Initial management

1.7.1.

In people diagnosed with delirium, identify and manage the possible underlying cause or combination of causes. [2010]

1.7.2.

Ensure effective communication and reorientation (for example explaining where the person is, who they are and what your role is) and provide reassurance for people diagnosed with delirium. Consider involving family, friends and carers to help with this. Provide a suitable care environment (see recommendation 1.4.1 in the section on preventing delirium). [2010]

Distressed people

1.7.3.

If a person with delirium is distressed or considered a risk to themselves or others, first use verbal and non-verbal techniques to de-escalate the situation. For more information on de-escalation techniques, see the NICE guideline on violence and aggression. Distress may be less evident in people with hypoactive delirium, who can still become distressed by, for example, psychotic symptoms. [2010]

1.7.4.

If a person with delirium is distressed or considered a risk to themselves or others, and verbal and non-verbal de-escalation techniques are ineffective or inappropriate, consider giving short-term haloperidol (usually for 1 week or less). Start at the lowest clinically appropriate dose and titrate cautiously according to symptoms. Take into account the Medicines and Healthcare products Regulatory Agency’s advice about the risks of using haloperidol for the acute treatment of delirium in older people, including the risks of cardiac and neurological side effects (especially in people living with Parkinson’s disease or dementia with Lewy bodies). [2010]

If delirium does not resolve

1.7.5.

For people in whom delirium does not resolve:

• re-evaluate for underlying causes
• follow up and assess for possible dementia (see the NICE guideline on dementia). [2010]

Why this is important

The serious nature of delirium and its consequences makes it important to establish all methods of prevention. Pharmacological agents may be a simple preventive treatment for delirium, but there is uncertainty about effectiveness and side effects so they should be used with caution. The evidence is limited: 3 low-quality studies were found, each of which was unrepresentative either of the population or the medication used, but there was some indication of clinical effectiveness. A large randomised trial (with at least 100 people in each arm) should be conducted in people in hospital who are at high risk of delirium to compare atypical antipsychotics, typical antipsychotics, benzodiazepines or acetylcholinesterase inhibitors with placebo, or each other, for preventing delirium. The included populations should be defined in terms of their delirium risk (for example people at high risk could be those with 2 or more risk factors for delirium). The primary outcome should be the incidence of delirium, measured at least daily using a validated diagnostic tool. The severity and duration of delirium should also be recorded, together with adverse effects of the medication, notably extrapyramidal symptoms and stroke.

Why this is important

Pharmacological interventions are currently used in clinical practice to manage the symptoms of delirium but the evidence for this is limited. One moderate-quality study showed that typical and atypical antipsychotics were clinically and cost effective compared with placebo, but there is no evidence for benzodiazepines. Pharmacological agents that alter the course of delirium or control particular symptoms might be useful in treating delirium, but we need to determine whether the medication should be given routinely or for selected symptoms, and what adverse events may occur. A large randomised trial (with at least 100 people in each arm) should be conducted in people in hospital with delirium to compare atypical antipsychotics, typical antipsychotics, or benzodiazepines with placebo, or each other, for the treatment of delirium. The outcomes should be recovery from delirium (complete response), and the duration and severity of delirium, measured using a validated diagnostic tool. Adverse events, notably extrapyramidal symptoms and stroke, should also be recorded.

Why this is important

Although there is moderate-quality evidence of clinical and cost effectiveness for multicomponent interventions for the prevention of delirium in people in hospital, there is no evidence in a long-term care setting. It is anticipated that such an intervention would benefit this long-term care population. A large, adequately powered, randomised trial, or a large, adequately powered, cluster randomised trial should be conducted in people in long-term care to compare a multicomponent intervention with usual care. The multicomponent intervention should include assessment by a trained and competent healthcare professional, who would recommend actions tailored to the person’s needs. The intervention should include the recommended interventions to prevent delirium, particularly reorientation, medication review, hydration and sleep hygiene. The primary outcome should be the incidence of delirium, measured at least daily using a validated diagnostic tool. The severity and duration of delirium should also be recorded using a validated tool, together with the consequences of delirium, including admission to hospital.

Why this is important

Although there is evidence for adverse outcomes consequent to delirium in hospital, there is very little evidence from long-term care. It is important to determine whether people in long-term care, who already have a high risk of death, dementia and other adverse outcomes, have a further increased risk of these outcomes if they develop delirium. The risk of hospital admission as a consequence of delirium is also unknown. A large cohort study should be conducted in people in long-term care to determine:

• the prevalence of delirium in this setting, and
• if the presence of delirium is a prognostic factor for death, dementia, admission to hospital, falls and other adverse outcomes.

The multivariate analysis conducted in this study should take into consideration the potential significant risk factors and confounding factors identified in the guideline. Such a study would also inform cost-effectiveness analyses for the prevention and treatment of delirium.

Why this is important

There is some evidence from multicomponent prevention studies to suggest that an education programme for healthcare professionals who care for people at risk of delirium reduces the incidence of delirium. However, the quality of this evidence is poor. There is a need to determine whether education has an important preventive effect on the incidence of delirium. There is also a need to find out if an educational programme increases awareness of delirium, so that delirium is recorded accurately, which is not the case in the UK at present. A cluster randomised trial should be carried out, with whole hospitals randomised to the educational interventions (thereby reducing the trial contamination effects of staff vicariously picking up education from colleagues randomised to the education programme arm). The primary outcomes (incidence of delirium and recording of delirium in the person’s healthcare record) should be measured at a minimum of 3 timepoints before and after the intervention.

Why the committee made the recommendations

The committee agreed with the recommendation in the previous version of the guideline that all staff should be observing the people in their care and should be alert for changes indicating delirium. They noted that some simple tools like the Single Question to Identify Delirium (SQiD) might be useful to help practitioners notice any changes. They did not add SQiD specifically to the recommendation because they agreed that it is just one of many ways to encourage observation and that many places already have systems set up for this. They noted that in some settings the recording of these observations could be inconsistent, and that routine recording of changes that might indicate delirium was important.

How the recommendations might affect practice

Better recording of the indicators of delirium will improve the chances of these changes being noticed and acted upon.

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Why the committee made the recommendations

The committee agreed that once a change that might indicate delirium has been noted and recorded, a member of staff competent to do so should carry out a formal assessment.

Several assessment tools had high enough sensitivity and specificity to be useful in clinical practice. However, the committee agreed that implementation issues need to be considered as well. For example, who can do the test, how long does it take and how much training is needed?

Balancing the evidence for accuracy and cost effectiveness with the practicality of implementing the tests, the committee agreed that the 4AT was the best option for most settings. It is among the most accurate of the tools reviewed, quick and simple to use, and has a broader range of evidence to support it.

The committee agreed that a range of health and social care practitioners would be able to carry out the 4AT and that special training is not needed, although practitioners should be assessed as competent in its use. They also discussed that some specialist professionals may not need to use a screening tool to carry out an assessment and diagnose delirium, but that it would generally be considered good practice. Overall, they agreed that its use will help ensure that delirium is picked up promptly in different care settings, especially those where a healthcare professional may not be immediately available.

For critical care and post-surgical settings, the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and Intensive Care Delirium Screening Checklist (ICDSC) worked best because they were specifically designed for those settings. However, the committee noted that training is needed for both CAM-ICU and ICDSC before practitioners can use them.

If the assessment shows delirium is likely, the committee agreed that the final diagnosis should be carried out by a healthcare professional with the necessary experience and expertise, for example, a specialist nurse, a GP, lead clinician or a member of the frailty team. Depending on the circumstances, this might be the same person who carried out the 4AT. If there is uncertainty about the diagnosis, a specialist such as a geriatrician or psychiatrist, may need to be involved.

The committee agreed that although the evidence allowed them to make recommendations overall, further, more specific, research on the accuracy and ease of use of different assessment tools in different settings, for different patient groups (including those with dementia, cognitive impairments, learning disabilities or affective disorders) and by different healthcare practitioners, would help to make future guidance more specific. They therefore made a recommendation for research on delirium assessment tools.

How the recommendations might affect practice

The committee noted that the assessment tools they recommended are already the most commonly used in practice. The change from healthcare professional in the previous version of this guideline to health or social care practitioner in this version will potentially reduce the workload for healthcare professionals who previously had to carry out assessments for delirium.

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