wiki:virtual_ward:delirium

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May be obviously agitated (hyperactive delirium) or withdrawn and sleepy (hypoactive delirium) or a mixture of the two.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May be obviously agitated (hyperactive delirium) or withdrawn and sleepy (hypoactive delirium) or a mixture of the two.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)

PINCH-ME:

Pain – assess for pain
Intracerebral (e.g. stroke) / Infection
N*utrition (including mouth care)
Constipation
Hypoxia / Hypoglycaemia / Hydration
Metabolic (e.g. hyponatraemia, hypercalcaemia) / Medication
Environmental (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)

Calculate total score:
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
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