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Delirium HAI

About

What is covered

This pathway covers the prevention, diagnosis and management of delirium.
Delirium (sometimes called 'acute confusional state') is a clinical syndrome characterised by disturbed consciousness, cognitive function or perception, which has an acute onset and fluctuating course.
It is a common but serious and complex clinical syndrome associated with poor outcomes.
Delirium may be present when a person presents to hospital or long-term care or may develop during a hospital admission or residential stay in long-term care.
Delirium can be hypoactive delirium or hyperactive delirium but some people show signs of both (mixed). Hypoactive and mixed delirium can be more difficult to recognise.
The main focus of this pathway is preventing delirium in people identified to be at risk, using a targeted, multicomponent, non-pharmacological intervention that addresses a number of modifiable risk factors ('clinical factors').
This pathway does not cover children and young people (under 18 years), people receiving end-of-life care, people with intoxication and/or withdrawing from drugs or alcohol or with delirium associated with these states.

Updates

Updates to this pathway

12 August 2014 Delirium: support for commissioning added
23 July 2014 'Delirium' (NICE quality standard 63) added to this pathway.
26 March 2014 Links to the 'Parkinson's disease' and 'Violence' pathways have been added.
23 January 2014 Minor maintenance updates
12 December 2013 Mental wellbeing of older people in care homes quality standard added to the pathway
10 December 2013 Links to the 'Intravenous fluids in adults in hospital pathway' added.
3 May 2013 Minor maintenance updates
04 December 2012 Minor maintenance updates

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Short Text

Delirium: diagnosis, prevention and management

What is covered

This pathway covers the prevention, diagnosis and management of delirium.
Delirium (sometimes called 'acute confusional state') is a clinical syndrome characterised by disturbed consciousness, cognitive function or perception, which has an acute onset and fluctuating course.
It is a common but serious and complex clinical syndrome associated with poor outcomes.
Delirium may be present when a person presents to hospital or long-term care or may develop during a hospital admission or residential stay in long-term care.
Delirium can be hypoactive delirium or hyperactive delirium but some people show signs of both (mixed). Hypoactive and mixed delirium can be more difficult to recognise.
The main focus of this pathway is preventing delirium in people identified to be at risk, using a targeted, multicomponent, non-pharmacological intervention that addresses a number of modifiable risk factors ('clinical factors').
This pathway does not cover children and young people (under 18 years), people receiving end-of-life care, people with intoxication and/or withdrawing from drugs or alcohol or with delirium associated with these states.

Updates

Updates to this pathway

12 August 2014 Delirium: support for commissioning added
23 July 2014 'Delirium' (NICE quality standard 63) added to this pathway.
26 March 2014 Links to the 'Parkinson's disease' and 'Violence' pathways have been added.
23 January 2014 Minor maintenance updates
12 December 2013 Mental wellbeing of older people in care homes quality standard added to the pathway
10 December 2013 Links to the 'Intravenous fluids in adults in hospital pathway' added.
3 May 2013 Minor maintenance updates
04 December 2012 Minor maintenance updates

Sources

NICE guidance

The NICE guidance that was used to create the pathway.
Delirium. NICE clinical guideline 103 (2008)
Parkinson's disease. NICE clinical guideline 35 (2006)

Quality standards

Mental wellbeing of older people in care homes

These quality statements are taken from the mental wellbeing of older people in care homes quality standard. The quality standard defines clinical best practice for mental wellbeing of older people in care homes and should be read in full.

Delirium

These quality statements are taken from the delirium quality standard. The quality standard defines clinical best practice for delirium and should be read in full.

Quality statements

Participation in meaningful activity

This quality statement is taken from the mental wellbeing of older people in care homes quality standard. The quality standard defines clinical best practice in mental wellbeing of older people in care homes and should be read in full.

Quality statement

Older people in care homes are offered opportunities during their day to participate in meaningful activity that promotes their health and mental wellbeing.

Rationale

It is important that older people in care homes have the opportunity to take part in activity, including activities of daily living, that helps to maintain or improve their health and mental wellbeing. They should be encouraged to take an active role in choosing and defining activities that are meaningful to them. Whenever possible, and if the person wishes, family, friends and carers should be involved in these activities. This will help to ensure that activity is meaningful and that relationships are developed and maintained.

Quality measures

Structure
Evidence of local arrangements to ensure that older people in care homes are offered opportunities during their day to participate in meaningful activity that promotes their health and mental wellbeing.
Data source: Local data collection.
Outcome
a) Feedback from older people in care homes that they are offered opportunities to take part in activity during their day.
Data source: Local data collection. Adult Social Care Outcomes Toolkit. The following documents from the toolkit include questions about choice and control, social participation and involvement, occupation and dignity: CHINT3 care home interview schedule and CHOBS3 care home observation schedule.
The Personal Social Services Adult Social Care Survey (England). This survey collects data on service users’ views and opinions over a range of outcome areas, including satisfaction with social care and support and quality of life. Appendix F of this report provides a link to model questionnaires.
b) Feedback from older people in care homes that they have taken part in activity during their day that is meaningful to them.
Data source: Local data collection. Adult Social Care Outcomes Toolkit. The following documents from the toolkit include questions about choice and control, social participation and involvement, occupation and dignity: CHINT3 care home interview schedule and CHOBS3 care home observation schedule.
The Personal Social Services Adult Social Care Survey (England). This survey collects data on service users’ views and opinions over a range of outcome areas, including satisfaction with social care and support and quality of life. Appendix F of this report provides a link to model questionnaires.

What the quality statement means for organisations providing care, social care, health and public health practitioners, local authorities and other commissioning services

Organisations providing care ensure that opportunities for activity are available and that staff are trained to offer spontaneous and planned opportunities for older people in care homes to participate in activity that is meaningful to them and that promotes their health and mental wellbeing.
Social care, health and public health practitioners ensure that they offer older people in care homes opportunities during their day to participate in spontaneous and planned activity that is meaningful to them and that promotes their health and mental wellbeing.
Local authorities and other commissioning services ensure that they commission services from providers that can produce evidence of activities that are undertaken within the care home and can demonstrate that staff are trained to offer spontaneous and planned opportunities for older people in care homes to participate in activity that is meaningful to them.

What the quality statement means for service users, family, friends and carers

Older people in care homes have opportunities during their day to take part in activities of their choice that help them stay well and feel satisfied with life. Their family, friends and carers have opportunities to be involved in activities with them when the older person wishes.

Source guidance

Definitions of terms used in this quality statement

Care homes
This refers to all care home settings, including residential and nursing accommodation, and includes people accessing day care and respite care. [Expert consensus]
Meaningful activity
Meaningful activity includes physical, social and leisure activities that are tailored to the person’s needs and preferences. Activity can range from activities of daily living such as dressing, eating and washing, to leisure activities such as reading, gardening, arts and crafts, conversation, and singing. It can be structured or spontaneous, for groups or for individuals, and may involve family, friends and carers, or the wider community. Activity may provide emotional, creative, intellectual and spiritual stimulation. It should take place in an environment that is appropriate to the person’s needs and preferences, which may include using outdoor spaces or making adaptations to the person’s environment. [Adapted from SCIE guide 15, Choice and Control, Living well through activity in care homes: the toolkit (College of Occupational Therapists) and expert consensus]
Mental wellbeing
Mental wellbeing includes areas that are key to optimum functioning and independence, such as life satisfaction, optimism, self-esteem, feeling in control, having a purpose in life, and a sense of belonging and support. [Adapted from the Mental health improvement programme, background and policy context (NHS Health Scotland)]

Equality and diversity considerations

Staff working with older people in care homes should identify and address the specific needs of older people arising from diversity, including gender and gender identity, sexuality, ethnicity, age and religion.
When tailoring activities to the needs and preferences of older people, staff should be aware of any learning disabilities, acquired cognitive impairments, communication and language barriers, and cultural differences. Staff should have the necessary skills to include people with cognitive or communication difficulties in decision-making (from Dignity in care [SCIE guide 15]: Choice and control). Staff should ensure that they are aware of the needs and preferences of older people who are approaching the end of their life.
When collecting feedback from older people about whether they have been offered opportunities for meaningful activity, staff should consider using alternative methods for older people who find it difficult to provide feedback. For example, tools such as Dementia Care Mapping can be used, and/or feedback from people who are considered suitable to represent the views of the older person, such as family members, carers, or an advocate.

Personal identity

This quality statement is taken from the mental wellbeing of older people in care homes quality standard. The quality standard defines clinical best practice in mental wellbeing of older people in care homes and should be read in full.

Quality statement

Older people in care homes are enabled to maintain and develop their personal identity.

Rationale

It is important that staff working with older people in care homes are aware of the personal history of the people they care for and respect their interests, beliefs and the importance of their personal possessions. Older people should be involved in decision-making and supported and enabled to express who they are as an individual and what they want. They should be able to make their own choices whenever possible. Enabling older people to maintain and develop their personal identity during and after their move to a care home promotes dignity and has a positive impact on their sense of identity and mental wellbeing.

Quality measures

Structure
Evidence of local arrangements to ensure that older people in care homes are enabled to maintain and develop their personal identity.
Data source: Local data collection.
Outcome
Feedback from older people in care homes that their personal identity is respected.
Data source: Local data collection. Adult Social Care Outcomes Toolkit. The following documents from the toolkit include questions about choice and control, personal cleanliness and comfort, social participation and involvement, occupation and dignity: CHINT3 care home interview schedule and CHOBS3 care home observation schedule.
The Personal Social Services Adult Social Care Survey (England). This survey collects data on service users’ views and opinions over a range of outcome areas, including satisfaction with social care and support and quality of life. Appendix F of this report provides a link to model questionnaires.

What the quality statement means for organisations providing care, social care, health and public health practitioners, local authorities and other commissioning services

Organisations providing care work to embed a culture built on dignity and choice in care homes and ensure that staff are trained to work in partnership with older people in care homes in order to enable them to maintain and develop their personal identity.
Social care, health and public health practitioners work with older people in care homes to tailor support and opportunities to their needs and preferences, with the aim of maintaining and developing their personal identity.
Local authorities and other commissioning services ensure that they commission services from providers that can produce evidence of the actions they have taken to embed a culture of dignity and choice, and that staff are trained to work in partnership with older people in care homes in order to enable them to maintain and develop their personal identity.

What the quality statement means for service users

Older people in care homes are given support and opportunities to express themselves as individuals and maintain and develop their sense of who they are.

Source guidance

Definitions of terms used in this quality statement

Care homes
This refers to all care home settings, including residential and nursing accommodation, and includes people accessing day care and respite care. [Expert consensus]

Enabled

‘Enabled’ refers to actions taken by staff working with older people in care homes to ensure that older people can maintain and develop their personal identity. This may include using life history to tailor support and opportunities to the needs and preferences of the individual. Staff should ensure that older people are able to choose their own clothes, have their most valued possessions with them and choose where to sit while they are eating. It may be necessary to adapt the older person’s environment and provide access to outdoor spaces. Staff should facilitate social inclusion by promoting and supporting social interactions and access to social networks, involvement with the community, and existing and new relationships. [Adapted from Dignity in care (SCIE guide 15), Choice and control and Social inclusion, and expert consensus]
Personal identity
This refers to a person’s individuality, including their needs and preferences, and involvement in decision-making in all aspects of their life. Maintaining a sense of personal identity can involve using life history to maintain and build a meaningful and satisfying life, as defined by the person themselves. Central to personal identity is the feeling of having a purpose in life, feeling valued, having a sense of belonging and a feeling of worth. Relationships, including those with family, carers and friends, are an important aspect of a person’s identity and can have a significant impact on mental wellbeing. An individual’s personal identity may change as their circumstances alter. [Adapted from Personalisation: a rough guide (SCIE guide 47), My Home Life: Promoting quality of life in care homes, ‘Voice, choice and control’ in care homes (Joseph Rowntree Foundation); and expert consensus]

Equality and diversity considerations

Staff working with older people in care homes should identify the specific needs arising from diversity, including gender and gender identity, sexuality, ethnicity, spirituality, culture, age and religion.
When ensuring that older people are enabled to maintain and develop their personal identity be aware of any learning disabilities, acquired cognitive impairments, communication or language barriers or cultural differences. Staff should ensure that they are aware of the needs and preferences of older people who are approaching the end of their life.
When collecting feedback from older people about whether they have been enabled to maintain and develop their personal identity staff should consider using alternative methods for older people who find it difficult to provide feedback. For example, tools such as Dementia Care Mapping can be used, and/or feedback from people who are considered suitable to represent the views of the older person such as family members, carers, or an advocate.

Recognition of mental health conditions

This quality statement is taken from the mental wellbeing of older people in care homes quality standard. The quality standard defines clinical best practice in mental wellbeing of older people in care homes and should be read in full.

Quality statement

Older people in care homes have the symptoms and signs of mental health conditions recognised and recorded as part of their care plan.

Rationale

Mental health conditions are highly prevalent among older people in care homes, but are often not recognised, diagnosed or treated. Ageing with good mental health can make a key difference in ensuring that life is enjoyable and fulfilling. The recognition and recording of symptoms and signs of mental health conditions by staff who are aware of the role of the GP in the route to referral can help to ensure early assessment and access to appropriate healthcare services.

Quality measures

Structure
Evidence of protocols to ensure that staff are trained to recognise the symptoms and signs of mental health conditions in older people, and record them in their care plan.
Data source: Local data collection.

What the quality statement means for organisations providing care, social care, health and public health practitioners, local authorities and other commissioning services

Organisations providing care ensure that staff are trained to be alert to the symptoms and signs of mental health conditions in older people in care homes and to record them in a care plan.
Social care, health and public health practitioners look for symptoms and signs of mental health conditions and record them in the older person’s care plan.
Local authorities and other commissioning services commission services from providers that can produce evidence of protocols for training staff to be alert to the symptoms and signs of mental health conditions in older people in care homes and to record them in a care plan.

What the quality statement means for service users

Older people in care homes are cared for by staff who recognise the symptoms and signs of mental health conditions (such as depression and anxiety) and record them in their care plan.

Source guidance

Definitions of terms used in this quality statement

Care homes
This refers to all care home settings, including residential and nursing accommodation, and includes people accessing day care and respite care. [Expert consensus]
Mental health conditions
These include common mental health conditions such as depression, generalised anxiety disorder and social anxiety disorder, and may also include dementia and delirium. People may have more than one mental health condition at a given time. (See the NICE guidelines on dementia (NICE clinical guideline 42), depression in adults (NICE clinical guideline 90), depression in adults with a chronic physical health problem (NICE clinical guideline 91), delirium (NICE clinical guideline 103), common mental health disorders (NICE clinical guideline 123) and social anxiety disorder (NICE clinical guideline 159) for more information.)
Recognised
Recognised in this context relates to staff observing and recognising the symptoms and signs of mental health conditions, and sharing information and concerns with healthcare professionals, including GPs. Staff should be continually alert to new or worsening symptoms and signs. Observation of behaviour should happen on an ongoing basis and in response to the presentation of relevant symptoms. [Expert consensus]
Trained staff
This refers to staff who have been trained to recognise and record the symptoms and signs of mental health conditions when caring for older people. Staff should be alert to the presentation of new symptoms and signs and aware of existing conditions. Staff should also be competent in recognising when older people need a referral for assessment and management of the mental health condition. [Expert consensus]

Equality and diversity considerations

When looking for symptoms and signs of mental health conditions, be aware of any learning disabilities, acquired cognitive impairments, communication and language barriers, sensory impairment and cultural differences. Staff should ensure that they are aware of the needs and preferences of older people who are approaching the end of their life.
It is important that staff are aware that older people in care homes have the same right to access healthcare as people living independently in the community. This is stated in the NHS Constitution.

Recognition of sensory impairment

This quality statement is taken from the mental wellbeing of older people in care homes quality standard. The quality standard defines clinical best practice in mental wellbeing of older people in care homes and should be read in full.

Quality statement

Older people in care homes who have specific needs arising from sensory impairment have these recognised and recorded as part of their care plan.

Rationale

Mild but progressive sight and hearing losses are a common feature of ageing and may go unnoticed for some time, but can have a serious effect on a person’s communication, confidence and independence. The recognition and recording of needs arising from sensory impairment by staff who are alert to the symptoms and signs and aware of the role of the GP in the route to referral can help to ensure early assessment and access to appropriate healthcare services. For older people in care homes this is essential to improve their quality of life and avoid isolation, which can have a detrimental effect on mental wellbeing.

Quality measures

Structure
Evidence of protocols to ensure that staff are trained to recognise specific needs arising from sensory impairment in older people, and record these needs as part of their care plan.
Data source: Local data collection.
Process
Proportion of older people in care homes who have regular sight tests.
Numerator – the number of people in the denominator who have had a sight test within the past 2 years.
Denominator – the number of older people in care homes.
Data source: Local data collection.

What the quality statement means for organisations providing care, social care, health and public health practitioners, local authorities and other commissioning services

Organisations providing care ensure that staff are trained to be alert to specific needs arising from sensory impairment in older people in care homes and to record them in a care plan.
Social care, health and public health practitioners are alert to and recognise specific needs arising from sensory impairment in older people in care homes and record them in their care plan.
Local authorities and other commissioning services commission services from providers that can produce evidence of protocols for training staff to be alert to specific needs arising from sensory impairment in older people in care homes and to record them in a care plan.

What the quality statement means for service users

Older people in care homes are cared for by staff who recognise needs that occur because of sight or hearing problems and record these as part of their care plan.

Source guidance

Definitions of terms used in this quality statement

Care homes
This refers to all care home settings, including residential and nursing accommodation, and includes people accessing day care and respite care. [Expert consensus]
Recognised
Recognised in this context relates to the recognition by staff working with older people in care homes of the needs arising from sensory impairment and the sharing of information with healthcare professionals, including GPs. Staff should be continually alert to new and existing needs. This should involve monitoring of existing impairments and recognition of new sensory impairments. This is likely to include ensuring regular sight and hearing checks are arranged, cleaning glasses, and changing hearing aid batteries, or referral to an appropriately trained professional. [SCIE research briefing 21 and expert consensus]
Regular sight test
Adults are normally advised to have a sight test every 2 years. However, in some circumstances, the ophthalmic practitioner may recommend more frequent sight tests, for example in people who:
  • have diabetes
  • are aged 40 or over and have a family history of glaucoma
  • are aged 70 or over. [NHS Choices]
Sensory impairment
Sensory impairment most commonly refers to sight or hearing loss. It includes combined sight and hearing loss, which is frequently referred to as dual sensory impairment or deafblindness. [Adapted from Basic Sensory Impairment Awareness (NHS Education for Scotland) and Social care for deafblind children and adults (Department of Health)]
Trained staff
This refers to staff who have been trained to recognise and record the symptoms and signs of sensory impairment when caring for older people. Staff should be aware that there are many different types of sight and hearing loss, with a large variation in the degree of impairment. Staff should also be competent in recognising when older people need a referral for assessment and management of the sensory impairment. [Expert consensus]

Equality and diversity considerations

Sensory impairment is common in older people. It is frequently perceived as an expected feature of ageing rather than as potentially disabling. It is important that sensory impairment is not considered as acceptable for older people in care homes. This may need to be emphasised during training to increase awareness and recognition of sensory impairments.
When looking for signs or symptoms of sensory impairment, be aware of any learning disabilities, acquired cognitive impairments, communication and language barriers, and cultural differences. Staff should ensure that they are aware of the needs and preferences of older people who are approaching the end of their life
It is important that staff are aware that older people in care homes have the same right to access healthcare as people living independently in the community. This is stated in the NHS Constitution.

Recognition of physical problems

This quality statement is taken from the mental wellbeing of older people in care homes quality standard. The quality standard defines clinical best practice in mental wellbeing of older people in care homes and should be read in full.

Quality statement

Older people in care homes have the symptoms and signs of physical problems recognised and recorded as part of their care plan.

Rationale

Physical problems can cause discomfort and affect activities of daily living, participation in social activities and independence, and therefore mental wellbeing. The recognition and recording of the symptoms and signs of physical problems by trained staff who are aware of the role of the GP in the route to referral can help to ensure early assessment and access to appropriate healthcare services. This is essential to improve the quality of life and mental wellbeing of older people in care homes.

Quality measures

Structure
Evidence of protocols to ensure that staff are trained to recognise the symptoms and signs of physical problems in older people in care homes, and record them as part of their care plan.
Data source: Local data collection.

What the quality statement means for organisations providing care, social care, health and public health practitioners, local authorities and other commissioning services

Organisations providing care ensure that staff are trained to be alert to symptoms and signs of physical problems in older people in care homes and to record them in a care plan.
Social care, health and public health practitioners look for symptoms and signs of physical problems in older people in care homes and record them in their care plan.
Local authorities and other commissioning services commission services from providers that can produce evidence of protocols for training staff to be alert to the symptoms and signs of physical problems in older people in care homes and to record them in care plans.

What the quality statement means for service users

Older people in care homes are cared for by staff who recognise the symptoms and signs of physical problems (such as pain, dizziness, problems with walking, constipation and continence problems) and record them in their care plan.

Source guidance

Definitions of terms used in this quality statement

Care homes
This refers to all care home settings, including residential and nursing accommodation, and includes people accessing day care and respite care. [Expert consensus]
Physical problems
Examples of physical problems that could potentially affect a person’s wellbeing include, but are not limited to:
  • joint and muscular pain
  • undiagnosed pain
  • incontinence
  • dizziness
  • constipation
  • urinary tract infection
  • reduced ability to move without support
  • unsteady gait. [Expert consensus]
Recognised
Recognised in this context relates to the recognition by staff working with older people in care homes of physical problems and the sharing of information with healthcare professionals, including GPs. Staff should be continually alert to new physical problems and should monitor existing physical problems. [Expert consensus]
Trained staff
Trained staff refers to staff who have been trained to recognise and record the symptoms and signs of physical problems when caring for older people. Staff should be alert to the presentation of new symptoms and competent in recognising when older people need a referral for assessment and management of physical problems. [Expert consensus]

Equality and diversity considerations

When identifying an older person’s needs arising from physical problems, be aware of any learning disabilities, acquired cognitive impairments, communication and language barriers, and cultural differences. Staff should ensure that they are aware of the needs and preferences of older people who are approaching the end of their life.
It is important that staff are aware that older people in care homes have the same right to access healthcare as people living independently in the community. This is stated in the NHS Constitution.

Access to healthcare services

This quality statement is taken from the mental wellbeing of older people in care homes quality standard. The quality standard defines clinical best practice in mental wellbeing of older people in care homes and should be read in full.

Quality statement

Older people in care homes have access to the full range of healthcare services when they need them.

Rationale

Older people in care homes typically have greater and more complex health needs than those living in the community, and these needs can affect their wellbeing if they are not addressed. Many care home residents experience problems accessing NHS primary and secondary healthcare services, including GPs. It is important that care homes have good links with GPs and referral arrangements, so that services can be accessed easily and without delay when they are needed. This is essential to prevent unmet healthcare needs from having a negative impact on mental wellbeing.

Quality measures

Structure
Evidence of referral arrangements to ensure that older people in care homes are given access to the full range of healthcare services when they need them.
Data source: Local data collection.
Outcome
Feedback from older people in care homes and from their family, friends and/or carers that they are satisfied with the care they have received.

What the quality statement means for organisations providing care, social care, health and public health practitioners, local authorities and other commissioning services

Organisations providing care ensure that they work in partnership with healthcare organisations to implement effective arrangements for access to primary, secondary, specialist and mental health services for older people in care homes.
Social care, health and public health practitioners facilitate access to primary, secondary, specialist and mental health services for older people in care homes by referring the person to the required service when they need it.
Local authorities and other commissioning services commission services from providers that can produce evidence of arrangements with local healthcare organisations which facilitate access to primary, secondary, specialist and mental health services for older people in care homes.

What the quality statement means for service users

Older people in care homes can see their GP and use hospital services when they need them.

Source guidance

Definitions of terms used in this quality statement

Care homes
This refers to all care home settings, including residential and nursing accommodation, and includes people accessing day care and respite care. [Expert consensus]
Healthcare services
These include primary care, and acute and specialist physical and mental health services. [GP services for older people living in residential care: a guide for care home managers. (SCIE guide 52)]

Equality and diversity considerations

When deciding if access to healthcare services is needed, staff working with older people in care homes should be aware of any learning disabilities, acquired cognitive impairments, communication and language barriers, sensory impairment, and cultural differences. Staff should ensure that they are aware of the needs and preferences of older people who are approaching the end of their life.
It is important that staff are aware that older people in care homes have the same right to access healthcare as people living independently in the community. This is stated in the NHS Constitution.

Assessing recent changes in behaviour

This quality statement is taken from the delirium quality standard. The quality standard defines clinical best practice for delirium and should be read in full.

Quality statement

Adults newly admitted to hospital or long-term care who are at risk of delirium are assessed for recent changes in behaviour, including cognition, perception, physical function and social behaviour.

Rationale

The early detection of delirium is important, because it allows supportive care and treatment for reversible causes to be put in place as quickly as possible. People may already have delirium when they are admitted to hospital or to long-term care, so it is important to assess for any recent changes or fluctuations in behaviour that may indicate that the person has delirium. If possible, family members and carers of people at risk of delirium should be involved in identifying any changes in behaviour.

Quality measures

Structure
Evidence of local arrangements to ensure that adults newly admitted to hospital or long-term care who are at risk of delirium are assessed for recent changes in behaviour, including cognition, perception, physical function and social behaviour.
Data source: Local data collection.
Process
Proportion of adults newly admitted to hospital or long-term care who are at risk of delirium who are assessed for recent changes in behaviour, including cognition, perception, physical function and social behaviour.
Numerator – the number in the denominator who are assessed for recent changes in behaviour, including cognition, perception, physical function and social behaviour.
Denominator – the number of adults newly admitted to hospital or long-term care who are at risk of delirium.
Data source: Local data collection. NICE clinical guideline 103 audit support, criterion 2.
Outcome
Detection of delirium.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (such as hospitals, residential care homes, nursing homes) ensure that guidance is available on changes in behaviour that may indicate that a person has delirium, and that systems are in place to assess recent changes in behaviour, including cognition, perception, physical function and social behaviour, in adults newly admitted to hospital or long-term care who are at risk of delirium.
Health and social care practitioners ensure that they assess adults newly admitted to hospital or long-term care who are at risk of delirium for recent changes in behaviour, including cognition, perception, physical function and social behaviour.
Commissioners (such as clinical commissioning groups [CCGs], local authorities) ensure that the hospitals and long-term care they commission services from can demonstrate (for example, by auditing current practice) that newly admitted adults who are at risk of delirium are assessed for recent changes in behaviour, including cognition, perception, physical function and social behaviour. CCGs may include this in local Commissioning for Quality and Innovation (CQUIN) targets for improving dementia and delirium care.

What the quality statement means for patients, service users and carers

Adults admitted to hospital or to a residential care home or nursing home who are thought to be at risk of delirium are assessed to spot any recent changes in their behaviour that may show that they have delirium. A person is at risk of delirium if any of the following apply: they are 65 or older, already have difficulties with memory or understanding (known as cognitive impairment), have dementia, have a broken hip or are seriously ill.

Source guidance

  • Delirium (NICE clinical guideline 103), recommendation 1.2.1 (key priority for implementation).

Definitions of terms used in this quality statement

Long-term care
Residential care provided in a home that may include skilled nursing care and help with everyday activities. This includes nursing homes and residential homes. [NICE clinical guideline 103, full guideline, glossary of terms]
Adults at risk of delirium
If any of these risk factors is present, the person is at risk of delirium:
  • Age 65 years or older.
  • Cognitive impairment (past or present) and/or dementia. If cognitive impairment is suspected, confirm it using a standardised and validated cognitive impairment measure.
  • Current hip fracture.
  • Severe illness (a clinical condition that is deteriorating or is at risk of deterioration). [NICE clinical guideline 103, recommendation 1.1.1]
Recent changes in behaviour
Recent (within hours or days) changes or fluctuations in behaviour may be reported by the person at risk, or a carer or family member, and may affect:
  • Cognitive function: for example, worsened concentration, slow responses, confusion.
  • Perception: for example, visual or auditory hallucinations.
  • Physical function: for example, reduced mobility, reduced movement, restlessness, agitation, changes in appetite, sleep disturbance.
  • Social behaviour: for example, difficulty with or unable to cooperate with reasonable requests, withdrawal, or alterations in communication, mood and/or attitude.
[Adapted from NICE clinical guideline 103, recommendation 1.2.1]

Equality and diversity considerations

A learning disability specialist nurse should be involved in assessing changes in behaviour in adults with a learning disability who are at risk of delirium, to ensure that the person’s specific needs are taken into account.

Interventions to prevent delirium

This quality statement is taken from the delirium quality standard. The quality standard defines clinical best practice for delirium and should be read in full.

Quality statement

Adults newly admitted to hospital or long-term care who are at risk of delirium receive a range of tailored interventions to prevent delirium.

Rationale

Delirium is potentially preventable, and interventions can be effective in preventing delirium in adults who are at risk. These preventative measures should be tailored to each person's needs, based on the results of an assessment for clinical factors that may contribute to the development of delirium. Such clinical factors include cognitive impairment, disorientation, dehydration, constipation, hypoxia, infection or other acute illness, immobility or limited mobility, pain, effects of medication, poor nutrition, sensory impairment and sleep disturbance.

Quality measures

Structure
Evidence of local arrangements to ensure that adults newly admitted to hospital or long-term care who are at risk of delirium receive a range of tailored interventions to prevent delirium.
Data source: Local data collection.
Process
a) Proportion of adults newly admitted to hospital or long-term care who are at risk of delirium who are assessed for clinical factors that may contribute to the development of delirium within 24 hours of their admission.
Numerator – the number in the denominator who are assessed for clinical factors that may contribute to the development of delirium within 24 hours of their admission.
Denominator – the number of adults newly admitted to hospital or long-term care who are at risk of delirium.
Data source: Local data collection. NICE clinical guideline 103 audit support, criterion 3.
b) Proportion of adults newly admitted to hospital or long-term care who are at risk of delirium who receive a range of tailored interventions to prevent delirium.
Numerator – the number in the denominator who receive a range of tailored interventions to prevent delirium.
Denominator – the number of adults newly admitted to hospital or long-term care who are at risk of delirium who have an assessment for clinical factors that may contribute to the development of delirium.
Data source: Local data collection.
Outcome
Incidence of delirium.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (such as hospitals, residential care homes, nursing homes) ensure that guidance is available on using a range of tailored interventions to prevent delirium.
Health and social care practitioners ensure that adults newly admitted to hospital or long-term care who are at risk of delirium receive a range of tailored interventions to prevent delirium.
Commissioners (such as clinical commissioning groups [CCGs], local authorities) ensure that the hospitals and long-term care they commission services from can demonstrate (for example, by auditing current practice) the use of a range of tailored interventions to prevent delirium. CCGs may include this in local Commissioning for Quality and Innovation (CQUIN) targets for improving dementia and delirium care.

What the quality statement means for patients, service users and carers

Adults admitted to hospital or to a residential care home or nursing home who are thought to be at risk of delirium are assessed and offered care to reduce their chances of getting delirium that takes into account their particular needs and circumstances.

Source guidance

  • Delirium (NICE clinical guideline 103), recommendations 1.3.2 (key priority for implementation) and 1.3.3.1 to 1.3.3.10.

Definitions of terms used in this quality statement

Long-term care
Residential care provided in a home that may include skilled nursing care and help with everyday activities. This includes nursing homes and residential homes. [NICE clinical guideline 103, full guideline, glossary of terms]
Adults at risk of delirium
If any of these risk factors is present, the person is at risk of delirium:
  • Age 65 years or older.
  • Cognitive impairment (past or present) and/or dementia. If cognitive impairment is suspected, confirm it using a standardised and validated cognitive impairment measure.
  • Current hip fracture.
  • Severe illness (a clinical condition that is deteriorating or is at risk of deterioration). [NICE clinical guideline 103, recommendation 1.1.1]
Tailored interventions to prevent delirium
Interventions to prevent delirium are provided by a multidisciplinary team and are tailored to the care setting and to the person's individual needs. They are based on the results of an assessment for clinical factors that may contribute to the development of delirium, including cognitive impairment, disorientation, dehydration, constipation, hypoxia, infection or other acute illness, immobility or limited mobility, pain, effects of medication, poor nutrition, sensory impairment and sleep disturbance. Interventions could include:
  • avoiding moving people within and between wards or rooms unless absolutely necessary
  • ensuring that the person is cared for by a team of healthcare professionals who are familiar to them
  • providing appropriate lighting and clear signage; for example, a 24 hour clock, a calendar
  • talking to the person to reorientate them
  • introducing cognitively stimulating activities
  • if possible, encouraging regular visits from family and friends
  • ensuring that the person has adequate fluid intake
  • looking for and treating infections
  • avoiding unnecessary catheterisation
  • encouraging the person to walk or, if this is not possible, to carry out active range-of-motion exercises
  • reviewing pain management
  • carrying out a medication review
  • ensuring that the person's dentures fit properly
  • ensuring that any hearing and visual aids are working and are used
  • reducing noise during sleep periods
  • avoiding medical or nursing interventions during sleep periods.
[Adapted from NICE clinical guideline 103, recommendations 1.3.1 and 1.3.3.1 to 1.3.3.10]

Equality and diversity considerations

A learning disability specialist nurse should be involved in providing tailored interventions aimed at preventing delirium for adults with a learning disability who are at risk, to ensure that the person's specific needs are taken into account.

Use of antipsychotic medication for people who are distressed

This quality statement is taken from the delirium quality standard. The quality standard defines clinical best practice for delirium and should be read in full.

Quality statement

Adults with delirium in hospital or long-term care who are distressed or are a risk to themselves or others are not prescribed antipsychotic medication unless de-escalation techniques are ineffective or inappropriate.

Rationale

Antipsychotic medication is associated with a number of adverse effects. Therefore it should only be considered as a short-term treatment option for delirium if a person is distressed or is a risk to themselves or others and de-escalation techniques have failed or are inappropriate. Antipsychotic medication may be inappropriate in a variety of circumstances; for example, if reversible causes such as pain or urinary retention have not been treated or excluded, if barriers to communication have not been overcome, or for people with specific conditions such as Parkinson’s disease or dementia with Lewy bodies.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with delirium in hospital or long-term care who are distressed or are a risk to themselves or others are not prescribed antipsychotic medication unless de-escalation techniques are ineffective or inappropriate.
Data source: Local data collection.
Process
Proportion of adults with delirium in hospital or long-term care who have been prescribed antipsychotic medication who were distressed or a risk to themselves or others and for whom de-escalation techniques were ineffective or inappropriate.
Numerator – the number in the denominator who were distressed or a risk to themselves or others and for whom de-escalation techniques were ineffective or inappropriate.
Denominator – the number of adults with delirium in hospital or long-term care who have been prescribed antipsychotic medication.
Data source: Local antipsychotic prescribing audits.
Outcome
Antipsychotic medication prescribing rates.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as hospitals, residential care homes, nursing homes, GPs) ensure that there are procedures and protocols in place to monitor the use of antipsychotic medication in adults with delirium, to ensure that this is only considered as a treatment option for delirium when the person is distressed or a risk to themselves or others and de-escalation techniques are ineffective or inappropriate.
Healthcare professionals ensure that they do not prescribe antipsychotic medication for adults with delirium who are distressed or a risk to themselves or others unless de-escalation techniques are ineffective or inappropriate.
Commissioners (such as clinical commissioning groups [CCGs], local authorities, NHS England area teams) ensure that staff in hospitals and long-term care homes are trained in de-escalation techniques if appropriate, monitor antipsychotic medication prescribing rates for adults with delirium, and support providers to develop, monitor and improve procedures and protocols to monitor this prescribing.

What the quality statement means for patients, service users and carers

Adults in hospital or in a residential care home or nursing home who have delirium are not given antipsychotic medication (which can be used to treat people who experience hallucinations or delusions) unless they are very distressed or are thought to be a risk to themselves or others, and if other ways of calming them down have not worked or are not suitable.

Source guidance

  • Delirium (NICE clinical guideline 103), recommendation 1.6.4 (key priority for implementation).

Definitions of terms used in this quality statement

Long-term care
Residential care provided in a home that may include skilled nursing care and help with everyday activities. This includes nursing homes and residential homes. [NICE clinical guideline 103, full guideline, glossary of terms]
Antipsychotic medication for adults with delirium
Short-term (usually for 1 week or less) use of appropriate antipsychotic medication, starting at the lowest clinically appropriate dose and titrating cautiously according to symptoms, should be considered for adults with delirium who are distressed or considered a risk to themselves or others when de-escalation techniques have been ineffective or are inappropriate. [Adapted from NICE clinical guideline 103, recommendation 1.6.4]
Antipsychotic drugs should be avoided, or used with caution if they are needed, in people with conditions such as Parkinson’s disease or dementia with Lewy bodies. [Adapted from NICE clinical guideline 103, recommendation 1.6.5]
De-escalation techniques
Communication approaches that can help solve problems and reduce the likelihood or impact of confrontation. This includes verbal and non-verbal communication such as signs, symbols, pictures, writing, objects of reference, human and technical aids, eye contact, body language and touch. [Adapted from Skills for Care’s National minimum training standards for healthcare support workers and adult social care workers in England, standard 5.5: Dealing with confrontation and difficult situations]

Equality and diversity considerations

A learning disability specialist nurse should be involved in treating the symptoms of delirium in adults with a learning disability, to ensure that the person’s specific needs are taken into account.

Information and support

This quality statement is taken from the delirium quality standard. The quality standard defines clinical best practice for delirium and should be read in full.

Quality statement

Adults with delirium in hospital or long-term care, and their family members and carers, are given information that explains the condition and describes other people’s experiences of delirium.

Rationale

Experiencing delirium can be upsetting and distressing, particularly if the person has hallucinations or delusions, and they may go on to have flashbacks. It is important to provide information that describes how others have experienced delirium in order to help adults with delirium, and their family members and carers, to understand the experience and to support recovery.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with delirium in hospital or long-term care, and their family members and carers, are given information that explains the condition and describes other people’s experiences of delirium.
Data source: Local data collection.
Process
a) Proportion of adults with delirium in hospital or long-term care who are given information that explains the condition and describes other people’s experiences of delirium.
Numerator – the number in the denominator who are given information that explains the condition and describes other people’s experiences of delirium.
Denominator – the number of adults with delirium in hospital or long-term care.
Data source: Local data collection.
b) Proportion of family members or carers of adults with delirium in hospital or long-term care who are given information that explains the condition and describes other people’s experiences of delirium.
Numerator – the number in the denominator whose family members or carers are given information that explains the condition and describes other people’s experiences of delirium.
Denominator – the number of adults with delirium in hospital or long-term care.
Data source: Local data collection.
Outcome
Patient and carer experience.
Data source: Local data collection. The Care Quality Commission’s Inpatient survey asks about information provision (not specific to adults with delirium).

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (such as hospitals, residential care homes, nursing homes) ensure that they have protocols and procedures in place so that adults with delirium, and their family members and carers, are given information that explains the condition and describes other people’s experiences of delirium.
Health and social care practitioners ensure that they give adults with delirium, and their family members and carers, information that explains the condition and describes other people’s experiences of delirium.
Commissioners (such as clinical commissioning groups [CCGs], local authorities) seek evidence from providers that they have protocols and procedures in place to ensure that adults with delirium, and their family members and carers, are given information that explains the condition and describes other people’s experiences of delirium.

What the quality statement means for patients, service users and carers

Adults with delirium, and their family members and carers, are given information that explains what delirium is and includes descriptions of other people’s experiences of delirium.

Source guidance

  • Delirium (NICE clinical guideline 103), recommendation 1.7.1 (key priority for implementation).

Definitions of terms used in this quality statement

Long-term care
Residential care provided in a home that may include skilled nursing care and help with everyday activities. This includes nursing homes and residential homes. [NICE clinical guideline 103, full guideline, glossary of terms]
Information for adults with delirium, and their family members and carers
Appropriate verbal and written information, which:
  • informs them that delirium is common and usually temporary
  • describes people’s experiences of delirium
  • encourages adults at risk of delirium, and their family members and carers, to tell their healthcare team about any sudden changes or fluctuations in behaviour
  • encourages the person who has had delirium to share their experience with the healthcare professional during recovery
  • advises the person of any support groups.
[Adapted from NICE clinical guideline 103, recommendation 1.7.1]
The Royal College of Psychiatrists’ leaflet on delirium is an example of written information for adults with delirium and their family members and carers.

Equality and diversity considerations

All written information should be accessible to adults with delirium, and their family members and carers, who have additional needs such as physical, sensory or learning disabilities. Adults with delirium, and their family members and carers, should have access to an interpreter or advocate if needed, and should be provided with information that meets their cultural, cognitive and language needs.

Communication of diagnosis to GPs

This quality statement is taken from the delirium quality standard. The quality standard defines clinical best practice for delirium and should be read in full.

Quality statement

Adults with current or resolved delirium who are discharged from hospital have their diagnosis of delirium communicated to their GP.

Rationale

Improving communication between hospitals and GPs, and within hospital departments, may help people who are recovering from or who still have delirium to receive adequate follow-up care once they are back in the community or a long-term care home. Follow-up care may include treatment for reversible causes, investigation for possible dementia and a greater emphasis on preventing delirium recurring. A person’s diagnosis of delirium may not be communicated to their GP because it is usually secondary to their main reason for admission, and it also may not be communicated between hospital wards when the person is transferred. A person’s diagnosis of delirium during a hospital stay should be formally included in the discharge summary sent to their GP, and the term ‘delirium’ should be used.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with current or resolved delirium who are discharged from hospital have their diagnosis of delirium communicated to their GP.
Data source: Local data collection.
Process
Proportion of adults with current or resolved delirium who are discharged from hospital who have their diagnosis of delirium communicated to their GP.
Numerator – the number in the denominator who have their diagnosis of delirium communicated to their GP.
Denominator – the number of adults with current or resolved delirium who are discharged from hospital.
Data source: Local data collection. The admitted patient care datasets contain data on the coding of delirium. Data for admissions to NHS hospitals in England are available at Hospital Episode Statistics online.
Outcome
Continuity of care from hospital to home.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as hospitals, GPs) ensure that systems are in place so that a diagnosis of delirium during a hospital stay is communicated to the person’s GP after discharge.
Healthcare professionals in all hospital care settings ensure that a diagnosis of delirium during a hospital stay is communicated to the person’s GP when they are discharged.
Commissioners (such as clinical commissioning groups [CCGs], NHS England area teams) ensure that they commission services that have systems in place to record people’s diagnoses of delirium during hospital stays in discharge summaries sent to GPs. CCGs may wish to seek evidence that protocols are in place to record episodes of delirium during hospital stays.

What the quality statement means for patients, service users and carers

Adults who have had delirium in hospital have their diagnosis of delirium shared with their GP by hospital staff when they are discharged.

Source guidance

  • Delirium (NICE clinical guideline 103), recommendation 1.5.2 (key priority for implementation).

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Education tools

NICE has developed online learning modules, in collaboration with a range of providers, including BMJ Learning, to update knowledge on evidence and NICE guidance.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Supporting information

Has the person any indicators of delirium? These are recent (within hours or days) changes in:
  • Cognitive function: for example, worsened concentration, slow responses, confusion.
  • Perception: for example, visual or auditory hallucinations.
  • Physical function: for example, reduced mobility, reduced movement, restlessness, agitation, changes in appetite, sleep disturbance.
  • Social behaviour: for example, lack of cooperation with reasonable requests, withdrawal, or alterations in communication, mood and/or attitude.
These may be reported by the person at risk, or a carer or relative.
Be particularly vigilant for signs of hypoactive delirium (marked in bold).

Glossary

Subtype of delirium characterised by people who have heightened arousal and can be restless, agitated and aggressive.
Subtype of delirium characterised by people who become withdrawn, quiet and sleepy.
A team of healthcare professionals with the different clinical skills needed to offer holistic care to people with complex clinical problems such as delirium.
Residential care in a home that may include skilled nursing care and help with everyday activities. This includes nursing homes and residential homes.
Diagnostic and Statistical Manual of Mental Disorders
Confusion Assessment Method
Confusion Assessment Method for the intensive care unit

Paths in this pathway

Pathway created: September 2012 Last updated: August 2014

© NICE 2014

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