Early identification of risk

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.

Conduct a delirium risk assessment in the pre-admission clinic or within 24 hours of presentation to hospital for admitted patients. Identify key risk factors that include any of the following:

• Age ≥65 years (≥45 years for Aboriginal and Torres Strait Islander people)
• Known cognitive impairment or diagnosed dementia
• A previous diagnosis of delirium
• A severe medical illness (a clinical condition that is deteriorating or is at risk of deterioration)
• Current hip fracture.

Patients with any of these risk factors should receive a validated screening test for cognitive impairment, which is recognised as a significant risk factor for developing delirium. Conducting cognitive screening on presentation to hospital helps identify patients who should be assessed for delirium and enables monitoring for delirium onset during a hospital stay by providing a baseline measure. This also applies to patients with known cognitive impairment. Offer screening for cognitive impairment using a validated tool that is culturally appropriate. (See ‘Related resources’ tab.)

Assess the risk of delirium before a planned admission, particularly for surgical and procedural interventions. Patients and carers should be advised of their risk and potential consequences of developing delirium, to inform decision-making and consent and to help with management if delirium does develop.

When screening identifies probable cognitive impairment, clinical assessment for delirium is necessary (see Quality statement 4). Note that a positive score on a screening tool is not a diagnosis, but a prompt for further assessment, early intervention and early family involvement.

Ensure systems, policies and procedures are in place to identify risk of delirium within 24 hours of presentation, and to support routine screening of cognitive function for patients at risk of delirium who present to a health service and are admitted for care. A structured approach can improve detection rates. Identify and use a local delirium screening and assessment pathway. This includes ensuring the availability of locally agreed, validated delirium screening and cognitive screening tools that are appropriate to the cultural backgrounds of relevant communities and protocols for when they will be used. Ensure that the staff who use these tools are trained and competent in their use, and that workforce proficiency is maintained.

Ensure policies and procedures are in place to inform at-risk patients and their family or carer about the risk of delirium and to encourage participation in care.

Ensure pre-admission protocols and consent processes incorporate an assessment of the risk of delirium and discussion with the patient before surgery or another procedure, as part of their informed consent. The Commission’s Informed Consent in Health Care – Fact sheet for clinicians can direct clinicians in obtaining valid informed consent

The 4AT has been validated both for screening for cognitive impairment and delirium assessment:

• 4AT: Assessment test for delirium and cognitive impairment, is available in 17 languages

A range of other validated tools for screening for cognitive impairment are available – for example:

• Abbreviated Mental Test Score (AMTS), incorporated in the NSW Health Delirium Screen for Older Adults available from the Agency for Clinical Innovation 

• Kimberly Indigenous Cognitive Assessment (KICA) tool, available from the Dementia Centre for Research Collaboration

See also:

• Screening and assessment tools for older people - Agency for Clinical Innovation, NSW

• Cognition measure and tools - Dementia Centre for Research Collaboration

• The Commission’s Informed Consent in Health Care – Fact sheet for clinicians.