After an episode of delirium in hospital, an older person’s cognitive function and ability to manage at home or in care may be impacted. To help patients make a smooth transition from the hospital to their home or care facility, consider how the patient will manage and how their family or carer will cope, and what services and supports are required. Discharge planning should be documented, include the patient, carers and other professionals, and incorporate referrals to community health and support services where required.
Involve the patient, carers and other professionals
- Involve the older person and their family or carer in discharge planning.
- Obtain recommendations from the treating team and allied health.
- Give the person and their family and carer written information about delirium and who to contact if they have any ongoing concerns.
- If the person is socially isolated, consider what extra supports they will require and how you can address these needs.
Document the episode, patient status and medication
The discharge summary paperwork to be provided to the GP should include:
- the patient’s episode of delirium, including details of persisting symptoms
- the person’s cognitive and functional status on discharge compared with their pre-morbid status
- any changes to their medication, including the reason for the change, possible side effects or drug interactions, how long the medication should be taken, and when it needs to be reviewed and by whom
- antipsychotics should be ceased unless there is good reason for their continuation; an ongoing evaluation and a plan to cease use should be included.
Refer to community health and support services
Describe the person’s need for monitoring and support by health professionals and other services in the community.
- The person’s GP will do the monitoring and follow-up, so provide test results and reports of all key and unresolved issues, including those needing further consideration or ongoing surveillance.
- Identify additional services needed and refer to inpatient or community health and support services.