethargy and fatigue.
Delirium and ageing
Studies have reported that:
- older patients in surgical, palliative care and intensive care settings experience the highest rates of delirium3
- patients may come to hospital with delirium or may develop delirium while in hospital4
- patients are frequently discharged from hospital with persisting symptoms of delirium5
- delirium is preventable in 30–40 per cent of cases5.
Older people who experience delirium are at greater risk of functional and cognitive decline, falls, hospital acquired infections, pressure injuries and incontinence. Delirium can cause longer lasting cognitive impairments in patients after surgery and may ‘lead to permanent cognitive decline and dementia in some patients’3. Delirium is also associated with higher mortality and morbidity, increased length of hospital stay and admission to residential care6,7.
Risk factors for delirium
A range of factors affects an older person’s risk of developing delirium in hospital. Some factors are predisposing, that is they are related to characteristics of the person; some are precipitating, that is they are related to the person’s illness or the hospital environment. Delirium involves an interaction between the patient’s predisposing vulnerabilities, which puts them at greater risk when faced with precipitating factors.
| Predisposing factors – related to the person | Precipitating factors – related to the illness or environment |
|---|---|
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Notes:
* Comorbidity can be measured using the Charlson Comorbidity Index.
** BUN:creatinine ratio is the ratio of blood urea nitrogen (BUN) to serum creatinine and is used to determine acute kidney problems or dehydration. In Australia, it is referred to as urea:creatinine ratio.
Delirium and discharge planning
After an episode of delirium in hospital, an older person’s cognitive function and ability to manage at home or in care may be impacted. To help patients make a smooth transition from the hospital to their home or care facility, consider how the patient will manage and how their family or carer will cope, and what services and supports are required. Discharge planning should be documented, include the patient, carers and other professionals, and incorporate referrals to community health and support services where required.
Involve the patient, carers and other professionals
- Involve the older person and their family or carer in discharge planning.
- Obtain recommendations from the treating team and allied health.
- Give the person and their family and carer written information about delirium and who to contact if they have any ongoing concerns.
- If the person is socially isolated, consider what extra supports they will require and how you can address these needs.
Document the episode, patient status and medication
The discharge summary paperwork to be provided to the GP should include:
- the patient’s episode of delirium, including details of persisting symptoms
- the person’s cognitive and functional status on discharge compared with their pre-morbid status
- any changes to their medication, including the reason for the change, possible side effects or drug interactions, how long the medication should be taken, and when it needs to be reviewed and by whom
- antipsychotics should be ceased unless there is good reason for their continuation; an ongoing evaluation and a plan to cease use should be included.
Refer to community health and support services
Describe the person’s need for monitoring and support by health professionals and other services in the community.
- The person’s GP will do the monitoring and follow-up, so provide test results and reports of all key and unresolved issues, including those needing further consideration or ongoing surveillance.
- Identify additional services needed and refer to inpatient or community health and support services.
Preventing and managing delirium
There are many things we can do to help older people and their families and carers understand, prevent and manage delirium. Here are some recommendations.
Preventing and managing delirium
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- Communicate effectively – use short sentences and ask single questions; use interpreters and liaison staff.
- Address sensory impairment – help patients wear their hearing and visual aids and check they are in good working order. Address reversible causes, such as impacted earwax.
- Give patients, their family and carers clear information about delirium. Explain the risk factors, what delirium is, the simple strategies that can prevent or manage delirium and how they can work with staff.
- Use a tool such as ‘This is me’, which has been adapted by some Victorian Hospitals and introduced as ‘A key to me’ or ‘About me’ to help reduce the older person’s agitation and improve their orientation and experience.
- Introduce the TOP5 Initiative, to encourage staff to:
- Talk to the carer
- Obtain the Information
- Personalise the care
- 5 Strategies developed.
“If we know the name of their football team or their granddaughter’s name it can help calm them – it doesn’t always work, but when it does work it’s really, really good.” (Nurse, Northern Health)
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- Provide orientation and reassurance - remind the person where they are, who you are and what time it is.
- Have large-font clock, calendars and signage on the ward.
- Light the room for that time of day.
- Promote cognitive stimulation, for example, talk about news or reminisce.
- Avoid room changes.
- Reduce environmental stimuli and invasive procedures to a minimum.
- Discourage daytime napping to aid night-time sleep.
- Encourage the family, carer and friends to be involved in patient care or to visit (if this is calming to the patient).
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- Encourage independence in activities of daily living and minimise risk of falls.
- Encourage movement - to reduce the risk of experiencing falls, developing pressure areas, constipation and incontinence, and to promote normal sleep patterns.
- For patients who use a walking aid - make sure it is accessible and that they use it.
- For patients unable to walk – encourage them to do in-bed (range of motion) exercise.
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- Encourage and help patients with eating and drinking to reduce the risk of constipation, dehydration and under-nutrition.
- Ensure dentures are well fitted and worn.
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- Avoid using mechanical restraints.
- Consider relaxation techniques, music or massage (this may also help with sleep).
- Avoid using indwelling catheters as they are a source of infection.
- Consider one-to-one nursing care, for example for patients at high risk of falls.
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- Ask the doctor or pharmacist to conduct a full medication review and reconciliation – they will consider the type and number of medications taken, including any sudden withdrawal of medications.
- Reducing, ceasing or avoiding the use of psychoactive drugs is recommended as they may worsen the delirium.
- Pharmacological therapy – should only be considered in severe cases of behavioural or emotional disturbance because there is no strong evidence they effectively improve prognosis. They may prolong the duration of the delirium and associated cognitive impairments or simply switch the patient’s delirium from hyperactive to hypoactive1. Always:
- document the indications for using and stopping use of antipsychotic medication in the patient’s medical history
- become familiar with the documented instructions regarding medication dosage, administration and the frequency with which a medical physician will review the patient’s status. It is recommended that only one antipsychotic medication is used at a time, start on a low dose, review frequently and use short term only.
- review the use and effectiveness of any medications regularly by monitoring the patient for over-sedation, postural hypotension and Parkinsonism. These adverse effects increase the risk for falls and pressure injuries and should be managed by dose reduction rather than addition of other medications. Escalate adverse reactions to the doctor or pharmacist.
- explain the rationale for starting or stopping any medications with the patient and their family and carer.
1. Inouye, S.K., R.G.J. Westendorp, and J.S. Sacznski, Delirium in elderly people. The Lancet, 2014. 383: p. 911-922.
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- Check for pain – conduct a pain screen or look for non-verbal cues if the patient cannot communicate.
- Ensure that pain relief is adequate and that a pain management plan is in place.
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- Orient the patient to the time.
- Keep the environment quiet, for example, use vibrating pagers rather than call bells.
- Keep lighting to a minimum.
- Schedule procedures, rounds and observations to avoid disturbing sleep.
- Give family or carers the option of staying overnight.
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1. Kiely, D., et al., Characteristics associated with delirium persistence among newly admitted post-acute facility patients. Journals of Gerontology Series A-Biological Sciences & Medical Sciences, 2004. 59(4): p. 344-9.
2. Dasgupta, M. and L.M. Hillier, Factors associated with prolonged delirium: a systematic review. International Psychogeriatrics, 2010. 22(3): p. 373-394.
3. Inouye, S.K., R.G.J. Westendorp, and J.S. Sacznski, Delirium in elderly people. The Lancet, 2014. 383: p. 911-922.
4. Travers, C., et al. Delirium in Australian Hospitals: A Prospective Study. Current Gerontology and Geriatics Research, 2013. 2013, 8.
5. Cole, M.G., Persistent delirium in older hospital patients. Curr Opin Psychiatry, 2010. 23(3): p. 250-254
6. Inouye, S., et al., Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study. Journal of General Internal Medicine, 1998. 13(4): p. 234-42.
7. Wass, S., P.J. Webster, and R.N. Balakrishnan, Delirium in the elderly: a review. Oman Medical Journal, 2008. 23(3): p. 150-157.
Reviewed 17 July 2024