Guidelines

Risk Factors

Risk factors for delirium outlined by NICE:

• ≥65 y/o
• Cognitive impairment (past or present)
• Dementia
• Current hip fracture
• Severe illness

Investigation and Diagnosis

To distinguish between delirium and dementia, NICE recommends using the:

• Confusion assessment method (CAM)
• Observational Scale of Level of Arousal (OSLA)

Recognition (Indicators)

Assess for acute changes or fluctuations (within hours or days), which may affect:

• Cognitive function (e.g. worsened concentration, slow responses, confusion)
• P​​​​​​perception (e.g. visual or auditory hallucinations)
• Physical function (e.g. reduced mobility, reduced movement, restlessness, agitation, changes in appetite, sleep disturbance)
• Social behaviour (e.g. difficulty engaging with or following requests, withdrawal, or alterations in communication, mood and/or attitude)

It is important not to miss features of hypoactive delirium, which can present as:

• Withdrawal
• Slow responses
• Reduced mobility and movement
• Worsened concentration and reduced appetite

Assessment and Diagnosis

• Exclude common causes of delirium (see above)
• Perform medication review and optimise where appropriate

NICE recommends using the 4AT to assess for delirium

Prevention

Prevention of various common causes of delirium as outlined by NICE:
 

Management

Treat any underlying causes

• Exclude reversible causes of delirium (see above)
• Medication review and optimise where appropriate

Management of distressed patients:

• 1st line: verbal and non-verbal de-escalation techniques

• 2nd line: short-term haloperidol (usually ≤1 week)
  • Avoid in those with Parkinson's disease or dementia with Lewy bodies
  • Lorazepam is preferred if necessary, or if an antipsychotic is necessary, quetiapine is preferred

References

Original Guideline