Delirium

1. Delirium Implementing NICE guidance THINK DELIRIUM! Delirium awareness workshop: slide set 2010 NICE clinical guideline 103 1

2. What this presentation covers • Aims and objectives • About NICE • Background • Scope • Key priorities for implementation Costs and savings Implementation in practice • Brainstorming and evaluation 2

3. Aims and objectives • Overall aim: • to raise awareness of how to prevent and manage delirium • Objectives: • to promote awareness and understanding of NICE’s recommendations • to help healthcare staff implement the recommendations as part of routine practice • to provide an opportunity to practise identifying the risk factors and indicators of delirium • to provide an opportunity to develop solutions to help prevent delirium. 3

4. Part 1 • Background to NICE and delirium 4

5. About NICE • The National Institute for Health and Clinical Excellence (NICE) provides guidance, sets quality standards and manages a national database (NHS Evidence). Its objective is to improve people’s health and prevent and treat ill health. • Most important for your work is the guidance it produces. • The recommendations in the guidance can help you look after people in your care. 5

6. Background • Delirium is sometimes called acute confusional state. • Delirium is a common but serious syndrome associated with poor outcomes. Some of the consequences of delirium are increased: • risk of dementia • risk of death • length of stay in hospital • in-hospital complications • risk of admission to long-term care. • Older people and people with dementia, severe illness or a current hip fracture are more at risk of delirium. • Delirium is preventable and treatable if dealt with urgently. 6

7. Pre-workshop quiz • Answers • ? 7

8. Part 2 • Scope of delirium guideline, key priorities for implementation and risk factor assessment 8

9. Scope • The guideline aims to prevent, identify, diagnose and treat delirium. • It focuses on preventing delirium in people identified to be at risk. • It covers adults in hospital and in long-term care. • It does not cover children and young people, people receiving end-of-life care and people with intoxication and/or withdrawing from drugs or alcohol, and people with delirium associated with these states. 9

10. Key priorities for implementation The areas identified as key priorities for implementation are: • initial assessment • risk factor assessment • indicators of delirium • interventions to prevent delirium • diagnosis • treating delirium: initial management • treating distressed people with delirium. 10

11. Initial assessment: risk factors • Assess the risk of delirium when people first present to hospital or long-term care. • The presence of any of these factors indicates risk of delirium: • age 65 years or older • current hip fracture • cognitive impairment (past or present) and/or dementia • severe illness. 11

12. Click here only when wishing to return to exercise 4 Exercise 1 – risk factors for delirium • When people present to hospital or long-term care it is important to assess them for risk factors for delirium. • These exercises will help you identify the risk factors for delirium. • Case study A: Harold • Harold is 82 years old and has been living at your care home for 5 years. He has been diagnosed with Alzheimer’s disease and has a catheter. Harold does not wear a hearing aid, but over the past day or two you have noticed that he has been asking you to repeat what you have said, and sometimes he seems to mishear you completely. He is otherwise normal for himself. 12

13. Click here only when wishing to return to exercise 4 Exercise 1 – risk factors for delirium • Case study B: George • George is 81 years old and has mild-to-moderate dementia. He has been on your ward for a few days following a fall and has a painful hip for which he has been taking regular analgesia. He has been reluctant to walk because he says his hip hurts. He tells you that he has been finding it difficult to sleep because of pain and that he has not had his bowels open recently. 13

14. Click here only when wishing to return to exercise 4 Exercise 1 – risk factors for delirium • Case study C: Barbara • Barbara is 63 years old. She has been admitted to the intermediate care facility in your care home 7 days after a fall that caused a fractured hip. She had this repaired 4 days ago . Her family report that previously she was independent. After her operation, she was found to have developed an infection in her wound site and was given antibiotics to treat this. She is finding it difficult to mobilise, which she says is because of pain in her hip. It was therefore agreed that she would be transferred to your care home for rehabilitation before discharge home. 14

15. Click here only when wishing to return to exercise 4 Exercise 1 – risk factors for delirium • Case study D: Charles • Charles is 66 years old and has been admitted to your ITU/coronary care unit after a heart attack for which he received a coronary artery bypass graft. He is currently stable but the doctors have asked the nursing staff to monitor his vital signs closely. 15

16. Part 3 • Assessing for indicators of delirium 16

17. Assessing for indicators of delirium • Assess people at risk for recent (within hours or days) changes or fluctuations in behaviour at presentation. • These changes may be reported by the person at risk, a carer or relative. • The behaviour changes may affect cognitive function, perception, physical function or social behaviour. • If any behaviour changes are present, a trained healthcare professional should carry out a clinical assessment to confirm diagnosis. • Observe, at least daily, all people in hospital or long-term care for recent changes or fluctuations in behaviour. 17

18. Exercise 2 – indicators of delirium • It is important to assess people at risk for recent (within hours or days) changes or fluctuations in behaviour (recommendations 1.2.1 and 1.4.1). • This exercise has been designed to help you identify the indicators of delirium. 18

19. Part 4 • Interventions to prevent delirium, clinical factors that may contribute to the development of delirium, and information and support 19

20. Interventions to prevent delirium • Ensure 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. • Provide a multicomponent intervention package (assessment and intervention) and: • assess people at risk for clinical factors contributing to delirium within 24 hours of admission • tailor interventions to the person’s individual needs • ensure delivery by a multidisciplinary team trained and competent in delirium prevention. 20

21. Clinical factors contributingto delirium • Addressing these clinical factors in a person at risk of delirium can prevent delirium: • cognitive impairment and/or disorientation • dehydration and/or constipation • hypoxia • infection • immobility or limited mobility • pain • multiple drugs • poor nutrition • sensory impairment • poor sleep patterns and sleep hygiene. 21

22. Information and support • Offer information to people who are at risk of delirium or who have delirium, and their families and/or carers. • Ensure that information provided meets the cultural, cognitive and language needs of the person. 22

23. Exercise 3 – preventing delirium • As slide 21 highlighted, certain clinical factors can contribute to delirium in people at risk of developing it. Intervening to address these clinical factors can prevent delirium. • This exercise will help raise your awareness of the interventions that can help to prevent delirium in people at risk. 23

24. Exercise 4 – preventing delirium • This exercise will help you practise designing a tailored multicomponent intervention package aimed at preventing delirium in people at risk of developing it. • Case study A Harold • Case study B George • Case study C Barbara • Case study D Charles 24

25. Part 5 • Diagnosing delirium and treating delirium 25

26. Diagnosis • If indicators of delirium are identified on admission or during a person’s stay, carry out a clinical assessment using: • DSM-IV criteria or • short CAM or • CAM-ICU. • A healthcare professional who is trained and competent in the diagnosis of delirium should carry out the assessment. • If there is difficulty distinguishing between the diagnoses of delirium, dementia or delirium superimposed on dementia, treat for delirium first. • Document the diagnosis. 26

27. Treating delirium: initial management For people diagnosed with delirium: • Identify and manage the possible underlying cause or combination of causes. • Ensure effective communication and reorientation and provide reassurance. Consider involving family, friends and carers to help with this. • Provide a suitable care environment (Ensure 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). 27

28. Treating distressed people with delirium • If a person with delirium is distressed or considered a risk to themselves or others, first use verbal and non-verbal techniques to de-escalate the situation. • If these 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. • Use antipsychotic drugs with caution or not at all for people with conditions such as Parkinson’s disease or dementia with Lewy bodies. 28

29. Exercise 5 – diagnosing and treating delirium • This exercise is designed to help you learn how delirium should be diagnosed and what treatment options are recommended. It will also encourage you to reflect upon when interventions could have been implemented in order to prevent delirium. 29

30. Exercise 5: treating delirium • Case study E • Aariz, who is 81 years old, has been a resident in your care home for the last 2 years. He has been diagnosed with Alzheimer’s disease. He is usually quite talkative, although he often shifts the conversation to his days as an electrician’s apprentice and frequently seems to think that it is the 1960s. Increasingly often he asks where he is, and he has been wandering at night. This has been going on for several months. In the last few days Aariz has been incontinent of urine (unusual for him), and has been shouting out, especially at night. Last night you found him trying to dismantle a plug in his bedroom. One of his visitors mentions to you that he has said he believes the staff are trying to poison him. 30

31. Exercise 5: treating delirium • Case study F • Gladys is 75 years old and has been admitted to your ward having been found lying on the floor by home care staff. She appears to be talking to herself, sometimes loudly, but it is hard to understand what she is saying. She seems anxious and repeatedly pulls at her bedclothes. She argues with the nursing staff and has refused, in an angry, snappy fashion, to have a blood sample taken. Nursing home staff say that she has recently moved rooms in the care home because of deterioration in her mobility. 31

32. Part 6 • Costing and saving, implementing the guideline in practice, and evaluation 32

33. Costs and savings • The guideline on delirium may result in a significant change in resource use in the NHS nationally. This is difficult to predict because current service levels vary across the country and the way in which the guidance is implemented is also likely to vary. However, the following recommendations in the key area of delirium prevention may result in additional costs/savings depending on local circumstances: • give a tailored multicomponent intervention package to people at risk of delirium • the package should be delivered by a multidisciplinary team trained and competent in delirium prevention. 33

34. Post-workshop quiz • Complete the post-workshop quiz. • ? 34

35. Implementing the guideline in practice • Principles of implementation: • designated lead within your organisation • support from multidisciplinary team • systematic approach to financial planning • systematic approach to implementing guidance • process to evaluate uptake and feedback. • Visit www.nice.org.uk/CG103 for versions of the guideline and support tools specific to delirium, including implementation advice, care plans, assessment documents, audit support and costing. 35

36. Brainstorming • What can we do to implement these recommendations in our organisation? • What modifications do we need to make to our current documentation around assessment, prevention and treatment of delirium to ensure we are able to implement the recommendations? 36

37. Evaluation • Please complete an evaluation form. 37