Delirium is a common condition affecting approximately 30% of older adult inpatients and anywhere from 10-50% of older patients who have had surgery. It is defined as an acute onset of fluctuating mental status changes, inattention, and either disorganized thinking or altered level of consciousness. Delirium can present as hyperactive, hypoactive, or mixed. The first steps in assessing delirium are to explore potential causes such as infection, pain, constipation through tests like bloodwork and imaging, and to treat the underlying cause. Non-pharmacological interventions like reassurance and redirection are preferred, with medication being a last resort option. It is important to involve nursing, occupational therapy, and other experienced colleagues for

1. Delirium
Laura Massey
FY1 Renal

2. What is delirium?

3. Delirium definition Inoye et. al 1990 ¹

Must be:
− Acute onset + fluctuating course
− WITH Inattention
− Plus either/ or
− Disorganised thought content
− Altered GCS

4. Delirium Types

Hyperactive – restless, agitated, swearing, non-cooperative
with routine tasks, wandering, hallucinations – often visual,
poor concentration, poor appetite, rapid personality change

Hypoactive – sleepy, withdrawn, 'like they're not there', poor
concentration, poor appetite, rapid personality change

Mixed

5. How many inpatients get delirium?

6. How many inpatients get delirium?

Approximately 30% of all older adult inpatients²
− 10% if all ages taken into account

Higher in intensive care environments

Anywhere between 10->50% of older patients who have had
surgery, most affected are those with;
− Fractured NOF
− Vascular patients

7. Assessing the person

ABCDE!!!
− ABG
− ECG
− CXR
− Routine set of bloods

If severe pain consider Ix for this e.g. CT abdo

Consider urinary retention – palpable bladder/ scan

Consider constipation – PR

Abbreviated AMTS /4 if drops a mark proceed to the full 10³
− Age, DOB, place, year

Day team may want to consider further collateral Hx, MMSE/
ACEIII if appropriate

8. How to treat

Good nursing technique, be reassuring, gentle redirection,
well lit rooms, clocks easily visible, visual and hearing aids
available.

TREAT THE CAUSE – pain/ infection/ constipation
commonest

Medication is a last resort – oral preferable to IM, IV not in
trust guidelines.
− Lorazepam 0.5mg PO/ IM max 2mg per day – be
wary in renal failure
− Haloperidol 0.5mg PO/ IM max 2mg per day

Contraindicated LBD/ Parkinson's, avoid in those with
alcohol excess

Be patient it can take 6 weeks or more to resolve

9. Good Sources of Information

Connect Guidelines

NICE guidelines for delirium

British Society of Geriatrics website
− Good powerpoint on post-operative delirium

Royal College of Psychiatrists Website

http://www.uptodate.com/contents/delirium-beyond-the-basics
Has excellent info sheets for carers and families.

Seniors, other experienced colleagues – nurses/ OT/ PT, SAFE
team, psych liaison.

10. Summary

Delirium is common and as an FY1 you should be vigilant in
looking for the signs

Explore the cause, and treat appropriately

Always try to reassure and redirect, encourage others
nursing for the patient to do so

Medication is a last resort, and avoid intravenous medication
to avoid delirium

If concerned about a patient – ABCDE

Never be afraid to ask for help – they're paid more to help
you make decisions!

11. References

1. Inouye, S.K. et. Al Ann Intern Medicine 1990 113:941

2.

3. Swain D.G, and Nightingale P.G, Clin Rehab 1997 Aug
11(3): 243-8
http://www.uptodate.com/contents/delirium-beyond-the-
basics