NICE Delirium Guidelines

Catherine PlowrightConsultant Nurse Critical CareSeptember 2010

• Full title– Delirium: diagnosis, prevention and

management

• Draft was out for consultation November 2009 to January 2010

• Published July

• There is a significant burden associated with this condition. Compared with people who do not develop delirium, people who develop delirium may:

• need to stay longer in hospital or in critical care

• have an increased incidence of dementia • have more hospital-acquired complications,

such as falls and pressure sores • be more likely to need to be admitted to

long-term care if they are in hospital • be more likely to die.

• Delirium is a common but complex clinical syndrome associated with poor outcomes

• It can be prevented and treated

• How many of your formally assess your patients?

Key priorities for implementation

Risk factor assessment• When people first present to hospital or

long-term care, assess them for the following risk factors:

• Age 65 years or older

• Cognitive impairment: – A previous history of cognitive

impairment– Or if cognitive impairment is suspected,

confirm it using a standardised and validated cognitive impairment measure

• Current hip fracture

• Severe illness (a clinical condition that is deteriorating or is at risk of deterioration)

• If any of above risk factors are present, the person is considered to be at risk

Indicators of prevalent delirium

• Assess people at risk for indicators of delirium, which are sudden changes or fluctuations in usual behaviour.

• These may be reported by the person at risk, or a carer or relative.

The changes may be in any of the following:

• 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 behaviour– for example, poor cooperation,

withdrawal, or alterations in communication, mood and/or attitude.

If any of these indicators 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.

Diagnosis of delirium

• Carry out a clinical assessment using the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria or short Confusion Assessment Method (short CAM)

• In critical care or in the recovery room after surgery, CAM-ICU should be used

Sedation & Delirium Assessments

• Step 1

RASS score

+4 Combative

+3 Very agitated

+2 Agitated

+1 Restless

0 Alert & Calm

-1 Drowsy

-2 Light sedation

-3 Moderate sedation

-4 Deep sedation

-5 Unrousable

• RASS– If RASS is -4 or -5 then stop and

reassess patient at a later time– If RASS is above -4 the proceed to Step

2

Step 2

Acute onset of mental status changes or a fluctuating course

Inattention

Disorganised thinking Altered level of consciousness

= DELIRIUM

AND

AND

OR

• This is positive if either question is answered as YES

1) is there an acute change from mental status baseline

2) Did the patient's mental status fluctuate during the last 24 hours

Acute onset of mental status changes or a fluctuating course

Step 2Acute onset of mental status changes

or a fluctuating course

Inattention

AND

• Feature is positive if Attention Screening Examination (ASE) is <8

• SAVEAHAART– Tell the patient you are going to say a

series of letters and ask them to squeeze your hand every time you say an “A”

Inattention

Step 2Acute onset of mental status changes

or a fluctuating course

Inattention

Disorganised thinking

AND

• This is positive if the combined questions & command score is <4

Disorganised thinking

1 point for each correct answer – use only 1 set of questions at a time

• Will a stone float on water?

• Are there fish in the sea?

• Does 1 pound weigh more than 2 pounds?

• Can you use a hammer to pound a nail/

• Will a leaf float on water?

• Are there elephants in the sea?

• Do 2 pounds weigh more that one

• Can you use a hammer to cut wood?

Command

• Tell the patient • “Hold up this many fingers”• “Now do the same with the other

hand”

• Patient scores a point if able to complete the whole command

Step 2Acute onset of mental status changes

or a fluctuating course

Inattention

Disorganised thinking Altered level of consciousness

= DELIRIUM

AND

AND

OR

• Feature is positive if patients current of consciousness is anything other that ALERT i.e. RASS not 0

Altered level of consciousness

• Within 24 hours of admission, assess for clinical indicators contributing to delirium

• Assess patients at least daily

• Based on this assessment, provide a multicomponent intervention package tailored to the person’s individual needs and care setting.

Interventions to prevent delirium

• Ensure that people at risk of delirium have a care environment that:

• Avoids unnecessary room changes

• Maintain a team of healthcare professionals who are familiar to the person at risk

Interventions to prevent delirium

• Orientate patients– Soft lights– 24 hour clock and calendar– Regular visits from family and friends

• Prevent dehydration and / or constipation • Prevent / reduce infections

– Avoid unnecessary catheterisation

Interventions to prevent delirium

• Pain control – use analgesia• Reduce polypharmacy effects• Prevent poor nutrition• Reduce immobility by mobilising early• Ensure hearing aids and glasses are there• Sleep

Non-pharmacological interventions

• In people diagnosed with delirium, identify and manage the possible underlying cause / causes

• Ensure effective communication and reorientation and provide reassurance for people diagnosed with delirium.

• Family, friends and carers may be able to help with this.

Pharmacological interventions

• If non-pharmacological approaches are ineffective, consider giving short-term (for 1 week or less) haloperidol or olanzapine if people with delirium are distressed or a risk to themselves or others

Information giving & support • Give information to people who are at risk

of delirium or who have it, and to their families and carers which:

• Describes people’s experience of delirium • Informs them that the experience of

delirium is common and is usually temporary

• Encourages people at risk and their families and/or carers to tell their healthcare team about any sudden changes or fluctuations in usual behaviour

• Encourages the person with delirium to share their experiences during recovery with the healthcare professional.

• Ensure that information provided meets the cultural, linguistic,

Research recommendations

• Pharmacological prevention

• Pharmacological treatment

• Multi component intervention

• Delirium in long-term care

• Education programme

Catherine.plowright@nhs.net