Guidelines for the diagnosis and

Management of delirium in the

Elderly
Contents Page

Grade of evidence 1

Acknowledgements 1

Definitions 2

Diagnosis 2

Abbreviated Mental Test score 3

Differential diagnosis 3

Patients at risk 3

Causes 4

History 4

Examination 4

Investigations 5

Treatment of underlying cause 6

Management of confusion 6

Sedation 7

Prevention of complications 8

Referral to Old Age Psychiatry 8

Discharge 9

Follow up 9

References 10, 11,12

Index 13

Appendix 1 Drugs causing

delirium

Appendix 2 Algorithm for

management

Appendix 3 Summary of
Carlisle guidelines for
management of delirium
Grade of evidence:
Grade 1 Based on Randomised Controlled Trial

Grade IIa Based on well designed non-randomised controlled trial

Grade IIb Based on well designed cohort or case-control analytic studies

Grade IIc Comparisons between times/places, with or without

interventions.
Dramatic results in uncontrolled trials

Grade IIl Expert opinion, clinical experience, descriptive studies, expert

committees.

Acknowledgements:
These guidelines were compiled by Dr Lesley Young and Dr Jim George with
funding from the NHS central audit fund. We wish to acknowledge the support and
co-operation of the following groups of people who assisted in the development of
these guidelines:

Staff of the from the medical and elderly care wards and audit departments in the
following hospitals:

Cumberland Infirmary, Carlisle

Newcastle General Hospital, Newcastle upon Tyne
North Tyneside General Hospital, North Shields
Royal Victoria Infirmary, Newcastle upon Tyne
St Luke's Hospital, Bradford
Bradford Royal Infirmary, Bradford
Selly Oak Hospital, Birmingham

Members of the joint working party on "Confusion in Crises", Royal College of Physicians, October 1995.
Dr Stephen Singleton, Director of Public Health, Northumberland.
 1

Guidelines for the diagnosis and management of delirium

Delirium (acute confusional state) is a common condition in the elderly affecting up
to 30% of all elderly medical patients. Patients who develop delirium have high
mortality, institutionalisation and complication rates, and have longer lengths of stay
than non-delirious patients [1]. Delirium is often not recognised by clinicians [2], and
is often poorly managed. The aim of these guidelines is to aid recognition of delirium
and to provide guidance on how to manage these complex and challenging patients.

Diagnosis

Delirium is characterised by a disturbance of consciousness and a change in

cognition that develop over a short period of time. The disorder has a
tendency to fluctuate during the course of the day, and there is evidence form
the history, examination or investigations that the delirium is a direct
consequence of a general medical condition, drug withdrawal or intoxication
(DSM IV) [3].

In order to make a diagnosis of delirium, a patient must show each of the

features 1- 4 listed below:

1. Disturbance of consciousness (i.e. reduced clarity of awareness of the

environment) with reduced ability to focus, sustain or shift attention.

2. A change in cognition (such as memory deficit, disorientation, language

disturbance) or the development of a perceptual disturbance that is not
better accounted for by a pre- existing or evolving dementia.

3. The disturbance develops over a short period of time (usually hours to

days) and tends to fluctuate during the course of the day.

4. There is evidence from the history, physical examination, or laboratory

findings that the disturbance is caused by the direct physiological
consequences of a general medical condition, substance intoxication or
substance withdrawal.

Delirium may have more than one causal factor (i.e. multiple aetiologies). A
diagnosis of delirium can also be made when there is insufficient evidence to
support criterion 4, if the clinical, presentation is consistent with delirium, and
the clinical features can not be attributed to any other diagnosis, for example
delirium due to sensory deprivation.

2
Aids to diagnosis
 Cognitive testing should be carried out on all elderly patients
admitted to hospital (grade llc) Use of cognitive screening tools
(such as the Abbreviated Mental Test score [4] and Mini Mental State
Examination [5]) may increase recognition of delirium present on
admission [4, 5].

Serial measurements may help detect the new development of delirium

or its resolution [6] (gradellc). However by themselves these tools cannot
distinguish between delirium and other causes of cognitive impairment [4, 5].

A history from a relative or carer of the onset and course of the

confusion is essential to help distinguish between delirium and
dementia. (grade III).

Abbreviated Mental Test Score (AMT) (A score of less than 8/10 is

abnormal)

1. Age
2. Time (to nearest hour)
3. Address for recall at end of test (42 West St)
4. Year
5. Name of hospital
6. Recognition of 2 persons (eg doctor, nurse)
7. Date of Birth
8. Year of 1st World War
9. Name of present monarch
10. Count backwards 20-1 (this also tests attention)

Differential diagnosis

The differential diagnosis of delirium includes:

Dementia
Depression
Hysteria
Mania
Schizophrenia

The simple screening tools, discussed earlier, are not able to distinguish between
delirium and other disorders, such as dementia [4, 5]. In order to differentiate
between delirium and dementia, the most helpful factor is an account of the patients
pre-admission state from a relative or carer. Serial measurements of cognition may
help to differentiate delirium from dementia or detect its onset during a hospital
admission [6] (grade Ilc).

3
Patients at risk

Delirium is more common in those with a pre-existing organic brain syndrome [7] or
dementia [8-19], and may co-exist with disorders such as depression, which are also
common in the elderly [10, 20].
Delirium is more common in patients who are:

Older [21]
Severely ill [11]
Demented [11]
Physically frail [22]
Admitted with an infection or dehydration [11, 21]
Visually impaired [11]
Polypharmacy [15, 16, 23]
Alcohol excess [12]

Early attention to possible precipitants of delirium and adopting the

approaches detailed under "management of confusion" in those patients at
increased risk of delirium may prevent the development of delirium and
improve the outcome in those who go on to develop it [24-26, 44] (Grade, l).

Identification of the underlying cause

Common causes of delirium include :

Infection (e.g. pneumonia, UTI)

Neurological (e.g. stroke, subdural haematoma, epilepsy)
Cardiological (eg myocardial infarction, heart failure)
Respiratory (eg pulmonary embolus, hypoxia)
Electrolyte imbalance (eg dehydration, renal failure)
Endocrine & metabolic (eg cachexia, thiamine deficiency, thyroid dysfunction)
Drugs ( particularly those with anticholinergic side effects, eg
antidepressants, antiparkinsonian drugs, sedatives) (see appendix 1)
Multiple causes.

History

In addition to standard questions in the history, the following information

should be specifically sought (grade III):

Full drug history including non-prescribed drugs

Alcohol history
Previous intellectual function (eg ability to manage household affairs, pay
bills etc.)
Functional status (eg activities of daily living)
Onset and course of confusion
Previous episodes of acute or chronic confusion

4
Symptoms suggestive of underlying cause (eg infection)
Sensory deficits
Aids used (eg hearing aid, glasses etc.)
Pre-admission social circumstances and care package
 Comorbid illness

Many patients with confusional states are unable to provide an accurate

history. Where ever possible corroboration should be sought from the carer
(grade III).

Communication between staff from different disciplines is essential to avoid

unnecessary repetition of information gathering.

Examination

A full physical examination should be carried out including in particular the

following areas:

Neurological examination (including assessment of speech)

Conscious level
Nutritional status
Evidence of pyrexia
Evidence of alcohol abuse or withdrawal (e.g. tremor)
Cognitive function using a standardised screening tool e.g. Abbreviated MTS
or MMSE (grade IIc)
Attention (e.g. serial 7`s, months of year backwards)

Investigations

The following investigations are almost always indicated in patients with delirium in
order to identify
the underlying cause (grade III):

Full blood count

Calcium
Urea and electrolytes
Liver function tests
Glucose
Thyroid function tests
Chest X-ray
ECG
Blood cultures
Urinalysis

5
Other investigations may be indicated according to the findings from the history and
examination.
These include:

EEG (see below)

 CT head (see below)
B12 and folate
Arterial blood gases
Specific cultures eg urine, sputum
Lumbar puncture (see below)

CT Scan (grade llb)

Although many patients with delirium have an underlying dementia or structural

brain lesion (eg previous stroke), CT has been shown to be unhelpful on a routine
basis in identifying a cause for delirium [7] and should be reserved for those
patients in whom an intracranial lesion is suspected. This might include patients with
the following features (grade III):

Focal neurological signs

Confusion developing after head injury
Confusion developing after a fall
Evidence of raised intracranial pressure

EEG

Although the EEG is frequently abnormal in those with delirium [27 -29], showing
diffuse slowing, its routine use as a diagnostic tool has not been fully evaluated.
EEG may be useful where there is difficulty in the following situations (grade III):

Differentiating delirium from dementia

Differentiating delirium from non-convulsive status epilepticus and temporal
lobe epilepsy
Identifying those patients in whom the delirium is due to a focal intracranial
lesion, rather than a global abnormality.

Lumbar puncture

Although various abnormalities have been seen in the CSF of patients with delirium
[30], routine LP is not helpful [31] in identifying an underlying cause for the delirium
(grade III). It should therefore be reserved for those in whom there is reason to
suspect a cause such as meningitis. This might include patients with the following
features:

Meningism
Headache and fever

6
Treatment of underlying cause

The most important approach to the management of delirium is the identification and
treatment of the underlying cause (grade III).
 Incriminated drugs should be withdrawn where ever possible (grade III).
Biochemical derangements should be corrected promptly [32] (grade
IIb)
Infection is one of the most frequent precipitants of delirium. If there is a
high likelihood of infection (eg abnormal urinalysis, abnormal chest
examination etc.), appropriate cultures should be taken and antibiotics
commenced promptly, selecting a drug to which the likely infective
organism will be sensitive (grade III).

Management of confusion

In addition to treating the underlying cause, management should also be directed at

the relief of the symptoms of confusion/delirium.

The patient should be nursed in a good sensory environment and with a reality
orientation approach, and with involvement of the multi-disciplinary team [18, 23, 25,
26, 33-35] (grade I).

This includes:

Good lighting levels

Regular and repeated visible and verbal clues as to orientation (eg
clocks, calendars)
Reassurance and explanation to the patient and carer of any procedures
or treatment, using short simple sentences
Sensory aids should be available and working where necessary
Avoidance of inter- and intra-ward transfers [36] (grade III)
Continuity of care from caring staff
Avoidance of physical restraints [37-39] (grade IIc) (see also under Falls)
Maintenance or restoration of normal sleep patterns
Approach and handle gently
Eliminate unexpected and irritating noise (e.g. pump alarms)
Attend to bowel and bladder elimination (see continence problems)
Encouraging visits from familiar friends and relatives may help to calm
an agitated patient. However communication with the relative regarding
the nature of the confusion is essential.

Depending on the layout and nature of the ward, these measures may be facilitated
by nursing the patient in a single room. For example, in a busy Nightingale ward, a
patient with delirium may be better managed in a side room, whereas in a ward with
small bays the presence of other patients may have a reassuring influence (grade
III).

7
Wandering and rambling speech

Patients who wander require close observation within a safe and reasonably closed
environment. It is often preferable to try distracting the agitated wandering patient
rather than using restraints or sedation. Relatives could be encouraged to assist in
this kind of management.
Attempts should be made to identify and remedy possible cause of agitation - e.g.
pain, thirst, need for toilet. Patients with delirium often exhibit confused and
rambling speech, it is usually preferable not to agree with rambling talk, but to adopt
one of the following strategies, depending on the circumstance (grade III) [40]:

Tactfully disagree (if the topic is not sensitive)

Change the subject
Acknowledge the feelings expressed - ignore the content

Sedation

All sedatives may cause delirium, especially those with anticholinergic side effects
[41] (such as thioridazine, chlorpromazine etc.). The use of sedatives and major
tranquillisers should therefore be kept to a minimum (grade III). Many elderly
patients with delirium have hypoactive delirium (quiet delirium) and do not require
sedation [42]. Early identification of delirium and prompt treatment of the
underlying cause may reduce the severity and duration of delirium [24-26].

Drug sedation may be necessary in the following circumstances (grade III)

in order to carry out essential investigations or treatment

to prevent patients endangering themselves or others
to relieve distress in a highly agitated or hallucinating patient

It is preferable to use one drug only, starting at the lowest possible dose and
increasing in increments if necessary after an interval of 30 minutes (grade III).

The preferred drugs are:

Haloperidol - 0.5mg-3mg orally as tablets or liquid up to 4 times daily or 2.5

- 5 mg by
intramuscular injection (grade III) (NB the oral and IM doses of haloperidol
are not equivalent)

Droperidol - 5-10mg orally or 5mg by intramuscular injection up to 4 times

daily.

If sedatives are prescribed, the prescription should be reviewed regularly and

discontinued as soon as possible.
For delirium due to alcohol withdrawal (delirium tremens) a benzodiazepine (eg
diazepam or chlordiazepoxide) or chlormethiazole are preferred in a reducing
course. Detailed guidelines for this condition are beyond the scope of these
guidelines.
8
Prevention of complications

The main complications of delirium are :

Falls
Pressure sores
Nosocomial infections
 Functional impairment
Continence problems
Over sedation

Restraints (including cotsides, "geriatric chairs" etc.) have not been shown to
prevent falls and may increase the risk of injury [37-39]. It may be preferable to
nurse the patient on a low bed or place the mattress directly on the floor. Adoption of
the good practices described should make the use of physical restraints
unnecessary for the management of confusion (grade III).

Pressure sores

Patients should have a formal pressure sore risk assessment ( eg Norton score, or
Waterlow score), and receive regular pressure area care, including special
mattresses where necessary (grade III). Patients should be mobilised as soon as
their illness allows.

Functional impairment

Assessment by a physiotherapist and occupational therapist to maintain and

improve functional ability should be considered in all delirious patients (grade III).
There is evidence that patients who are managed by a multidisciplinary team do
better than those cared for in a traditional way [18, 23, 25-26, 33-35] (grade I, IIb).

Continence

A full continence assessment should be carried out. Regular toiletting and prompt
treatment of UTI`s may prevent urinary incontinence. Catheters should be avoided
where possible because of the increased risks of trauma in confused patients, and
the risk of catheter associated infection (grade III).

Referral to Old Age Psychiatry services

Many patients with delirium have an underlying dementia which may be best
followed up and managed by an Old Age Psychiatrist. Patients who fail to improve
despite adequate treatment and resolution of the suspected cause of the delirium
may benefit from referral to an Old Age Psychiatrist for further assessment (grade
III) [35].

9
Discharge

As with all elderly patients discharge should be planned in conjunction with all
disciplines involved in caring for the patient, both in hospital and in the community
(including informal carers). Practical arrangements should be in place prior to
discharge for activities such as washing, dressing, medication etc. in accordance
with the joint statement of the British Geriatrics Society and the Association
Directors of Social Services [43] (grade III).
 Communication with all parties involved in the patients care is vital.
Prior to discharge it is useful to assess the patients cognitive and
functional status ( eg using standardised tools such as AMT and Barthel
Index).
Discharge summaries should be completed promptly.

Follow up

Delirium is a common first presentation of an underlying dementing process. It may

also be a marker of severe illness and comorbidity. It is therefore often appropriate
to refer the patient to a Geriatrician, Psychiatrist of Old Age, CPN or Social Worker
for the Elderly or Consultant in Geriatric Medicine for further assessment and follow
up.

10
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11

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12

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Psychoger. 1991;3(2):211-229.

[28] Jacobsen SA, Leuchter AF, Walter DO. Conventional and quantitative EEG in
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[36] Mattice M. Intrahospital room transfers: a potential link to delirium in the

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 13
Index

A Abbreviated Mental
Test score 3
Acknowledgements 1
Algorithm
Appendix 2
Assessment 4
B, C Causes
3
Cognitive tests 3
Complications 8
Continence 8
CT scans 5
D Definitions
2
Dementia 3
Depression 3
Diagnosis 2
Differential diagnosis 3
Aids to diagnosis 2
Diagnostic criteria 2
Discharge 9
Drugs...
causing delirium Appendix 1
treatment of delirium 7
E EEG
5
Examination 4
F Falls
8
Follow-up 9
Functional impairment 8
G Grade of evidence
1
H History
4
I Incontinence
8
Investigations 5
J, K
L Lumbar puncture
6
M Management of
confusion 6,
7
Multidisciplinary team 6,8,9
N, O Old age psychiatry
8
P, Q Pressure sores
8
Prevention 3,6
R Reality Orientation
6
References 10
Rehabilitation 8
Restraints 6,8
Risk factors 3
 S Sedation
7
indications 7
types 7
Summary of guidelines Appendix 3
T Treatment
6
underlying cause 6
confusion 6,7
U, V Underlying cause
4
W Wandering
8
XYZ

14
Appendix 1
DRUG TYPE EXAMPLES RISK COMMENTS
Benzodiazepines Diazepam, Temazepam HIGH Benzodiazepine withdrawal is also a common
Chlordiazepoxide cause of delirium

Antidepressants Amitriptyline HIGH Risk greatest in drugs with anticholinergic and

Doxepin, Trazadone sedative effects

Antiparkinsonian drugs Levodopa HIGH All have anticholinergic or dopaminergie effects,

Bromocriptine which can cause confusion
Selegeline
Benzhexol
Orphenadrine
Pergolide

Analgesics NSAIDs HIGH All analgesics (except paracetamol) can cause

Opiates confusion. Of the NSAIDs indomethacin is most
Aspirin likely to cause delirium. Confusion due to aspairin
is dose related. Opiates have a very high risk of
causing confusion

Lithium HIGH

Steroids HIGH Risk may be dose related

Antihypertensive Methyl Dopa HIGH

medications -Blockers MEDIUM
-Blockers
ACE Inhibitors LOW
CA-Channel Blockers Diuretics may lead to delirium by causing
Diuretics electrolyte disturbances

Antiarrhythmics Digoxin MEDIUM Lignocaine has highest risk

Amiodarone Risk with digoxin is dose related
Disopyramide
Lignocaine

Major tranquillizers Chlorpromazine MEDIUM Sedating drugs, with anticholinergic effects (e.g.
Thioridazine Chlorpromazine) have higher risk than non-
Trifluoperazine sedating drugs such as haloperidol
Haloperidol LOW
Droperidol

Anticonvulsants Primidone LOW Risk highest with primidone

Phenytoin Lowest risk with valproate and carbamazepine
Carbamazepine Risk with phenytoin may be dose related
Valproate

Anticholinergic drugs Chlorpheniramine MEDIUM Drugs in this group are often bought over the
Antihistamines Atropine counter
Antispasmodics

Histamine blockers Cimetidine LOW Cimetidine may be more likely to cause confusion
Ranitidine, Famotidine than the other drugs in this group

Antibiotics Benzyl Penicillin LOW Although delirium has been attributed to most
Co-Trimoxazole antibiotics
Amphotericin Most cases of confusion occurring during
Antituberculous Drugs MEDIUM antibiotic treatment are likely to be due to the
Rifampicin
 Isoniazid infection rather than the treatment
Antiparasitic Drugs
Meppacrine
Chloroquine, Quinine
Antiviral Drugs
Amantadine
Acyclovir, Zidovudine

Respiratory drugs Aminophylline LOW May cause dose related confusion

Oral hypoglycaemic Tolbutamide UNCERTAIN These drugs may cause hypoglycaemia and
agents Glibenclamide hyponatraemia, both of which can cause delirium

Antineoplasstic drugs Methotrexate, Vinca UNCERTAIN
Alkaloids, Fluorouracil,
Altretamine, Asparginase,
Procarbazine, Carmustine,
Dacabazine, Interferon-
Delirium frequently occurs in malignant disease,
therefore it is difficult to attribute the confusion to
the drugs. However the drugs listed have been
associated with confusion more often than others
 Appendix 2
Guidelines for the diagnosis and management of delirium

AMT

<8/10 >8/10

Delirium unlikely
Possible delirium Consider other diagnosis
e.g. dementia or depression

Is there a change from the usual mental

state?

YES NO

Delirium

Identify underlying cause (or causes)

History
Examination
Investigations

Infection Drugs Other

Cardiac
Endocrine, Metabolic

Cultures Review all drug U&E

Urinalysis treatment LFT,TFT,Glucose
FBC,ESR ECG
CXR Other tests (see guidelines)

Empirical Treatment Discontinue likely drugs Treat any causes found

Improving Worsening

Continue Review Diagnosis

Monitor with AMT

Seek expert help
(See below)
Avoid sedatives
Avoid restraints Ensure good communication
Use reality orientation with patient, carers and
Avoid complications other professionals
at all times

Multidisciplinary discharge
planning

Follow up Expert will depend on local availability, but may

include Consultant in Old Age Psychiatry or Geriatric
Medicine
Appendix 3

Summary of Carlisle guidelines for management of delirium

The
featur
es of
deliriu
m
accor
ding
to
DSM
IV
are:

In all stages during the hospital admission, ensure good communication with 1. Disturbance of consciousness (i.e. reduced clarity of
awareness of the
the patient and carer: and between professionals caring for the patient. environment) with reduced ability to focus,
sustain or shift attention.

1. Identification of delirium using established diagnostic criteria (see over).

2. A change in cognition (such as memory deficit,
disorientation, language
disturbance) or the development of a perceptual disturbance that is not better
accounted for by a pre-existing or evolving dementia.
2. Recognition of delirium can be increased by the routine assessment of cognitive
state, e.g. using the AMT (see over). Repeated use of the AMT may help to 3. The disturbance develops over a short period of time (usually
hours to days) and
determine recovery or onset of delirium in those not delirious on admission. Tends to fluctuate during the course of the day.

3. Assessment of patients pre-admission cognitive, functional and social

status. 4. There is evidence from the history,
physical examination, or laboratory
This information may need to be clarified with the carer. findings that the
disturbance is caused by the direct physiological
Consequences of a general medical condition, substance intoxication
or substance withdrawal
4. Identification of risk factors such as dementia, severe illness, sensory
impairments, alcohol use.

Abbreviated Mental Test Score (AMT)

5. Identification of underlying cause (commonly infection or drugs).
1. Age
6. Treatment of underlying cause or removal of offending drugs
2. Time (to nearest hour)
7. Avoidance of physician restraints.
3. Address for recall at end of test (42
West St)
8. Avoidance of major tranquillizers, where possible, but if necessary use only one
drug and in the lowest dose possible (e.g. haloperidol 0.5mg orally up to QS). 4. Year
Review drug treatment regularly.
5. Name of hospital
9. Multi-disciplinary team involvement in treatment and discharge planning.
6. Recognition of 2 persons (e.g. doctor, nurse)
10. Create optimum environment for care (e.g. single room, good lighting).
7. Date of birth
11. Use reality orientation techniques and rehabilative care models.
8. Year of 1st World War
12. Ensure adequate discharge and follow-up to avoid unnecessary readmission
and to provide support to patient and carers. 9. Name of present monarch

10. Count 20-1