Delirium

Information

Services vary depending on geography (e.g. availability of hospital at home, referral processes etc). Please also refer to locality guidelines for MOE services.

Delirium is characterised by confusion and/or altered conscious level associated with a physical cause. It is acute in onset and fluctuating in nature. Treatment should be focused on identifying and treating the precipitant cause(s). Older people and those with pre-existing dementia are at greater risk of delirium. Delirium is a risk factor for subsequent cognitive impairment.

Features of delirium can include:

Impairment of consciousness (disorientation, poor concentration)
Change in behaviour (hyper or hypoactive)
Irritability and disturbed sleep / reversal of sleep-wake cycle
Changes in thinking and perception, including paranoia, hallucinations
Impaired memory recall/retention during delirium, and amnesia of events after delirium

Causes of delirium are numerous and there are often multiple contributing factors. Common causes include:

Infection
Medications (including abrupt withdrawal from psychoactive medications)
Alcohol (consumption and withdrawal)
Metabolic failure
Neurological (space occupying lesion, post ictal, normal pressure hydrocephalus)

The more information in the referral, the easier it is to triage to the appropriate service.

Who to refer:

Patients with delirium require urgent assessment and treatment of the cause. This may be clear and in these cases treatment can often be initiated by primary care.
Refer patients to Hospital-at-Home-.aspx who would otherwise require admission to hospital, or where the cause of delirium is not clear.
Patients who have a sudden increase in care needs that cannot be met by existing care package or family may require admission to hospital but a discussion with the local Hospital at Home team first would be advisable.

Who not to refer:

Patients with a history suggestive of longer term cognitive decline rather than delirium should be referred to old age psychiatry services for appropriate work up.

How to refer:

If acutely unwell and Hospital at Home admission is appropriate, please refer to locality Hospital at Home team.
Other referrals via SCI Gateway Geriatric Medicine will be triaged to appropriate service.

Primary Care Management

In all patients with delirium, consideration needs to be given to the likely causes – remember there may be more than one. If admission to hospital is being considered, please give careful consideration to a Hospital at Home referral instead; changes in environment will usually make delirium worse. If in doubt, all Hospital at Home services are happy to discuss referrals by telephone.

Other associated symptoms precipitating delirium (i.e. suggesting intercurrent illness)
Alcohol history
Collateral history essential (partner, family, carers)
Cardiovascular, respiratory, abdominal, and neurological examinations as appropriate to identify intercurrent illness.
Full medication review (in particular considering anticholinergic burden- please see polypharmacy review in resources)
FBC, U&E, LFT, Calcium, TFT, CRP, B12/folate, Blood glucose
MSU (do not use dipstick in >65 to assess for infection)
Assessment of risk of staying at home vs hospital admission – this will include falls risk, family’s ability to support and their understanding of delirium, existing care arrangements, risk and appropriateness of acute admission, etc.
Please provide patients and families with a diagnosis of delirium and information about delirium; explanation and reassurance goes a long way to alleviating patients’ and families’ concerns.