British recommendations for prevention of delirium

Published: October, 2011

The National Institute for Health and Clinical Guidance (NICE) in Britain creates medical practice guidelines for the country's National Health Service. Last year, the institute released delirium guidelines. Administrators, doctors, and other clinicians are the intended audience, but friends and family members might also find the NICE suggestions for preventing delirium useful. We've made a few minor edits for clarity.

  1. Ensure that people at risk of delirium are cared for by a team of healthcare professionals who are familiar to the person at risk. Avoid moving people within and between wards or rooms unless absolutely necessary.

  2. Give a tailored multicomponent intervention package. Within 24 hours of admission, assess people at risk for clinical factors contributing to delirium. Based on the results of this assessment, provide a multicomponent intervention tailored to the person's individual needs and care setting as described in recommendations.

  3. The tailored multicomponent intervention package should be delivered by a multidisciplinary team trained and competent in delirium prevention.

  4. Address cognitive impairment and/or disorientation by providing appropriate lighting and clear signage; a clock (consider providing a 24-hour clock in critical care); and a calendar that should also be easily visible to the person at risk. Talk to the person to reorient them by explaining where they are, who they are, and what your role is. Introduce cognitively stimulating activities (for example, reminiscence) and facilitate regular visits from family and friends.

  5. Address dehydration and/or constipation by ensuring adequate fluid intake to prevent dehydration by encouraging the person to drink. Consider offering subcutaneous or intravenous fluids, if necessary. Manage fluid balance in people with comorbidities (for example, heart failure or chronic kidney disease).

  6. Assess for hypoxia and optimize oxygen saturation, if necessary, as clinically appropriate.

  7. Address infection by looking for and treating infection, avoiding unnecessary catheterization and implementing infection control procedures in line with NICE infection control guidelines.

  8. Address immobility or limited mobility through the following actions by encouraging people to mobilize soon after surgery and walk (provide appropriate walking aids if needed). Encourage all people, including those unable to walk, to carry out active range-of-motion exercises.

  9. Address pain by assessing for pain, looking for nonverbal signs of pain, particularly in those with communication difficulties (for example, people with learning difficulties or dementia, or people on a ventilator or who have a tracheotomy). Start and review appropriate pain management in any person in whom pain is identified or suspected.

  10. Carry out a medication review for people taking multiple drugs, taking into account both the type and number of medications.

  11. Address poor nutrition by following the advice given on nutrition in NICE nutrition support in adults' guidelines. If people have dentures, ensure they fit properly.

  12. Address sensory impairment by resolving any reversible cause of the impairment, such as impacted ear wax. Ensure that hearing and visual aids are available to, and used by, people who need them and that they are in good working order.

  13. Promote good sleep patterns and sleep hygiene by avoiding nursing or medical procedures during sleeping hours. If possible, schedule medication rounds to avoid disturbing sleep. Keep noise to a minimum during sleep periods.

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