Delirium: Prevention, Diagnosis and Management in Hospital and Long-Term Care
National Institute for Health and Care Excellence. (2023).
London (United Kingdom): National Institute for Health and Care Excellence, (Clinical Guideline 103), 1-447.
This guideline provides recommendations for the identification and treatment of delirium in adults in hospital and long-term care settings. Both pharmacological and non-pharmacological interventions for reducing the presence, severity, duration, and consequences are explored. Of note, although speech-language pathologists do not diagnosis delirium, findings relevant to multidisciplinary treatment of cognitive deficits secondary to delirium are included in this article summary. This documents is an update from the National Institute for Health and Clinical Excellence (2010). For more information, please see the Notes on This Article section.
National Clinical Guideline Centre (United Kingdom); National Institute for Health and Care Excellence (United Kingdom)
This guideline is an update of: <br />
<ul>
<li>National Institute for Health and Clinical Excellence. (2010). Delirium: Diagnosis, Prevention and Management (Clinical Guideline 103). Retrieved from <a title="https://www.nice.org.uk/guidance/cg103/update/CG103/documents/delirium-full-guideline2" href="https://www.nice.org.uk/guidance/cg103/update/CG103/documents/delirium-full-guideline2" target="_blank" rel="noopener">www.nice.org.uk</a></li>
</ul>
The following document is referenced within this article summary and is available elsewhere in the Evidence Maps: <br />
<ul>
<li>National Institute for Health and Clinical Excellence. (2017). Nutrition Support for Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition (Clinical Guideline 32). Retrieved from <a title="http://www.nice.org.uk/CG103" href="http://www.nice.org.uk/CG103" target="_blank" rel="noopener">www.nice.org.uk</a> </li>
</ul>
<div>Providers should be aware that adults in hospital or long-term care may be at risk of delirium, which can have serious consequences (e.g., increased risk of dementia and/or death), increase length of stays, and increase risk of new admission to long-term care. These individuals should be observed at every opportunity for any changes in the risk factors for delirium.</div>
<div>When adults first present to hospital or long-term care, assess them for the following risk factors associated with developing delirium:</div>
<ul>
<li>being 65 years or older;</li>
<li>current hip fracture; and</li>
<li>severe illness (i.e., a clinical condition that is deteriorating or is at risk of deterioration).</li>
</ul>
<div>Upon initial admission or presentation within the hospital or long-term care facility, screen adults at risk for recent (within hours or days) changes or fluctuations that may indicate delirium. Observe the individuals at least daily for these changes. These may be reported by staff, the person at risk, a care partner, or relative. Be particularly vigilant for behavior indicating hypoactive delirium (marked *). If changes to any of the following neuropsychological behaviors are noted, the person at risk for delirium should be assessed for: </div>
<ul>
<li>cognitive function (e.g., worsened concentration*, slow responses*, confusion);</li>
<li>perception (e.g., visual or auditory hallucinations);</li>
<li>physical function (e.g., reduced mobility*, reduced movement*, restlessness, agitation, changes in appetite*, sleep disturbance); or</li>
<li>or social behavior (e.g., lack of cooperation with reasonable requests; withdrawal*; alterations in communication, mood and/or attitude).</li>
</ul>
<p>Ensure that any changes that may indicate delirium are documented in the person's record or notes.</p>
<div>Avoid moving people within and between wards and rooms unless absolutely necessary. Within 24 hours of admission, assess individuals for the presence of clinical risk factors of delirium. Based on their specific results, a team of healthcare professionals should provide a multicomponent intervention tailored to the person's individual needs and care setting. These professionals should be both trained and competent in delirium prevention and familiar to the person at risk.</div>
<div>The multicomponent intervention package within the hospital or long-term care facility may include addressing cognitive impairment and/or disorientation by providing:</div>
<ul>
<li>appropriate lighting and clear signage;</li>
<li>an easily visible and/or accessible clock (consider providing a 24-hour clock in critical care);</li>
<li>explanations to the person at risk for delirium regarding where they are, who they are, and what the clinician's role is;</li>
<li>cognitively stimulating activities; and</li>
<li>the facilitation of regular visits from family and friends (as able).</li>
</ul>
<div>The multicomponent intervention package within the hospital or long-term care facility may include addressing dehydration and/or constipation by <span style="color: #333333;">encouraging the person to drink and ensuring adequate intake of fluids. Additional considerations are needed for managing fluid balance in people with comorbidities (e.g., heart failure or chronic kidney disease).</span></div>
<div>The multicomponent intervention package within the hospital or long-term care facility may include addressing sensory impairment by resolving any reversible cause of the impairment, such removing impacted cerumen, and ensuring access to functional glasses and/or hearing aids.</div>
<div>The multicomponent intervention package within the hospital or long-term care facility may include addressing poor sleep hygiene by avoiding disturbing sleep and reducing noise to a minimum during sleep periods.</div>
<div>If indicators of delirium are identified, a health care professional who is competent to do so should carry out an screening using the 4AT screening tool for delirium and cognitive impairment. In critical care or step down units, the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) or the Intensive Care Delirium Screening Checklist (ICDSC) should be used in place of the 4AT. If the screening tool indicates delirium, a licensed healthcare provider with relevant expertise should make the final diagnosis. If there is difficulty distinguishing between diagnoses of delirium, dementia, or delirium superimposed on dementia, then the delirium should be managed first. Ensure that the diagnosis of delirium is documented both in the person's record or noted, and in their primary care health record.</div>
<div>Efforts should be made to ensure effective communication, reorientation, and reassurance to the person diagnosed with delirium. Consider involving family, friends, and care partners to assist in this.</div>
<div>For people in hospitals and skilled nursing facilities whom delirium does not resolve, re-evaluation for potential underlying causes and assess for possible dementia.</div>
<div>People in acute and critical care hospitals at risk for delirium, their care partners, and families should be offered information, which:</div>
<ul>
<li><span style="color: #333333;">informs them that delirium is common and usually temporary;</span></li>
<li><span style="color: #333333;">describes people's experience of delirium;</span></li>
<li><span style="color: #333333;">encourages people at risk and their families and/or care partners to tell their healthcare team about any sudden changes or fluctuations in behavior;</span></li>
<li><span style="color: #333333;">encourages the person who has had delirium to share their experience of delirium with the healthcare professional during recovery; and</span></li>
<li><span style="color: #333333;">advises the person of any support groups.</span></li>
</ul>
<div><span style="color: #333333;">All provided information should meet the cultural, cognitive and linguistic needs of the person.</span></div>
