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Individual care by a trained multidisciplinary team can help prevent delirium for those people identified at risk, according to new guidelines published yesterday (28 July). The National Institute for Health and Clinical Excellence (NICE) also recommends health professionals should 'think delirium' whenever people are admitted to hospital or long-term care.

This new clinical guideline describes methods of preventing, identifying, diagnosing and managing delirium. In particular, the guideline focuses on preventing delirium in people identified to be at risk, using a targeted, multi-component, drug-free intervention that is tailored for each individual.

Delirium is a recent and usually fluctuating change in a person’s awareness, often shown as disorientation or confusion, or through difficulties with memory. It can often be triggered by an infection, operation or a new drug. It can affect up to 1 in 3 hospital patients in the UK, but is potentially preventable in about a third of these cases. Delirium can lead to longer stays in hospital, bed pressure sores, and may increase the risks of dementia and death. However, the condition is poorly recognised in UK hospitals and long-term care, and preventative methods are generally not in place.

Preventing delirium in people at risk during their admission to hospital is anticipated to bring cost savings and release resources to the NHS. This is through a reduction in bed stay and a reduction in hospital-acquired complications. The NICE guideline is based on the best available evidence and will provide doctors, nurses and care assistants with a gold standard for effective treatment.

Dr Fergus Macbeth, Director of the Centre for Clinical Practice at NICE, said: "This new guideline will encourage doctors, nurses and care assistants in hospitals and long-term care settings to ‘think delirium’ and take steps to prevent this serious condition. It is vitally important, too, that those who care for people at risk of delirium are familiar with the indicators and symptoms that suggest the onset of this condition.

"In implementing this guideline, healthcare professionals and those working in long-term care will be providing people with, and at risk, of delirium with the highest level of care."

Professor John Young, Honorary Consultant Geriatrician, Bradford Teaching Hospitals Foundation NHS Trust, Chair of the Guideline Development Group, said: “We know delirium is preventable, which is why the new guideline contains recommendations especially designed to ensure people at risk of delirium receive good quality care. Our recommendations put the individual first by emphasising the need for individual, tailored interventions which will vary for each different person.

"Our guideline development group included a range of people, including health and long-term care professionals and patient representatives who are familiar with the serious effects delirium can have. We discussed all the best available evidence in developing this clinical guideline and I’m confident these recommendations are set to make a real difference to the diagnosis, prevention and management of delirium in England and Wales."

Important recommendations in the guideline include:

• When people first present to hospital or long-term care, assess them for the following risk factors. If any of these risk factors is present, the person is at risk of delirium.

- Age 65 years or older.

- Cognitive impairment (past or present) and/or dementia ¹. If cognitive impairment is suspected, confirm it using a standardised and validated cognitive impairment measure.

- Current hip fracture.

- Severe illness (a clinical condition that is deteriorating or is at risk of deterioration) ².

• Ensure that people at risk of delirium are cared for by a team of healthcare professionals who are familiar to the person at risk. Avoid moving people within and between wards or rooms unless absolutely necessary.
• Give a tailored multi-component intervention package:

- Within 24 hours of admission, assess people at risk for clinical factors contributing to delirium.

- Based on the results of this assessment, provide a multi-component intervention tailored to the person’s individual needs and care setting as described in recommendations

• The tailored multi-component intervention package should be delivered by a multidisciplinary team trained and competent in delirium prevention
• At presentation, assess people at risk for recent (within hours or days) changes or fluctuations in behaviour. These may be reported by the person at risk, or a carer or relative. Be particularly vigilant for behaviour indicating hypoactive delirium ³.
• If a person with delirium is distressed or considered a risk to themselves or others and verbal and non-verbal de-escalation techniques are ineffective or inappropriate, consider giving short-term (usually for 1 week or less) haloperidol or olanzapine. Start at the lowest clinically appropriate dose and titrate cautiously according to symptoms.

This clinical guideline is for doctors, nurses and other staff working in acute and critical care and surgical wards in hospitals. It is also aimed at GPs, nurses and care assistants working in long-term care.

Rachel White, patient member of the Guideline Development Group said: "My own experience of delirium, the most terrifying episode of my life, happened only nine months before I became a patient member on the Guideline Development Group.

"Much of the group’s work centred on examining evidence-based highly technical medical research, and as such I had expected the resulting recommendations to be objective and dispassionate, concentrating purely on process and cost. However, the patient was at the very heart of everything we did. This guideline is the result of the work of clinicians, nurses and carers that are not only experts in their fields, seeing every day the distressing effects delirium can cause, but are dedicated to effecting real change.

For me, recovering from my illness posed many challenges, but dealing with the after-effects of delirium was by far the hardest. So, my own hopes for this clinical guideline are simple - if it can prevent the condition or at least alleviate its symptoms, it will make an enormous difference to patients and their families."

Notes to Editors

About the guideline

1. Further information on the clinical guideline ‘Delirium: diagnosis, prevention and management’ .

2. Delirium (sometimes called ‘acute confusional state’) is a common clinical syndrome characterized by disturbed consciousness, cognitive function or perception, which has an acute onset and fluctuating course. It usually develops over one to two days. It is a serious condition that is associated with poor outcomes. However, it can be prevented and treated if dealt with urgently.

3. If any of the following risk factors are present, the person is at risk of delirium: age 65 years older, cognitive impairment (past or present) and/or dementia, current hip fracture or severe illness (a clinical condition that is deteriorating or is at risk of deterioration).

4. This clinical guideline has been produced for NICE by the National Clinical Guideline Centre (NCGC).

5. This guideline covers both adult patients (18 years and over) in a hospital setting and adult patients (18 years and over) in long-term residential care.

6. This guideline does not cover children and young people (younger than 18 years), people receiving end-of-life care, or people with intoxication and/or withdrawing from drugs or alcohol, and people with delirium associated with these states.

About NICE

1. The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health.

2. NICE produces guidance in three areas of health:

• public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
• health technologies - guidance on the use of new and existing medicines, treatments, procedures and medical technologies within the NHS
• clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.

References

1. If dementia is suspected, refer to further information on the diagnosis, treatment and care of people with dementia in ‘Dementia: supporting people with dementia and their carers in health and social care’ (NICE clinical guideline 42).

2. For further information on recognising and responding to acute illness in adults in hospital see 'Acutely ill patients in hospital' (NICE clinical guideline 50).

3. Delirium can be hypoactive or hyperactive but some people show signs of both (mixed). People with hyperactive delirium have heightened arousal and can be restless, agitated and aggressive. People with hypoactive delirium become withdrawn, quiet and sleepy. Hypoactive and mixed delirium can be more difficult to recognize.