DELIRIUM

Recognition

Definition

• Delirium “is a common clinical syndrome characterised by disturbed consciousness, cognitive function or perception, which has an acute onset and fluctuating course. It usually develops over 1–2 days. It is a serious condition that is associated with poor outcomes. However, it can be prevented and treated if dealt with urgently.” (NICE guidelines 2019).

Risk Factors

• Over age 65
• Previous cognitive impairment
• Hip fracture
• Severe illness

Causes

• Pain
• Infection
• Sensory impairment
• Dehydration
• constipation

History

If possible, ascertain if patient has:

• Had previous admissions with delirium
• Any current treatment for psychiatric disorders
• Any history of cognitive impairment
• Any allergies

General symptoms

• Agitated
• Hallucinations
• Reduced concentration
• Disrupted sleep

General Signs

• Uncooperative
• Aggressive
• Withdrawn
• Confused

Severity

•  Severity depends on patients’ risk to self and others

Initial Assessment and Investigations

• ABCDE assessment
• Sit patient up if able to tolerate
• Assess patient’s airway
• Monitor oxygen saturations and respiratory rate
  • If patient is hypoxic give Oxygen (O₂) to achieve target saturations. Initially give 15 L/min via a reservoir mask if the patient is acutely unwell
• Target saturations:
  • 94 - 98% for patients not at risk of hypercapnic respiratory failure
  • 88 - 92% for patients at risk of hypercapnic respiratory failure due to conditions such as Chronic Obstructive Pulmonary Disease (COPD)
• Arterial blood gas (ABG) if concerned about patient’s ventilation
• Chest X-ray if concerned about the patient’s ventilation. If the patient is unwell request a portable X-ray
• Obtain intravenous access by placing 2 large bore cannulae in the antecubital fossa. Take blood to check Full Blood Count (FBC), Urea and Electrolytes (U&Es), Glucose, C-Reactive Protein (CRP) and Venous Blood Gas (VBG)
• Intravenous (IV) fluids as required by clinical picture and balanced with patients’ risk of fluid overload. See more details in the “Circulation” Chapter in the “Response” Section under “Fluid Challenge”
• Consider sepsis six if sepsis suspected. For further information see “Sepsis” Section in “Medical Emergencies” Chapter
• Check pupils are equal and reactive
• Assess Glasgow Coma Scale or ACVPU using the NEWS2 chart
• Check patient’s temperature and blood sugar
• Examine patient’s abdomen and legs
• Consider venous thromboembolism prophylaxis
• Call for senior help if not already done

Response

Management

Immediate pharmacological management

• This is only required if the patient is an immediate risk to themselves or others
• First line
  • Haloperidol
    • Contraindicated in patients with the following ECG changes:
      • Prolonged QTc
      • Ventricular arrhythmias
    • Contraindicated in patients with Parkinson’s disease
• Second line
  • Lorazepam

Non-pharmacological management

• Ensure hearing aids are working
• Ensure room is well lit
• Ensure family member or familiar face present
• Ensure adequate hydration
• Prescribe laxatives if patient is constipated
• Prescribe analgesia if patient is in pain
• Treat underlying infection
• Review medications, as certain medications may exacerbate the delirium, such as opiates

Referrals

• Discuss with senior member of the team
• Contact critical care outreach team
• Consider referral to Intensive Care Unit (ICU) if:
  • Failure to respond to medical management
  • Patient requires ventilator support
  • Patient requires blood pressure support
  • Deterioration of blood gas following medical management

Future management

• Check for an underlying cause, consider assessment for dementia