Recognising, symptoms, screening, preventing, managing delirium
This information is drawn from a self-paced course available on the Dementia Training Australia website: https://dta.com.au. Search for Decoding Delirium
Recognising Delirium

A delirium is a serious medical condition producing sudden and often severe changes in a person’s mental function, which are different to their usual function. While changes are acute, they also fluctuate - they vary and may come and go. The person typically has difficulty thinking clearly, maintaining focus or attention, and may appear confused or disorientated. They may also display changes in their usual behaviour and sleep patterns.  Delirium occurs quickly, over a period of hours or days, and may signal serious underlying illness, injury, or infection. Medical conditions such as pain, constipation and dehydration can also trigger delirium.
Older people are at a higher risk of developing delirium, but it can occur at any age including in children. Delirium is often seen in older people in hospitals (e.g. up to one-third of older people (aged 65 and older) have delirium when they are admitted to hospital) . Delirium is also common in people living in aged care (prevalence of 10% to 30% in Australia) and can occur in people living at home in the community, especially those older than 85 years and/or with dementia.
Key features of delirium
Cognition: ·      worsened concentration ·      slow responses ·      confusion ·      reduced awareness ·      difficulty recalling words | Perception: ·      visual or auditory hallucinations ·      delusions  | Physical function: ·      reduced mobility ·      reduced movement ·      restlessness ·      agitation ·      changes in appetite ·      sleep disturbance |
Social Behaviour: ·      lack of co-operation with reasonable requests ·      withdrawal ·      alterations in communication, mood, or attitude paranoia, anxiety |
Symptoms
Sudden changes in behaviour and new psychological symptoms may be a sign that the person is experiencing delirium. Symptoms of delirium involve abnormal changes in the person’s mental state and always involve changes in their level of consciousness and thinking, such as being unable to maintain focus or pay attention.Â
The person may appear agitated or restless (hyperactive delirium) due to increased psychomotor activity or they may appear sleepy, lethargic, and withdrawn (hypoactive delirium).
Common delirium symptoms
False beliefs or delusions, e.g. thinking staff are poisoning you
Appears confused and forgetful, e.g. don’t know what has happened and what is going on
Visual hallucinations, e.g. see spiders on the bedsheets and scary figures in the room
Hypo-alert / changed sleeping patterns, e.g. drowsy, speech is irregular
Disoriented to time or place, e.g. don’t know where he is
Hyper-alert, upset, irritable, afraid, angry, e.g. so aggressive staff have to call security
Screening for delirium
In hospitals, all people aged 65 or older and Indigenous people aged 45 and over should be routinely screened to detect cognitive impairment - including delirium - on presentation to hospital using a validated tool, such as the 4AT. The 4AT measures the following attributes of a person.
Alertness – whether the person is drowsy or agitated
Awareness – whether the person is aware of, for example, the current year and where they are
Attention – whether the person has the attention to, for example name the months of the year backwards from December
Acute change or fluctuating course – whether the person’s symptoms started suddenly or are now coming and going
Detailed information about the 4AT is available at https://www.the4at.com/.
Preventing Delirium
Hospital and residential aged care staff should assess people at risk for delirium within 24 hours of admission. Based on the results of this assessment, staff may need to provide clinical management, environmental changes and psychosocial interventions.
Clinical management
Reducing the use of psychoactive drugs
Appropriate pain management
Maintaining adequate hydration and nutrition
Maintaining bladder and bowel function
Avoiding the use of physical restraints (e.g., bed rails, catheters)
Environmental changes
Re-orientating to time, place and person (e.g., clocks and calendars, signage)
Limiting room changes
Providing a calm environment with reduced noiseÂ
Providing familiar and reassuring objects and pictures (e.g. personal possessions, family photos)
Psychosocial interventions
Providing access to working hearing aids and clean glassesÂ
Promoting good sleep hygiene
Encouraging mobilityÂ
Providing consistent routines
Involving families and friends in care
Managing Delirium
If a person is diagnosed with delirium, the responsible staff need to identify, treat, and manage the possible underlying cause or combination of causes. For example, if a chest infection is causing delirium, antibiotics will be commenced; if dehydration is a cause, additional fluids will be given. It is important to:
identify the underlying causes by examining or obtaining (e.g. from family) the patient’s history
address the underlying causes and/or precipitating factors using the preventative measures above.Â
manage symptoms of delirium and perform a risk assessment. Use PITCHED to help prevent, find and treat common delirium causes.
o  P - PainÂ
o  I - Infection
o  T - ThirstÂ
o  C - Constipation
o  H - Hunger/Hypoxia
o  E - Environment
o  D – Drugs
o  See Appendix A for a more detailed outline of the PITCHED process
provide supportive and person-centred care
prevent adverse events and complications (e.g., falls and pressure sores)
educate family and carers
continue to assess and monitor.
Appendix 1


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