Delirium Decision Tree
(DDT)
What are the Risk Factors?
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Severe Illness
Sensory Impairment (hearing/vision)
Age (age 65 years and over)
Cognitive Impairment (dementia)
Dehydration
Multiple Medications (Sedatives/Hypnotics/Narcotics/Anti-cholinergics/Psychotropics)
ETOH/Substance abuse
Previous Delirium
Infection
Recovery from Surgery
Impairment of Activities of Daily Living (bathing/dressing/toileting/grooming/feeding)
Pain
Patient at risk (any checks identified above)
Administer Confusion Assessment Method (CAM)
1st 8 hours on admission
Positive CAM
Assess using CAM
Q shift and prn
Search for reversible
causes and treat:
CXR
EKG
CBC
Electrolytes
BUN/CR
TSH/B12
Urinalysis
 Medication Review
Nurses Assess:
 Vital Signs/O2 sat
 Assess/treat pain
 Fluid balance
 Blood Sugar
Elimination
No risks identified
Normal Care unless changes in
cognition/function identified by team
Negative CAM
Assess q24 hours and prn
(with any cognitive and/or functional changes)
Interventions
Environmental
• Clocks/Calendars
Cognitive
• Frequent orientation
Communication
• Simple short sentences
Safety
• Fall prevention/Safe environment
Psychological
• Don’t dispute delusions; reassurance
Pharmacology
• Avoid Polypharmacy
• Avoid Benzodiazepines
• For agitated delirium please consider an
antipsychotic
Function
• Balance: rest, activity
Confusion Assessment
Method (CAM)
Need presence of (1) & (2) and
either (3) or (4)
1. Abrupt change?
2. Inattention, can’t focus?
3. Disorganized thinking?
Incoherent, rambling, illogical?
4. Altered level of consciousness?
(Hyper-alert to stupor?)
Trigger Questions
1. Acute changes in behavior?
2. Changes in function?
3. Changes in cognition? MMSE
4. Changes in medications?
5. Physiologically stable?
DELIRIUM IS A MEDICAL EMERGENCY!
FORM # W-00426
10/11
Adopted from HSC Delirium Clinical Practice Guidelines