=====Delirium/Acute confusion=====
===Definition===
  *Commonly presents with acute confusion, and a change in level of alertness. 
  *May be obviously agitated (hyperactive delirium) or withdrawn and sleepy (hypoactive delirium) or a mixture of the two.
===Causes===
  *Delirium often has a trigger (or more than one) which should be explored and treated where possible.
  *Delirium may be associated with poorer outcomes for patients, and is associated with longer term cognitive impairment.
===Symptoms===
  *Commonly presents with acute confusion, and a change in level of alertness. 
  *May be obviously agitated (hyperactive delirium) or withdrawn and sleepy (hypoactive delirium) or a mixture of the two.
  *A history of preceding cognitive impairment should be sought.
  *A comprehensive review of symptoms and changes to normal routine should be explored.
===Signs===
  *Look for signs of causative conditions
  *Consider infection but be aware that acute confusional state is not always a UTI
  *Ensure not constipation
  *Ensure not in urinary retention
  *Explore sensory impairment and ensure has appropriate aids (glasses, hearing aids)
<wrap em>PINCH-ME:</wrap>
  ***P**ain – assess for pain
  ***I**ntracerebral (e.g. stroke) / Infection
  ***N***utrition (including mouth care)
  ***C**onstipation
  ***H**ypoxia / Hypoglycaemia / Hydration
  ***M**etabolic (e.g. hyponatraemia, hypercalcaemia) / Medication
  ***E**nvironmental (e.g. disturbed sleep, sensory deficits – ensure has glasses, hearing aids)
===Blood tests:===
  *FBC, U&E, LFT, Bone, CRP
  *Urine culture if warranted based on clinical assessment
  *4AT test (only takes a couple of minutes)

|**1. ALERTNESS**\\ This includes patients who may be markedly drowsy (eg. difficult to rouse and/or obviously sleepy during assessment) or agitated/hyperactive. Observe the patient. If asleep, attempt to wake with speech or gentle touch on shoulder. Ask the patient to state their name and address to assist rating | |
|Normal (fully alert, but not agitated, throughout assessment)  |0 |
|Mild sleepiness for <10 seconds after waking, then normal |0 |
|Clearly abnormal |4 |
|**2. AMT4**\\ Age, date of birth, place (name of the hospital or building), current year. | |
|No mistakes |0 |
|1 mistake |1 |
|2 or more mistakes/untestable |2 |
|**3. ATTENTION**\\ Ask the patient: “Please tell me the months of the year in backwards order, starting at December.” To assist initial understanding one prompt of “what is the month before December?” is permitted. ||
|Achieves 7 months or more correctly |0 |
|Starts but scores <7 months / refuses to start |1 |
|Untestable (cannot start because unwell, drowsy, inattentive) |2 |
|**4. ACUTE CHANGE OR FLUCTUATING COURSE**\\ Evidence of significant change or fluctuation in: alertness, cognition, other mental function (eg. paranoia, hallucinations) arising over the last 2 weeks and still evident in last 24hrs ||
|No |0 |
|Yes |4 |
^Calculate total score: ||
^4 or above | possible delirium +/- cognitive impairment |
^1-3 |possible cognitive impairment\ |
^0 |delirium or severe cognitive impairment unlikely (but delirium still possible if [4] information incomplete) |
===Management===
  *Supportive management
  *Treat underlying issues
  *Review medications
  *Assess for risks to safety (e.g. pressure ulcers, falls)
  *Support for patient and informal carers
  *Engagement:
  *Support reassurance, orientation
  *Ensure physical comfort
  *Ensure safety at home
===When to admit===
  *If safety cannot be maintained at home
  *If concerns about being acutely unwell / unstable
  *If concerns regarding preceding head injury and acute confusion (especially if on anticoagulation) - refer to NICE head injury guidance