- freely available
Medicina 2019, 55(8), 491; https://doi.org/10.3390/medicina55080491
1.1. List of All Recommendations in the Scottish Intercollegiate Guidance Network (SIGN) Guideline on Risk Reduction and Management of Delirium
- The 4AT tool should be used for identifying patients with probable delirium in emergency department and acute hospital settings.
- Use of the 4AT tool could be considered for use in community or other settings for identifying patients with probable delirium.
- For intensive care unit settings, Confusion Assessment Method – Intensive Care Unit (CAM-ICU) or Intensive Care Delirium Screening Checklist (ICDSC) should be considered to help identify patients with probable delirium.
- Computed tomography (CT) brain scan should not be used routinely but should be considered in hospital patients with delirium in the presence of:
- new focal neurological signs;
- a reduced level of consciousness (not adequately explained by another cause);
- a history of recent falls;
- a head injury (patients of any age);
- anticoagulation therapy.
- Electroencephalogram should be considered when there is a suspicion of epileptic activity or non-convulsive status epilepticus as a cause of a patient’s delirium.
- The following components should be considered as part of a package of care for patients at risk of developing delirium:
- orientation and ensuring patients have their glasses and hearing aids;
- promoting sleep hygiene;
- early mobilization;
- pain control;
- prevention, early identification, and treatment of postoperative complications;
- maintaining optimal hydration and nutrition;
- regulation of bladder and bowel function;
- provision of supplementary oxygen, if appropriate.
- With the aim of avoiding excessively deep anesthesia, depth of anesthesia should be monitored in all patients aged over 60 years who are under general anesthesia during surgery expected to last for more than one hour.
- The use of earplugs should be considered as part of a sleep-promotion strategy in intensive care.
- All patients at risk of delirium should have a medication review conducted by an experienced healthcare professional.
- Healthcare professionals should follow established pathways of good care to manage patients with delirium.
- First, consider acute, life-threatening causes of delirium, including low oxygen level, low blood pressure, low glucose level, and drug intoxication or withdrawal.
- Systematically identify and treat potential causes (medications, acute illness, etc), noting that multiple causes are common.
- Optimize physiology, management of concurrent conditions, environment (reduce noise), medications, and natural sleep, to promote brain recovery.
- Specifically detect, assess causes of, and treat agitation and/or distress, using nonpharmacological means only if possible (see Section 3 for pharmacological treatment).
- Communicate the diagnosis to patients and caregivers, encourage involvement of caregivers, and provide ongoing engagement and support.
- Aim to prevent complications of delirium such as immobility, falls, pressure sores, dehydration, malnourishment, and isolation.
- Monitor for recovery and consider specialist referral if not recovering.
- Consider follow-up
- Healthcare professionals should be aware that older people may have pre-existing cognitive impairment that may have been undetected or exacerbated in the context of delirium. Appropriate cognitive and functional assessment should be considered. Timing of this assessment must take into account persistent delirium.
1.2. List of All ‘Good Practice Points’ in the SIGN Guideline on Risk Reduction and Management of Delirium.
- A formal assessment and diagnosis must be made by a suitably trained clinician whenever patients with probable delirium are identified.
- Where delirium is detected, patients and their family/caregivers should be informed of the diagnosis.
- Where delirium is detected, the diagnosis of delirium should be clearly documented to aid transfers of care (e.g., handover notes, referral and discharge letters).
- Consideration should be given to imaging patients with non-resolving delirium where no clear cause is identified or there are features to suggest primary central nervous system pathology.
- Lumbar puncture should not be performed routinely on patients with delirium.
- Ward moves should be avoided wherever possible for patients at risk of delirium.
- Prior to surgery, patients and caregivers should be advised of the risk of developing delirium, to alleviate distress and help with management if it does occur.
- Where possible, assistance should be sought from a patient’s relatives and caregivers to deliver care to reduce the risk of delirium developing.
- Areas with patients at high-risk of delirium, such as trauma orthopaedic wards, should have protocols for commonly required medication (e.g., analgesia and anti-emesis) that contain choices for first-line treatments that minimise the risk of causing delirium.
- Promote cognitive engagement, mobilization, and other rehabilitation strategies.
- Patient records should be coded to highlight a previous episode of delirium so that hospital staff are aware of the increased risk on readmission.
- Ensure that delirium is noted in the discharge letter for the primary care team.
- All patients who have had delirium should be reviewed by the primary care team.
- In patients who have experienced delirium in intensive care units (ICU), consideration should be given to follow-up for psychological sequelae including cognitive impairment.
2. Detection of Delirium
3. Managing Delirium
4. Risk Reduction and Prevention of Delirium
5. Comparison between SIGN and National Institute of Healthcare and Care Excellence (NICE) Guidelines
6. Implementing the Guideline and the Future of Delirium Care
Conflicts of Interest
- Marcantonio, E.R. Delirium in hospitalized older adults. New Engl. J. Med. 2017, 377, 1456–1466. [Google Scholar] [CrossRef] [PubMed]
- Partridge, J.S.; Martin, F.C.; Harari, D.; Dhesi, J.K. The delirium experience: What is the effect on patients, relatives and staff and what can be done to modify this? Int. J. Geriatr. Psychiatr. 2013, 28, 804–812. [Google Scholar] [CrossRef] [PubMed]
- Harrison, J.K.; Garrido, A.G.; Rhynas, S.J.; Logan, G.; MacLullich, A.M.; MacArthur, J.; Shenkin, S. New institutionalisation following acute hospital admission: A retrospective cohort study. Age Ageing 2017, 46, 238–244. [Google Scholar] [CrossRef] [PubMed]
- Bond, P.; Goudie, K. Identifying and managing patients with delirium in acute care settings. Nurs. Older People 2015, 27, 28–32. [Google Scholar] [CrossRef] [PubMed]
- Bush, S.H.; Marchington, K.L.; Agar, M.; Davis, D.H.J.; Sikora, L.; Tsang, T.W.Y. Quality of clinical practice guidelines in delirium: A systematic appraisal. BMJ Open 2017, 7, e013809. [Google Scholar] [CrossRef] [PubMed]
- Scottish Intercollegiate Guidelines Network (SIGN). Risk reduction and management of delirium. Edinburgh: SIGN. 2019. (SIGN publication no. 157). Available online: http://www.sign.ac.uk/sign-157-delirium.html (accessed on 26 June 2019).
- 4AT Rapid Clinical Test for Delirium. Available online: www.the4at.com (accessed on 26 June 2019).
- Gusmao-Flores, D.; Salluh, J.I.; Chalhub, R.T.; Quarantini, L.C. The confusion assessment method for the intensive care unit (CAMICU) and intensive care delirium screening checklist (ICDSC) for the diagnosis of delirium: A systematic review and meta-analysis of clinical studies. Crit. Care 2012, 16, R115. [Google Scholar] [CrossRef] [PubMed]
- Healthcare Improvement Scotland. Think Delirium. Improving the Care for Older People. Delirium Toolkit. Available online: https://www.whatdotheyknow.com/ request/238377/response/593545/attach/4/Delirium%20 toolkit.pdf (accessed on 26 June 2019).
- Burry, L.; Mehta, S.; Perreault, M.M.; Luxenberg, J.S.; Siddiqi, N.; Hutton, B.; Fergusson, D.A.; Bell, C.; Rose, L. Antipsychotics for treatment of delirium in hospitalised non-ICU patients. Cochrane Database Syst. Rev. 2018, 6, CD005594. [Google Scholar] [CrossRef] [PubMed]
- Serafim, R.B.; Bozza, F.A.; Soares, M.; Brasil, P.E.A.D.; Tura, B.R.; Ely, E.W.; Salluh, J.I. Pharmacologic prevention and treatment of delirium in intensive care patients: A systematic review. J. Crit. Care 2015, 30, 799–807. [Google Scholar] [CrossRef] [PubMed]
- Abraha, I.; Trotta, F.; Rimland, J.M.; Cruz-Jentoft, A.; Lozano-Montoya, I.; Soiza, R.L.; Pierini, V.; Dessì Fulgheri, P.; Lattanzio, F.; O’Mahony, D.; et al. Efficacy of non-pharmacological interventions to prevent and treat delirium in older patients: A systematic overview. The SENATOR project ONTOP Series. PLoS ONE 2015, 10, e0123090. [Google Scholar] [CrossRef] [PubMed]
- Siddiqi, N.; Harrison, J.K.; Clegg, A.; A Teale, E.; Young, J.; Taylor, J.; Simpkins, S.A. Interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst. Rev. 2016, 3, CD005563. [Google Scholar] [CrossRef] [PubMed]
- Woolf, S.H.; Grol, R.; Hutchinson, A.; Eccles, M.; Grimshaw, J. Potential benefits, limitations, and harms of clinical guidelines. BMJ 1999, 318, 527–530. [Google Scholar] [CrossRef] [PubMed]
- Davis, D.; Searle, S.D.; Tsui, A. The Scottish Intercollegiate Guidelines Network: Risk reduction and management of delirium. Age Ageing 2019, 48, 485–488. [Google Scholar] [CrossRef] [PubMed]
© 2019 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).