SESLHD PROCEDURE COVER SHEET COMPLIANCE WITH THIS DOCUMENT IS MANDATORY This Procedure is intellectual property of South Eastern Sydney Local Health District. Procedure content cannot be duplicated. Feedback about this document can be sent to [email protected]NAME OF DOCUMENT Prevention, Diagnosis and Management of Delirium in Older People TYPE OF DOCUMENT Procedure DOCUMENT NUMBER SESLHDPR/345 DATE OF PUBLICATION August 2018 RISK RATING Medium LEVEL OF EVIDENCE National Safety and Quality Health Service Standards: 1 Governance for Safety and Quality in Health Service Organisations 2 Partnering with Consumers 9 Recognising and Responding to Clinical Deterioration IN Acute Health Care 10 Preventing Falls and Harm from Falls ACSQHC Delirium Clinical Care Standards 2016 REVIEW DATE August 2022 FORMER REFERENCE(S) Prevention, Diagnosis and Management of Delirium in Older People in Acute and Sub-Acute Care SESIAHS PD 209 EXECUTIVE SPONSOR or EXECUTIVE CLINICAL SPONSOR Professor Peter Gonski Director Aged Care and Rehabilitation AUTHOR Janine Masso SESLHD CNC Dementia Delirium SESLHD Aged Care CNCs Position responsible for the document Kimberley Thomsett SESLHD Clinical Stream Nurse Manager Aged Care, Rehabilitation and Medicine KEY TERMS Delirium, older people, deteriorating patient SUMMARY This procedure provides staff with information and tools to assist in prevention, identification and management of delirium in older people.
Transcript
SESLHD PROCEDURE COVER SHEET
COMPLIANCE WITH THIS DOCUMENT IS MANDATORY This Procedure is intellectual property of South Eastern Sydney Local Health District.
Procedure content cannot be duplicated. Feedback about this document can be sent to [email protected]
NAME OF DOCUMENT
Prevention, Diagnosis and Management of Delirium in Older People
TYPE OF DOCUMENT
Procedure
DOCUMENT NUMBER
SESLHDPR/345
DATE OF PUBLICATION
August 2018
RISK RATING
Medium
LEVEL OF EVIDENCE
National Safety and Quality Health Service Standards: 1 Governance for Safety and Quality in Health Service Organisations 2 Partnering with Consumers 9 Recognising and Responding to Clinical Deterioration IN Acute Health Care 10 Preventing Falls and Harm from Falls ACSQHC Delirium Clinical Care Standards 2016
REVIEW DATE
August 2022
FORMER REFERENCE(S)
Prevention, Diagnosis and Management of Delirium in Older People in Acute and Sub-Acute Care SESIAHS PD 209
EXECUTIVE SPONSOR or EXECUTIVE CLINICAL SPONSOR
Professor Peter Gonski Director Aged Care and Rehabilitation
AUTHOR
Janine Masso SESLHD CNC Dementia Delirium SESLHD Aged Care CNCs
Position responsible for the document
Kimberley Thomsett SESLHD Clinical Stream Nurse Manager Aged Care, Rehabilitation and Medicine
KEY TERMS
Delirium, older people, deteriorating patient
SUMMARY
This procedure provides staff with information and tools to assist in prevention, identification and management of delirium in older people.
SESLHD PROCEDURE Prevention, Diagnosis and Management of Delirium in Older People
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1. POLICY STATEMENT Delirium is an acute change in mental status that is common among older patients in hospital. Despite being a serious condition that is associated with increased mortality, delirium is poorly recognised, both in Australian hospitals and internationally. Prevention is the most effective strategy, but outcomes for patients with delirium can also be improved by early intervention4. SESLHD is committed to involving patients/clients/residents, carers and their families in the development of care plans that consider their needs and preferences. SESLHD clinicians are also committed to educating older people regarding their risks of developing delirium and addressing their concerns and those of carers and families. This procedure’s consistent approach to preventing, identifying and managing delirium in older patients integrates the principles of person-centred care. This procedure should be read in conjunction with local facility Pathways for the management of older people with cognitive impairment/delirium. Some of the benefits of this consistent approach are: • Improved quality and safety outcomes for older people with delirium • Enhanced person-centred care • Reduction of hospitalisation related costs • Reduction in admissions to Residential Aged Care Facilities • Strengthened knowledge and practice of person-centred care principles.
Scope:
This procedure relates to, but is not limited to, people aged over 65 years. It is relevant to other adults who have complex co-morbidities. Delirium is not isolated to patients in aged care wards and all health professionals should be aware of delirium screening, risk prevention and management. This procedure does not include the management of children, or young people withdrawing from drugs or alcohol.
2. BACKGROUND Delirium is a medical emergency. Diagnosis and treatment of the underlying cause is paramount. Delirium is an acute confusional state and is a common and serious condition in older people that can, at times, be prevented. It is characterised by a disturbance in attention and awareness and a change in cognition that develops over a short period of time - hours or days. Delirium can fluctuate during the course of the day. Evidence from history, medical examination or laboratory findings can show that the disturbance is a direct physiological consequence of another medical condition, drug withdrawal or intoxication.
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Rates of falls, incontinence and pressure injury are more than trebled in hospitalised persons with delirium. Depression, significant distress and post-traumatic stress disorder have been associated with survivors of delirium.
2.1 Definitions Delirium: A disturbance in attention and awareness and cognition that develops over a short period of time, hours or days. The disturbance may fluctuate in severity throughout the day2.
Hypoactive delirium: A subtype of delirium with symptoms of a hypoactive level of psychomotor activity that may be accompanied by sluggishness and lethargy that approaches stupor2.
Hyperactive delirium: A subtype of delirium with symptoms of a hyperactive level of psychomotor activity that may be accompanied by strong mood changes, agitation, and/or refusal to co-operate with medical care2. Disturbance in attention: Reduced ability to direct, focus, sustain and shift attention. Disturbance in awareness: The person has a reduced orientation to the environment and their place in the environment.
Disturbance in cognition: Memory deficit, disorientation, language, visuospatial ability or perception. Fluctuate: Continually changing or shifting unpredictably. Tardive Dyskinesia: Characterised by abnormal tongue movements, lip pursing, grimacing, blinking, and gyrating motions of the face and extremities, this disorder may be triggered by psychotropic drugs.
3. RESPONSIBILITIES 3.1. Supervisors and Senior Medical Officers will be responsible for:
• Training medical staff in screening, prevention and management of delirium • Monitoring compliance with this procedure • Providing ongoing training and support to medical staff implementing this procedure.
3.2. Medical Staff across SESLHD will be responsible for: • Ensuring their own clinical practice in the screening, prevention and management of
delirium is in line with this procedure.
3.3. Nursing Unit Managers across SESLHD will be responsible for: • Monitoring compliance with this procedure • Supporting staff with the implementation of this procedure.
3.4. Clinical Nurse Educators and Clinical Nurse Consultants • Ensuring nurses are trained in the use of the recommended screening tools.
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• Providing ongoing training and support to nursing staff in the screening, prevention and management of delirium in accordance with this procedure.
3.5. Nurses across SESLHD will be responsible for:
• Ensuring their own clinical practice in the screening, prevention and management of delirium is in line with this procedure
• Familiarising themselves with this procedure and local delirium/confusion management pathways
• Ensuring they have current knowledge and training in the use of tools included in this document
• Raising any concerns with their supervisors/Nurse Unit Managers.
4. PROCEDURE 4.1. Early Screening
On admission people over 65 years (≥ 45 years for Aboriginal and Torres Strait Islander peoples) should be screened to identify their risk of delirium using the paper Admission Risk Assessment Tool (ADRAT) or electronically on eMR2 (Electronic Medical Record). At pre-admission clinic an Abbreviated Mental Test (AMTS) and a Delirium Risk Assessment tool (DRAT) should be completed either on paper form or electronically using ‘ad hoc’ charting on eMR2. Risk of delirium, if present, should be documented and a management plan including preventative strategies should be developed and implemented. People at a higher risk Those who are known to have cognitive impairment/dementia, severe medical illness, and hip fracture are considered to be at high risk of delirium and should have a cognitive assessment repeated regularly during their admission to identify any changes to their cognitive status using a validated tool such as AMTS or 4AT (Rapid Clinical Instrument for Delirium Detection) http://sesinet/sites/Forms/Approved_Forms/Forms/AllItems1.aspx. The Rowland Universal Dementia Assessment (RUDAS) should be used for people from Culturally and Linguistically Diverse Backgrounds (CALD). An interpreter should be involved to complete cognitive assessment and/or gather information from and provide delirium information to CALD carer or family members.
4.2. Interventions to Prevent Delirium The prevention of delirium is possible and more effective than early detection and treatment. Multiple interventions have been shown to assist in the prevention of delirium. They include: • Medication review • Correction of dehydration, malnutrition and constipation • Mobility activities • Oxygen therapy • Pain assessment and management • Regular reorientation and reassurance
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• Activities for stimulating cognition • Non-drug measures to help promote sleep • Assistance for patients who usually wear hearing and visual aids.
These interventions should be implemented for patients at risk of delirium as well as for those with delirium4.
4.3. Assessing for Delirium Signs and Symptoms of Delirium may fluctuate throughout the day and night may include: • Acute onset • Difficulty focusing or sustaining attention • Disorganised thinking • Disturbance of sleep/wake cycle • Speech or language disturbance • Disorientation to time or place • Disturbance in psychomotor behaviour
o Increased e.g. agitation o Decreased e.g. lethargy
• Mood swings • Misinterpretations of the senses/hallucinations/illusions. Cognitive assessment Cognitive assessment should be completed when assessing for delirium, using AMTS or 4AT or RUDAS. An abnormal result from a cognitive assessment should prompt completion of the Confusion Assessment Method (CAM). It is also recommended that the CAM be repeated whenever there is an acute change in the person’s cognitive function during admission. Some specialty areas such as Palliative care may require additional assessments for delirium and local clinical protocols should be followed. Intensive Care Units (ICU) CAM-ICU (Appendix A) is the preferred tool for identifying delirium in the ICU. CAM-ICU should be completed at least once per nursing shift and also if there is a change in the patient’s level of consciousness or behaviour. A positive CAM identifies that delirium is present and should prompt action: • Notify treating medical team • Document in medical records • Commence investigation into the cause of delirium • Develop and document a delirium management plan incorporating non-
pharmacological strategies • Provide information and education to patient/resident and carer.
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Comprehensive assessment to identify the underlying causes The underlying cause of delirium is often multi-factorial. Infections such as urinary tract infections and pneumonia, electrolyte imbalance and pain are common causes of delirium; however, a rigorous assessment is required to identify the cause or causes of each individual case of delirium so that appropriate treatment can be commenced. Assessment should be based on a biopsychosocial framework and include a detailed history of the onset and course of the confusion, previous episodes of confusion, sensory deficits, safety issues, alcohol use and social and environmental circumstances. Pre-morbid functional activities of daily living, symptoms of underlying causes and co-morbid illnesses should also be included. The assessment process should also pay particular attention to the following: • Mental/cognitive status • Pain • Full physical assessment including history and examination • Clinical investigations • Medication review • Drug and alcohol assessment, with a referral for a Drug and Alcohol consultation if
required. 4.4. 4.4.1 Investigations
The clinical picture should guide investigations. The following investigations may be indicated in patients with delirium in order to identify the underlying cause: • Full blood count • Urea and electrolytes • Glucose • Calcium • Albumin and protein • MSU • Chest X-Ray • Drug toxicity • ECG • Bladder scan and/or abdominal X-ray • Magnesium and phosphorus levels • C-reactive protein (CRP) • Cardiac enzymes • Drug and alcohol screen • Liver function tests.
Other tests may be considered, including blood gases, thyroid function, B12 and folate, CT brain, VDRL, lumbar puncture and CSF examination and EEG.
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4.4.2 Medication review Some medications may affect cognitive function and worsen confusion including: • Drugs with anticholinergic effects • Anticonvulsants, e.g. phenytoin, carbamazepine, valproate • Anti-Parkinson drugs, e.g. levodopa, rotigotine, pergolide, bromocriptine • Alcohol • Antipsychotics • Opioids • Benzodiazepines • Corticosteroids (high dose) • Cardiovascular medications, e.g. digoxin, metoprolol, propranolol • Some anti-bacterials and antivirals, e.g. aciclovir, trimethoprim with sulfamethoxazole,
ciprofloxacin (AMH Aged Care Companion).
4.4.3 Interventions to treat the cause and manage delirium Non-Pharmacological Management of Delirium
The confusion associated with delirium can produce behavioural symptoms which may put the patient/client/resident, staff and others at risk. A behaviour monitoring chart assists in identifying possible triggers of behaviour that places people at risk and can also be a means of identifying strategies that maintain the older person’s comfort and also be useful in planning individualised care. Family members should be encouraged to stay with the older person if practicable, to provide reassurance, orientation and emotional comfort. Information about the person’s history and preferences can be collected on a Person Centred Profile/TOP Form. This information can be used to promote person-centred care and incorporated into their care plan. Non-pharmacological management of delirium includes optimal management of the following domains, which are based on known precipitating factors. These include: • Hydration and nutrition: Oral diet and fluids should be encouraged and
fluid balance and food intake charts should be routinely in place. • Mobility: A falls risk assessment should be attended routinely and a
mobility assessment conducted when appropriate. Bed and chair alarm devices may be useful for acutely delirious patients. Safe mobility should be encouraged.
• Bowel and bladder function: A stool chart and urine output should be monitored. A toileting regime may be included in the care plan. Remove IDC as soon as no longer clinically required.
• Sleep: Good sleep routines should be promoted, e.g. some quiet time without electronic devices or mental stimulation prior to sleep time, ensure room is at a comfortable temperature and darkened, avoid caffeine prior to sleep time.
• Sensory input: Ensure that spectacles, dentures and hearing aids are in
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place if they are usually required. • Pain: Pain should be assessed and managed appropriately, a non-verbal
pain assessment tool e.g. Abbey Pain Scale or PAINAD should be used for patients who have difficulty with communication.
• Promoting cognition: Provide an environment which supports orientation; consider the use of calendars and clocks and lighting appropriate to the time of day and an environment that is not over or under stimulating, encourage family to bring a few familiar objects.
• Communication: Use clear and simple language, giving one message at a time to assist understanding. Provide visual cues with verbal messages to assist communication e.g. show the meal and talk about it being lunchtime.
• Family/Carers: Discuss patient’s individual likes and dislikes, social history and usual routine, encourage family/carer to stay with patient when possible. Provide delirium brochure in the appropriate language to assist family/carer with an understanding of delirium.
• Emotional well-being: Provide reassurance and support to the patient/resident and family/carer.
Preventing Falls and Pressure Injury Delirium is a fluctuating condition. Potential risks should be identified and interventions included in the care plan to ensure the safety of the older person, visitors and staff. Risks should be re-evaluated on a regular basis. Staff should not assume that a person with delirium will remember any instructions; their safety may rely on staff observation. Falls and pressure injury risks should be assessed and documented according to the corresponding policies.
Falls - SESLHDPR/380 - Falls Prevention and Management for Older Patients in Acute and Sub-Acute Care Facilities Pressure Injury – NSW Ministry of Health Policy - PD2014_007 Pressure Injury Prevention and Management
4.5. Minimising use of Antipsychotic Medications
Pharmacological Management of Behavioural Symptoms of Delirium There is limited evidence of efficacy of drugs and significant risk of adverse effects. Antipsychotics and benzodiazepines can worsen delirium. There are no specific drug treatments and, in particular, drugs are not helpful for calling out or wandering6. There is no evidence that antipsychotics or sedatives improve prognosis. Only consider drug treatment if: • The person’s degree of agitation/aggression interferes with their (or other
people’s) ability to receive essential nursing or medical care • The person’s behaviour threatens the safety of self or others • Anxiety/delusions/hallucinations are causing significant distress to the
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Consultation with a geriatrician or psycho-geriatrician is recommended. If a geriatrician or psycho-geriatrician is not available, consultation must be made with a senior medical officer with experience in the management of geriatric syndromes prior to prescribing. When an antipsychotic medication is newly prescribed to assist the management of delirium, a plan should be developed and documented for a review and cessation of the medication when it is no longer required. Delirium Clinical Care Standard recommends: • Prior to prescribing antipsychotic medications pharmaceutical guidelines
should be consulted such as The AMH Aged Care Companion https://agedcare.amh.net.au.acs.hcn.com.au/chapters/neurological-mental-health/delirium
• Discuss the choice of antipsychotic medicine with the patient and carer, including the risks and benefits, dosage and duration
• Use a low dose, closely monitor the response before considering any dose increases, and limit use for as short a period as possible
• Use antipsychotic medicines with caution or not at all for people with Parkinson’s disease or dementia with Lewy Bodies4.
The use of psychotropic medications requires informed consent from the patient’s ‘person responsible’ • Antipsychotic medications may exacerbate the delirium and therefore the
minimum effective dose should be used for the shortest possible time • These medications should be reviewed daily • The oral route of administration is recommended • Monitor vital signs after administration of any drug which causes sedation • Monitor for adverse effects.
Cautions in the use of psychotropic drugs in patients with delirium
Use the oral route of administration if possible.
Monitor vital signs closely during and after the administration of psychotropic drugs.
Avoid the use of ‘as needed’ (prn) orders unless both the indication for administration and the maximum dose per 24 hours are clearly specified. Use of ‘as needed’ medication must be reviewed daily because of the changing clinical situation.
In general, benzodiazepines should be avoided in delirium (especially in patients with significant respiratory depression) except for cases due to alcohol withdrawal or seizures.
Monitor the patient intensively if repeat doses of psychotropic drugs are given. A record of medications given should be kept and must accompany the patient if they are moved to another location.
It is recognised that restraint is a precipitating factor for delirium and increases morbidity and mortality. Restraints should only be used as a last resort to maintain the safety of the patient, staff or others. Alternative methods of management should be tried whenever possible before consideration of restraint.
It is recommended that all staff members are provided with education about restraint use and the requirements of the procedure SESLHDPR/483 Restraint use with Adult Patients to ensure restraint is only used in appropriate situations.
4.7. Transition from Hospital Care
Discharge Planning Diagnosis of delirium should be noted in the discharge letter and an individualised care plan, along with a request for the GP to provide a follow up cognitive screen. Carers/family should be provided with printed information to assist their understanding of delirium and early future recognition of delirium. Such as the NSW Health Delirium Brochure. The individualised care plan care plan should provide the patient and carer with information about ways of reducing the patient’s risk of future delirium, any changes in medications including reason for ceasing or changed and if antipsychotic medication has been commenced, include a plan for review and withdrawal.
4.8. Education for Clinical Staff
Delirium education should be provided for all clinical staff on a regular basis. Education regarding cognitive screening should be attended by all clinicians who have this responsibility. My Health Learning ‘The Confused patient’ Course no. 39966589 is a useful introductory module. The District Dementia/Delirium CNCs are available to support positions who have local responsibility for this education.
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• Mini Mental Status Examination (MMSE) - SEI060.310 • Pain Assessment in Advanced Dementia – NH700302 • Person-centred Profile - SES060.127 • Rowland Universal Dementia Assessment (RUDAS) - SMR060.925 • TOP 5 Hospital Toolkit
SESLHD Facility Pathways
• Prince of Wales Hospital 3 Steps in Delirium Management in the Older
Person • St George Hospital Assessment and Management of Older Patients with
Confusion and Delirium • The Sutherland Hospital Confusion Care Pathway
6. AUDIT
This procedure will be audited annually by the SESLHD Aged Care Senior Nurses Network using indicators provided in Delirium Clinical Care Standard ACSQHC 2016 pp.25-26.
7. REFERENCES
1. Abbey J, De Bellis A, Piller N, Esterman A, Giles L, Parker D and Lowcay B. The Abbey pain scale: a 1-minute numerical indicator for people with end-stage dementia. Int J Palliat Nurs. 2004 Jan; 10(1):6-13.
2. American Psychiatric Association, 2013, Diagnostic and Statistical Manual of Mental
Disorders 5th edition, Washington DC, American Psychiatric Association.
3. Australian Commission on Safety and Quality in Healthcare, 2014, A Better Way to Care – Safe and high quality care for patients with cognitive impairment (dementia and delirium) in hospital. Actions for health service managers. Sydney; ACSQHC.
4. Australian Commission on Safety and Quality in Health Care. Delirium Clinical care
Standard. Sydney. ACSQHC, 2016
5. Australian Health Ministers Advisory Council 2007 ‘Clinical Practice Guidelines for the Management of Delirium In Older People’
6. Australian Medicines Handbook Pty Ltd. (AMH) Aged Care Companion, last modified
by AMH: April 2018, Online edition viewed 04.04.18
7. Delirium in Older People, Australian and New Zealand Society for Geriatric Medicine Position Statement 13, Revised 2012
8. Ely EW, Inouye SK, Bernard GR, Gordon S, Francis J, May L, Truman B, Speroff T,
Gautam S, Margolin R, Hart RP, and Dittus R, ‘Delirium in Mechanically Ventilated Patients Validity and Reliability of the Confusion Assessment Method for the
10. ICU Delirium and cognitive impairment study group, Vanderbilt University http://www.icudelirium.org/delirium/monitoring.html viewed 04.04.2018
11. Inouye, S., van Dyck, C., Alessi, C., Balkin, S., Siegal, A., & Horwitz, R. 1990.
Clarifying confusion: the Confusion Assessment Method. ‘A new method for detection of delirium’. Annals of Internal Medicine, 113(12), 941-948.
12. Inouye, S, Westendorp RGJ, S a czyn ski JS 2 01 3 , ’Delirium in elderly
people’, thelancet.com Published online August 28, 2013
13. Lippincott ’s Nursing Guide to Expert Elder care, 2011 14. NSW Ministry of Health Policy - PD2013_049 Recognition and Management of
Patients who are clinically deteriorating
15. Peisah C, and Skladzien E, 2014, ‘The use of restraints and psychotropic medications in people with dementia – A report for Alzheimer’s Australia paper 38. Alzheimer’s Australia Inc.
16. Warden V, Hurley A and Volicer L, 2003. ‘Development and Psychometric
Evaluation of the Pain Assessment in Advanced Dementia (PAINAD) Scale’, Journal of American Medical Directors Association. 4(1): 9-15
17. NSW Ministry of Health Policy - PD2014_007 Pressure Injury Prevention and
Management
8. REVISION AND APPROVAL HISTORY Date Revision No. Author and Approval Jan 2009 0 Colleen McKinnon Area Dementia/Delirium CNC. Approved by
Executive Sponsor Elizabeth Koff, Director Clinical Operations and Clinical Council 28 January 2009.
Jan 2014 1 Janine Masso District CNC Dementia/Delirium (Acute) April 2015 2 Converted to procedure and revised by District Policy Officer.
Author to continue review as a procedure. June 2015 2 Janine Masso - Revised as a Procedure July 2015 2 Updates endorsed by Peter Gonski, Executive Sponsor August 2015 2 Changes made as requested by SESLHD Drug and Quality Use of
Medicines Committee and endorsed by Executive Sponsor – November 2015
April 2018 3 Update approved by Executive Sponsor. July 2018 3 Processed by Executive Services prior to progression to SELSHD
Quality Use of Medicines Committee. August 2018 3 Endorsed by SESLHD Quality Use of Medicines Committee and
