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Delirium

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. 


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.

  1. Alertness – whether the person is drowsy or agitated

  2. Awareness – whether the person is aware of, for example, the current year and where they are

  3. Attention – whether the person has the attention to, for example name the months of the year backwards from December

  4. 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 noise 

  • Providing familiar and reassuring objects and pictures (e.g. personal possessions, family photos)


Psychosocial interventions

  • Providing access to working hearing aids and clean glasses 

  • Promoting good sleep hygiene

  • Encouraging mobility 

  • 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. 

  • manage symptoms of delirium and perform a risk assessment.  Use PITCHED to help prevent, find and treat common delirium causes.

o   P - Pain 

o   I - Infection

o   T - Thirst 

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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