Delirium in the Community

Delirium is a common and serious medical condition that results in a person experiencing a sudden change in their behaviour. The onset of delirium always indicates the presence of a physical disorder or acute illness.
Any person can get delirium but it is more common when a person is older, has a cognitive or sensory impairment, is very ill, or requires complex treatments.
Of those aged 80 and older living at home, one in 10 people could have delirium at any time. In care home residents, six in 10 could have delirium at any time.
Nurses and nursing assistants working in these settings are well placed to recognise delirium in the people they care for.
It is important to remember that delirium is particularly common in people with dementia – if you see sudden changes in the physical or mental health of a person living with dementia don’t discount delirium. The types of changes to look out for a listed HERE. Early recognition of delirium could help prevent the person falling over, becoming even more unwell and/or being admitted to hospital. In some cases, early recognition of delirium might even prevent their death.

Delirium can be difficult to recognise and sometimes the signs are subtle. That is why any change in a person should trigger the question “Could this person have delirium?” A useful tool to consider using here is called SQiD (the Single Question in Delirium). The single question: ‘Do you think [name of patient] has been more confused lately?’ is usually put to a member of the family or a friend but if you know the person well you may be able to answer the question yourself. Although this seems simple SQiD is almost as good at delirium detection as psychiatric interview and other more sophisticated identification tools. See Sands et al (2010) for example.

It is always better to rule out delirium than miss it completely. Remember, if you identify delirium, it is very likely that the patient has a medical condition that requires assessment and treatment urgently.

Nationally, Scotland has recently adopted its own set of Guidelines regarding the Risk Reduction and Management of Delirium called SIGN Guidleine 157.

Health Improvement Scotland published a patient information booklet to complement Scotland’s first clinical guideline for delirium. These can be used alongside resources produced by @ihubscot to improve delirium care across Scotland: http://bit.ly/37M5vcu

SIGN Guideline 157 asks that health professionals in Scotland adopt a standard assessment tool called the 4AT tool and this should be used for identifying patients with probable delirium in emergency department and acute hospital settings. They go on to suggest that the 4AT tool should also be used in community or other settings for identifying patients with probable delirium. If you are unfamiliar with the 4AT then now would be a good time to adopt it and get your team used to using it.

Identifying delirium is however only part of the issue. It is really important that you and your team create, develop and follow a local escalation plan which provides you and your team with instructions regarding what to do if delirium is suspected. It is worth checking if your organisation has an existing delirium escalation plan in place. If not, you might find the template and the information on this RCN site very useful. https://www.rcn.org.uk/clinical-topics/older-people/delirium/delirium-champion

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