On 8 October 2024 the RCN Older Persons Forum hosted a webinar discussing delirium. The three speakers for the session were Dr Ahmad Khundakar, Senior Lecturer from Teeside University, Dio Giotas, Clinical Nurse Specialist in dementia and delirium at Guy’s and St Thomas’ NHS Foundation Trust, and Dr Gary Mitchell, Reader at Queens University Belfast. The speakers have also contributed to this blog post about the webinar.
Delirium is a sudden change in mental function that can present with confusion, anxiety, hallucinations or severe lethargy that commonly affects older people admitted to hospital. Ninety six percent of cases are experienced by older people. When older people with dementia experience trauma or a change in their homeostasis such as infection, constipation, or dehydration, they are more at risk of delirium.
Delirium causes great distress to patients, families and carers and has potentially serious consequences such as increased likelihood of admission to long term care and increased mortality.
People who have delirium may need to stay longer in hospital; have an increased incidence of dementia and have more hospital-acquired complications such as falls and pressure ulcers.
Dr Ahmad Khundakar, Senior Lecturer Teeside University
It’s a tremendous pleasure to write my first blog for the RCN. Although I’m neither a nurse nor a clinician, I have a deeply personal connection to the profession through my mother. As a Lecturer and dementia researcher at Teesside University, I have long been interested in understanding dementia-related illnesses, such as Alzheimer’s and Parkinson’s disease. In my lab-based work, I lead projects that focus on developing new diagnostic methods for Lewy body dementias using advanced molecular techniques. I’ve also explored the basis of hallucinations in dementia with Lewy bodies and the impact of late-life depression and antidepressants on brain function.
A Personal Journey into Delirium Research
My interest in delirium research became profoundly personal when my mother, a dedicated nurse who later became a matron at the Royal Hospital for Sick Children in Edinburgh in the 1970s, was diagnosed with Parkinson’s disease and later developed dementia. As her condition progressed, she struggled to recognise signs of delirium, especially during hospital stays. The lack of recognition of the hyperactive and, particularly, hypoactive symptoms of delirium had a severe impact on her cognitive symptoms of dementia, leading to significant issues like malnutrition and dehydration, which greatly diminished her quality of life. Witnessing her struggles firsthand highlighted the devastating human impact of delirium in the context of neurodegenerative disease and its profound effects on patients and families.
My Motivation to Research Delirium
My mother’s nursing career and her battle with Parkinson’s disease have deeply influenced my approach to studying delirium and dementia. While I had a good understanding of the theoretical aspects of these conditions, nothing could have prepared me for experiencing them through my mother’s journey. This added a profoundly personal dimension as I watched her identity and dignity gradually diminish, along with her knowledge of the profession she loved. Her experience underscored the complexities of managing delirium and dementia in care settings, motivating me to advocate for better recognition and management of both.
Looking Forward
Sadly, my mother passed away during the COVID-19 pandemic. While her experience was traumatic for all of us, it has renewed my focus on improving the recognition and understanding of delirium in dementia. Together with esteemed delirium advocate and psychiatrist Dr Mani Krishnan, I am currently studying the state of delirium in care homes on Teesside and exploring potential non-pharmacological treatment strategies. I am committed to emphasising the importance of recognising delirium and improving the quality of life for those affected by dementia.
Dio Giotas, Clinical Nurse Specialist in dementia and delirium at Guy’s and St Thomas’ NHS Foundation Trust
I work in one of the largest NHS Trusts in England and my role as a dementia and delirium clinical nurse specialist has many strands. My colleagues and I look after Guy’s and St Thomas’s hospitals from inpatient wards and outpatient clinics to the memory clinic while we’re also responsible for dementia and delirium training and education across all staff in the Trust.
We sit under our Chief Nurse’s direct team, within the adult safeguarding team and along with the learning disabilities team. We’re geriatrician- led service and we tend to see more people over the age of 65 without, however, turning down anyone under 65 years old with delirium, memory or cognitive issues.
A typical day on the job starts with checking the incoming referrals and preparing to see our patients right after a whole team huddle. It also includes answering bleeps and our hotline calls with queries that may come from anyone in the country who needs advice on dementia and/or delirium. Depending on the day we will have several training sessions to deliver, meetings or talks in various events in and out of the Trust on top of our clinical work.
Fostering and promoting holistic and trusted relationships with patients, families and staff is vital in making every contact count and providing substantial, tailored support. In fact, our services are very personal. We visit the patient and check in with them to see how they feel whether the care is to their standards, and we assess them for delirium or screen them for dementia (if they have a formal diagnosis, we review them to ensure they have all the relevant support at home that is specific to their needs). We contact and meet the family in person, and we ensure that they’re coping with their caring responsibilities towards their loved one at home. We carry out an all-wrapped around biopsychosocial education on dementia/delirium and we gather some collateral to identify the changes in our patients and preserve as much as possible their independence, personhood and agency. At the same time, we explore what are the family’s needs and we link them up with local (to them) services so they can receive the support they need at home.
Our staff are as important in delivering high quality person-centred care and it’s them to make the impossible possible for the patients with dementia and delirium under their care with us specialist in a role of mentor/coach.
We, of course, face challenges which are more intense during the discharge process. That’s because post diagnostic support for people and families living with dementia varies dramatically from one borough to another. In this webinar I’m aiming to empower the attending fellow nursing colleagues with awareness, confidence and knowledge on delirium so they can enhance their practice with more evidence-based, modern and reliable approaches and tools to support their patients in any care setting.
Dr Gary Mitchell, reader at Queens University Belfast, RCN Older People's Forum Committee Co-Chair and Clinical Guideline CG103 (Delirium) Expert Panel Member
Delirium: What Every Nurse, Nursing Assistant & Nursing Student Needs to Know
As nurses/nursing assistants/nursing students caring for older adults, we play a crucial role in preventing, identifying, and managing delirium. The latest (updated in 2023) provides essential information to help us deliver the best possible care.
Here are the key points:
Think delirium
First and foremost, we need to be aware that any older person in our care may be at risk of delirium. This condition can have serious consequences, including increased risk of dementia and death, as well as longer hospital stays.
Risk factors and early signs
When admitting patients, assess for these key risk factors:
- age 65 or older
- cognitive impairment or dementia
- current hip fracture
- severe illness.
We should also be vigilant for recent changes that may indicate delirium, such as:
- Worsened concentration or confusion
- hallucinations
- reduced mobility or restlessness
- changes in appetite or sleep
- difficulty engaging or following requests.
Prevention is key
For at-risk patients, NICE recommends a tailored multicomponent intervention package within 24 hours of admission. This includes:
- ensuring adequate hydration and nutrition
- promoting mobility
- managing pain effectively
- reviewing medications
- addressing sensory impairments
- promoting good sleep hygiene.
Assessment and diagnosis
If we notice signs of potential delirium, it's crucial to perform a formal assessment. NICE now recommends using the 4AT tool in most settings, while the CAM-ICU or ICDSC are preferred in critical care or post-surgical areas.
Treatment approach
When delirium is diagnosed:
- identify and manage the underlying cause(s)
- provide effective communication and reorientation
- create a suitable care environment
- use de-escalation techniques for distressed patients
- consider short-term haloperidol only if absolutely necessary and with caution.
Information and support
We should offer clear information to patients at risk of or experiencing delirium, as well as their families. This includes explaining that delirium is common and usually temporary, and encouraging them to report any sudden changes in behavior.
Key takeaways
- Be proactive in assessing delirium risk factors and early signs.
- Implement preventive measures as part of routine care.
- Use appropriate assessment tools when delirium is suspected.
- Focus on non-pharmacological interventions for prevention and management.
- Educate patients and families about delirium.
- By staying informed and implementing these evidence-based practices, we can make a significant difference in reducing the incidence and impact of delirium among our older patients. Remember, our vigilance and care can prevent suffering and potentially save lives.
