Delirium

What is delirium?

Delirium is a change in a person’s mental state or consciousness. Someone with delirium may be confused, have difficulties with understanding and memory or may show personality changes.

Delirium is usually temporary. It can start very suddenly, with symptoms developing over hours or it can develop over several days.

There are different types of delirium:

• hyperactive (agitated and restless)
• hypoactive (drowsy and withdrawn)
• mixed delirium (hyperactive and hypoactive states come and go).

Is delirium common?

Delirium is among the most common of medical emergencies.

Delirium often occurs in patients in hospital with other problems.

Delirium may start when a patient is first admitted to hospital or when they go into long-term care or it may develop during their stay.

Delirium is most common in people who are 65 or older who also:

• have difficulties with memory or understanding
• have dementia
• have a broken hip
• are seriously ill.

What are the symptoms of delirium?

Symptoms of delirium include:

• disorientation
• confusion
• rambling speech
• difficulties following instructions
• increasing agitation or restlessness, sometimes leading to aggression
• not wanting to eat or drink
• hallucinating (seeing or hearing things or people that are not there)
• changes to alertness
• personality changes, including paranoia (feelings and thoughts of fear).

Sometimes symptoms are worse in the evenings or overnight, causing the person to be awake at night and sleepy in the day.

Symptoms can improve within a few hours or days, but for some people they may last longer. People with delirium will sometimes experience symptoms that last for weeks or months.

How will delirium feel?

If a person is having an episode of delirium, they may:

• be less aware of what is going on around them
• be unsure about where they are or what they are doing there
• be unable to follow a conversation or to speak clearly
• have vivid dreams, which are often frightening and may carry on when they wake up
• see or hear people or things which aren’t there
• worry that other people are trying to harm them
• become very agitated or restless
• feel very slow or sleepy
• sleep during the day but wake up at night
• have moods that change quickly
• be frightened, anxious, depressed or irritable
• be more confused than usual, particularly at night
• feel upset towards their family for not taking them home.

The following videos give an overview of what it can be like to have delirium:

1. Delirium Awareness and management Delirium Superimposed on Dementia:https://www.youtube.com/watch?v=2Hg1VP-Enw4&feature=youtu.be

2. Delirium Awareness Video – County Durham & Darlington NHS Foundation Trust: https://www.youtube.com/watch?v=7NA6iJJdsK88

What will make a person more likely to suffer from delirium?

Delirium is more common in those who are over 65 years of age.

It is also more common in men.

If a person has misused alcohol, they are also more at risk of suffering from delirium.

The following health factors will increase the risk of delirium developing:

• more than one health condition or illness
• living with dementia
• frailty
• hearing or visual impairments
• depression
• previous episodes of delirium.

What could trigger an episode of delirium?

The following factors could trigger an episode of delirium:

• surgery or injury
• illness of the brain, such as stroke or head injury
• terminal illness
• infection or sepsis
• pain
• constipation
• malnutrition
• dehydration
• medications such as painkillers or sedatives
• medications being discontinued or new medications being commenced
• alcohol and/or drug withdrawal.

Diagnosis/identification

It is important to identify delirium as soon as possible. Relatives and carers can provide helpful information so that medical staff can spot if someone is experiencing an episode of delirium. This may include if they notice anything about the patient’s behaviour that is different to usual.

If delirium is suspected, various tests can be used by healthcare professionals to support diagnosis:

These tests may include asking patients questions to check for alertness, using approved checklists or undertaking observations.

The tests or checks may be completed more than once as delirium can develop at any time during a person’s illness. Examples of these tests include:

• 4AT – This is a quick bedside scoring tool that identifies if delirium is present. It is based on clinic assessment of the patient’s alertness, attention and if their behaviour has changed.
• CAM (Confusion Assessment Method) – This is a quick test that identifies if delirium is present by assessing inattention, disorganised thinking and altered level of consciousness.
• SQiD (Single Question in Delirium) – This test will determine if further tests for delirium are needed.

If tests show that delirium is likely, a member of staff will carry out further tests to identify the cause.

The diagnosis will be recorded in the patient’s notes so that others involved in their care are aware of this.

Patients and their family or carers will also be informed of the diagnosis.

Further tests may be needed to find out what is causing the delirium so that this can be addressed and the cause of the delirium can be stopped.

How can the risk of delirium be reduced?

There are measures that can be taken to reduce the risk of delirium developing. This is very important for those staying in hospital or having long-term care.

These measures may include:

• making sure the person is wearing glasses or hearing aids if these are needed
• explaining to the person where they are and arranging for them to having familiar items e.g. photos with them
• helping the person to sleep, for example by reducing noise and light
• helping the person to sit up, get out of bed or get moving as soon as they can
• keeping pain under control
• encouraging the person to drink and eat regularly
• checking that the person is going to the toilet regularly.

If the person is a heavy smoker, drinker or regularly uses sleeping pills or sedatives, they should let staff know. Sometimes withdrawal from these drugs can worsen delirium.

Those having surgery and their family will be told about the risk of developing delirium, as this can help them to cope if it happens.

If a patient is at risk of developing delirium, you may need to ask an experienced healthcare professional to check their medications to see if anything they are taking may be increasing the risk.

An ‘All about me’ booklet or something similar can help healthcare staff taking care of the individual.

How can delirium be treated?

Treatment for delirium varies and may include:

• treating the underlying causes of delirium e.g. Infections, constipation/difficulties with passing urine or dehydration
• managing medications for other conditions and treating any side effects caused by these
• making changes to the environment to help people to feel more settled and to get sleep
• making sure the physical needs of the patient are met, for example that they are getting enough to eat and drink.

There is not enough evidence to show whether medicines are useful to treat delirium. In some cases however, calming or sedating drugs may be required, especially if the person remains extremely distressed or if they could hurt themselves or the people looking after them because of their delirium.

Having family members and carers around is likely to be very reassuring and helpful in the treatment of delirium. Familiar items such as photos of loved ones or other comforting objects are also a good idea and can help to bring back memories of the past. Radio or television can also be helpful for this.

Stimulating activities during the day can help people to rest during the evening and if they are well enough, a short supervised trip out of the ward environment may be agreed.

What can be done to help recovery?

Delirium is distressing, but once the underlying causes have been managed, symptoms will usually improve.

Some people will slowly get better with time and just being at home can allow a quicker recovery.

Medical staff encourage people who have suffered from delirium and their relatives to talk openly about their experiences. This helps to fill in the blanks and make sense of what has happened. This may help speed up their recovery.

While some people will return to how they were before the episode of delirium, others may experience longer-term problems. The person may:

• be a little more confused
• be less able than usual to carry out their daily tasks
• have unpleasant memories of their experiences.

What will happen when the patient leaves hospital?

Medical staff will discuss with the patient and their relatives or carers whether extra support is needed when they return to their home or care setting. Medical staff will make sure this is in place before they leave hospital. Support may include rehabilitation to improve, restore and maintain everyday skills and mobility.

A discharge letter will be sent to their GP. It will tell them about the patient’s delirium and say if they need an appointment so that they can be reviewed by their GP or the wider primary health care team. If the patient has any concerns, they or their relatives should speak to the medical staff at their appointment.

Further tests

We will gather information from the patient and their relatives or carers while they are in hospital to work out if there has been a decline in their reasoning. If so, they may be offered an appointment at a delirium clinic or with a community based memory service.

The patient’s GP will monitor their recovery and may repeat delirium tests. They may refer the patient for further memory tests.

What happens if delirium happens again?

Having an episode of delirium increases the patient’s risk of experiencing delirium again in the future. The hospital will make a note on the patient’s medical records that they have had delirium. This will help them decide what treatment will be given if they return to hospital for delirium or another condition.

This leaflet has been adapted from the Tees, Esk and Wear Valleys NHS Foundation Trust leaflet Delirium in Adults and older people –  Condition information for adults and older people across the Trust and their carers.

References

1. Delirium: prevention, diagnosis and management, National Institute for Health and Care Excellence (NICE), Clinical guideline [CG103], Published: 28 July 2010, Last updated: 14 March 2019, https://www.nice.org.uk/Guidance/CG103
2. Delirium in adults, National Institute for Health and Care Excellence (NICE), Quality standard [QS63], Published: 24 July 2014, https://www.nice.org.uk/guidance/qs63

Useful sources of information

NICE Guidelines
https://www.nice.org.uk/guidance/cg103/informationforpublic

Royal College of Psychiatrists
Delirium | Royal College of Psychiatrists (rcpsych.ac.uk)

NHS Website
www.nhs.uk/conditions/confusion

Health and Social Care: Public Health Agency
www.publichealth.hscni.net/publications/delirium-information-patients-and-relatives

Dementia UK
www.dementiauk.org/delirium
Tel. 0800 888 6678

Alzheimer’s Society
www.alzheimers.org.uk/get-support/daily-living/delirium
Tel: 0300 222 1122

Age UK
www.ageuk.org.uk
Tel. 0800 678 1602

Carers UK
www.carersuk.org
Tel. 020 7378 4999

Health Education England: Minded for Families
www.mindedforfamilies.org.uk

Comments, concerns, compliments or complaints

Patient Experience Team (PET)

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Leaflet feedback

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