Keywords

12.1 Introduction

Delirium is a common complication following surgery, particularly for older adults. Often described as an ‘acute confusional state’ it can be hard to detect, treat, and manage. Healthcare practitioners’ knowledge around delirium care can often be limited. This chapter aims to provide an overview of delirium, its assessment, and its management and how it can impact patient recovery following fragility fracture.

12.2 Learning Objectives

At the end of this chapter, and following further study, the practitioner will be able to:

  • Describe what delirium is and the subtypes of hyperactive, hypoactive, and mixed delirium.

  • Gain insight into the experience of delirium for the patient, loved ones, and practitioners.

  • Identify patients at increased risk of developing delirium and have an awareness of preventative strategies.

  • Apply evidence-based tools to assist in diagnosis and assessment of delirium.

  • Instigate an interprofessional investigation to highlight the triggers of delirium and necessary treatments/actions.

  • Identify management strategies and care priorities for the patient with delirium.

  • Discuss the medication possibilities within delirium management.

  • Articulate the similarities and differences between delirium, dementia, and depression.

  • Identify the impact of an acute confusional state (delirium) on the ability to provide informed consent and maintain self-advocacy.

12.3 Delirium

Delirium is a neuropsychiatric syndrome that manifests as an acute decline of attention and cognition when a person is medically unwell. Despite advances in the understanding of delirium physiology, its mechanisms, pharmacology, and assessment, there has not been a significant improvement in delirium management globally, so it still remains a challenging worldwide problem [1]. Delirium often highlights the existence of medical issues within the patient, making its investigation imperative. There are also many undesirable consequences associated with delirium as shown in Box 12.1.

Seen in both the medical and surgical hospital settings, studies have shown a prevalence of delirium in hospital patients of 32% in Europe (increasing to 68% in intensive care units), 40% in the USA, 17% in Asia, and 12.3% in Africa [2,3,4,5,6]. There is limited data on the prevalence and outcomes of delirium in low- and middle-income countries, despite their medically and socioeconomically vulnerable patient populations; so it is assumed that the prevalence may be higher than the numbers available from research reports.

Rates of delirium are very high among surgical patients. A meta-analysis revealed the global prevalence of postoperative delirium to be 20% [7, 8] reaching as high as 60–65% in patients undergoing surgery for fragility hip fracture [9, 10].

It is estimated that approximately 20–80% of cases of delirium go undiagnosed or unassessed [11,12,13]. Detection is particularly low if patients present with hypoactive delirium or also have pre-existing dementia. This is especially relevant because the inability to detect delirium implies an increased risk of negative patient and institutional outcomes (See Box 12.1). If practitioners are not assessing for delirium, they are likely also to be missing the opportunity to prevent its occurrence.

Box 12.1: Consequences of Delirium

  • More hospital-associated complications (such as pressure injuries and falls) [14].

  • Increased stay in hospital or need for high dependency/critical care in hospital [14].

  • Restrictions in motor functionality [6].

  • Increased mortality rate [1].

  • Increased incidence of cognitive decline or impaired cognitive functions [15].

  • More likely that the patient will not return to their premorbid baseline function and will require long-term care/support on discharge (increased chance of discharge to an institution rather than return home) [2].

  • More likely to die in the short and long term [14].

Globally, healthcare costs associated with delirium are considerable: €182 billion per year in Europe, $164 billion in the USA [16], $8.8 billion AU in 2016–2017 in Australia [17] and $961,131 CAD in 2012 in Canada [18]. Better prevention and management of delirium would not only improve patient and institutional outcomes but could also relieve some healthcare financial burden.

12.4 The Experience of Delirium

Caring for someone who has delirium can be challenging. Caregivers cannot fully understand what the person suffering from delirium is experiencing. As patients with delirium can often be resistant to treatment, having some insight into their direct experience can help in understanding how best to manage those suffering from delirium, how best to help their loved ones feel less anxious, and how to empower practitioners to feel confident in their caregiving.

12.4.1 Patient Experience

Often the experience of delirium is described as a waking dream, or nightmare, where the world around the patient is confusing, odd, and unexplained but feels very real. There is a lot of fear as many experience the feeling of threat, persecution, and conspiracy. This knowledge helps in understanding why a patient may behave in certain ways and gives insight into what behavioural approaches may be the most appropriate. It may also help us spot delirium earlier, thus prompting medical management sooner. It can be appropriate to ask the patient what they are experiencing to gain a better understanding of their experience and how best to provide care. Patients may not disclose what they are experiencing unless asked. It is imperative that practitioners provide reassurance to the patient that they are going to keep them safe.

‘I believed everything that I now know I was imagining but at the time, I believed it 110%…. But up until that moment it was fact and although they told me it wasn’t happening I thought they are in with everybody else’ [19]

‘…my experiences [of delirium] changed and developed. The episodes of delirium I experienced ranged from absolute terror and fear; through anger, the unnerving and bizarre; to paranoia, the annoying, interesting and, with hindsight, the vaguely funny’. [20]

12.4.2 Loved Ones Experience

It is also vital to acknowledge the experience of the loved ones of the patient with delirium. Often naïve to what delirium is and how it may present, witnessing a delirious episode can be very alarming for the patient’s family members, partners, and friends. Acknowledging this allows practitioners to empathise with the loved one and consider how to best support them.

‘I suppose I just learnt with my Dad that it comes in all shapes or forms; it was very, very confusing. He did not recognise me which I would say even against the episodes where he was seeing rats and spiders crawling over people and up walls, I think probably the most distressing thing was not being recognised by my dad, that was the first time I ever experienced anything like that’ [19].

Loved ones can be vital in helping healthcare professionals spot delirium and monitor its progress. It is important to heed comments by family members about any changes in behaviour.

‘I’m not an expert in this area, but I could see he was not himself’ [21].

12.4.3 Healthcare Professionals Experience

The act of caring for someone who is delirious should be valued as an experience worthy of understanding. Caring for someone who is delirious can be unpredictable. Practitioners can feel uncertain and unprepared to take on this aspect of care, especially when it comes in addition to an already busy workload.

‘When we actually have a delirious patient, and nothing seems to be working. I don’t know what would be better, I guess, and that’s what makes it very frustrating because you feel very helpless’. [22].

12.5 Delirium Screening and Assessment

Delirium is a common complication in patients who have a fragility hip fracture and following surgery. As in other populations, patients who develop delirium have poorer outcomes when compared to those who do not [2, 3]. The good news is that the factors that increase a person’s risk for developing delirium are well known and nurses and other caregivers are ideally positioned to mitigate risk of delirium by screening for risk factors on admission and beyond. Factors that contribute to the development of delirium are commonly divided into two categories: predisposing and precipitating.

Predisposing risk factors are those that are present on admission and tend to be non-modifiable. The most significant predisposing risk factor for delirium is dementia, considered an independent predictor for delirium. Other examples of predisposing factors include advanced age, sensory impairment, and functional dependence.

Precipitating factors often occur as a consequence of hospitalisation and illness and tend to be modifiable. Examples of precipitating factors include sleep deprivation, medications, immobility, and severity of illness. The greater the number of predisposing factors, the fewer precipitating factors needed to create a delirious episode. Table 12.1 provides a list of common predisposing and precipitating risk factors [23].

Table 12.1 Common predisposing and precipitating factors for delirium
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Several studies have demonstrated that, with early identification of risk and prompt initiation of prevention strategies, as many as 30% of cases of delirium can be avoided or the severity ameliorated [22, 24, 25]. In the acute care setting, prompt identification of baseline mental status and predisposing risk factors for delirium should be part of the nursing admission process.

While often not possible in the case of hip fracture; for older adults undergoing elective surgery, it is advisable to complete a robust geriatric assessment to identify and optimise baseline vulnerabilities prior to surgery. Often known as a Comprehensive Geriatric Assessment (CGA) (See Chap. 6 for more information about CGA), when used preoperatively this assessment has shown to improve patient and clinic outcomes [9].

12.5.1 Screening for Risk Factors Predictive of Delirium

Cognitive screening can be problematic in emergency/urgent care where time is limited, especially where best practice relies on patients proceeding to surgery as soon as possible. There are several ‘rapid’ tools and questions that can assist in identifying those with cognitive impairment and increased risk for delirium. Asking the patient (or family) if they ‘have any memory problems’ is important. Listening to how questions are answered can also provide clues to baseline mental status. The Single Question in Delirium (SQID) is a rapid screening for delirium. It involves asking the patient and or family: ‘...have you felt more confused lately?’

The Delirium Elderly at Risk screening tool (DEAR) is an easy-to-use admission risk screen that has been validated in both elective and emergent orthopaedic populations [26, 27]. The DEAR consists of five predisposing risk factors: advanced age (≥ 80), history of cognitive impairment, use of sensory aids, functional impairment, and chronic benzodiazepine or alcohol use. Including a risk screen in nursing admission assessment provides an opportunity to initiate strategies to prevent or ameliorate the severity of delirium. Those identified with cognitive impairment and high risk for developing delirium should then be supported with prevention interventions specific to their risk. A more detailed assessment and ongoing monitoring for signs and symptoms of delirium will then assist in developing an optimal plan of care.

12.5.2 Assessment for the Presence of Delirium

The Confusion Assessment Method (CAM or ICU CAM) is considered the ‘gold standard’ for assessment and diagnosis of delirium. An abbreviated version, the bCAM consists of four questions that identify behaviours associated with delirium shown in Fig. 12.1. According to the bCAM training manual, for a patient to meet criteria for delirium, they must positively display features 1 AND 2 and EITHER feature 3 AND/OR 4. This tool requires staff to be educated on its use and studies have shown that it is poorly utilised by nurses [27].

Fig. 12.1
A diagram of a rectangle divided into 4 sections with each section labeled 1. altered mental status or fluctuating course. 2. Inattention. 3. altered level of consciousness. 4. disorganized thinking.

bCAM abbreviated confusion assessment method questions [27]

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The ‘4AT’ is a brief, easy-to-use, validated tool used to assess for moderate to severe cognitive impairment and the presence of delirium with little training needed [28]. It is sometimes preferred to the ‘abbreviated mental test score’ (AMTS) and is free to use and download (www.the4at.com). It can be used for both initial screening and as a daily assessment tool to monitor delirium. It allows assessment of patients with severe drowsiness or agitation. The four questions contained in the 4AT are as follows:

  1. 1.

    Alertness: How awake is the patient? Are they easily awoken?

  2. 2.

    AMT4 (an abbreviated version of the AMT). Ask patient to recall:

    1. (a)

      Where are you now?

    2. (b)

      What is your birthday? (day, month, year).

    3. (c)

      How old are you?

    4. (d)

      What is the current year?

  3. 3.

    Attention: List months of year backwards starting with December.

  4. 4.

    Acute Change or Fluctuating Course: Has the patient experienced any hallucinations, paranoia, exhibiting strange behaviours, or acting ‘not quite right’?

The nursing delirium screening scale (NuDESC) [29] is also an easy-to-use tool to identify delirium based on observation of five features: inappropriate behaviour, inappropriate communication, illusions/hallucinations, and psychomotor retardation. Each item is scored based on its severity (0 = absence, 1 = mild, and 2 = severe), and a score equal to or greater than two indicates delirium.

Table 12.2 provides a sample of the variety of screening and assessment tools available. When selecting a tool, it is important to review the complexity, time, and training required to complete as well as the setting and population of patients where will be used.

Table 12.2 Overview of common delirium assessment tools
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In the fast-paced acute care setting, it is especially challenging to tease apart normal vs abnormal behaviour in patients admitted with pre-existing cognitive impairment. Often, abnormal behaviour is attributed to pre-existing dementia which contributes to the large number of missed cases. In addition, delirium presents in a variety of ways (See Table 12.3). The hyperactive subtype is the most easily recognisable but sometimes misdiagnosed as agitated dementia or a psychotic disorder. The hypoactive subtype is easily overlooked as the patient is not demanding of nursing time or attention. This subtype is most often misdiagnosed as lethargy or slow recovery from anaesthesia. There are times when the patient may exhibit behaviours that fluctuate between the two, referred to as the mixed subtype.

Table 12.3 The subtypes of delirium
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In cases where the patient may be suffering from subsyndromal delirium—a milder state characterised by the presence of certain delirium symptoms but without meeting full diagnostic criteria thresholds—the most valuable assessment comes from the family who are best positioned to pick up on subtle changes. Comments from the family such as: ‘My Mother is normally confused, but this is different’, ‘My Father is not acting like himself’, and/or comments from the patient themselves suggesting confusion or disorientation should trigger further investigation.

For those hospitalised patients who are at increased risk, as well as those who may develop delirium during hospitalisation, medical management by a geriatrician/physician is recommended. Oversight by a clinician with geriatric expertise will help guide the team on ways to ameliorate delirium severity and aid in the referral for a more comprehensive geriatric assessment after discharge.

Growing sophistication of electronic medical record programmes provide an opportunity for consistent electronic monitoring of risk factors from information entered on the patient’s condition during hospitalisation. Moon et al. [29] reported the sustained high predictive ability of their automated process to identify delirium in hospitalised older adults, the Auto-DELRAS.

Not to be overlooked is the practitioner’s clinical judgement as a valuable ‘tool’ in identifying those who may be developing or suffering from delirium. When in doubt, since delirium is a geriatric emergency, it is best to err on the side of delirium rather than ignoring subtle changes. Nurses and other caregivers should be encouraged to trust their instincts /clinical judgement even if all the criteria for delirium on an assessment tool are not present. Care management strategies for those at risk or those suffering from delirium are not harmful and potentially improve care even in the absence of delirium. Interventions may include involvement of family, reorientation/reassurance, sensory aids in place, mobility, assessing and addressing pain, monitoring for constipation/urinary retention, and others.

12.6 Managing the Delirious Patient

Using a tool to identify delirium is only helpful if repeated and supported with a detailed assessment of the patient’s condition. The 4AT, for example, can provide a diagnosis but it does not provide details about the severity or duration of the delirium and, importantly, its causes. Once diagnosed, the patient requires rapid intervention to identify the cause (or causes), initiation of treatment, and close monitoring. In addition, the patient will need ongoing supportive care. In all the aspects of delirium detection and management, it should be stressed that a multidisciplinary approach is vital.

12.6.1 Initial Actions and Investigations

Once delirium has been diagnosed actions should be taken immediately to discover the causes of the delirium. This will allow treatment and interventions to take place as soon as possible with the aim of preventing the delirium escalating and to aid in its resolution. Some institutions have suggested a time window in which these initial actions should take place (e.g. 4 h from time of diagnosis).

12.6.1.1 Review of Medical Causes

A review of the medical causes of delirium should always be seen as a multidisciplinary review where investigations are taken on by the relevant healthcare professional or team. While there may be some more obvious medical causes for delirium, it is suggested that a full medical review is completed to ensure no potential triggers are missed. This should take place alongside ongoing Comprehensive Geriatric Assessment (Chap. 6). There are several mnemonics used as aide-memoires for delirium, one of which is DELIRIUM. There are many other mnemonics for delirium (such as ‘PINCH ME’—Pain, Infection, Nutrition, Constipation, Hydration, Medication, Environment [30]), and there will be relevant alternatives for different languages. While not exhaustive of all the potential causes, it is a good starting off point to run through.

D—Drugs? Dehydration?

E—Electrolytes disturbances?

L—Lots of pain?

I—Inflammation? Infection?

R—Respiratory failure (hypoxia/hypercapnia)?

I—Impaction of stool (constipation)?

U—Urinary retention?

M—Metabolic disorder (liver/renal failure, hypoglycaemia)/MI?

It is worth also considering alcohol withdrawal, nicotine withdrawal, psychiatric or psychological issues and whether the patient’s basic physical needs are addressed: are they hungry, thirsty, need to use the toilet, do they have their glasses/hearing aids? While usually not the causal factors of delirium, these may add to the experience and severity of a delirium.

By going through this review, the delirium trigger (or often triggers) can be identified which then leads on the informed medical treatment plan. Delirium triggers should be constantly reviewed however as a patient may develop additional triggers over time (e.g. a post-op infection which takes 48 h to present, constipation following several days of morphine or urinary retention following urinary catheter removal).

12.6.1.2 Falls Assessment

Delirious patients are more likely to fall; patients over the age of 65 years with delirium have a 30% risk of falling compared to 10% of their non-delirious counterparts [31]. A prompt falls risk assessment should be completed with the emphasis on reducing risk. A low bed, bed alarms, or enhanced observation should be employed to help maintain a safe environment. In the patient who is agitated and wandering, physical restraint is never appropriate; a patient is more likely to settle if allowed to mobilise with support and supervision to maintain safety. The use of bed rails is always discouraged as they act as a barrier that can frighten or agitate the patient further, increasing the risk of them climbing over the rails and falling from a greater height; close monitoring is more effective. The prevention and management of falls are considered in detail in Chap. 4.

12.6.1.3 Inform Family

Early contact with the patient’s family can be the single most effective intervention to assist the healthcare team in the management of the delirious patient. It allows families to feel involved in care, helps reduce stress, and provides an opportunity to seek help in managing the delirium. The presence of a relative, friend, or carer can be calming, facilitating interventions, and relieving the need for close observation by a healthcare team member. This must, though, be done with caution; the presence of a relative with the patient does not reduce the overall risk from delirium, so regular observation and detailed instruction is needed to ensure any change in condition is acted on promptly and appropriately.

12.7 Non-pharmacological Care Interventions

Informed and sympathetic patient care is paramount within delirium management in addition to daily medical and nursing duties (i.e. medication rounds, checking observations). There are several non-pharmacological interventions which practitioners can adopt which can not only improve the patients experience but also improve the experience of the healthcare professional caring for that patient. As stressed before, while delirium care is largely undertaken by nurses, the multidisciplinary team should be aware of how best to support a patient with delirium. The ‘Hospital Elder Life Program’ (HELP) is an example of a system of patient support that aims to maintain cognitive and physical function during hospitalisation and maximise mobility on discharge, helping with discharge and avoiding hospital re-admission [32]. There are also other, more general geriatric models which could be considered when looking at delirium care in hospitals include the 4Ms Model of Care and NICHE (Nurses Improving Care to Health System Elders). All focus on regular monitoring and intervention. A summary of suggested delirium care interventions can be seen in Box 12.2. These interventions should be regularly completed in addition to daily reviews of delirium triggers and treatment plans.

Box 12.2: Suggested Interventions for Delirium Care

  • Regular reassurance and compassion. If appropriate, explain delirium to the patient to help them understand their experience.

  • Daily orientation to time, date, place (verbally by staff and visible clock, orientation board, etc.).

  • Adapt communication (consider simple, clear instructions, or information) and consider methods such as the VERA framework [33].

  • Regular updates on surgical/medical plans (when this does not cause distress).

  • Early mobilisation (maintaining function/normal routine as much as possible).

  • Hearing /vision adaptations (ensuring hearing aids, glasses, etc.).

  • Sleep hygiene (promoting day/night routine to promote usual routine, reduce noise and patient contact at night where possible).

  • Regular visits from friends and family and availability of familiar objects such as photographs (to promote orientation and enable meaningful engagement between patient and staff).

  • Reduce unnecessary moves within the hospital where possible.

  • Ensure adequate nutritional and fluid intake (offering drinks regularly/assisting with meals).

  • Consider need for a non-verbal pain assessment tool such as the Abbey Pain Tool, FPD-R, PAINAD, or MOBID-2 [34].

  • Careful monitoring for the presence of hypoactive delirium which can often be missed as believed to be a tired or sedated patient.

As with patients with dementia, adaptive communication is vital with patients experiencing delirium. At all times, it is best to validate the patients experience (e.g. ‘I understand you are feeling very frightened at the moment’) rather than ignore it, and then work with the patient to find what can make them feel more relaxed. Trial and error is sometimes needed to find out what works for the patient. For example, patients can respond well to being informed they are in hospital at some times but at others this might fuel their anxiety and paranoia so more of a ‘distraction’ technique is needed.

12.8 Medication

Medication management related to delirium involves being aware of what medications the patient is currently on (long term and short term) and what medications may be required to assist in the treatment and management of delirium. A comprehensive review of the patient’s current medications is essential to identify and modify/remove any medications which may be causing or adding to delirium. Tools such as the Anticholinergic Burden Calculator (http://www.acbcalc.com) [35] or the ‘Beers’ List (Beers Criteria Medication List - DCRI) [36] can be useful to practitioners when reviewing the medication of a patient with delirium. Additionally, consideration of pharmacological treatments for patients who are experiencing alcohol/substance/nicotine withdrawal may be required.

A common error in treating delirium involves the use of antipsychotic medications in excessive doses, the overuse of benzodiazepines or giving either of these drug types too late. If it is necessary to medicate the patient, the goal should be reduction of symptoms, not sedation. Sedation should be avoided and only considered as a last resort if the delirium is posing a significant risk to the patient or others. With proactive early assessment and intervention, patients should not need medication, but if they do, the following could be considered (for guidance only; drug, doses, and administration should be based on local evidence-based policy and prescriber decision-making):

  • An antipsychotic (such as Haloperidol, a first generation antipsychotic) is often the treatment in delirium (unless the patient has Parkinsons/Lewy Body Dementia, seizures, or an ECG shows changes such as a raised QTc).

  • A benzodiazepine (such as Lorazepam, a benzodiazepine) is often a first-line treatment in patients with delirium who do not meet the criteria for haloperidol, or where only a short duration of action is needed (e.g. for essential investigations).

    If delirium medication is needed, the following are important considerations:

  • Dose: Give a low dose in a timely manner rather than planning to ‘wait and see’ which often then results in an excessive escalation of delirium symptoms and the need for higher doses. Consider the age (and size) of your patient. It is often advised to give lower doses in elderly patients.

  • Timeline: How long does the patient need the medication? Daily reviews of delirium medication are advised and a weaning plan prescribed, if necessary, when it is time to stop the medication.

  • Discharge planning: In most cases, it is advised that patients are not discharged on delirium medication, but this must be discussed on an individual basis.

12.9 Dementia and Depression

It is worth noting the importance of dementia and depression when considering delirium, as well as orthogeriatric care in general. Dementia and depression can be important predictive factors of delirium, impact the way management and care for a delirious patient are implemented, and they may affect the final patient outcome. With all delirious patients, but particularly with patients who have dementia or depression, it is important to understand their pre-delirium cognitive/psychological baseline status and regularly discuss the situation with their loved ones to help understand what is their normal or expected cognitive presentation, and what might be a manifestation of acute delirium.

It is important to understand the similarities and differences between dementia, depression, and delirium (the ‘3 Ds’). One particularly important factor is the pattern of onset when diagnosing delirium. Delirium symptoms tend to present within hours to days, depression in weeks to months and dementia over several months to years. Often delirium can be misdiagnosed as dementia or depression and vice versa. Frustratingly, delirium, dementia, and depression can have similar symptoms so care should be taken when making a diagnosis. Table 12.4 outlines some of the key presentations and how they overlap for ‘The 3 Ds’ [37, 38].

Table 12.4 Key features of delirium, dementia, and depression
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12.10 COVID-19 and Delirium

Little is yet known about the association between acute mental changes and adverse outcomes in hospitalised adults with COVID-19. However, studies so far have suggested that delirium is a significant issue, particularly within the older population, being cited as one of the top six most common presenting symptoms of Covid infection [39, 40]. The ability of healthcare providers to assess and manage delirium was, especially initially, influenced by whether a patient has a diagnosis of Covid. The fear of the unknown and the fear of transmitting infections to others made healthcare teams change the way that they behaved and worked with patients [41]. By wearing protective equipment and limiting visits to patients’ rooms to minimise the exposure to the virus, delirium care could have been jeopardised because the patient could not communicate adequately and recognise familiar faces and voices [42]. During times of visiting restrictions where it was prohibited for loved ones to visit patients and to provide care patient social isolation was increased [42]. Patients with Covid infections requiring intensive care stays, often with prolonged mechanical ventilation time, high use of sedatives and extensive immobilisation, were also at increased risk of delirium [43]. For those in ICU, the ABCDEF approach to care appears to have been effective in shortening the duration of delirium [44]. Hospital-wide adaptations can be made to maximise delirium prevention, or management, even with restrictions in place due to infection prevention. This includes ways of improving communication with patients when visiting is restricted such as enabling video or phone communication with loved ones or authorising visiting rights to the most relevant loved on of a patient [45].

12.11 Advocacy and Consent

12.11.1 Consent

Many ethical issues including capacity and consent are considered in detail in Chap. 17. However, some of these are considered here because of the additional vulnerability created by cognitive impairment. A central aspect of care for all patients with cognitive difficulties is decision-making; be it long term, acute, or temporary. Having the capacity to consent to decisions and treatments in delirium can be confusing as a patient’s lucidity can fluctuate. If a patient is deemed to lack capacity (following a formal assessment following local guidelines), best interest decisions should be made. Practitioners must consider what is

  1. (a)

    In the patient’s best interest

  2. (b)

    The least restrictive option

Practitioners must first ask: ‘Can the decision or treatment be delayed to allow time for mental capacity to return?’ If not, such as in a time-pressured situation such as surgical fixation following fracture, the best interest decision to ascertain the onward course of care is needed. Any best interest ‘meeting’ or discussion must involve as many team members as possible to ensure the decision reached involves aspects that might not be considered by individuals. If all team members cannot be gathered, other forms of communication must be used to ensure all involved are consulted (e.g. via telephone or email) and to ensure all decisions and rationale are documented to provide clarity. The patient may also be able to put forward opinions even if not able to fully make the decision. Family members, or those with power of attorney should also be included in this decision process.

Each country, state, or institution will have guidelines regarding capacity, competence, and consent such as the UK’s Mental Capacity Act 2005 [46]. The terminology around capacity may vary between countries. For example, the USA refers to capacity as the inability to make decisions regarding medical treatment and care and refers to competency as a legal term related to ability (or inability) in decision-making. Overall, however, capacity has shared factors across the globe. It is time- and decision-specific: a patient should not be deemed as lacking capacity for all decisions but should be assessed for each important decision that needs to be made at the time it needs to be made. Capacity is assessed by looking at the patients’ ability to understand the information given to them, retain this information, weigh up the pros and cons, and replay their thoughts and reasonings to the assessor [23, 46].

Many countries have human rights legislation that states that all individuals have the right to their liberty being maintained. This can put practitioners in a difficult ethical situation, especially if the patient who lacks capacity resists the treatment being attempted in their best interests, for example, the ‘wandering’ patient who may try to leave during treatment or the acutely delirious postoperative patient who declines medication. Examples from other countries including the Mental Capacity Act [46] and the Human Rights Act [47] provide guidance on how this can be addressed, providing a frame-work to legally ‘deny’ the patient without capacity their usual rights to liberty and enforce treatment that is in their best interest.

12.11.2 Advocacy

An advocate can only provide opinion and information; the medical or surgical team can note personal preferences and previous decisions made, but this does not give the advocate rights to demand or decline treatments that may be in the best interest of the patient. In the UK, for example, anyone can advocate for someone as long as they can confidently:

  1. 1.

    State they know the wants and beliefs of the person who they are advocating for

  2. 2.

    Are not in receipt of financial benefit from their relationship (e.g. a paid carer)

There are cases where a patient has no available family or friends to advocate for them. In the UK, in this situation, the surgical or medical team can proceed using the information they have at hand to make the ‘best interest’ decision. In non-emergency situations, where capacity is questioned and unlikely to improve, practitioners can seek the help of an independent mental capacity advocate (IMCA); usually appointed by local authorities and who are charged with the gathering and evaluation of information regarding the views of the individual without capacity and making representations on their behalf.

A more formal position of advocacy in many countries is referred to as ‘Durable Power of Attorney’ (DPA) or ‘Lasting Power of Attorney’ (LPA). An LPA/DPA is appointed legally with consent from the patient (this consent being given at a time when the patient is confirmed to have capacity to make this decision). LPA/DPAs are usually appointed for specific areas such as health or finance and are there to make decisions on behalf of patients only when the patient lacks the capacity speak for themselves.

Summary of Main Points for Learning

  • Delirium is a neuropsychiatric syndrome that manifests as an acute decline of attention and cognition when a person is medically unwell. It is a medical emergency which prompts investigation into its causes.

  • Delirium is related to increased in-hospital and post-discharge morbidity (complications) and mortality (death).

  • Delirium can present as hyperactive, hypoactive, or mixed in presentation. It can be a distressing experience for the patient, their loved ones, and the healthcare professionals caring for them.

  • In some cases, delirium can be prevented. Early assessment is vital to help highlight those at risk.

  • Delirium is underdiagnosed across the globe due to poor understanding of delirium and the, often, ‘quiet’ nature of hypoactive delirium.

  • There are many tools available to assess for the presence of delirium, most of which also rely on a degree of professional judgement.

  • Delirium requires an interdisciplinary approach to investigation, treatment, and presentation management.

  • Liaison with loved ones is crucial for delirium management as it can help understanding of whether a patient is outside of their cognitive baseline (therefore potentially delirious) and if the delirium is improving/resolving.

  • Medications can be used within the care for a delirium patient, but these should be reviewed on a regular basis and ceased when delirium improves or resolves.

  • Delirium can be hard to spot in someone who already has a cognitive impairment such as dementia. Delirium, dementia, and depression have several similarities which can make diagnosis complicated.

  • Delirium often affects a patient’s decision-making ability, however due to the fluctuant nature of delirium this may vary.

12.12 Translating Knowledge into Action

  • Think about how well delirium is understood in your institution. How could delirium knowledge be improved among staff? Could patients and families be offered a delirium information leaflet to improve their understanding of delirium?

  • Is delirium included in annual competencies for staff and as part of staff orientation to your institution?

  • Do you currently use a delirium screening or assessment tool? Consider reviewing the assessment tools mentioned in this chapter and which may work best for you and your institution.

  • What delirium tools and processes does your institution currently use? Should these be reviewed? Are they used well among staff?

  • Consider how you currently go about a delirium investigation: Is the multidisciplinary team involved? Would staff benefit from a structured system to work from when investigating delirium triggers (such as the DELIRIUM mnemonic).

  • Does your organisation have a delirium policy covering assessment, prevention, and management? Are medications underused or overused with the management of ‘challenging’ patients with delirium?

  • Do staff in your institution have good understanding of your local policies on capacity, competency, and consent? Are practitioners confident to assess capacity and apply the correct measures for patients with delirium where confusion can fluctuate greatly.

12.13 Useful Resources for Further Study

Videos

What is delirium?

https:///www.youtube.com/watch?v=qmMYsVaZ0zo

https://www.youtube.com/BPfZgBmcQB8

VERA—Communication method

https://www.youtube.com/craoo582xm0