SIGN issues new guidance on delirium

  • SIGN

  • curated by Pavankumar Kamat
  • Clinical Guidance Summaries
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Guideline name: Risk reduction and management of delirium

Update type: New guideline

Published: Mar 2019

Takeaway

  • Scottish Intercollegiate Guidelines Network (SIGN) has issued a guidance which focuses on detection, assessment, treatment, follow up, and risk reduction of adults with delirium.
  • The guidance is applicable to all settings, including home, long-term care, hospital, and hospice. It excludes delirium exclusively secondary to use of alcohol and illicit substances and also excludes delirium in children.

Detection of delirium

  • The 4 As test (Arousal, Attention, Abbreviated Mental Test 4, Acute change) or 4AT tool should be utilised for identification of patients with probable delirium in the emergency department and acute hospital settings, and could be used in community or other settings.
  • Routine use of CT brain scan is not recommended, but may be appropriate in patients presenting with delirium if they have the following:
    • New focal neurological signs
    • Diminished consciousness levels
    • History of recent falls
    • Head injury (all age groups)
    • Anticoagulation therapy

Non-pharmacological treatment

  • Clinicians should follow established care pathways for managing delirium
    • Delirium may have multiple aetiologies. All potential causes should be identified and treated.
    • It is crucial to consider acute, life-threatening causes of delirium, including reduced oxygenation, low blood pressure, low glucose levels, and drug intoxication or withdrawal.
    • Optimisation of physiology, comorbidities, environment (noise reduction), medications, and natural sleep is advised.
    • Patients and carers should be informed about the diagnosis and provided ongoing engagement and support.
    • Specific causes of agitation and/or distress should be managed non-pharmacologically only if possible.
    • Complications of delirium, including immobility, falls, pressure ulcers, dehydration, malnourishment, and isolation should be prevented.
    • Patients should be monitored for recovery and referred to a specialist if recovery is not satisfactory.

Pharmacological treatment

  • Antipsychotics, dexmedetomidine, acetylcholinesterase inhibitors, and benzodiazepines have limited evidence to support their efficacy in treating delirium.
  • Although there is insufficient evidence supporting pharmacological treatment of delirium, it may be advisable in specific situations, including intractable distress and compromised safety of the patient.

Follow-up

  • Patients experiencing delirium in ICU should be followed up for psychological sequelae including cognitive impairment.
  • Older individuals may have pre-existing cognitive impairment which may remain undetected or exacerbated in the presence of delirium. Appropriate cognitive and functional assessment is recommended.

This summary is reviewed by Prof.  Rishabh Prasad  MBBS, MA, MSC, FRCGP, FFCI, FRSA