Delirium

What is Delirium?

Delirium is a condition where people have increased confusion, difficulty concentrating and changes in their thinking. It is very common with about 1 in 4 patients being affected during their hospital stay. Delirium may be the reason why you or your relative has been admitted to hospital, or may develop during a hospital stay.

Who gets Delirium?

Anyone can develop delirium but certain things put people at higher risk:

• Old age
• Frailty
• Hearing or visual impairment
• Dementia or pre-existing memory problems
• Being in hospital with a serious illness or broken hip

What are the symptoms?

People with delirium may:

• Struggle to think clearly
• Have trouble concentrating, for example following a conversation
• Be suspicious and mistrustful of staff or visitors
• Believe things that are untrue (delusions). Sometimes people believe they are being harmed or poisioned and may be quite frightened. They may even call family members or even the police
• Not be aware of what is going on around them or of where they are
• Hallucinate (see or hear things which are not there)
• Have problems with recent memory
• Become more active; agitated, feel the need to wander or even become aggressive (this is often called a hyperactive delirium)
• Become less active; withdrawn, quiet or even drowsy (this is often called hypoactive delirium)

What Causes it?

Most cases of delirium have several causes acting together.

Common causes include:

• Pain
• Infection – this is a common cause, but not always the cause
• Nutrition not eating enough leading to malnutrition
• Constipation
• Hydration not drinking enough leading to dehydration
• Medication (e.g. morphine, codeine)
• Metalbolic problems e.g. Low sodium
• Mobility not being active enough
• Environment such as being in a new or strange place (especially the very busy hospital environment)
• Alcohol use or withdrawal
• Surgical problem (e.g. gallstones) or surgery itself

Sometimes quite minor illness e.g. constipation and dehydration can result in significant delirium, especially in those who may have pre-existing memory problems.

How is Delirium treated?

Delirium is treated by treating the underlying causes above and avoiding anything that would make it worse. Things that can help include:

• Ensuring good hydration and nutrition
• Avoiding unnecessary ward moves
• Avoiding the use of a urinary catheter if possible (although sometimes this is needed to treat incomplete emptying of the bladder)
• Avoiding constipation developing
• Reviewing and changing medications which may be part of the cause

What can help if someone becomes agitated or aggressive?

Delirium can be frightening for those affected and they can become agitated and aggressive. Being reassured by people they know can really help and you may be asked as a carer to help by sitting with the patient to help them remain calm. If you would like to stay for longer periods with the person there are options to do this, please speak to the nurse in charge of the ward.

Some people become so agitated that they are at risk of harming themselves or others. Medications known as sedatives may then be needed. These are only used when necessary, in the lowest possible doses and for short periods.

They will only be used in the following situations:

• To protect patients or others from harm
• To carry out essential tests
• To give essential treatments

How can I help?

As a relative or carer you can do lots to help:

• Stay calm and reassure them
• Talk in clear short, simple sentences, repeat things if necessary
• Limit the number of visitors at one time
• Remind them of the time and date
• Bring them a clock, calendar or newspaper
• Bring some familiar things or photos from home and talk about them
• Make sure they have their glasses and hearing aid, and the room is bright and well lit
• Ask the nurses if you can help at meal times or when you visit help them drink and bring them foods they enjoy
• Explain what is happening to them and their progress, share this leaflet with them
• Be aware that people with delirium can have a higher risk of falls when delirious

If your relative has Dementia, or memory problems, ask the ward team to help you complete a ‘This is Me’ document; this will help the team to communicate better with your relative and understand their care needs more fully.

Do all patients with delirium need admission to hospital?

Not necessarily. Being in your own environment with people, routines and surroundings that you know is likely to improve recovery from delirium. The decision on whether someone can be looked after in their usual environment depends on the cause of delirium, the support available to them at home, and the wishes of the patient and caregivers. If it is possible to manage the patient at home, this may be preferable.

How long will it take to get better?

Most people with delirium get better. In many cases symptoms will improve within a week but it may take weeks to completely recover and some people do not recover to how they were before. In a small number of cases, delirium can highlight that someone previously had a dementia that was undiagnosed, and delirium can also increase the risk of dementia being diagnosed in the future.

This may particularly be the case in those who have frailty and dementia.

The ward team will work with you to plan a safe discharge where delirium is taking longer to resolve.

What tests are needed?

Delirium can be diagnosed by reviewing the symptoms and performing a test of memory and concentration. We use the 4AT test (www.the4at.com) to screen for delirium. It should be repeated if there is new confusion. Gathering more information, performing an examination and carrying out further tests e.g. blood tests or urine tests, can help identify causes of delirium. Occasionally a CT scan of the brain may be needed if a stroke or bleed on the brain is suspected. Please tell us what the person is like normally and if there are changes that have come on suddenly.

Who are the Liaison Mental Health Team?

Delirium is generally managed by the clinical team looking after the patient. However sometimes the team need the expert opinion of mental health specialists based in the hospital called Liaison Mental Health Teams. They help ensure that patients with both physical and mental health problems (such as delirium) receive timely, safe and effective care during their hospital stay. They may wish to speak with carers or relatives so may contact you.

Further information

If you (or the person you care for) have been affected by delirium and you would like more information then please contact the nurse in charge of the ward, who will be happy to answer your questions or direct you to the most appropriate member of the team who can.

Thank you to Dr George Crowther, Consultant in Old Age Liaison Psychiatry,
Leeds and York Partnership Foundation Trust and Old Age Liaison Psychiatry Team.