Delirium – information and podcast series

What is delirium?

Delirium is a sudden onset of new confusion, or worsening of an existing confusion, or a new presentation of drowsiness. Delirium is a common condition. It usually occurs due to an acute underlying medical or physiological cause, such as an infection. It can come on quickly, usually over a couple of hours or days. It is not a permanent illness. Delirium will usually improve once the underlying causes are treated but this can take weeks or sometimes months.

People with delirium may have difficulty concentrating, be less aware of what is going on around them, confused, emotional, behave in a way that is out of character or their sleep may be disturbed. Symptoms usually fluctuate considerably throughout the day and night.

Who can get delirium?

Delirium is more common for people who

• Are aged 65 years and over.
• Experience previous memory problems, dementia or have had delirium before.
• Have had recent surgery, for example for a broken hip.
• Have an acute illness or infection
• Have many medical conditions, or sight or hearing loss.

People can develop delirium anywhere including in hospital, care homes and living at home.

What can cause delirium?

There are various things that can trigger a person to develop delirium and sometimes it can be difficult to identify what the causes are. Some examples of underlying illnesses and conditions to consider include:

• Pain.
• Infections.
• Not eating.
• Not drinking enough, which can lead to dehydration.
• Constipation.
• Side effects of certain medicines

You may have noticed things in relation to these areas that could help identify the causes of delirium.  For example:

• Pain – is the person saying they are in pain, are they wincing or holding themselves as if they may be in pain?  Have they had a recent fall or injury?
• Infection – have you noticed the person is showing signs of an infection such as hot to touch, sweating more, pass urine more often, productive cough?
• Nutrition – have they reduced or stopped eating, or taking a poor diet or experienced unexpected weight loss?
• Constipation – are there signs of constipation such as not attending or repeated visits to the toilet, tummy pain etc?
• Hydration – have you noticed that the person is not drinking as much as usual for them, or are you having difficulty getting them to drink? This may indicate they are becoming dehydrated.
• Medication – have they started any new medication where side effects may be contributing, or have any medication been stopped suddenly?

How can you tell if someone has delirium?

The behaviour of a person with delirium will change quickly, over hours or days. Family often notice a drastic change overnight.  The person may appear restless and agitated (hyperactive delirium). Or they may be withdrawn and drowsy (hypoactive delirium). They are likely to be confused, which means they might not know where they are or might not recognise friends and family.  They might not be able to hold a conversation; rather they may appear to be rambling and not making much sense. They may see, smell or hear things, which are not actually happening (hallucinations), or be suspicious of people around them (delusions).  These symptoms usually fluctuate throughout the day and night, with symptoms seeming to improve at times and then worsening again.

You may have noticed other things about the person too, which could suggest they are becoming unwell. They may go to the toilet less frequently or more frequently. They may be hot, clammy, or sweating more. They may be experiencing pain, have poor balance, difficulty walking, or experiencing falls or have difficulty getting up from a chair.

Think Delirium Poster (PDF)

How can you get help?

It is important for family to get help early to ensure the best recovery from symptoms.  The first point of contact may be the person’s GP.   It might be helpful for family to prepare for this conversation to help provide as much information as possible when making the call and asking for help.

Some information to consider saying may include:

“I’m calling about my family member” (Name);

“I am concerned that they may have delirium”.

“They’re showing behaviour which is unusual or out of character for them, for example…..**(more confused, agitated, rambling etc) when they would usually for example…. **(be settled, orientated, independent etc)”. **insert own words

• Give some examples of changes, such as, “sleeping a lot during the day, or agitated and on the go a lot of the time, or rambling and not making a lot of sense”.
• Explain how long these new symptoms have been occurring for and if they appeared quickly within a few hours or days
• Describe any underlying causes you may have identified, for example they have been running to the toilet and saying it “stings” or they have coughing the last two days or they had a fall yesterday and haven’t been able to sleep due to the pain
• If the person is deteriorating and changing over time, express your concerns, so they know why you are worried and are asking for help

When speaking with the doctor you could ask them to check their medications for side effects especially if they are taking multiple medicines. Certain medicines have side effects that can contribute to someone developing delirium.

Also, alert the doctor if you feel that your loved one is in pain to ensure regular appropriate pain relief is considered.  The GP may request to see the person and complete a ‘delirium screen’ by taking a urine sample, blood samples, to listen to the person’s chest or tummy etc.

What can you do to help?

Usually once the underlying cause is treated, the delirium will get better over time.  Here are some things you can do to support the person with delirium to recover.

• Try to keep to a good routine that the person is used to.  Encourage exercise and getting up out of bed during the day wherever possible.  This will also help to encourage a good night’s sleep, if possible. It is worth noting, however, that delirium symptoms can often be worse at night.  If there is more than one family member available to provide support, consider alternating periods of supervision, to prevent one person getting overly exhausted or overwhelmed.
• Encourage regular eating habits. If they are not eating regular meals, try to encourage them to eat little and often.
• Encourage regular drinks. 6-8 cups of water, or other types of drinks a day is recommended to try to prevent dehydration.  You may need to encourage regular sips rather than expect them to drink a lot in one go.
• Ensure they use their glasses and / or hearing aids, if required, and that the hearing aid is working well.  Being unable to see or hear what is going on around them can add significantly to their level of confusion or distress
• Encourage the person to go to the toilet regularly, to avoid becoming constipated.
• Talk to your loved one in a calm reassuring way.  Help them to understand and remember where they are. Chat to them, write things down, be friendly and smile.  Talk in short simple sentences.  It can be useful to use familiar things such as photographs to help distract the person and comfort them. Talk about things they enjoy, memories that make them happy.  Avoid conversations like past traumas that may upset them.
• Encourage them to engage in activities and hobbies that they like.  Repeat what you have said or rephrase it to help understanding.  Acknowledge the emotion that surrounds what the person is saying, for example, “I can see that you are frightened/anxious/worried, tell me more about that”.
• Delirium can be distressing, especially if the person is experiencing hallucinations – explain to them what is happening, for example “I know this must be scary, you have a chest infection and this has caused a delirium, but the doctor has given you antibiotics and you will be better soon”

Preparing for a hospital admission

Whilst hospital admissions are usually unplanned, you can do some things in preparation for this eventuality, if it occurs.  If your family member has been in hospital before, you may be aware of a Life Story document such as ‘This is me’ or ‘All about me’; this provides a detailed picture of your family member, which will be very useful for the hospital staff. If you can, try to complete this, if not before admission then ask about this on the ward. You can also access and print this document.

Include as much relevant information as you can on the person’s personal and family history. This is intended to let staff know, how your family member presents usually when they do not have delirium.  This will enable the hospital staff to consider that the symptoms are delirium, rather than mistaking them for a dementia type illness, or a deterioration in someone’s dementia (if they have a diagnosis already). It might also be good to have a number of copies ready of your completed forms and keep hold of the original, so you can make further copies

It is also helpful to send in some photographs or familiar items that can help provide comfort and familiarity.

It is important to send in their glasses and hearing aids if they wear them.  Not being able to see or hear well can increase the level of confusion the person is experiencing and risks making their delirium symptoms worse.

All About Me Life Story Booklet

Delirium podcast series

This is the ‘Pinch Me Pod’, a podcast resource from the Northern Health and Social Care Trust, to help explore the topic of delirium in detail, and what the multidisciplinary team can do to recognise and manage delirium in the hospital setting. We hope that this podcast will begin to answer some of the questions you may have and help you navigate the medical minefield that delirium can sometimes feel like.

During admission to hospital

Being admitted to hospital can be a difficult time for older people because of the change in environment, different faces and ongoing medical interventions.  It can increase the risk of a person developing delirium, or can make delirium symptoms worse.  However, there are circumstances when people require treatment and care that can only be provided in hospital, and on those occasions, admission to hospital is vitally important and unavoidable.

Our focus in hospital is to try to identify people who are at risk of developing a delirium, or who already have a delirium.  The health care team will endeavour to identify and treat the underlying causes and explore various interventions that will help alleviate any distressing symptoms.   It is often difficult for staff to identify if a person has delirium, as they do not know how the person normally is when they are not in hospital.  Family can therefore play a valuable role throughout the person’s stay in hospital, especially in providing crucial information to help staff understand important facts about your loved one.  Express your concern to staff that you think they have a delirium.  Don’t be afraid of feeling ‘pushy’.  The more information you can give the better.  Inform staff if they have had an episode of delirium before.

Have a clear plan with your family as to who will be the lead contact for the hospital staff; make sure that person has all the information they need to be giving a picture of what is the normal routine and recent events leading to the admission.

Find out about visiting arrangements and if you can help support or care for your loved one in hospital.  Ask about the hospitals Care Partnership agreement.  There may be times when the hospital may want to ring family out of hours for example, would that be okay?

We would encourage family to consider providing photographs or familiar items that could help staff engage with the person as these can be helpful in providing comfort, support and reassurance.

Most wards have an Activity Trolley, with a selection of activities and puzzles for example, for patients to use during their hospital stay.  These activities can help provide stimulation, improve concentration, be fun and also help provide comfort to the person whilst their delirium symptoms are resolving.  You are welcome to use these resources whilst you are visiting or supporting your loved one in hospital.

There may be times when the person is required to move wards during their admission.  Whilst this is not ideal and has the potential to increase a person’s confusion, there are times when this may be unavoidable.

If the person is at high risk of falls, staff may use ‘assistive technology’ such as a ‘pressure pad’ on their chair, which alerts staff if the person may be walking without supervision to enable them to help quickly.

If a person is showing signs of distress, there may be occasions when they require an increased level of support and supervision.  A member of staff may be allocated to engage and support the person more closely – this is called E.P.C.O. – ‘Enhanced Patient Care and Observation’ – if this is required then ward staff should discuss this with you in more detail and provide you with an information leaflet to explain this further.

Most people with delirium will be looked after by their own medical and health care team on the ward.  Occasionally, if a person’s delirium is not resolving or perhaps worsening, and the person is distressed, medication may be considered to try to alleviate distressing symptoms or increasing risks – this is usually a low dose of medication, for a short period of time only.

If symptoms are not improving, then Staff could consider referring to the Mental Health Liaison Service to complete an assessment and explore alternative treatment.  If this happens, a member of the Mental Health Liaison Team will endeavour to contact a family member to discuss things further.

Capacity to make decisions

Delirium can often affect a person’s ability to understand why they need care or why they are in hospital.   This may mean they ‘lack capacity’ to make specific decisions for themselves and they will require safeguards to be implemented to protect them from harm and promote their Human Rights.   For example, if a person requires additional supervision from staff to support them (EPCO) or they are prevented from leaving hospital for their own safety, they may require a legal order being completed called a ‘Deprivation of Liberty’ (DoL) or Short Term Detention.   If this is required, a member of staff will contact the patient’s family to discuss this fully.

Capacity can fluctuate and is often temporary and subject to change over time, therefore further assessment of capacity may be required as a person’s delirium resolves.  It is important to note that capacity refers to specific individual decisions, so it is entirely possible for patients’ to be able to make decisions for some things, but not others.

Discharging from hospital

When a person is ready to discharge from hospital, you may hear the term ‘End of Acute Episode’ (EOAE) used. It is possible that delirium symptoms are still obvious at this stage, and the person may still be experiencing some level of confusion.   This means they may require some level of support after they discharge from hospital.  If this is required, the Hospital Social Work Team  will be involved to assist in discharge planning. This will include the social worker communicating with members of the health care team (e.g. physiotherapy, occupational therapy, nursing staff etc.) to assess the level of support required.

The Hospital Social Work Team will look to see if a patient needs additional help to facilitate their return home, or in the event that a return home is not feasible, will discuss what alternatives are available to meet a patient’s needs on discharge.

If you have concerns about your loved one discharging from hospital, please raise this with nursing staff on the ward, who can refer onto the Hospital Social Work Team.

Future considerations

There are some people for whom delirium symptoms do not completely go away. If any problems with thinking or memory continue in the months after having delirium, then advice should be sought from a GP or other healthcare professional, to consider a referral to the Memory Service in the community for further assessment.

When a person has experienced a delirium, then they are at risk of experiencing further episodes of delirium in the future.  Look out for signs so as you can spot these early and seek help quickly!

If your relative experienced symptoms of delirium during their admission to hospital, we would welcome your feedback about their experience.

Please use our online service user feedback form.

Or you can share your feedback at www.careopinion.org.uk.