Delirium/Acute confusion
Definition
- Commonly presents with acute confusion, and a change in level of alertness.
- May be obviously agitated (hyperactive delirium) or withdrawn and sleepy (hypoactive delirium) or a mixture of the two.
Causes
- Delirium often has a trigger (or more than one) which should be explored and treated where possible.
- Delirium may be associated with poorer outcomes for patients, and is associated with longer term cognitive impairment.
Symptoms
- Commonly presents with acute confusion, and a change in level of alertness.
- May be obviously agitated (hyperactive delirium) or withdrawn and sleepy (hypoactive delirium) or a mixture of the two.
- A history of preceding cognitive impairment should be sought.
- A comprehensive review of symptoms and changes to normal routine should be explored.
Signs
- Look for signs of causative conditions
- Consider infection but be aware that acute confusional state is not always a UTI
- Ensure not constipation
- Ensure not in urinary retention
- Explore sensory impairment and ensure has appropriate aids (glasses, hearing aids)
PINCH-ME:
- Pain – assess for pain
- Intracerebral (e.g. stroke) / Infection
- N*utrition (including mouth care)
- Constipation
- Hypoxia / Hypoglycaemia / Hydration
- Metabolic (e.g. hyponatraemia, hypercalcaemia) / Medication
- Environmental (e.g. disturbed sleep, sensory deficits – ensure has glasses, hearing aids)
Blood tests:
- FBC, U&E, LFT, Bone, CRP
- Urine culture if warranted based on clinical assessment
- 4AT test (only takes a couple of minutes)
| 1. ALERTNESS This includes patients who may be markedly drowsy (eg. difficult to rouse and/or obviously sleepy during assessment) or agitated/hyperactive. Observe the patient. If asleep, attempt to wake with speech or gentle touch on shoulder. Ask the patient to state their name and address to assist rating | |
| Normal (fully alert, but not agitated, throughout assessment) | 0 |
| Mild sleepiness for <10 seconds after waking, then normal | 0 |
| Clearly abnormal | 4 |
| 2. AMT4 Age, date of birth, place (name of the hospital or building), current year. | |
| No mistakes | 0 |
| 1 mistake | 1 |
| 2 or more mistakes/untestable | 2 |
| 3. ATTENTION Ask the patient: “Please tell me the months of the year in backwards order, starting at December.” To assist initial understanding one prompt of “what is the month before December?” is permitted. |
|
| Achieves 7 months or more correctly | 0 |
| Starts but scores <7 months / refuses to start | 1 |
| Untestable (cannot start because unwell, drowsy, inattentive) | 2 |
| 4. ACUTE CHANGE OR FLUCTUATING COURSE Evidence of significant change or fluctuation in: alertness, cognition, other mental function (eg. paranoia, hallucinations) arising over the last 2 weeks and still evident in last 24hrs |
|
| No | 0 |
| Yes | 4 |
| Calculate total score: | |
|---|---|
| 4 or above | possible delirium +/- cognitive impairment |
| 1-3 | possible cognitive impairment\ |
| 0 | delirium or severe cognitive impairment unlikely (but delirium still possible if [4] information incomplete) |
Management
- Supportive management
- Treat underlying issues
- Review medications
- Assess for risks to safety (e.g. pressure ulcers, falls)
- Support for patient and informal carers
- Engagement:
- Support reassurance, orientation
- Ensure physical comfort
- Ensure safety at home
When to admit
- If safety cannot be maintained at home
- If concerns about being acutely unwell / unstable
- If concerns regarding preceding head injury and acute confusion (especially if on anticoagulation) - refer to NICE head injury guidance