Key messages

  • The first step in screening an older person for delirium is completing a baseline cognitive screen and then use a validated delirium screening tool.
  • Observe and investigate any change in a patient’s cognitive status, behaviour or self-care throughout their stay in hospital.
  • If you identify a concern during the cognitive screening process, be alert that it could indicate the older person is experiencing delirium.
  • Escalate your concern and use a validated tool to help confirm the diagnosis and work as a team to identify underlying causes in order to treat them and to manage and relieve the symptoms.
  • It is important to distinguish between dementia, depression and delirium.

The evidence for prevention is very strong…the approach to promote is to identify at risk individuals and do all the things that are necessary to prevent delirium. If delirium still occurs, then identify it as soon as possible and treat it as best you can.
Psychiatrist, rural hospital

Cognitive screening, on admission to hospital and routinely throughout the stay, provides a baseline to identify a decline in a person’s cognition that may be due to delirium, dementia or depression. This process is known as differential diagnosis.

Delirium assessment aims to confirm the diagnosis, identify and treat the causes, and manage and relieve the symptoms, and collect information that is useful in developing treatment plans.1,2,3

It can include:

  • taking a recent medical history, including premorbid function and cognition, diet, falls, bowel and bladder function
  • requesting a medication review, including a notation of changes in medication
  • completing a physical and mental status examination, including vital signs, chest examination, cognitive and delirium screening
  • completing other investigations, for example, urinalysis, full blood examination, chest X-ray.

Tools for screening and assessment

To improve the recognition and early diagnosis of delirium use the following tools:

With the medication that Mum was on, she was seeing things, doing things, pulling out her tubes from her arms, verbally abusing people; she wouldn’t kill a fly, let alone doing anything like that. And they just wouldn’t believe that it wasn’t my Mum.
Lyn

  • Confusion Assessment Method (CAM) - this tool can be used in a range of settings including ICUs and emergency departments1,4. It focuses on four cardinal delirium features: acute onset and fluctuating course, inattention, disorganised thinking, and altered level of consciousness. A diagnosis of delirium requires that both the first and second criteria are present, and either the third or fourth.
  • Family Confusion Assessment Method (FAM-CAM) - this tool obtains information from family and carers, who are often the first to recognise a change to the person’s thinking and behaviours in hospital. It is also important to seek information about the person’s baseline from other sources, such as their GP, other service providers, or residential care staff. This is especially important if a patient does not have regular visitors.  
  • 4AT - this tool is designed for health professionals to use at first contact or when delirium is suspected.

1. Inouye, S.K., R.G.J. Westendorp, and J.S. Sacznski, Delirium in elderly people. The Lancet, 2014. 383: p. 911-922.

2. Australian and New Zealand Society for Geriatric Medicine Position Statement 13: Delirium in Older People 2012.

3. Hogan, B., et al., National guidelines for seniors' mental health: The assessment and treatment of delirium. The Canadian Journal of Geriatrics, 2006. 9(Supplement 2): p. S43-S51.

4. Wei, L., et al., The Confusion Assessment Method: a systematic review of current usage. Journal of the American Geriatrics Society, 2008. 56(5): p. 823-30.