Quality statement 1: Assessing recent changes in behaviour

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.