Rationale and impact

These sections briefly explain why the committee made the recommendations and how they might affect practice.

Indicators of delirium: daily observations

Recommendations 1.5.1 to 1.5.2

Why the committee made the recommendations

The committee agreed with the recommendation in the previous version of the guideline that all staff should be observing the people in their care and should be alert for changes indicating delirium. They noted that some simple tools like the Single Question to Identify Delirium (SQiD) might be useful to help practitioners notice any changes. They did not add SQiD specifically to the recommendation because they agreed that it is just one of many ways to encourage observation and that many places already have systems set up for this. They noted that in some settings the recording of these observations could be inconsistent, and that routine recording of changes that might indicate delirium was important.

How the recommendations might affect practice

Better recording of the indicators of delirium will improve the chances of these changes being noticed and acted upon.

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Assessment and diagnosis

Recommendations 1.6.1 to 1.6.2

Why the committee made the recommendations

The committee agreed that once a change that might indicate delirium has been noted and recorded, a member of staff competent to do so should carry out a formal assessment.

Several assessment tools had high enough sensitivity and specificity to be useful in clinical practice. However, the committee agreed that implementation issues need to be considered as well. For example, who can do the test, how long does it take and how much training is needed?

Balancing the evidence for accuracy and cost effectiveness with the practicality of implementing the tests, the committee agreed that the 4AT was the best option for most settings. It is among the most accurate of the tools reviewed, quick and simple to use, and has a broader range of evidence to support it.

The committee agreed that a range of health and social care practitioners would be able to carry out the 4AT and that special training is not needed, although practitioners should be assessed as competent in its use. They also discussed that some specialist professionals may not need to use a screening tool to carry out an assessment and diagnose delirium, but that it would generally be considered good practice. Overall, they agreed that its use will help ensure that delirium is picked up promptly in different care settings, especially those where a healthcare professional may not be immediately available.

For critical care and post-surgical settings, the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and Intensive Care Delirium Screening Checklist (ICDSC) worked best because they were specifically designed for those settings. However, the committee noted that training is needed for both CAM-ICU and ICDSC before practitioners can use them.

If the assessment shows delirium is likely, the committee agreed that the final diagnosis should be carried out by a healthcare professional with the necessary experience and expertise, for example, a specialist nurse, a GP, lead clinician or a member of the frailty team. Depending on the circumstances, this might be the same person who carried out the 4AT. If there is uncertainty about the diagnosis, a specialist such as a geriatrician or psychiatrist, may need to be involved.

The committee agreed that although the evidence allowed them to make recommendations overall, further, more specific, research on the accuracy and ease of use of different assessment tools in different settings, for different patient groups (including those with dementia, cognitive impairments, learning disabilities or affective disorders) and by different healthcare practitioners, would help to make future guidance more specific. They therefore made a recommendation for research on delirium assessment tools.

How the recommendations might affect practice

The committee noted that the assessment tools they recommended are already the most commonly used in practice. The change from healthcare professional in the previous version of this guideline to health or social care practitioner in this version will potentially reduce the workload for healthcare professionals who previously had to carry out assessments for delirium.

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