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Care for patients with delirium update

Wednesday 15 May 2019

Care for patients with delirium update

Delirium is common in our hospitalised patients and leads to poorer outcomes and increased mortality. Early identification of patients at risk of delirium, prompt diagnosis and early intervention are crucial for reducing severity of delirium and complications that arise from it. Early treatment of underlying contributing factors is essential.

What can I do to improve care for my patients with delirium?

  • Aim to prevent delirium in patients at risk by doing things like providing adequate lighting, glasses and hearing aids; clocks, calendars, orientation boards; noise reduction strategies; family and carer involvement; avoiding room changes; reducing clutter; avoiding catheters and lines where possible; encouraging cognitive stimulation and mobilisation during the day; managing bowels, bladder and pain
     
  • Screen for delirium using a validated tool such as the 4AT Screening Instrument for Cognitive Impairment and Delirium - available on all wards

     
  • Document in the notes if the patient has delirium so that all staff are aware of and appreciate the risks the patient faces, and can manage them accordingly
     
  • Discuss this diagnosis with the patient and their family or carer, and how you plan to manage their delirium. Document this in the health record.
     
  • See Mater's procedure document: Delirium—assessment and management for a full list of all the non-pharmacological strategies available including the delirium information brochure for families/carers
     
  • Ensure you look for, and treat, underlying causes such as pain, constipation, urinary retention, acute infection and hypoxia


What is the role of antipsychotic medication?

  • Antipsychotic medications have a number of serious adverse effects for older people and can worsen delirium
     
  • Should delirium symptoms worsen or when the patient’s behaviour becomes hazardous to themselves or others, non-pharmacological measures should be continued and the use of antipsychotic medication considered
     
  • Non-pharmacological strategies should always be tried prior to any consideration of pharmacological options – this is now Mater policy and a recommendation from the evidenced based Delirium Clinical Care Standard
     
  • Discuss the use of antipsychotic medication with the legal carer or substitute decision maker, including consent, risks and benefits and duration. Document discussion and consent to use antipsychotic medication in the medical chart. Where the legal carer cannot be contacted and urgent administration of medication is required, document all attempts to contact and subsequent actions in the health record.
     
  • For guidelines on use see the assessment and management document or the Therapeutic Guidelines: psychotropics. Always use a low dose and closely monitor response before considering any dose increase and limit use for as short a time as possible
     
  • Avoid use in patients with Parkinson’s disease, dementia with Lewy bodies because they are at much higher risk of adverse reactions. to these medications


What is Mater doing to improve care for patients with delirium?

  • Mater has developed a procedure on delirium management and assessment
     
  • Mater has rolled out a validated screening tool for delirium – the 4AT. Anyone can use it and it is quick and easy to administer – just 4 simple questions may help identify delirium in your patient at admission or any time during their stay
     
  • Mater has also developed and rolled out a specific delirium staff education program to assist staff to identify and manage patients with delirium better
     
  • Mater will trial an antipsychotic time out checklist in several wards over the coming weeks as a safety and quality initiative. Our nursing staff or pharmacists may contact you to confirm some information prior to administering antipsychotics to your patients with delirium if this information is not in the health record. In order for the nursing staff to proceed with administration of antipsychotics it will need to be demonstrated that: the patient is at risk to themselves or others; underlying causes have been considered; non-drug therapies have been trialled and failed; and, importantly that consent has been obtained and documented. This is an important initiative in ensuring your patient’s safety and we appreciate your support of our nursing staff and pharmacists during this trial. We would also value your feedback which can be emailed to Sharon.Penboss@mater.org.au


Together, we can provide high quality care for our patients with delirium and prevent the onset of delirium in those at risk. This means better, safer care for patients and families.

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