- Five facts everyone should know about delirium
- An awareness of delirium is important when working with older people in hospitals. Why?
- What is delirium?
- Can I help prevent delirium?
- How can I recognise delirium?
- What can I do if I recognise an older person has delirium?
- Pharmacological management of delirium symptoms
- What are the care or management principles I should follow if an older person has delirium?
- What should I consider when planning discharge for a person with delirium?
- What can patients, families or carers do to help a person with delirium in hospital and at home?
- Case study
- Ten to 15 per cent of older people admitted to hospital are delirious at the time of admission, and a further five to 40 per cent are estimated to develop delirium while in hospital .
- In general medical units, approximately 20 per cent of older patients will experience delirium during their hospitalisation ; reported rates are higher in people undergoing cardiac or hip surgery [59, 60].
- Delirium in older hospitalised people is often overlooked or misdiagnosed due to limited staff knowledge of delirium features or a perception that all cognitive impairment is due to dementia [61, 62].
- Older people who experience delirium are at greater risk of falls, functional decline and cognitive decline. Delirium is also associated with higher mortality and morbidity, increased length of hospital stay and admission to residential care .
- Several studies have reported patients are frequently discharged from hospital with persisting symptoms of delirium .
A range of factors that can affect an older person's risk of developing delirium in hospital have been studied. Some factors are related to characteristics of the person (predisposing) and some are related to their current illness or the hospital environment (precipitating) .
Pre-existing cognitive impairment, for example, dementia
Age 70 years and older
History of alcohol abuse
Previous episode of delirium.
Addition of three or more medications during hospitalisation
Severe medical illness
Abnormal serum sodium
Use of indwelling catheter
Use of mechanical restraint.
Identifying and addressing an older person's predisposing risk on admission, and minimising exposure to precipitating risk factors during hospitalisation, can reduce the incidence of delirium .
Delirium is a transient mental disorder, characterised by a disturbance of consciousness with a reduced ability to focus, sustain or shift attention. It also involves a change in cognition (such as memory deficit) or the development of a perceptual disturbance. Delirium develops over a short period of time and the disturbance fl uctuates during the course of the day .
Delirium usually only lasts for a few days but symptoms may persist for weeks or even months .
Delirium may be divided into three 'subtypes', which refer to the level of psychomotor activity or arousal . These subtypes include:
- Hyperactive - Characterised by increased motor activity, restlessness, agitation, hallucinations and delusions and inappropriate behaviour.
- Hypoactive or 'quiet' delirium - Characterised by reduced motor activity, lethargy, withdrawal, drowsiness and staring into space.
- The 'mixed' subtype shows alternating features of the other two forms.
Hypoactive delirium is the most common presentation in older people and can
be mistaken for a lack of motivation, dementia or depression .
A range of strategies to prevent delirium and manage delirium symptoms have been studied .
The following strategies may help to prevent delirium in the older person:
Provide orienting information (for example, the name and role of staff members, large font clock and calendar).
Encourage family or carer and friends to visit and be involved in patient care.
Promote relaxation and sufficient sleep and discourage daytime napping.
Promote cognitive stimulation.
Ensure that pain relief is adequate.
Avoid room changes (may increase disorientation).
Avoid use of indwelling catheters.
The Yale Delirium Prevention Trial was the first controlled clinical trial to demonstrate that delirium could be prevented in older hospitalised people [66, 73]. The program included interventions, delivered by highly trained and supervised volunteers, to address six modifi able risk factors for delirium: cognitive impairment, sleep deprivation, immobility, vision and hearing impairment and dehydration. A significant reduction in both the incidence and duration of delirium was demonstrated in those people who received the intervention. More recently, the program has become known as the Hospital Elder Life Program (HELP) and has been widely implemented in the United States [73, 74].
The HELP program has been adapted to the Australian health care setting, in the Recruitment of Volunteers to Improve Vitality in the Elderly (ReViVe) program, at the Prince of Wales Hospital in Sydney, and has shown similarly promising results .
It is important to establish the role of the family or carers in identifying delirium. It is often a family member or carer who first notices a change in an older person's cognition or behaviour.
Symptoms of delirium fluctuate through the course of the day and are often worse at night. Symptoms include:
- Difficulty focusing, sustaining or shifting attention.
- Disturbance of the sleep-wake cycle, for example, agitated or restless at night and drowsy during the day.
- Disorientation to place and time.
- Recent memory may be impaired.
- Speech or language disturbances, for example, rambling speech.
- Increased or decreased psychomotor activity.
- Emotional disturbances, for example, fearfulness, irritability, anger, sadness.
- Hallucinations and delusions.
For further information refer to the following sections:
- Delirium detection and diagnosis
- Screening for cognitive impairment
- Cognitive assessment tools
- Differential diagnosis.
Delirium detection and diagnosis
The Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) criteria  is the 'gold standard' for delirium diagnosis. A number of delirium screening or diagnostic tools have been developed based on the DSM-IV criteria.
The Confusion Assessment Method (CAM) has been the most widely studied delirium diagnostic tool and enables non-psychiatrically trained clinicians to quickly detect delirium in a range of settings :
- The CAM diagnostic algorithm comprises the four cardinal delirium features: (1) acute onset and fl uctuating course, (2) inattention, (3) disorganised thinking, and (4) altered level of consciousness.
- A diagnosis of delirium, according to the CAM algorithm, requires that both the fi rst and second criteria are present, and either the third or fourth.
Delirium assessment tools:
Screening for cognitive impairment
The detection of delirium in older hospitalised people may be improved by implementing a delirium screening protocol in high-risk settings (for example, cardiac and orthopaedic surgery). This might involve a formal cognitive assessment on admission (using a validated cognitive assessment tool) and regular repeated cognitive assessments. If evidence of deterioration in an older person's cognitive status were detected, this would lead to the use of a delirium assessment tool (for example, CAM).
An older person's cognitive status should be formally assessed on admission to settings even where there is a lower risk of developing delirium. If cognition is impaired, the onset of the impairment should be established as it may be due to delirium (refer to Differential diagnosis). Pre-existing cognitive impairment is a major risk factor for the development of delirium.
Cognitive assessment tools
The most commonly used cognitive assessment tools are the Mini Mental-State Examination (MMSE) and the Abbreviated Mental Test (AMT). The MMSE has been criticised for its lack of sensitivity to mild cognitive impairment and the Modified Mini Mental-State Examination (3MS) was specifi cally developed to address this limitation.
Cognitive assessment tools have also been criticised for failing to take into account educational level, literacy and English proficiency, and tools such as the Mini-Cog and the Rowland Universal Dementia Assessment Scale (RUDAS) have been developed for use with people from culturally and linguistically diverse backgrounds.
The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) is completed by someone who knows the person being assessed well. Informant-based questionnaires provide complementary information on a person's cognitive status and may be used in situations where testing a person's cognition is difficult due to illness, dysphasia or literacy deficit.
To provide appropriate care, clinicians must be able to differentiate between changes in mental status due to dementia, and those related to an acute health condition.
Refer to Differentiating the 3D's - Dementia, Delirium, and Depression, for a comparison of characteristic features.
Further information, tools and educational resources on differential diagnosis include:
The first step in delirium management is to identify and treat the cause or causes . This involves:
Collating recent medical history (for example, a change in cognition, medication changes, dietary intake, falls, bowel and bladder function).
Physical examination (for example, vital signs, mental status).
Investigations (for example, urinalysis, full blood examination, chest x-ray).
Attention should also be given to the relief of symptoms associated with delirium. There is considerable overlap between strategies to prevent delirium and strategies to manage the symptoms [99, 100]:
Provide reorientation and reassurance when attending to the patients' needs.
Use simple language and ask single questions.
Educate the patient (where possible) and their family or carer about delirium.
Encourage the patient's family or carer and friends to be involved in their care, if this is calming to the patient.
Ensure that pain relief is adequate.
Encourage independence in activities of daily living.
Minimise environmental injury risks (for example, use of high-low bed in lowest position).
Avoid mechanical restraints - these may increase agitation, injury-risk and functional decline .
Institute relaxation strategies to assist with normalising sleep patterns.
Consider the need for specialised one-to-one nursing care (for example, if the patient is at high risk of falls).
Optimise communication (for example, use interpreters and liaison staff).
For more information on models of care for the prevention and management of delirium, refer to Models of care for the prevention and management of delirium.
For further information, tools and educational resources on the management of delirium, refer to:
Pharmacological therapy for the management of delirium symptoms should be reserved for persons experiencing severe behavioural or emotional disturbance .
A 'severe behavioural or emotional disturbance' may be defined as one that threatens the person's own safety or the safety of others, interferes with essential medical or nursing care or causes significant distress to the person experiencing it [106, 107].
- The indication(s) for use of the medication should be documented in their medical history and reviewed regularly.
- Only one antipsychotic medication should be used at a time.
- The patient should be started on a low dose of antipsychotic medication.
- The patient should be reviewed frequently and medication dosage increased incrementally, if necessary, to achieve relief of symptoms.
- Prescription of antipsychotic medication should be accompanied by instructions regarding medication dosage and administration and the frequency with which a medical physician should review the patient's status [47, 82, 92, 93].
Further information and tools on pharmacological management of delirium include:
All health care settings should consider implementing a structured approach to screen for delirium in older people.
The approach taken will depend on the level of risk for the development of delirium in each setting (See Screening for cognitive impairment).
Modifiable risk factors for the development of delirium in older persons should be addressed:
Avoid indwelling catheters.
Avoid mechanical restraints.
Ensure people who wear visual and hearing aids are assisted to use them.
Avoid frequent room changes.
Any sudden change or decline in an older person's cognition, behaviour or self-care ability is indicative of delirium and should be investigated.
Delirium in the older person is typically caused by an acute health condition, which requires prompt investigation and treatment.
Ensure that older people receive adequate pain relief.
Employ environmental, behavioural and social strategies to manage the symptoms of delirium.
Increase staff knowledge and awareness about delirium.
Orientation and cognitive enhancement strategies should be utilised to help minimise confusion in the older person, provide:
- Regular orientation to person, place and time.
- A large font clock and calendar in patient areas.
- Lighting appropriate to the time of day.
- Cognitively stimulating activities (for example, newspaper discussion, exercise group).
Employ overnight strategies that promote sleep and assist with orientation to time.
Maintain a quiet environment (for example, use vibrating pagers rather than call bell).
Keep lighting to a minimum.
Delay non-essential observations or treatments if the person is asleep.
An older person's cognitive function and ability to manage at home may decline following an episode of delirium in hospital.
The older person may require a period of rehabilitation before returning home or community services support upon their discharge to home.
Regardless of whether an older person is returning to their own home or to residential care, the following points provide a checklist for discharge planning:
Document the episode of delirium in the patient's discharge summary, including details of any persisting symptoms.
Document any follow-up or monitoring to be completed by the older person's GP.
Consider the older person's need for additional support, for example, referral to inpatient or community services.
Provide written information about delirium to people who have experienced it and their family or carers (for example, a consumer brochure about delirium).
Ensure the older person and their family or carers are aware of who to contact should they have any ongoing concerns.
Consider the older person's need for post-delirium counselling .
Further information, tools and educational resources for planning discharge include:
The following points may assist family members or carers help care for an older person who is at risk of developing delirium:
Having some familiar things around can be comforting (for example, family photos, own dressing gown, a blanket for the bed).
People can lose track of time in hospital. It may help to gently remind the older person about the time of day, the day of the week and the month. You could also talk about where the older person is, and why.
Let staff know if you notice that your relative/spouse/friend seems more confused than usual, or is experiencing memory problems.
The following points may assist family or carers help with the care of an older person experiencing delirium:
- People with delirium find it reassuring to see familiar people. Visit as often as possible, however, it is preferable to have fewer visitors over a longer period of time, so it may help to work out a 'visiting' roster with family members or friends.
- Speak slowly in a clear voice.
- Tell the person your name and call them by name, it may help them focus their attention.
- Remind the person where they are, and what day and time it is.
- Open the curtains in the room.
- If the person wears glasses or hearing aids, help them put them on.
- If the person is agitated or aggressive, do not try to restrict their movements, it may make things worse.
- Sometimes people see or hear things that aren't real when they have delirium. Don't argue about details; focus on the person's feelings and reassure them.
- Let staff know any personal information that may help calm and orient someone with delirium, for example, names of family and friends, favourite music or significant life events.
For further information, tools and resources refer to:
Mr Schwartz is an 82 year old man, who wears glasses and has some hearing loss. Mr Schwartz had a fall at home while changing a light bulb and his neighbour, who heard his calls for help, found him on the floor and called an ambulance. He was taken to hospital, where an x-ray revealed that he had a fractured neck of femur.
Prior to his presentation at the emergency department (ED), Mr Schwartz was living alone at home independently.
Following surgery to repair the fracture Mr Schwartz was admitted to the orthopaedic ward. His pain was managed with regular paracetamol and codeine . The IDC was removed the following morning . He was referred to physiotherapy for mobilisation and rehabilitation .
Two days later, the physiotherapist found Mr Schwartz was difficult to rouse during the middle of the afternoon. She documented in Mr Schwartz's history that he was unable to participate in physiotherapy due to his sleepy state .
When Mr Schwartz's daughter visited later that day, she found that he had not eaten any of his evening meal. He seemed confused and unable to keep track of their conversation. She was very concerned about her father's deterioration and mentioned it to the nurse who was looking after him. The nurse, who had only met Mr Schwartz that afternoon, told his daughter that it was not uncommon for older people to be a 'bit confused' for a couple of days after having an anaesthetic .
The next afternoon when Mr Schwartz's daughter visited, he was less responsive than the day before. He was in bed and seemed unaware of her presence; staring into space. She spoke to the nurse who took a set of observations (temperature, pulse, respirations, blood pressure and oxygen saturation) and tested Mr Schwartz's urine, which showed signs of infection.
The nurse notified the medical registrar who reviewed Mr Schwartz and diagnosed delirium and prescribed antibiotics to treat the infection. On further investigation, Mr Schwartz was also found to be constipated and a bowel management regimen was developed.
As his confusion reduced and his activity levels improved, Mr Schwartz resumed physiotherapy and was referred to occupational therapy for assistance in regaining his independence with self-care and transfers.
After another week on the ward, Mr Schwartz was much improved and he was able to ambulate 25 metres with a frame and supervision. A referral was made to the Triage Rehabilitation and Aged Care (TRAC) team who recommended ongoing rehabilitation in a Geriatric Evaluation and Management (GEM) unit.
The following strategies from The toolkit were utilised:
Establish the patient's cognitive function at admission by performing a cognitive assessment, using a validated instrument.
Identification and management of risk factors associated with the development of delirium in older people (for example, indwelling catheters, constipation, infection).
Identification and investigation of signs and symptoms of delirium (for example, decline in function, change in cognition, alertness, perception or attention).
Knowledge and awareness that confusion is not a normal part of ageing.
Interdisciplinary communication and documentation.
The nurse, who had only met Mr Schwartz that afternoon, referred back to Mr Schwartz's notes from the ED and noted the decline in his cognitive function. He took a set of observations (temperature, pulse, respirations, blood pressure and oxygen saturation) and tested Mr Schwartz's urine, which showed signs of infection.
As Mr Schwartz's confusion resolved and his activity levels improved, he resumed physiotherapy. He was also referred to the unit's Functional Maintenance Program (FMP), where an Allied Health Assistant assisted him with regaining his independence with selfcare, transfers and mobility.
Once Mr Schwartz was able to ambulate 25 metres with a frame and supervision, a referral was made to the Triage Rehabilitation and Aged Care (TRAC) team. TRAC recommended ongoing rehabilitation in a Geriatric Evaluation and Management (GEM) unit to ensure Mr Schwartz regained his premorbid level of independence prior to discharge home.
Fick, D. and Mion, L., 2008, 'Delirium superimposed on dementia', American Journal of Nursing, Volume 108(1), pp. 52-60.
Forrest, J., et al, 2007, 'Recognising quiet delirium', American Journal of Nursing, Volume 107(4), pp. 35-39.
Gillis, A. and MacDonald, B, 2006, 'Unmasking delirium', The Canadian Nurse, Volume 102(9), pp. 19-24.
Hart, B., Birkas, J., Lachman, M. and Saunders, L., 2002, 'Promoting positive outcomes for elderly persons in hospital: prevention and risk factor modification', AACN Clinical Issues, Volume 13(1), pp. 22-33.
Wahland, L.O., and Armanius Bjorlin, G., 1999, 'Delirium in clinical practice: Experiences from a specialised delirium ward', Dementia and Geriatric Cognitive Disorders, Volume 10(5), pp.389-392.
Palliative care and delirium
- Guidelines for a palliative approach in residential aged care 
- Medical Care of the Dying . The Victoria Hospice Society in Canada published the 4th edition of this textbook in 2006. Refer to an excerpt from the chapter on Confusion, delirium, and dementia in palliative care.
Alcohol withdrawal delirium
- Management of alcohol withdrawal delirium. An evidence-based practice guideline .