A guide to the directory

Where tools fit in the patient journey

Delirium assessment is a repeated clinical task. The setting changes, and the question may change with it.

Emergency and medical care

  1. Emergency department

    Look for recent change. Assess possible delirium when indicators are present.

  2. Medical admissions

    Review the assessment, baseline cognition and information from family or carers.

  3. Hospital ward

    Continue observation. Reassess when there is a new concern or a change.

  4. Longer stay and discharge

    Delirium may persist or recur. Record the course and communicate follow-up needs.

Perioperative care

  1. Before surgery

    Establish baseline cognition and look for delirium where indicated. Risk prediction is a separate task.

  2. Recovery room / PACU

    Account for anaesthesia, sedation and arousal. NICE names CAM-ICU or ICDSC here.

  3. Postoperative ward

    Continue observation and use a structured assessment when delirium is suspected.

  4. Ongoing recovery

    Reassess new or persisting problems. Include cognition and delirium in handover and follow-up.

Across the whole stay

Observe during care

Listen to the patient, family and staff. Watch for changes in attention, alertness and behaviour.

New concern or positive monitoring result

Arrange prompt structured assessment and clinical review. Do not wait for the end of a shift.

Act and continue review

Assess possible causes and care needs. A negative score does not dismiss a convincing concern.

“Episodic” describes the assessment process. It does not mean that a patient should be assessed only once. On general wards, NICE recommends observation at least daily for changes suggesting delirium. The choice and frequency of formal monitoring scores need a clear local pathway.

This diagram adapts the patient-journey framework in Penfold et al. (2024), supplementary Figure 1, and Alasdair MacLullich’s teaching slides. It is a guide to the decisions, not a fixed assessment timetable.

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References

National Institute for Health and Care Excellence (2023) Delirium: prevention, diagnosis and management in hospital and long-term care. CG103, recommendations 1.5 and 1.6. Recommendations.

Penfold, R.S. et al. (2024) ‘Delirium detection tools show varying completion rates and positive score rates when used at scale in routine practice in general hospital settings: a systematic review’, Journal of the American Geriatrics Society, 72, pp. 1508–1524. Article and supplement.