New/worsening confusion, altered consciousness (drowsy/withdrawn in hypoactive delirium, restless and agitated in hyperactive delirium, hallucinations)

Figure 1: Document 4AT in Flowsheets in Epic

Raise an inpatient consult request to Liaison Psychiatry on Epic and call 07786 705 327

Confirm presence of Delirium

Complete 4AT tool (figure 1)

Complete delirium bundle

Document baseline cognition if possible

The underlying cause of delirium is often multi-factorial. Common contributory medical causes of delirium include :

Drugs (anticholinergics [inc. opiates], benzodiazepines [inc. withdrawal], ETOH withdrawal/Dehydration

Electrolyte disturbance

Lots of pain

Infection /Inflammation (inc. surgery)/Intracranial

Respiratory failure

Impaction of stool

Urinary retention

Metabolic disorder

• FBC, U+E, CRP, LFT,

• Blood sugar, Calcium

• Chest X‑ray

• ECG

• Blood cultures

• Pulse oximetry (arterial gas if sats <93%)

• Urinalysis

• Lighting levels appropriate for time of day.

• Regular and repeated (at least 3 times daily) cues to improve personal orientation.

• Use of clocks and calendars to improve orientation.

• Hearing aids and spectacles should be available as appropriate and in good working order.

• Continuity of care from nursing staff.

• Encouragement of mobility and engagement in activities and with other people.

• Approach and handle gently.

• Elimination of unexpected and irritating noise (e.g. pump alarms).

• Regular analgesia, for example regular paracetamol.

• Encouragement of visits from family, friends and carers who may be able to help calm the patient. Explain the cause of the confusion to relatives. Encourage family to bring in familiar objects and pictures from home and participate in rehabilitation.

• Consider completing “This is Me” passport

• Fluid intake to prevent dehydration (use subcutaneous fluids if necessary).

• Adequate nutrition, fluid intake and mobility to prevent constipation.

• Adequate CNS oxygen delivery (use supplemental oxygen to keep saturation above 95%).

• Encourage usual sleep pattern (use milky drinks at bedtime, exercise during the day).

• Consider referral to dementia specialist nurse for support

• Print off and give information leaflet to patient and carers (page 9)

• Inter and intra ward transfers

• Use of physical restraint

• Constipation.

• Anticholinergic drugs where possible and keep drug treatment to a minimum.

Catheters where possible

• when psychosocial interventions/de-escalation techniques are not effective and there is significant risk to self/others

• in order to carry out essential investigations or treatment

• to prevent patient endangering themselves or others

• to relieve distress in a highly agitated or hallucinating patient

• Consider legal implications

The preferred drug is Lorazepam 500 micrograms to 1mg. This should be given orally or if necessary, IM. It can be given up to every two hours to a usual maximum dosage of 2mg [Orally or IM] in 24 hours, depending on the severity of distress, severity of the psychotic symptoms, weight and sex.

One to one care of the patient is often required and should be provided while the dose of medication is titrated upward in a controlled and safe manner.

If there is no response to lorazepam, the SABP guidelines should be followed

Do not use haloperidol in patients with Parkinson’s disease, Lewy Body Dementia or ECG QTc >500ms and seek specialist advice

Taken from Surrey and Border’s Partnership Rapid Tranquilisation policy: Policy Ref No: SABP/Risk/Procedure 27 Date for review July 2022 – FPH ONLY

https://www.sabp.nhs.uk/aboutus/policies/clinical/ClinicalRapidTranq

Observations And News Should Be Done Every 10 Mins for 1 Hour After Sedation, Then Every 30 Minutes Until Ambulatory

These patients often have frailty and may deteriorate quickly. They have a low threshold for sedative treatment.

Senior nurse/doctor to review the following measures and refer patient to medical consultant or emergency team as appropriate:

• GCS: 12 or less – NEWS call; 8 or less call anaesthetist for airway protection

• Respiratory rate: 10 or less

• Pulse 50 or less or 120 or more

• Systolic blood pressure: 90 or less

• Temperature: 35 or less

• O2 sats: 92% or less

give IV Flumazenil 200 micrograms over 15 seconds, then 100micrograms at 60-second intervals if needed. Maximum total dose: 1mg in 24 hours

1. National Institute for Health and Care Excellence [NICE] (2023) Delirium: prevention, diagnosis and management in hospital and long-term care. CG103. Available at: https://www.nice.org.uk/guidance/cg103 (Accessed: 24 May 2024).
2. Joint Formulary Committee (2024) ‘Lorazepam’, in British National Formulary. Available at: https://bnf.nice.org.uk/drugs/lorazepam/ (Accessed: 24 May 2024).
3. Bellelli, G. et al. (2014) 'Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people', Age and Ageing, 43(4), pp. 496-502. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4066613/ (Accessed: 24 May 2024).
4. MacLullich, A., Ryan, T. and Cash, H. (2014) 4AT: rapid clinical test for delirium. Available at: https://www.the4at.com/ (Accessed: 24 May 2024).

If you have any concerns, then please contact registrar, consultant or psych liaison team for further advice.

When managing violence and aggression a number of key considerations (includes legal, procedural and ethical) need to be taken into account during the decision-making process. These include:

• Communication/lower level options attempted? Exhausted? Failed?

• What is the immediate risk? Harm to self, others?

• Honestly held belief – is it a necessary & proportionate response to the risk posed

• Do you have the legal authority? MHA, MCA, Common Law

• Least restrictive/shortest period of time?

• Risks involved in the physical intervention

• Rapid tranquillisation required?

• Post incident monitoring (handout & NICE 2015)

• Changing risk assessments and care/management plans

- Staff MUST document clearly their decision making process and why lower level options were not used or failed and the outcomes of their decision making. It needs to be stated in the patient’s notes which legal framework you will be working under; the diagram below can support the identification of the relevant framework.

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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