DELIRIUM CARE PATHWAY

Guidance to the detection and management of delirium in adult inpatients

1. RECOGNISE
 DELIRIUM CARE PATHWAY
History of sudden change from usual cognitive baseline (often fluctuating)
 Obtain collateral history from relative/ friend/carer/GP
 Look for: Hypoactivity, Lethargy, Reduced consciousness, Attention deficit,
Guidance to the detection
Sleep disturbance, andHyperactivity,
Hallucinations, management of delirium
slurred in adult inpatients
speech, Confusion Predisposing factors:

Age > 65 years, immobility, pain,

2. DIAGNOSE dementia, sensory impairment,
pelvic/limb/NOF #, previous
Complete 4AT (on reverse) record score and delirium diagnosis in notes episodes of delirium

 4 or above: possible delirium +/- cognitive impairment

 1-3: possible cognitive impairment
 0: delirium or severe cognitive impairment unlikely (but delirium still
possible if [4] information incomplete)

3. CONSIDER CAUSE Precipitating factors:

• Investigations: FBC, UEs, CRP, LFT, Ca, B12, Folate, TFT, Urinalysis, CXR, ECG,
consider neuroimaging (CT/MRI), bladder scan, rule out constipation, cognitive
impairment pain assessment scale (on intranet), medication review
4. MANAGEMENT: START DELIRIUM CAREPLAN
Medical
1. Correct and manage precipitating
and predisposing factors
2. If in distress with risk to
self/others: senior review,
document capacity and best
interest and consider:
Regular short term, low dose
antipsychotic (1 week or less)
such as Haloperidol or
Risperidone. Start at lowest
clinically appropriate dose, titrate
cautiously according to
symptoms. Contraindicated in
Parkinson’s disease, Lewy
body syndromes and
prolonged QTc.
In lewy body dementias and
Parkinson’s disease use
Quetiapine.
3. Repeat 4AT daily until
resolved
4. Repeat 4AT as often as needed
Environmental
 Adequate lighting/use of
sensory aids (prescription
glasses/hearing aids)
 Staff continuity
 Promotion of mobility and
encourage independence
 Falls prevention strategies
 Orientation aides (clock and
calendar)
 Promote sleep hygiene
 Provide occupation and
distraction
 Oral hydration and nutrition if
safe to do so
 Consider close supervision
 Involve relatives/carers in day
to day management (open
visiting times). Offer ‘ Delirium’
leaflet.
Avoid: restraints; confrontation; ward
moves; unnecessary interventions/
investigations; catheters; excess
environmental noise
Infection, acute illness, surgery,
polypharmacy, catheterisation,
metabolic disorder, electrolyte
disturbance, dehydration, low
BP, hypoxia, pain, environment,
constipation, urine retention ,
Some medications such as
steroids etc.
 If no clinical
improvement is observed
after 72 hours:
 Re-evaluate and
optimise management
 Repeat 4AT
 For further advice and
guidance please
contact Jo Dron or Iain
Tredway on 3208
/6845 bleep 955
Update September 2018
OTLPCM002