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Delirium: diagnosis, prevention and management [CG103]

Measuring the use of this guidance

Recommendation: 1.1.1

When people first present to hospital or long-term care, assess them for the following risk factors. 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)

What was measured: Percentage of people with dementia admitted to hospital whose case notes included evidence that a standardised mental status test had been carried out.
Data collection end: November 2017
54%
Area covered: National
Source: Royal College of Psychiatrists. National Audit of Dementia.

What was measured: Proportion of people with dementia admitted to hospital whose case notes included evidence that an initial assessment for indicators of delirium had been carried out.
Data collection end: November 2017
51%
Number that met the criteria: 1136 / 2228
Area covered: England and Wales
Source: National Audit of Dementia: Spotlight audit

What was measured: Proportion of people with dementia admitted to hospital who had either an initial assessment for delirium, SQiD, confusion assessment or who had delirium noted on admission.
Data collection end: November 2017
68%
Area covered: England and Wales
Source: National Audit of Dementia: Spotlight audit


Recommendation: 1.2.1

At presentation, assess people at risk for recent (within hours or days) changes or fluctuations in behaviour. These may be reported by the person at risk, or a carer or relative. Be particularly vigilant for behaviour indicating hypoactive delirium (marked*). These behaviour changes 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, lack of cooperation with reasonable requests, withdrawal*, or alterations in communication, mood and/or attitude. If any of these behaviour changes are present, a healthcare professional who is trained and competent in diagnosing delirium should carry out a clinical assessment to confirm the diagnosis.

What was measured: Proportion of patients aged over 65 who were admitted to hospital for a non-elective reason and who had an assessment for the presence or absence of delirium or a documented diagnosis of delirium.
Data collection end: May 2015
36.7%
Number that met the criteria: 1496 / 4846
Data collection end: December 2016
39.7%
Number that met the criteria: 1875 / 5387
Area covered: England and Wales
Source: Royal College of Physicians. National Audit of Inpatient Falls audit report.

What was measured: Percentage of people with dementia admitted to hospital whose case notes included evidence that an initial assessment for indicators of delirium had been carried out.
Data collection end: November 2016
45%
Number that met the criteria: 4466 / 10047
Area covered: National
Source: Royal College of Psychiatrists. National Audit of Dementia.

What was measured: Percentage of people with dementia admitted to hospital whose case notes included evidence that a clinical assessment for delirium had taken place when an initial screen indicated that delirium may be present.
Data collection end: November 2016
85%
Number that met the criteria: 2220 / 2603
Area covered: National
Source: Royal College of Psychiatrists. National Audit of Dementia.

What was measured: Proportion of people with dementia admitted to hospital whose case notes included evidence that a clinical assessment for delirium had taken place when an initial screen indicated that delirium may be present.
Data collection end: November 2017
84.4%
Number that met the criteria: 616 / 744
Area covered: England and Wales
Source: National Audit of Dementia: Spotlight audit


Recommendation: 1.3.2

At presentation, assess people at risk for recent (within hours or days) changes or fluctuations in behaviour. These may be reported by the person at risk, or a carer or relative. Be particularly vigilant for behaviour indicating hypoactive delirium (marked*). These behaviour changes 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, lack of cooperation with reasonable requests, withdrawal*, or alterations in communication, mood and/or attitude. If any of these behaviour changes are present, a healthcare professional who is trained and competent in diagnosing delirium should carry out a clinical assessment to confirm the diagnosis.

What was measured: Proportion of people with dementia admitted to hospital whose case notes included evidence that a clinical assessment for delirium had taken place within 24 hours of admission when an initial screen indicated that delirium may be present.
Data collection end: November 2017
51.3%
Number that met the criteria: 319 / 622
Area covered: England and Wales
Source: National Audit of Dementia: Spotlight audit


Recommendation: 1.5.1

If indicators of delirium are identified, carry out a clinical assessment based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria or short Confusion Assessment Method (short CAM) to confirm the diagnosis. In critical care or in the recovery room after surgery, CAM‑ICU should be used. A healthcare professional who is trained and competent in the diagnosis of delirium should carry out the assessment. If there is difficulty distinguishing between the diagnoses of delirium, dementia or delirium superimposed on dementia, treat for delirium first.

What was measured: Proportion of intensive care unit patients who received an CAM-ICU screening tool assessment.
Data collection end: August 2012
33%
Data collection end: February 2013
73%
Area covered: Local
Source: Poon, ASK. and Hearn M. (2013) The effect of education on compliancy to CAM-ICU screening in intensive care unit. Intensive care medicine. Conference S487.


Recommendation: 1.5.2

Ensure that the diagnosis of delirium is documented both in the person's hospital record and in their primary care health record.

What was measured: Proportion of people with dementia admitted to hospital whose case notes indicated delirium or acute confusion during the initial admission and who had this recorded on their discharge letter or summary.
Data collection end: November 2017
48%
Number that met the criteria: 450 / 947
Area covered: England and Wales
Source: National Audit of Dementia: Spotlight audit



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