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									GP and Residential Aged Care Kit                                   Clinical Information Sheet - Delirium


Delirium
This Clinical Information Sheet has been developed to assist RACF staff, medical practitioners and
relevant professionals (pharmacists, allied health clinicians) involved in the management of residential
aged care patients with delirium. It addresses issues that may occur in RACF, particularly:
- Strategies to prevent the onset of delirium from avoidable causes;
- Early detection and assessment of delirium; and
- Management of residents experiencing delirium.

This CIS covers:
 About Delirium;
 Prevention;
 Assessment;
 Management;
 Non-pharmacological Strategies;
 Medication; and
 Sources of Information.

Reference cards:      Confusion Assessment Method (CAM) Tool
                      NEECHAM Confusion Scale

This Clinical Information Sheet is a guide only. It should be used with consideration to:
 Resident’s preferences, existing medical care plans, and advance care plan;
 Health professional’s role, knowledge, preferences and professional experience;
 Policies and resources available within the RACF;
 Requirements of local professional registration and regulatory bodies; and
 Relevant local legislation.

About Delirium
Delirium is an acute condition of altered conscious state that is often precipitated by an underlying
physical abnormality such as medication toxicity; acute infection or disease; or alcohol/drug
withdrawal. Delirium, especially if prolonged, may be associated with long term cognitive and physical
decline [1-3]. In adults aged over 85 years the incidence of delirium is approximately 13% [4]. The
risk of developing delirium whilst in a RACF may be as high as 40-60% [2].

Older adults are at significant risk of delirium if they are admitted to hospital, where 15-50% of over 65
year olds develop delirium [2, 3]. It is most prevalent (25-60%) in elderly patients admitted for hip
fracture surgery [1-4]. Delirium usually develops within the first two days of hospitalisation, and rarely
presents after the sixth day [2]. It is associated with longer hospital stays and higher mortality rates.
For those not already in long term care, older adults who develop delirium whilst hospitalised are more
likely to be discharged to a RACF [2]. Due to the trend for early hospital discharge, patients transferred
to RACF may still have symptoms of delirium.

As the signs and symptoms of delirium are non-specific and older adults regularly have concurrent
diagnoses, often of a cognitive nature, delirium may go unrecognised and untreated in the hospital or
RACF unless staff are trained in its prevention and identification [4].



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Definition
Delirium is a condition of altered conscious state with specific diagnostic criteria outlined in the
American Psychological Association Diagnostic and Statistical Manual of Mental Disorders (DSM-
IV). The criteria for diagnosing delirium are [2, 4]:
- There is a disturbance to the resident’s consciousness with reduced attention; and
- Changes to the resident’s cognition (e.g. memory, orientation, language) cannot be attributed to
    a pre-existing, established, or evolving cognitive disorder such as dementia; and
- The resident’s alteration to consciousness develops rapidly, usually within hours to days, and
    levels of consciousness fluctuate throughout the day.

Prevention
Risk factors
The presence of any of the following factors increases a person’s risk of developing delirium [1, 3-5]:
- Aged over 80 years;
- Low body mass index (BMI);
- Concurrent dementia, particularly when onset is later in life;
- Concurrent depression;
- Cancer;
- Chronic renal failure;
- Visual or hearing impairment;
- Pain, particularly post-operative pain;
- Indwelling catheter; and
- Previous episodes of delirium.

Assess residents at high risk
Residents at a high risk of developing delirium should be regularly assessed until their risk
decreases. It is recommended that residents with the following conditions be screened for delirium
[2]:
- Residents taking a large number of medications, particularly anticholinergics;
- High body temperature (e.g. fever);
- Low blood pressure;
- Dehydration; and
- Sensory impairment.

Delirium prevention plans
Development of protocols to manage factors that increase a resident’s risk of developing delirium
can assist in the prevention of delirium, particularly for those residents at high risk (e.g. post-
operative, underlying dementia) [4, 5]. Protocols to address risk factors have not been shown to
reduce the severity of an episode, their use has been shown to prevent the development of delirium
and reduce the duration of its course [5].

Areas for which protocols may be developed include [4]:
- Cognitive impairment;
- Sleep management;
- Management of immobility;
- Management of visual and/or hearing impairment; and

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-   Management of dehydration.

Assessment
Diagnosis
Diagnosis includes detection of altered conscious state and other signs and symptoms, assessment
of type of presentation, and differentiation from other conditions, particularly dementia and
depression.
Signs and symptoms
Signs and symptoms experienced by the resident may include [3, 4]:
      - Altered conscious state, usually fluctuating in nature, onset occurring rapidly and lasts less
         than 6 months;
      - Altered psychomotor activity (hyper- or hypoactive);
      - Alterations in perceptual awareness;
      - Disordered perception of time, person and place;
      - Disturbed sleep/wake cycle;
      - Slowed, slurred speech;
      - Impaired judgement;
      - Emotional disturbances particularly lability;
      - Apathy, withdrawal, decreased appetite and decreased motivation;
      - Impaired concentration and attention;
      - Disorganised thinking;
      - Memory deficits, especially recent memory; and
      - Neurological signs such as tremor, unsteady gait and difficulty reading/writing.
Types of delirium
Specific signs and symptoms depend upon the type of delirium – hyperactive, hypoactive, mixed or
nocturnal [2, 3].
     1. Hyperactive delirium: The resident presents with agitated behaviour that may include
          delusions or hallucinations. The presentation of hyperactive delirium is often confused
          with schizophrenia, agitated dementia or other psychotic disorders. However, visual
          hallucinations are more common in delirium than schizophrenia, in which patients more
          often have auditory hallucinations [2, 3].
     2. Hypoactive delirium: The resident presents with inactive, withdrawn behaviour including
          quiet confusion, disorientation and apathy. This presentation may be confused with
          dementia [2, 3].
     3. Mixed delirium: The resident displays clinical signs associated with both hyperactive and
          hypoactive delirium, and throughout the condition’s course may fluctuate between the two
          types for varying lengths of time [2, 3].
     4. Nocturnal delirium: The resident displays signs of delirium at night or in the early evening
          (often called Sundown Syndrome) [2, 3].
Differential diagnosis
Signs and symptoms of delirium are non-specific and may occur with depression, dementia and
other psychotic illnesses. In most instances underlying illness, metabolic or chemical disturbance is
the cause of delirium, therefore the general practitioner will be investigating to determine
concurrent diagnoses. Table one outlines the primary differences between the presentation of
delirium, depression and dementia. It should be noted that residents diagnosed with dementia may
also be suffering from concurrent delirium and in fact having dementia places the resident at an
increased risk of delirium [1, 3, 4, 6].



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Table One: Clinical features of delirium, depression and dementia [2, 3]

                     Delirium                   Depression                   Dementia

   Onset             Abrupt                     Often corresponds to         Slow, insidious onset
                                                changes in life              that is often unnoticed
                                                circumstance
   Daily course      Fluctuating course         Usually doesn’t              Usually doesn’t
                     Often worse at night       fluctuate throughout day     fluctuate throughout the
                                                Occasionally worse in        day
                                                the morning                  May be worse during
                                                                             moments of stress
   Length of         Hours to weeks             Variable but at least 6      Months to years
   course                                       weeks
                                                May be months to years
   Consciousness Reduced                        Clear                        Clear
   Alertness     Increased or decreased         Normal                       Usually normal
                 or variable depending
                 upon type
   Activity      Increased, decreased or        Variable, may be         Variable
                 mixed depending upon           agitated or have slowing
                 type
   Attention         Fluctuates but generally   Highly distractible          Generally normal
                     disordered
   Orientation       Usually impaired but       Usually normal               Often impaired
                     may fluctuate              although may have little
                                                interest in answering
   Speech            Incoherent, slow or        May be slow                  Difficulty finding the
                     rapid                                                   correct words
   Affect            Variable                   Flat                         Labile

Delirium assessment tools
A variety of assessment tools are available to test general cognitive function as well as others
specifically designed for delirium screening and severity assessment. No single assessment tool has
been shown to incorporate a full assessment of delirium. Experts recommend the use of at least 3 of
the following tools, including one designed specifically for delirium, in screening for delirium,
assessing its severity and monitoring response to a delirium management plan [2, 6].
Confusion Assessment Method (CAM)
The Confusion Assessment Method (CAM) is an assessment tool that has been validated for
assessing delirium and is capable of distinguishing between delirium and dementia. The CAM can
be completed after the resident has been interviewed, however those using the CAM require
specific training in its use [1]. Following administration of the CAM assessment tool a resident will
be identified as being positive for delirium if test results show [6]:
      - Presence of acute onset and fluctuating course; AND
      - Inattention; AND EITHER
      - Disorganised thinking; OR
      - Altered level of consciousness.
The reference cards include the CAM tool for delirium assessment.
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NEECHAM Confusion Scale
The NEECHAM Confusion Scale has been validated for assessment of delirium in populations of
older adults in hospital but not specifically in RACFs. The scale is considered particularly useful as
staff are able to collect data during regular care. Assessment covers attention, orientation, ability to
follow commands, behaviour, physiological measures and continence. The reference cards include
the NEECHAM Confusion Scale.
Delirium Rating Scale (DRS)
The Delirium Rating Scale (DRS) has been validated for assessment of delirium and severity [3].
Folstein Mini-Mental State Examination (MMSE)
The (MMSE) provides a broad screening of cognitive function [1]. This screening test detects
deficits in orientation, attention, memory and language, although it is ideally used when a baseline
measure (taken prior to the onset of signs and symptoms) exists [3]. Although this assessment has
strong reliability in assessing general mental status, it is not recommended for use in isolation in
assessing delirium [2]. However it may be a useful tool for monitoring the resident’s response to
management interventions [3].
Basic assessments of concentration
In using simple assessment techniques consider the resident’s age, background and general
education level. The following simple assessments can be used to get a basic understanding of the
resident’s concentration abilities [4]:
      - Serial 7s – the resident is requested to count backwards from 100 in 7s;
      - Count backwards from 20 to 1;
      - Spell a simple word backwards (e.g. ‘world’); and
      - Recite the months of the year backwards.

Causes of delirium
In many residents with delirium, multiple potential causes will be present, and so it may be difficult
to attribute the delirium to a single cause [7]. About 40% of cases of delirium in older adults are
related to medication use [5]. There may be an underlying physiological cause such as cerebral
hypoxia, metabolic disorders or chemical disturbances; or drug or alcohol withdrawal. In many
cases no acute cause of delirium can be ascertained, despite thorough investigation. Common
causes of delirium include [1, 3-5]:
- Medication use;
- Unrelieved pain, particularly post-operative pain;
- Dehydration;
- Faecal impaction;
- Urinary retention;
- Distancing from sensory aids;
- Infection;
- Fluid and electrolyte imbalances; or
- Cerebral hypoxia.

The underlying cause(s) of the delirium must be ascertained by history, physical examination
(looking particularly for organ failure) and relevant investigations [7]. Because delirium may be
due to more than one underlying cause, consider a range of investigations [4]:
- Blood tests: Raised white blood cell count is indicative of infection; low sodium, low potassium
    or high urea [4]; liver function tests may indicate hepatic failure ormetastases [5]; thyroid
    function tests to detect hypo- or hype-rthyroidism [5].

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-   Urinalysis: It is not unusual to find asymptomatic bacteriuria in older RACF residents therefore
    even if the urinalysis results indicate presence of a urinary tract infection, continue
    investigations to determine if there is another cause for delirium [4, 5].
-   Calcium and glucose levels.
-   Chest X-ray may identify respiratory infection or other abnormalities including heart failure [5].
-   ECG and cardiac enzymes may detect silent myocardial infarction or cardiac arrhythmia [5].
-   Blood cultures may be considered where there is reason to suspect the resident has septicaemia
    or endocarditis [5].
-   EEG may be considered where there is uncertainty in the diagnosis. Findings on EEG during
    delirium include general cerebral dysfunction and slowing [3, 4]. EEG will also detect
    underlying epilepsy [3].

Management
Goals
The primary aim is to promptly treat underlying causes, relieve distress and prevent injury.

Management goals are to [2-4]:
- Identify and treat underlying causes;
- Resolve any acute signs and symptoms within 48 hours;
- Minimise the use of physical and chemical restraint;
- Meet the resident’s ongoing care needs; and
- Prevent harm being done to the resident, others or the environment.

Because early detection is essential in preventing deleterious effects, all RACF health workers
should be trained in the identification and management of delirium [1, 4, 5].

Management plan
For residents who have repeated episodes of delirium, consider developing a management plan with
the following information:
- Usual pattern of presenting symptoms and precipitating factors;
- How to identify and respond to an episode of delirium;
- Resident’s delirium risk factors and preventive protocols;
- When and how to assess conscious state to screen for delirium;
- Assessment of likely causes (e.g. recent medications or illness event, temperature, BP,
    hydration, urinalysis, urine micro & culture, E&U, FBE);
- Non-pharmacological strategies; and
- PRN medication for symptoms.

Referral
In most instances delirium can be best managed within the familiar environment of the RACF. The
resident may require transfer to an acute care facility as a result of underlying disease causing the
delirium. The general practitioner may consider admission to an acute facility if the resident’s
signs and symptoms do not abate within 48 hours of management (e.g. Royal Melbourne Hospital
Delirium Management Unit). Residents with severe disruptive behaviour may require management
in an acute psychogeriatric facility if management strategies within the RACF are unsuccessful [6].



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Non-pharmacological Strategies
Ensure adequate hydration, nutrition and pain relief, and the provision of a familiar and safe
environment. Delirium can be bewildering and distressing to residents and relatives, and so it is
important to explain the nature of the diagnosis and the reasons for any unusual behaviours or ideas
[7].

Whilst the effectiveness of non-pharmacological interventions is not supported by research [5],
expert opinion recommends the use of strategies that promote a calm, orientating environment with
adequate support and prevention from injury.

Physical needs
Factors to consider include [2, 3, 5]:
- Close monitoring;
- Provide care to a routine schedule to promote comprehension and orientation;
- Promote a regular sleep/wake cycle;
- Treat the resident’s pain if applicable;
- Ensure sensory aids are fitted;
- Decrease caffeine intake to reduce agitation; and
- Address underlying causes or risk factors relating to nutrition, elimination or dehydration.

Environment
Environmental strategies are focused on the safety of the resident, as well as reducing distractions
within the environment that may exacerbate the signs and symptoms of delirium. Factors to
consider include [2, 4-6]:
- Avoid both under- and over-stimulation;
- Lighting;
- Noise management;
- Stimulation modification;
- Use environmental cues to provide orientation (e.g. clock, calendar, photos);
- Provide a night time environment conducive to sleep; and
- Explain the purpose of equipment in the resident’s room and remove any unnecessary
   unfamiliar items.

Communication
Communication strategies focus on providing information in a manner in which the resident will be
able to comprehend and providing support throughout the experience of delirium. Factors to
consider include [3-7]:
- Address the resident by name;
- Provide reassurance;
- Frequent reorientation to person, place and time;
- Use one-step commands when completing tasks with the resident;
- Limit choices;
- Use non-verbal communication to support verbal messages;
- Talk with and listen to the resident to determine his or her needs; and
- Approach the resident from the front, as peripheral stimuli are more likely to be interpreted as
    hostile.

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Behavioural symptoms
Factors to consider include [2, 3, 5]:
- Provide 1:1 supervision if necessary to maintain safety;
- Avoid use of restraints;
- Use distraction and time out;
- Avoid threatening gestures;
- Consider adapting the environment to allow for safe wandering (e.g. use of alarms on exits,
   painted lines on the floor); and
- Remove dangerous objects from the environment.

Emotional and social
Factors to consider include [2, 3, 5, 6]:
- Encourage family and significant others to remain with the resident;
- Encourage activities that do not increase stress;
- Acknowledge and support the resident’s emotions; and
- Music therapy may promote relaxation.

Medication
The resident’s current medication should be reviewed, as medication is a common cause of
delirium. Older adults have a lower renal and hepatic clearance of drugs therefore many
medications have a longer half life, increasing the risk of drug toxicity or interactions. Consider
ceasing any medication suspected of causing or contributing to the resident’s delirium [2, 4, 5],
particularly anticholingeric medications or drugs that have an anticholinergic side effect (e.g.
tricyclic anti-depressants) [4, 5, 7]. If delirium is due to drugs with anticholinergic properties, most
patients will recover without specific treatment once the drugs are withdrawn [7].

Medication may be needed to treat symptoms of delirium, or underlying causes such as infection.

Psychotropics
Most residents with delirium do not need treatment of symptoms with psychotropic drugs, but
sometimes medication is required to relieve anxiety, agitation, aggression, delusions and/or
hallucinations [7]. Consider the risks of medication use (e.g. increased potential for drug
interactions and/or toxicity) versus the benefits (e,g. managing behavioural problems, reducing
hallucinations and improving orientation) [3, 4].

Antipsychotics are recommended to control disturbing behaviour and/or aggression, unless the
delirium is related to alcohol or drug withdrawal (then use benzodiazepines). Although they may
be administered intramuscularly or intravenously, the preferred route is oral [4]. The general rule in
prescribing is to commence on a low dose and increase gradually according to clinical response [4].

Haloperidol, is a first generation antipsychotic recommended for use with older adults. If the
patient is intolerant of haloperidol, use a low dose of a second generation antipsychotic such as
risperidone or olanzapine [7]. Haloperidol, risperidone and olanzapine are available in liquid form
[4]. Avoid chlorpromazine as its strong anticholinergic effects may worsen the delirium [7].




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                                         Haloperidol
              Commence on 0.5mg/day and increase to maximum of 10mg/day [2, 4, 7].
                        Standard dose in the elderly is 1-2mg BD [3, 5]

                                         Risperidone
              Commence on 0.5mg/day and increase to maximum of 10mg/day [2, 4, 7].
                       Standard dose in the elderly is 0.5-1mgBD [3, 5]

                                         Olanzapine
              Commence on 2.5mg/day and increase to maximum of 10mg/day [2, 4, 7].

             Continue until cognitive state is stable for 2 days then gradually taper dose.


If the most prominent symptom needing treatment is anxiety. If agitation is inadequately controlled
with haloperidol, use oxazepam 15mg orally [7].

Monitor vital signs closely during and after the administration of sedative drugs, particularly if
repeated doses are given. A record of medications given should accompany the resident if they are
moved to another location [7].

Sources of Information
Where to go for more information
Psychogeriatric Assessment Teams
Psychogeriatric Assessment Teams are also known as Aged Psychiatry Assessment and Treatment
Teams (APATT). These teams consist of experts in aged care psychiatry. They asses and treat
people aged over 65 with psychiatric illness in Victoria. Contact numbers for the closest
Psychogeriatric Assessment Team can be obtained by contacting the Dementia Helpline on 1800
100 500.
Cognitive, Dementia and Memory Service (CDAMS)
CDAMS is a specialist diagnostic clinic which aims to assist people with cognitive deficits and
those who support them. These Victorian government initiatives provide education, assessment,
support and advice. Referrals can be made through general practitioners, community agencies or by
self referral directly to CDAMS.

Contact during business hours:
       Bundoora Extended Care Centre, CDAMS Bundoora: phone: (03) 9495 3272
       Royal Melbourne Hospital CDAMS Royal Park: phone: (03) 8387 2000
       Caulfield General Medical Centre, CDAMS Caulfield: phone: (03) 9276 6010
       Austin & Repatriation Medical Centre, CDAMS West Heidelberg: phone: (03) 9496 2596
       Grace McKellar Centre, CDAMS Barwon (Geelong): phone: (03) 5279 2438
       Queen Elizabeth Centre, CDAMS Grampians (Ballarat): phone: (03) 5320 3704
       Arapiles Building Wimmera Base Hospital, CDAMS Grampians (Horsham): phone: (03)
       5381 9333




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References
1. Milisen, K., Foreman, M., Abraham, I., De Geest, S., Godderis, J., Vandermeulen, E., Fischler,
      B., Delooz, H. , O. Broos, P., A Nurse-Led Interdisciplinary Intervention Program for
      Delirium in Elderly Hip-Fracture Patients. Journal of the American Geriatrics Society,
      2001. 49(5): p. 523-532.
2. Rapp, C., Acute confusion/delirium protocol. Journal of Gerontological Nursing, 2001. 27(4): p.
      21-32.
3. Gleason, O., Delirium. American Family Physician, 2003. 67(5): p. 1027-1034.
4. Burns, A., Gallagley, A. , Byrne, J., Delirium. J. Neurol. Neurosurg. Psychiatry, 2004. 75: p.
      362-367.
5. Maher, S. ,Almeida, O., Delirium in the elderly. Current Therapeutics, 2002. March: p. 39-45.
6. Registered Nurses Association of Ontario, (RNAO). Screening for delirium, dementia and
      depression in older adults. 2003, Registered Nurses Association of Ontario, (RNAO).
      Toronto. p. 88 p.
7. eTG, Therapeutic Guidelines: Neurology Version 2, in http://www.tg.com.au (accessed June
      2006), eTG. 2002
8. National Health And Medical Research Council, (NHMRC), Guidelines for the development
      and implementation of clinical practice guidelines. 1995, Canberra: AGPS.

Levels of Evidence
Background information on the management of delirium provided in this Clinical Information Sheet
is based on Level I evidence produced by expert opinions in the field, particularly the Registered
Nurses Association of Ontario. This Clinical Information Sheet has been developed with
consideration to legislation and any requirements of, or recommendations from, professional
registration groups or regulating bodies (e.g. NBV, RCNA, ANF) overseeing the aged care industry
in Victoria, Australia.

The following table outlines the level of evidence of each reference:
 Ref No    Author                                                Year      Level Evidence
 1         Milisen, K. et al                                     2001      Level IV B evidence
 2         Rapp, C. et al                                        2003      Level IV C evidence
 3         Gleason, O.                                           2003      Level IV C evidence
 4         Burns, A                                              2004      Level IV C evidence
 5         Maher, S.                                             2002      Level IV C evidence
 6         Registered Nurses Association of Ontario              2003      Level I evidence
 7         eTG                                                   2002      Level IV C evidence

Literature was identified through a standardised search for systematic reviews and clinical guidelines
published by relevant health organisations; and ‘clinical guidelines’ and ‘practice guidelines’ in
CINAHL & MEDLINE databases and HONcode search engine. Literature was evaluated according to
relevance to residential aged care patients, and strength of evidence using the NHMRC (1995) [8] scale
for randomised control data and lower levels of evidence when RCT is not available. The scale was
adapted by adding a level of evidence (level V) for non-referenced material, eg developed in local
RACFs. Prescribing information is consistent with the Australian Therapeutic Guidelines, at the time of
writing.

Applicability of information
This Clinical Information Sheet has been developed with consideration to legislation and any
requirements of or recommendations from professional registration groups or regulating bodies (e.g.
NBV, RCNA, ANF) overseeing the residential aged care industry in Victoria, Australia. Readers

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outside Victoria, Australia are advised to review the material in the context of their local legislation
and health system regulations.

This Clinical Information Sheet was developed using the process outlined in Section 5, and is
provided under the terms of the disclaimer in Section 1 of the GP and Residential Aged Care Kit:
http://nwmdgp.org.au/pages/after_hours/

For more detailed or up to date information than is provided in this CIS, please refer to cited
sources and current literature.




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