Revised Delirium Clinical Care Standard

The Australian Commission on Safety and Quality in Health Care (the Commission) has recently updated the Delirium Clinical Care Standard. This Standard aims to reduce delirium incidence, severity, and duration through improved preventative, diagnostic, and treatment strategies.

It is thought that up to 18% of Australians 65 years of age and older have delirium upon presentation to hospital, with an additional 2-8% developing the condition during their stay. Delirium is an acute deterioration of mental status that results in confused thinking and reduced awareness of the environment. This condition is associated with increased mortality as well as an increased risk of falls, prolonged hospital stay, and a subsequent diagnosis of dementia. Risk factors for delirium include acute illness, surgery, injuries, and adverse effects of medicines. Medicines most commonly implicated include anticholinergics, corticosteroids, dopaminergic drugs, opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), propranolol, sotalol, and benzodiazepines.

The updated Delirium Clinical Care Standard includes the following quality statements:

1. Early identification of risk;
2. Interventions to prevent delirium;
3. Patient-centred information and support;
4. Assessing and diagnosing delirium;
5. Identifying and treating underlying causes;
6. Preventing complications of care;
7. Avoiding use of antipsychotic medicines; and
8. Transition from hospital care.

One of the key changes in the revised Standard is the addition of quality statement 3 relating to patient-centred information and support. The goal of this section of the Standard is to ensure that patients who are at risk are provided with information about delirium in a way that they can understand. Patients who go on to experience delirium should be supported and cared for in a manner that reduces the severity of symptoms and associated distress.

Another change relates to the prevention of complications of care. Version 1 of the Standard focussed only on the prevention of falls and pressure injuries. The updated version expands on this to also include the risks associated with functional decline, malnutrition and dehydration. The recommendations regarding the avoidance of antipsychotics have also been strengthened to reflect current evidence. The new Standard emphasises that non-drug strategies should be the mainstay of care for the management of delirium.

The revised Standard complements the Comprehensive Care Standard that is part of the National Safety and Quality Health Service (NSQHS) Standards. To comply with the NSQHS Standards, health service organisations must integrate best-practice strategies for the early recognition, prevention, treatment and management of cognitive impairment. This includes the Delirium Clinical Care Standard, where relevant.

The Commission acknowledges the additional challenges currently faced due to the COVID-19 pandemic. People with cognitive impairment may find the current hospital experience even more difficult than usual. The widespread use of masks may worsen disorientation, and visitor restrictions may produce anxiety for some. Patients with cognitive impairment may also find it difficult to follow infection control instructions. To address this, the Commission provides resources to support health service organisations to provide safe care for people with cognitive impairment during this time.