Information for consumers - Delirium Clinical Care Standard

What the standard says

A patient with any key risk factor for delirium is identified on presentation and a validated tool is used to screen for cognitive impairment, or obtain a current score if they have known cognitive impairment. Before any planned admission, the risk of delirium is assessed and discussed with the patient, to enable an informed decision about the benefits and risks.

What this means for you

When you come to hospital or are planning admission for a procedure or other treatment, your clinician will check if you have any of the risk factors for delirium.

If so, you will be offered a short screening tool to see if you have problems with:

• Your memory
• Putting your thoughts together
• Communicating with others.

In the screening tool, a clinician will ask you a series of questions. If you have any difficulties with these questions, you may be at risk of delirium. You and your carer or family will also be asked about any recent changes in your behaviour.

If you are planning surgery or a procedure and you are at risk of delirium, you will be advised about the risk and what this means for you. This can help you to make a decision about having the surgery or a procedure, especially if it is not essential.

What the standard says

A patient at risk of delirium is offered a set of interventions to prevent delirium and is regularly monitored for changes in behaviour, cognition and physical condition. Appropriate interventions are determined before a planned admission or on admission to hospital, in discussion with the patient and their family or carer.

What this means for you

If you are at risk of developing delirium, your clinicians will offer care to prevent it from happening. They may do things such as checking and changing your medicines, giving you more fluids or helping you stay as mobile as possible. Your family or carers will be encouraged to be involved in your care and will be given information about delirium and how to prevent it. You will also receive regular checks on your physical condition, thinking and memory (cognition). Cognition is the ability to put your thoughts together and communicate them.

What the standard says

A patient at risk of delirium and their family or carer are encouraged to be active participants in care. If a patient is at significant risk or has, delirium, they and their family or carer are provided with information about delirium and its prevention in a way that they can understand. When delirium occurs, they receive support to cope with the experience and its effects.

What this means for you

If you are at risk of delirium, you and your family or carer will be given information and advice about delirium and how it can be prevented. You should be given this information in a way that you can understand it, whether it is written information or someone talking to you. Being prepared and acting early can help to reduce the effects of delirium. You and your family or carer will be encouraged to alert your healthcare team of any changes in your behaviour, thinking or physical condition. The health service organisation will have systems in place to take action if your health worsens. It is important that you and your family or carer know what to expect, what you can do if this happens and how to ask for help.

Your family or carer can provide valuable information to the clinicians caring for you and should be involved in your care if you wish them to be. An interpreter can be used for these conversations if required. If you develop delirium, the plan for your care will be discussed with you and your family or carer, and informed consent will be sought for any treatment you receive. The aim of your care will be to reduce your symptoms and any distress experienced with delirium.

People with delirium may:

• Appear confused and forgetful
• Be unable to pay attention
• Be different from their normal selves
• Be very agitated, quiet and withdrawn, sleepy, or a combination of these
• Have rapid and unpredictable mood changes
• Be unsure of the time of day or where they are
• Have changes to their sleeping habits, such as staying awake at night and being drowsy during the daytime
• Feel fearful, distressed, upset, irritable, angry or sad
• Have hallucinations and see frightening things that are not there but seem very real to them
• Lose control of their bladder or bowels
• Have delusions or become paranoid, and strongly believe things that are not true – for example, they may believe that someone is trying to physically harm them or has poisoned their food.

These symptoms fluctuate during the day, and may worsen in the evening or night.

Family members or carers can support you because they are familiar to you. They can:

• Reassure you
• Remind you about eating and drinking
• Bring in familiar objects
• Help the healthcare team to get to know you and understand what you are normally like.

What the standard says

A patient with cognitive impairment on presentation to hospital, or who has an acute change in behaviour or cognitive function during a hospital stay, is promptly assessed using a validated tool by a clinician trained to assess delirium. The patient and their family or carer are asked about any recent changes in the patient’s behaviour or thinking.

A diagnosis of delirium is determined and documented by a clinician working within their scope of practice.

What this means for you

Using a validated tool, assess for delirium in:

• Patients with cognitive impairment on presentation to hospital
• Patients who have a sudden decline in cognitive function or change in behaviour during their hospital admission.

Seek information about the patient’s usual mental status from the patient or their family or carer, general practitioner, or other primary care provider or similar. Ask about behavioural changes, such as:

• Confusion or worsened concentration
• Agitation or restlessness
• Sleepiness, including altered levels of consciousness
• Whether the patient has been less communicative or less responsive than usual
• Whether the patient has had difficulty cooperating with reasonable requests or has had other alterations in mood.

Family members or carers are often the best source of information about acute changes in a patient’s mental status or behaviour. As delirium symptoms can vary throughout the day, more than one assessment may be required to diagnose delirium.

Identifying hypoactive, hyperactive or mixed cases of delirium is necessary to implement appropriate treatment strategies. Hypoactive delirium is more common in older people, but is often missed and has a worse prognosis than other subtypes of delirium, including worse long-term cognition when delirium has a longer duration. Delirium is less likely to be recognised in patients with frailty or dementia.

Where delirium is detected, the diagnosis is determined and documented by a clinician working within their scope of practice. Document the diagnosis to aid in transfers of care, including in handover notes, referral and discharge letters. A history of delirium increases the risk of recurrence, and documenting an episode of delirium allows for preventive measures and monitoring for new delirium in subsequent healthcare encounters.

Discuss the diagnosis with the patient and their family or carer.

Current international clinical guidelines include validated delirium diagnostic tools, some of which require training to use the tool effectively.

What the standard says

A patient with delirium is offered a set of interventions to treat the causes of delirium, based on a comprehensive assessment that includes relevant multidisciplinary consultation.

What this means for you

If you are diagnosed with delirium, a clinician will carry out a medical check to identify what is causing the delirium and how best to treat it. You and your family or carer will be consulted as part of the assessment. This may include a physical examination, tests (such as blood or urine tests, chest X-ray), a check of the medicines you are taking and any recent changes to them, and checking whether you are in pain. You will receive treatments for anything that may be causing your delirium. For example, your medicines may be changed, you may be given more fluids or you may be given antibiotics if you have an infection.

What the standard says

A patient with delirium receives care to prevent functional decline, dehydration, malnutrition, falls and pressure injuries, based on their risk.

What this means for you

If you have delirium, your care will include a plan to keep your physical health from getting worse while you are in hospital or another health service organisation. The plan includes ways to prevent falls and having an injury from a fall, such as wearing safe footwear or hip protectors, and care to prevent pressure injuries. You will be offered a nutritious diet to prevent malnutrition and dehydration. You will be encouraged to keep mobile. Your family or carers are encouraged to be involved in your care.

What the standard says

Antipsychotic medicines are not recommended to treat delirium. Behavioural and psychological symptoms in a patient with delirium are managed using non-drug strategies.

What this means for you

If you have delirium and you are distressed, your healthcare team will investigate what is causing your distress and reassure you, and address anything that is disturbing you, such as pain, discomfort or noise. Your family or carers will be encouraged to be involved in your care.

Antipsychotic medicines (such as the active ingredients quetiapine, olanzapine and risperidone) are not usually recommended, because they do not help to treat the underlying cause of delirium and their side effects can result in serious harm. They may be considered if you are likely to harm yourself or others, and if it is not possible to reduce your distress in other ways. In this case, a clinician may discuss using an antipsychotic medicine at a low dose for a short time. A single dose may be enough. When an antipsychotic medicine is being considered for this reason, your clinician will discuss with you and your family or carer the choice of antipsychotic medicine, its side effects and benefits, dose, and how long you need to take it for.

Use of devices that restrict movement is avoided whenever possible.

What the standard says

Before a patient with persistent or resolved delirium leaves hospital, an individualised comprehensive care plan is developed collaboratively with the patient and their family or carer. The plan describes the patient’s post-discharge care needs and includes strategies to help reduce the risk of delirium and related complications, a summary of changes in medicines and any other ongoing treatment. This plan is provided to the patient and their family or carer before discharge, and to their general practitioner and other regular clinicians within 48 hours of discharge.

What this means for you

Before you leave hospital, a clinician will talk with you and your family or carer about your episode of delirium and the ongoing care you will need when you leave hospital. They will help develop a plan with you and your family or carer in a format that you understand. The plan sets out your goals of care and any extra care you need to stay well and avoid complications from delirium. This may include eating a nutritious diet and drinking enough water. The plan will describe ongoing treatments such as the medicines you need to take and if any medicines have been stopped or changed. It will also include any community support services you have been referred to. You will be given a copy of this plan before you leave hospital. Your general practitioner and other regular clinicians should receive a copy within two days of you leaving hospital.