Dementia / Delirium Combined Pathway and Care Bundle for Emergency Department and Acute Medical Assessment Unit

(Follows assessment for delirium using 4AT rapid assessment tool at earliest point of contact- see reverse side)

Known Diagnosis of Dementia

Don’t assume acute presentation is due

to dementia.

Assess for delirium or other acute illness.

This algorithm is for use only in adults, and is not intended for delirium due to alcohol or drug intoxication/ withdrawal.

4AT Score 1-3: Cognitive Vulnerability

Also Possible Dementia – but many people with 4AT 1-3 don’t have dementia.

Don’t label patient: need collateral history.

(Note: 4AT is a screening tool only).

4AT Score ≥4: Probable Deliriumand possibly Dementia also

**Most delirium occurs in a person with dementia or other cognitive

vulnerability**

(dementia may be mild or not yet diagnosed)

• Follow Delirium Algorithm on reverse side.

• Discharge only if senior doctor directs.

• CNM2 (Shift Leader) or Patient Flow liaison informs Bed Manager re. high priority for bed.

• Patient (if appropriate) and family or carer informed.

National guidance document to support this algorithm and pathway, and more resources for acute hospital delirium/dementia care in Ireland:https://dementiapathways.ie/care-pathways

NICE Clinical Guideline Delirium (No. 103; 2010 - updated 2019) https://www.nice.org.uk/guidance/cg103

SIGN Guideline for Delirium 2019: https://www.sign.ac.uk/sign-157-delirium.html

Psychotropic medications for non-cognitive symptoms of dementia: (National Clinical Guideline No. 21). Available at: https://health.gov.ie/national-patient-safety-office/ncec/national-clinical-guidelines/

Validation of 4AT in ED: O'Sullivan D, Brady N, Manning E, O'Shea E, O'Grady S, O 'Regan N, Timmons S. Validation of the 6-Item Cognitive Impairment Test and the 4AT test for combined delirium and dementia screening in older ED attendees. Age Ageing. 2018; 47:61-68. https://academic.oup.com/ageing/article/47/1/61/4101644

Sepsis Pathway Link: https://www.hse.ie/eng/about/who/cspd/ncps/sepsis/resources/

Acknowledgments: National working group to develop acute hospital dementia/delirium pathways. Membership details available at:https://dementiapathways.ie/care-pathways

Inform ED staff / Registrar

Inform CNS Dementia, Frailty team, MDT as appropriate/available

Decision made to Discharge orAdmit Patient is made by ED team

Discharge:

Letter to GP to include:• Details of abnormal

4AT result.• Need for follow-up

as indicated (e.g. with GP or memory assessment service)

Admission:

• CNM2 (Shift Leader) informs Bed Manager re high priority for bed.

• Reassess for delirium using 4AT if any acute change in alertness, cognition, function; or psychosis.

Dementia / Delirium Care Bundle:

1. Carer involvement (know the person).

2. Individualized communication.

3. Assess pain.

4. Support nutrition and hydration.

5. Keep environment as calm as possible; use dementia-friendly cubicle or side room if available.

NOTE: Care pathways cannot cover all clinical scenarios. Ultimate responsibility for the interpretation and application of this algorithm andpathway, the use of current information and a patient's overall care and wellbeing resides with the treating clinician.

Version 1.0 - Date 27.3.2020

YES Delirium Screening is Positive

Document result Contact the treating team for a formal

delirium assessment today

Delirium on general hospital wards: identifying patients at risk, delirium screening and next steps

Patient is admitted to your ward

Screening for Delirium 1. Complete 4-AT on admission to the ward for all patients at risk of delirium 2. Screen at risk patients daily for delirium. The screening tool used will vary per local protocol.

Recommended screening tools include: - 4-AT (www.the4at.com) - RADAR (Recognising Acute Delirium As part of your Routine) - SQID (Single Question in Delirium)

3. Document delirium status each day in the care plan or specific delirium recording tool (e.g. end-of-bed file).

Identify the patient at risk of delirium

Age over 65 years or any one of: - Pre-existing cognitive impairment e.g. mild cognitive impairment, or dementia, or 4-AT 1-3 - Previous delirium - Other brain disorders (e.g. head injury, stroke, Parkinson’s Disease) - Functional dependence or frailty - Poor mobility - Poor nutrition - Visual or hearing impairment - Depression - Major trauma / Post-operative - Multiple co-morbid illnesses - Severe medical illness or infection (NEWS ≥6) - Urea and electrolyte imbalance - Alcohol or substance misuse - Polypharmacy and / or high risk medications (e.g. benzodiazepines)

Check ED/AMAU 4-AT score; Has this patient possible delirium?

Assessing for Potential Causes of Delirium: ‘PINCH ME’

P – Is the person in pain? Has urinary retention been excluded? IN – Infection: is there a possible infection? Refer to sepsis pathway as appropriate (link overleaf) C – Constipation: When was the last bowel movement? H – Hydration / Nutrition: is there major electrolyte imbalance? Has hypoxia, hypotension, hypoglycaemia been considered? M – Medication: omission of regular medication or addition of new medication? E – Environment: change of environment, noise or activity levels impacting sleep/ rest?

Delirium screening negative

Daily screening, see box above Continue to address risk factors

Strategies for delirium prevention & management - Avoid new sedatives - Avoid restraint (physical and chemical) - Avoid use of urinary catheters where possible - Ensure adequate fluids/nutrition and access to drinks/snacks - Avoid constipation - Provide own hearing aids and glasses - Promote relaxation and sufficient sleep in a quiet area - Regular re-orientation - Encourage and assist early and regular mobilisation - Encourage/ allow family members/ carers to stay with the patient - Encourage independence with activites of daily living - Assess for and manage any pain; use dementia friendly pain score

where applicable e.g. PAINAD/ Abbey Pain Scale - Medication review by team

Extra tips for caring for the patient with possible or proven delirium

Explain gently what is happening Smile and make eye contact to reassure Consider enhanced care (i.e. “special”) by a staff member trained in dementia/delirium support Encourage familiar faces – staff and family Limit ward and bed moves Use medications to manage symptoms of delirium rarely and always with senior decision-maker input Communicate with family and carers, offer patient information leaflet, discuss reason for ‘special’ Record delirium on the discharge letter to the GP and follow-up according to local protocol.

Patient is already diagnosed as having delirium in ED/AMAU

Note: Clinical algorithms are for reference only and do not replace clinical judgement

Assess for possible causes of delirium (see PINCH ME box) Identify and treat all possible risks/precipitants Reassess for resolution/persistence every 24-48 hours Monitor symptoms using behaviour chart (as per local protocol) Once resolved, resume daily screening for reoccurrence Follow local protocol for accessing expert delirium assessment

NO

Early Identification and Management of Delirium in the Emergency Department/ Acute Medical Assessment Unit

DELIRIUM is an acute change in cognitive function that has an organic cause and is likely to be reversible or preventable All Older Adults (≥ 65) presenting to ED/AMAU:

screen for delirium using 4AT at triage or first contact after triage 4AT Rapid Clinical Test for Delirium 1. Alertness Normal (fully alert, but not agitated throughout assessment) 0 Mild sleepiness for <10 seconds after Waking but then normal 0 Clearly abnormal 4 2. AMT4 (Age, date of birth, place (name of hospital), current year) No mistakes 0 1 mistake 1 ≥ 2 mistakes/ untestable 2 3. Attention (months of year backwards) Achieves 7 months or more correctly 0 Starts but scores <7 1 Untestable (too unwell, drowsy, inattentive) 2 4.Acute Change or Fluctuating Symptoms (need collateral history) No 0 Yes 4 Total ______

Result of 4AT (Collateral history necessary) ≥ 4: Probable delirium +/- cognitive impairment 1-3: Possible cognitive impairment 0 : Delirium or severe cognitive impairment unlikely

No evidence of delirium (4AT 0-3) NB Collateral history necessary to

derive this score Proceed with admission/discharge If 4AT score is 1-3: ensure

documentation of cognitive status. Person may have undiagnosed dementia

See reverse side for dementia/ cognitive vulnerability pathway for ED / AMAU

Assess for delirium risks: those with any risk factors should have regular screening for delirium.

Suspected Delirium (4AT ≥4): This is a medical emergency

Flag for Urgent Medical Review

- Discuss diagnosis with senior doctor and/or nurse in ED/AMAU

- Discuss diagnosis with carer/ relative and patient as appropriate

- Assess for possible Causes of Delirium

Ensure admitting team know that delirium is suspected

Delirium has a high mortality. Most patients will need admission. Only discharge after

discussion with a senior colleague.

Highlight to shift leader/ patient flow liaison to source urgent bed This patient will require enhanced supervision while in ED, due to increased risk of falls, dehydration, and medication error

Strategies for delirium prevention/management in ED / AMAU - Avoid new sedatives - Avoid restraint (physical and chemical) - Avoid use of urinary catheters where possible - Ensure adequate fluids/nutrition and access to drinks/snacks - Avoid constipation - Promote relaxation and sufficient sleep in a quiet area - Encourage and assist early and regular mobilisation - Provide own hearing aids and glasses - Encourage/ allow family members/ carers to stay with the patient - Encourage independence with activities of daily living (toileting/washing) - Assess for and manage any pain; use dementia friendly pain score where

applicable e.g. PAINAD/ Abbey Pain Scale - Medication review

Assess for Potential Causes of Delirium: ‘PINCH ME’

P – Is the person in pain? Has urinary retention been excluded? IN – Infection: is there a possible infection? Refer to sepsis pathway as appropriate (link overleaf) C – Constipation: When was the last bowel movement? H – Hydration/ nutrition: is there major electrolyte imbalance? Has hypoxia, hypotension, hypoglycaemia been considered? M – Medication: omission of regular medication or addition of new medication E – Environment: change of environment, noise or activity levels impacting sleep/ rest

Managing someone with delirium who is distressed and/or combative, and felt to be a threat to themselves or others

The management of delirium is primarily NON PHARMALOGICIAL. ALWAYS try to de-escalate the situation first. Explain what is happening, re orientate, try to nurse in a quiet area, consider need for one to one care. 1. The evidence for the benefit of antipsychotics in treating delirium is very weak. If emergency treatment with medication is needed because the patient or others are at immediate risk and/or urgent care is compromised, low dose ORAL antipsychotic medication is preferred. Small doses should be given e.g. Haloperidal (0.5 -1mg), Quetiapine (12.5 -25mg), Olanzapine (2.5mg), Risperidone (0.5mg) - Avoid antipsychotics in those with Lewy body dementia or Parkinson’s disease - Get an ECG and check QTc before using antipsychotic agents 2. Benzodiazepines worsen delirium and are reserved for alcohol or benzodiazepine withdrawal (follow withdrawal protocols); or where emergency treatment is required (as per 1) but antipsychotics are contraindicated: e.g. lorazepam (0.5-1mg) may be considered 3. A decision to use IM or IV sedation must be made by a senior doctor (i.e. Registrar/ Consultant). This should be administrated in an area where the patient can be properly monitored and where airway support is available. Flumazenil should be available if using lorazepam. Procyclidine/ Benztropine should be available if using antipsychotic agents.

NOTE: Clinical algorithms are for reference only and do not replace clinical judgement

This algorithm is not intended for delirium due to alcohol or drug intoxication/ withdrawal

Identify the patient at risk of delirium

Age over 65 years or any one of the following:

- Pre-existing cognitive impairment (e.g. mild cognitive impairment or dementia) - Previous delirium - Other brain disorders (e.g. head injury, stroke, Parkinson’s Disease) - Functional dependence or frailty - Poor mobility - Poor nutrition - Visual or hearing impairment - Depression - Major trauma - Multiple co-morbid illnesses - Severe medical illness or infection (NEWS ≥6) - Urea and electrolyte imbalance - Alcohol or substance misuse - Polypharmacy and / or high risk medications (e.g. benzodiazepines)

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