Recognising and preventing delirium

Delirium is a sudden change in a person’s mental state. It is a serious condition that is sometimes mistaken for dementia or, more rarely, depression.

Unlike dementia, delirium develops quickly and is usually temporary. Having delirium can mean:

• longer hospital stays
• increased risk of dementia
• increased mortality.

Treatment will depend on the underlying cause and should be managed by a healthcare professional, such as a GP.

Delirium is preventable in 30% of cases.

• Aged over 65 years.
• Cognitive impairment and/or dementia.
• Current hip fracture.
• Severe illness.

Most people living in care homes will be at risk. Care staff have an important role to play in looking out for any changes and providing support to reduce the risk of delirium occurring.

Hyperactive delirium

Makes a person restless, agitated, aggressive.

Symptoms include:

• Increased confusion
• Hallucinations or delusions
• Sleep disturbance
• Being less co-operative.

Hypoactive delirium

Makes a person withdrawn, quiet, sleepy.

Symptoms include:

• Poor concentration
• Being less aware
• Reduced mobility or movement
• Reduced appetite.

Mixed delirium occurs when the person moves between the two types.

The severity of symptoms can vary during the course of the day.

If any of these changes occur, an assessment from a healthcare professional (usually the GP) should be requested.

General principles

To help prevent delirium in anyone at risk:

• Make sure support is provided by carers who are familiar to them.
• Avoid moving the person unnecessarily, and keep their surroundings familiar.
• Request a review if they are taking multiple medications.
• Check on admission, and then daily, for any changes that might indicate delirium and refer for an assessment if needed.

Factors that make delirium more likely are listed below, with steps to help reduce the risk.

Cognitive impairment or disorientation

• Make sure the person can see a clock and a calendar.
• Talk to the person to help orientate them.
• Make sure any hearing aids and glasses are being worn and work well.

Dehydration or constipation

• Encourage the person to drink.
• Support the person to avoid or address constipation.

Infection

• Look for signs of infection.
• Avoid using a catheter as far as possible.

Disturbed sleep

• Avoid disturbing the person during sleep periods.

Limited mobility

• Encourage the person to walk.
• Provide support to do a range of active exercises, even if walking isn’t possible.

Pain

• Look for signs of pain, particularly if the person has a learning disability or dementia (Abbey Pain Scale is a tool that might help with this).
• Make sure pain is well-managed.

Poor food intake

• Make sure any dentures are clean, being worn and fit well.
• Look at the advice in our ‘Nutrition support in adults’ guideline (NICE guideline 32).

Being well-informed may help reduce any distress for the person and their family.

Care staff should provide information that shows:

• where to find support
• the importance of telling care staff about any sudden changes
• delirium is a common condition that is usually temporary
• how other people with delirium have felt.

The public delirium information from the Royal College of Psychiatrists may be helpful.

Experiences of people with delirium

• Worrying that people are trying to harm you.
• Seeing and hearing things that are not there.
• Difficulty following what is being said.
• Feeling afraid, irritable, anxious, depressed.
• Having vivid dreams that continue when awake.
• Difficulty speaking clearly.

• Delirium: prevention, diagnosis and management - NICE guideline, including assessment and care plan templates in tools and resources
• Delirium in adults- NICE Quality Standard
• Delirium awareness video - produced by Dr Sophia Bennett and Dr Mani Krishnan, part of the #ICanPrevent delirium conversation
• Delirium- Alzheimer's Society
• Delirium (confusion) - Dementia UK
• Delirium toolkit - Healthcare Improvement Scotland