Delirium Pathway

1. Delirium Pathway NHS Grampian

2. Delirium Overall Pathway Screening

3. Screening Back to overall pathway

4. Prevention Back to overall pathway

5. Prevention – Clinical Factors Back to prevention pathway Back to overall pathway

6. Ensuring familiarity • Involve family member(s) or usual carer(s), if possible, in routine care; they know the person better • Use personal items in the bed side (photos of family members, etc.) • Same member(s) of staff caring for the person during the shift • Any other measures as applicable individually Back to prevention pathway

7. Identification Back to overall pathway

8. Management Back to overall pathway

9. General Management • Offer opt-in for Butterfly scheme; inform the treating team of the diagnosis • Effective communication & re-orientation • Introduce yourself clearly, repeatedly, if necessary • Explain where the person is & why they are in hospital • Ensure familiarity • Encourage visits from friends/family • Stimulation level in the environment to be tailored to the needs of the person • Avoid transfers

10. General management (Contd.) • Correct sensory impairment • Ensure wearing spectacles/hearing aids • Look for ear wax if deaf/hard of hearing • Day-time routine • Find out usual routine from family/carers & adhere to this as closely as possible • Encourage patient to get up & sit out of bed • Dress in their daytime clothes • Early mobilisation to toilet/dayroom • Early involvement of Physio/OT • Night-time routine • Find out usual routine from family/carers & adhere to this as closely as possible; Clarify what normal sleep times are for the patient • Ensure the ward area/room is quiet • Ensure appropriate level of lighting as used routinely by the person (some persons may not like complete darkness) Back to management pathway Back to overall pathway

11. Identification & management of underlying causes • Infection • Constipation • Urinary retention • Dehydration • Medication (polypharmacy) • Pain • Head injury • Stroke • Endocrine disorders • Alcohol withdrawal Please note that delirium is often caused by many factors; the list here is not exhaustive; specific investigations including neuro-imaging may be needed in some cases Back to management pathway Back to overall pathway

12. Infection • Pyrexial? Raised WCC/CRP? • Urine symptoms?.......... Dipstick (+/-) MSU (+/-) • Chest symptoms?.......... CXR Sputum culture • Skin Site…………………….. Risk factors…………………… • Other Specify………………………………………………………….. • Treat according to NHSG antimicrobial guidelines Back to management pathway Back to overall pathway

13. Constipation • PR exam? ..............(If impacted, consider enema) • Stop/reduce contributory drugs if able (opiates, iron, calcium channel blockers, amitriptyline) • Laxatives • Initially Movicol 1 sachet twice daily + Senna 2 tablets at night • Once bowels cleared, stop movicoland consider senna +/- other laxative Back to management pathway Back to overall pathway

14. Urinary Retention • Check abdomen for distended bladder • Particular attention if • not passing urine; • passing frequent small amounts of urine; • renal failure on bloods • NB: Often co-exists with constipation and/or UTI • Management: Back to management pathway Back to overall pathway

15. Dehydration • Clinically dehydrated? • Biochemically dehydrated?Urea>Creat; Na ( = severe) • Push oral fluids: Maintain & monitor fluid intake chart • Intravenous fluids if severely dehydrated (clinically/biochemically) or if poor oral intake Back to management pathway Back to overall pathway

16. Medication • Review drug chart & attempt to stop/reduce drugs that may precipitate or worsen delirium • Common offenders include • Bladder stabilisers (Oxybutynin, Tolterodine, Solifenacin) • Tricyclic antidepressants (Amitriptyline, Imipramine)* • Anticholinergics (Hyoscine/Buscopan, atropine eyedrops) • Benzodiazepines (diazepam, lorazepam, Zopiclone)* • Antihistamines (particularly sedative antihistamines) • Digoxin (check blood levels) • Lithium (check blood levels) • Opiates (morphine, codeine, Tramadol)* • High dose Steroids* (*may be dangerous to withdraw abruptly) Back to management pathway Back to overall pathway

17. Alcohol withdrawal • Usual onset within 24-72 hours of last drink • Agitation, restlessness, tremors, visual/auditory hallucinations, autonomic dysfunction, paranoid ideation usual features • Longer acting benzodiazepines drug of choice eg. Chlordiazepoxide; symptom triggered flexible dosing schedule to be used Back to management pathway Back to overall pathway

18. Pain • Often patients with delirium/dementia will not be able to say that they are in pain • Be alert to the possibility of pain • Regular analgesics would be more beneficial Back to management pathway Back to overall pathway

19. Management of behaviour that challenges • Talk to the patient calmly, reassure and de-escalate the situation • Delirium is a scary experience for the patient: remember, they may not know • where they are • who you are or that you’re trying to help • Don’t be confrontational • Try to distract & change the topic rather than challenging abnormal beliefs • Talk about something that will be of interest to the patient; you may be able to get this from “This is me” document or by speaking to the family/carers • Sit with the patient, they may require one-to-one nursing for a period of time (delirium fluctuates, so they will settle eventually) • Ensure personal safety of the person with delirium and those around them including yourself • Identify any causes of upset • e.g. pain, needing the toilet, wanting a cigarette

20. Management of behaviour that challenges (contd.) • Drugs should only be used: • To relieve patient distress • To prevent patient endangering themselves or others • To allow essential investigation/intervention • Ensure you complete an Adults with Incapacity (Scotland) Act 2000 Section 47 form & treatment plan if appropriate

21. Management of behaviour that challenges (contd.) • Antipsychotic drugs are first preference if needed • Start low, go slow; oral if possible • Haloperidol 0.5-1mg, max 2 mg/24hr initially (total, including oral & parenteral) • If consistent evening agitation, consider regular antipsychotic in early evening (1800h) • Caution: Parkinsonian symptoms, QTc prolongation, Dementia in Lewy Body Disease • Avoid benzodiazepines (diazepam/lorazepam), unless: • Alcohol withdrawal (use diazepam withdrawal regime) • Parkinsonism (Parkinson’s disease or Lewy Body Dementia; even then, consider reduction in dopaminergic agents) • If needed, use lorazepam 0.5mg (oral/parenteral), max 2 mg/24 hours • Caution: Falls, respiratory depression (Flumazenil should be available), sedation, paradoxical agitation • Link to NHS Grampian Rapid Tranquilisation policy

22. Management of behaviour that challenges (contd.) • Discuss with the Liaison Psychiatry team during in-hours or with the duty Psychiatry team out-of-hours regarding use of Mental Health (Care & Treatment) (Scotland) Act 2003 • If the person needs more than one dose of parenteral antipsychotic/benzodiazepine for their behaviour • If the person is refusing to stay in hospital for their treatment Back to management pathway Back to overall pathway

23. Discharge Planning • Make sure that Delirium is recorded as a diagnosis in the discharge summary • Inform the GP of delirium • May need follow-up from GP in 3-6 months to review cognitive function (delirium may be a marker for underlying undiagnosed dementia) Back to overall pathway