Early IdentificationDelirium on andIdentification

Early
general Management
hospital wards: and Management of of NCPS
Delirium in the Emergency Delirium
identifying patients at risk, deliriumin the
screeningEmergency
and
Department/
next Department/
steps
Acute Medical Assessment
to your ward Unit
COLOUR VERSION

This algorithm is not intended for delirium due to

Patient is admitted
Acute Medical Assessment
Identify the patient at risk of delirium
Unit This algorithm
Patient is already is for use
diagnosed as only
havingin adults,
delirium and is not intended for
in ED/AMAU
delirium due to alcohol or drug intoxication/ withdrawal.
DELIRIUM is an acute change in cognitive function that has an organic cause and is likely to be reversible or preventable
alcohol or drug intoxication/ withdrawal

Age over 65 years or any one of: Check ED/AMAU 4-AT score; YES Delirium Screening is Positive
NO
DELIRIUM is an
- Pre-existing acute
cognitive change
impairment e.g. mildin cognitiveHas
function
All that
this patient possible
Older Adults (≥ 65)has an organic
delirium?
presenting cause
to ED/AMAU: and is likely to4AT
 Document result
beRapid
reversible or for
Clinical Test preventable.
Delirium
cognitive impairment, or dementia, or 4-AT 1-3
- Previous delirium
screen for delirium using 4AT at triage or first contactafter triage
Contact the treating team for a formal
1. Alertness
RCSI DEVELOPING HEALTHCARE LEADERS WHO MAKE A DIFFERENCE WORLDWIDE

All Older Adults (≥ 65) presenting to ED/AMAU:

- Other brain disorders (e.g. head injury, stroke,
Parkinson’s Disease)
Screening for Delirium
delirium assessment today
4AT Rapid Clinical Test for Delirium
Normal (fully alert, but not agitated throughout
screen for delirium using 4AT at triage or first contact after triage Result of 4AT (Collateral history necessary) assessment) 0
- Functional dependence or frailty 1. Complete 4-AT on admission to the Mild(see
sleepiness for box)
<10 seconds after
≥ 4: Probable delirium
ward for all +/- cognitive
patients at risk impairment
of delirium  Assess for possible causes of delirium PINCH ME
 Identify and 1.
treatAlertness
- Poor mobility Waking but then normal 0
1-3: Possible2.cognitive impairment all possible risks/precipitants
- Poor nutrition
- Visual or hearing impairment
Screen at risk patients daily for
0 : Deliriumdelirium.
or severe Thecognitive impairment
screening tool unlikely
used will vary
 Reassess Normal (fully alert, but not agitated throughout 4
for resolution/persistence Clearly
every abnormal
24-48 hours
 Monitor symptoms using behaviour chart (as per local protocol)
- Depression Result of 4AT (Collateral history necessary) per local protocol. assessment) 2. AMT4 (Age, date of birth, place (name of 0
No evidence of delirium (4AT 0-3) Suspected Delirium  Once(4AT ≥4):
resolved, resume daily screening for reoccurrence
hospital), current year)
- Major trauma / Post-operative
≥ 4 : -Probable delirium +/- cognitiveNBimpairment
Recommended screening tools include: Mild sleepiness
 Follow local protocol for accessing expert for <10
deliriumseconds
assessmentafter waking
Multiple co-morbid illnesses
Collateral history
- 4-AT necessary to
(www.the4at.com) This is a medical emergency No mistakes 0
1-3 : Possible cognitive impairment derive this(Recognising
- RADAR score Acute Delirium As but then normal
1 mistake 01
- Severe medical illness or infection (NEWS ≥6) Assessing for Potential Causes
 Proceed withpart of your Routine)
admission/discharge Flag for Urgent Medical Review
Clearly abnormal ≥ 2of Delirium:
mistakes/ ‘PINCH ME’
untestable 42
0 : -Delirium or severe
Urea and electrolyte cognitive impairment
imbalance
-unlikely
SQID (Single Question in Delirium) P – Is the person in pain? Has urinary retention been excluded?
- Alcohol or substance misuse  If 4AT score is 1-3: ensure - Discuss diagnosis with senior doctor 3. Attention
3. Document delirium status each day in IN – Infection: is there a possible infection? Refer (months of year backwards)
to sepsis pathway
- Polypharmacy and / or high risk medications documentation of cognitive status. and/or nurse in ED/AMAUas appropriate 2. AMT4
(link overleaf) (Age, date
Achieves of birth,
7 months orplace (name of
more correctly 0
the care plan or specific delirium
(e.g. benzodiazepines) Person may have undiagnosed
No evidence of delirium dementia
Suspected Delirium (4AT ≥4):
recording tool (e.g. end-of-bed file). - Discuss diagnosis with carer/ relative
C – Constipation:hospital),
When wascurrent Starts but
year)
the last bowel scores
movement? <7
Untestable (too unwell, drowsy, inattentive)
1
2
and patient as appropriate H – HydrationNo / Nutrition: is there major electrolyte imbalance? Has
(4AT 0-3) mistakes 0
 See reverse side for dementia/ hypoxia,
- Assess for possible Causes of Deliriumhypotension, hypoglycaemia been considered?
4.Acute Change or Fluctuating Symptoms 1
This is a medical emergency
cognitive vulnerability pathway for screening
Delirium negative
Ensure
M – Medication:
admittingmedication?
team know that
1 mistake
omission of regular medication or addition of new
(need collateral history)
NB CollateralStrategies for delirium
history prevention
necessary to &ED / AMAU
management  Daily screening, see box above delirium is Esuspected
≥ 2 mistakes/ untestable No 02
– Environment: change of environment, Yes noise or activity levels 4
- Avoidderive
new sedatives
this score Flag for
 Assess for delirium risks: those Urgent
 ContinueMedical
to address Review
risk factors
Delirium has a high mortality. impacting Most patients
sleep/ rest?
- Avoid restraint (physical and chemical) with any• riskDiscuss
factors should
diagnosis havewith senior will need doctor
admission. Only discharge 3. after
Attention (months Total
of year backwards) ______
- Avoid use of urinary catheters where possible regular screening for delirium. discussion with a senior colleague.
Achieves 7 months or more correctly 0
• Proceed with admission/discharge and/or nurse in ED/AMAU
- Ensure adequate fluids/nutrition and access to drinks/snacks Extra tips for caring for the patient with possible or proven delirium <7
• If 4AT score is 1-3: ensure • Discuss diagnosis with carer/ relative Starts but scores 1
- Avoid constipation
 Explain gently what is happening Untestable (too unwell,
Identify thedrowsy,
patient atinattentive)
risk of delirium 2
documentation
- Provide own hearing ofaids
cognitive
and glasses and patient as appropriate
Highlight to shift leader/ patient flow liaison to source urgent bed
 Smile and make eye contact to reassure
- Promote relaxation and sufficient sleep in a quiet area •
status. Person may have Assess Thisfor possible
patient will
Consider causes
require of care
enhanced
enhanced delirium
supervision by a in
while
(i.e. “special”) ED,
staff Age over 65 years
due totrained in dementia/delirium
member supportor any one of the following:
- Regular re-orientation increased risk of falls, dehydration,
 Encourage familiar faces and and family error 4. Acute Change
medication
– staff or Fluctuating
- Pre-existing Symptoms
cognitive impairment (e.g. mild
undiagnosed dementia
- Encourage and assist early and regular mobilisation cognitive impairment or dementia)
• See- Encourage/
reverseallow sidefamily
formembers/
dementia/ Ensure admitting  Limit ward
team andknow
bed moves that (need collateral- Previous history)delirium
carers to stay with the patient  Use medications to manage symptoms of delirium rarely and always with senior decision-maker input
Strategies for delirium delirium prevention/management
is suspected in ED / AMAU No - Otherreason
brain disorders 0
cognitive
- Encourage vulnerability
independence with pathway
activites of daily living  Communicate with family and carers, offer patient information leaflet, discuss for ‘special’(e.g. head injury, stroke,
for- EDAssess for and manage any pain; use dementia
/ AMAU friendly new
- Avoid pain score
sedatives  Record delirium on the discharge letter to the GP Yesand follow-up according to local protocol.
Parkinson’s Disease) 4
where applicable e.g. PAINAD/ Abbey Pain Scale - Functional dependence or frailty
• Assess for delirium risks: those Delirium has a high
- Avoid restraint (physical and chemical) mortality. Most patients - Poor mobility
- Medication review by team
willof need
with any risk factors should have - Avoid use urinaryadmission. Only
catheters where discharge after
possible
Total
Note: Clinical algorithms are for reference only and do not replace clinical judgement
- Poor nutrition ______
regular screening for delirium. discussion with a senior colleague.
- Ensure adequate fluids/nutrition and access to drinks/snacks
- Visual or hearing impairment
- Depression
- Avoid constipation Identify the patient at risk of delirium - Major trauma
- Promote relaxation and sufficient sleep in a quiet area - Multiple co-morbid illnesses
Age over 65 ye ars ormedical
- Severe any oneillnessof the following:
or infection (NEWS ≥6)
- Encourage
Highlight to shift leader/ and flow
patient assistliaison
early and
toregular
sourcemobilisation
urgent bed
- Provide own hearing aids and glasses • Pre-existing
- cognitive
Urea and impairment
electrolyte imbalance (e.g. mild cognitive
This patient will require enhanced supervision while in ED, due to impairment-- Alcohol
or or substance misuse
dementia)
- Encourage/
increased risk of falls, allow family
dehydration, andmembers/ carerserror.
medication to stay with the patient Polypharmacy and / or high risk medications
(e.g. benzodiazepines)
• Previous delirium
- Encourage independence with activities of daily living (toileting/washing)
- Assess for and manage any pain; use dementia friendly pain score where • Other brain disorders (e.g. head injury, str
applicable e.g. PAINAD/ Abbey Pain Scale Parkinson’s Assess
Disease) for Potential Causes of Delirium:
Strategies for delirium prevention/management
- Medication review in ED/AMAU • Functional dependence‘PINCH ME’
or frailty
• Avoid new sedatives • Poor mobilityP – Is the person in pain? Has urinary
• Managing someone with delirium who is distressed and/or combative,
Avoid restraint (physical and chemical) retention been excluded?
• Poor nutrition
and felt to be a threat to themselves or others
• Avoid use of urinary catheters where IN – Infection: is there a possible infection?
The possible
management of delirium is primarily NON PHARMALOGICIAL. • Visual or hearing impairment
• Ensure adequate fluids/nutrition and access to drinks/snacks • Depression Refer to sepsis pathway as appropriate (link
ALWAYS try to de-escalate the situation first. Explain what is happening, re orientate, try to overleaf)
• Avoid constipation nurse in a quiet area, consider need for one to one care. • Major trauma/Hip fracture
C – Constipation: When was the last bowel
• Promote relaxation and sufficient sleep in a quiet area • Multiple co-morbid illnesses
1. The evidence for the benefit of antipsychotics in treating delirium is very weak. If movement?
• Encourage and assist early and regular mobilisation
emergency treatment with medication is needed because the patient or others • areSevere
at medical illness or infection (INEWS ≥4 or ≥5 on
H – Hydration/ nutrition: is there major
• Provide own hearing aids and glasses • oxygen) electrolyte imbalance? Has hypoxia,
immediate risk and/or urgent care is compromised, low dose ORAL antipsychotic medication
• Encourage/ allow family members/is preferred. Small doses should be given e.g. Haloperidal (0.5 -1mg), Quetiapine (12.5 -
carers
25mg), to stay(2.5mg),
Olanzapine with the patient
Risperidone (0.5mg) Urea and electrolyte
hypotension, hypoglycaemia been
imbalance
• Encourage independence with activities of daily
- Avoid living (toileting/washing)
antipsychotics in those with Lewy body dementia or Parkinson’s disease considered?
- Get an ECGfriendly
and checkpain
QTc before Alcohol or substance misuse
• Assess for and manage any pain; use dementia scoreusing
where antipsychotic agents M – Medication: omission of regular
applicable e.g. PAINAD/ Abbey Pain2. Benzodiazepines
Scale •
worsen delirium and are reserved for alcohol or benzodiazepine Polypharmacy and/or or high risk
medication or addition medications
of new medication
withdrawal (follow withdrawal protocols); or where emergency treatment is required (as(e.g.
per benzodiazepines)
E – Environment: change of environment,
• Medication review 1) but antipsychotics are contraindicated: e.g. lorazepam (0.5-1mg) may be considered
noise or activity levels impacting sleep/ rest
3. A decision to use IM or IV sedation must be made by a senior doctor (i.e. Registrar/
Consultant). This should be administrated in an area where the patient can be properly Assess for Potential Causes of Delirium:
Managing someone with delirium who is distressed and/ormonitored and where airway support is available. Flumazenil should be available if using NOTE: Clinical algorithms are for reference
lorazepam. Procyclidine/ Benztropine should be available if using antipsychotic agents. only‘PINCH ME’clinical judgement
and do not replace
combative, and felt to be a threat to themselves or others
P – Is the person in pain? Has urinary retention
The management of delirium is primarily NON PHARMACOLOGICAL.
been excluded?
ALWAYS try to de-escalate the situation first. Explain what is happening, re orientate,
IN – Infection: is there a possible infection?
try to nurse in a quiet area, consider need for one to one care.
Refer to sepsis pathway as appropriate
1. The evidence for the benefit of antipsychotics in treating delirium is very weak. (link overleaf)
If emergency treatment with medication is needed because the patient or others are C – Constipation: When was the last bowel
at immediate risk and/or urgent care is compromised, low dose ORAL antipsychotic
movement?
medication is preferred. Small doses should be given e.g. Haloperidal (0.5 -1mg),
Quetiapine (12.5 - 25mg), Olanzapine (2.5mg), Risperidone (0.5mg) H – Hydration/nutrition: is there major
- Avoid antipsychotics in those with Lewy body dementia or Parkinson’s disease
electrolyte imbalance? Has hypoxia,
- Get an ECG and check QTc before using antipsychotic agents.
hypotension, hypoglycaemia been
2. Benzodiazepines worsen delirium and are reserved for alcohol or benzodiazepine considered?
withdrawal (follow withdrawal protocols); or where emergency treatment is required
M – Medication: omission of regular medication
(as per 1, but antipsychotics are contraindicated: e.g. consider lorazepam (0.5-1mg).
or addition of new medication
3. A decision to use IM or IV sedation must be made by a senior doctor (i.e.
Registrar/ Consultant). This should be administrated in an area where the patient can E – Environment: change of environment, noise
be properly monitored and where airway support is available. Flumazenil should be or activity levels impacting sleep/ rest
available if using lorazepam. Procyclidine/ Benztropine should be available if using
antipsychotic agents. NOTE: Clinical algorithms are for reference only
and do not replace clinical judgement
Version 2.1 - Date 05.11.2021