• Assess mental status of all elderly patients on admission
• If subsequent changes in mental function, reassess

Assessment

• History taken from patient and a relative
• On admission, medical staff complete 4AT assessment test for delirium on all elderly patients
• The six item cognitive impairment test (6 CIT) for cognitive impairment
• usually completed by nursing staff a few days after admission, especially if dementia is suspected or a referral to memory clinic is needed
• A full clinical examination, including a neurological and rectal examination (where possible)
• Basic investigations as below

High risk patients

• Dementia
• Visual impairment
• Physical frailty
• Any severe illness
• Infection
• Dehydration
• Renal impairment
• Recent surgery (e.g. fractured neck of femur)
• Alcohol excess
• Polypharmacy 

Investigations

• FBC, U&E, glucose, LFT, CRP, and bone biochemistry
• Blood glucose
• Thyroid function tests
• Blood cultures
• Urinalysis
• Chest X-ray
• ECG
• Pulse oximetry
• Consider need for: lumbar puncture, blood gases, EEG, B₁₂, folate
• Consider CT scan of head only where a brain lesion suspected (fall, head injury, focal neurological signs, evidence of raised intracranial pressure)

Differential diagnosis

• Confusion is a symptom, not a diagnosis
• Any combination of delirium, dementia or acute functional psychosis
• distinguishing features

Delirium (acute confusional state)

• Acute confusion in a previously well patient
• develops over a short period (hours to days)
• always associated with clouding of consciousness
• usually precipitated by an acute medical or surgical problem

Dementia

• Continuing confusion relatively unchanged for a month or more

Delirium superimposed on dementia

• Acute confusion in a patient with previous cognitive impairment
• suddenly much worse

Environment

• Nurse in quiet environment; in a side room if possible
• appropriate lighting for time of day
• clocks and calendars to improve orientation
• hearing aids and glasses available and in good working order
• elimination of unexpected irritating noise (e.g. pump alarms)
• Avoid physical restraints
• Nursing staff carry out a risk assessment to avoid bed rails if possible
• in some cases, these do not prevent falls and can increase risk of injury
• may be preferable to nurse patient on a low bed or a mattress or protective mat on the floor
• No inter- and intra-ward transfers

Patient

• Ascertain what is worrying the patient
• often a simple cause which can be addressed
• Regular and repeated cues to improve personal orientation (at least 3 times daily)
• Continuity of care from nursing staff
• Encouragement of mobility
• Good sleep pattern (milky drinks at night, exercise during day)
• Approached and handled gently

Relatives and friends

• Encourage family and friends, who may be able to calm patient, to visit
• Ask family to complete a THIS IS ABOUT ME form
• Explain cause of confusion to relatives
• Encourage them to bring in familiar objects and pictures and to participate in rehabilitation (e.g. to help with feeding and drinking)

Clinical treatment

• Treat or remove underlying causes
• treat infection
• stop all non-essential medication
• correct hypoglycaemia/hypoxia/hypothermia
• Correct and/or maintain fluid and electrolyte balance, nutrition and vitamin supply
• In alcohol dependence or malnutrition, give Pabrinex ampoules 1 & 2, two pairs as IV infusion 8-hrly for 3 days
• For alcohol withdrawal delirium - see Alcohol withdrawal guideline
• Regular analgesia given when needed (e.g. paracetamol)
• Avoid catheters and constipation

Aggressive and violent patients

• If patient severely disturbed and a danger to self or others - see Aggressive and violent patients guideline (these are designed predominately for use in younger patients)

• Try all non-pharmacological methods of management first
• medication may make the patient more confused
• only if the patient is severely distressed or poses imminent danger to self or others, consider sedation with lorazepam or haloperidol
• Use one drug only, starting at lowest possible dose
• While dose of psychotropic medication is titrated upward, ensure one-to-one nursing
• Treat underlying cause of confusion so no further anti-psychotic treatment is necessary
• try to avoid use of anti-psychotics due to increased risk of stroke

Lorazepam

• Lorazepam 500 microgram-1 mg (15 microgram/kg) 6-hrly
• give orally (preferably) or by slow IV injection into a large vein
• only if oral or IV routes are not possible, use IM route in the same doses as IV
• maximum of 2 mg in 24 hr

Promethazine

• As an alternative to lorazepam, consider promethazine 25-50 mg 12 hourly

Haloperidol

• Haloperidol 0.5-1 mg 8-hrly, reducing to 500 microgram oral/IM 8-hrly
• maximum dose of 3 mg in 24 hr for a maximum duration of 1 week
• Do not use haloperidol in:
• heart disease, dementia or Parkinson's disease
• known to have a prolonged QT interval
• on other drugs that prolong the QT interval
• normal range for QTc interval is up to 440 milliseconds
• QTc prolongation defined as >450 milliseconds for men and >470 milliseconds for women

Length of treatment

• If maintenance treatment required, consider haloperidol 500 microgram oral daily or 12-hrly
• Review all medication at least every 24 hr
• Stop after 1 week
• No long-term treatment should be required in patients with delirium

Side-effects

• If extrapyramidal symptoms and pyrexia occur, consider neuroleptic malignant syndrome

Risperidone

• If haloperidol is contra-indicated and lorazepam or promethazine have not been effective, consider Risperidone 250 micrograms 12 hourly
• before prescribing, seek senior advice from consultant
• see persistent aggression section below

Delirium

Reconditioning of patient

• Good food, adequate fluids, sufficient sleep
• Bowel regulation, pain control, avoidance of sedation
• Appearance (clothes, shoes, teeth, spectacles, hearing aids, hair and shaving)

Rehabilitation

• Start early and be comprehensive
• avoid permanent immobility, pressure sores, infections and thromboembolic disease
• Always liaise with physiotherapist, occupational therapist and nursing staff
• Where rehabilitation likely to be prolonged, refer to geriatric medicine

Monitor

• Repeat 4AT score to check whether it has reduced following treatment of the condition that induced the delirium

Slow to resolve

• Review diagnosis
• Consider vitamin B12 and folate assays, syphilis and HIV serology

Dementia

Insomnia, restlessness, wandering or difficult behaviour

• Avoid medication
• Check for sources of pain or discomfort, and treat effectively
• Keep regular behavioural charts. Check for any treatable triggers to the behaviour
• if necessary, refer to mental health liaison team
• If above does not resolve problem, give paracetamol 1 g 8-hrly (max 6-hrly)
• if weight <50 kg, reduce dose
• if not effective after 24 hr, review and consider limited trial of stepped-up pain relief
• Review every 24 hr and stop if behaviour no better

Persistent aggression

• If aggression is not modified by behavioural techniques, discuss with elderly care consultant or psycho-geriatrician
• only they can prescribe risperidone for short-term use (increased risk of stroke/death)
• starting dose: 250 microgram 12-hrly, increasing in increments of 250 microgram on alternate days
• maximum of 500 microgram 12-hrly
• Review medication weekly and stop at earliest opportunity
• Maximum treatment is 6 weeks
• Typical and atypical anti-psychotic medications (haloperidol, olanzepine) are not licensed for use in dementia
• long-term use doubles the risk of death

Monitor

• If change occurs, repeat 4AT assessment test and/or the six item cognitive impairment test (6 CIT)
• If sedation given, monitor respiratory rate, pulse and blood pressure

• Many elderly patients will make a full recovery and can be discharged without referral to another agency
• Offer reassurance and support
• delirium is very unpleasant
• If community care assessment needed, refer to social services
• Consider referral to mental health liaison team

Dementia

• For patients with established dementia, give relatives or carers details of carer support agencies
• For patients with a 6 CIT >7, but not previously known to have dementia, advise GP
• patient requires review after discharge to confirm or exclude a diagnosis of dementia
• advise GP if doubt at review, refer to a memory clinic

Medication

• In patients with delirium, stop all sedatives/anti-psychotics

Anti-psychotic medication

• Long-term is not indicated for difficult behaviour or aggression
• unless patient has a psychotic illness such as schizophrenia or mania
• such use is unlicensed and increases mortality in patients with dementia
• If treatment with anti-psychotic agents is to continue past discharge, inform patient and their relatives of the unlicensed use of the drug and risk of death and stroke
• give clear plan for reducing and stopping the drug to GP, patient and family
• maximum period for prescription should be six weeks only