Clinical guidelines on delirium and transient loss of consciousness

NICE quality standard on delirium

The National Institute for Health and Care Excellence published a quality standard on delirium (July 2014). In response to the question, ‘Why is this quality standard needed’, NICE states: ‘It can be difficult to distinguish between delirium and dementia because symptoms overlap, and some people may have both conditions. Delirium is a potentially reversible condition if the causes are identified and they are treatable. If clinical uncertainty exists over the diagnosis, initial management should be for delirium.’

The quality standard deploys a series of quality measures including:

Assessing recent changes in behaviour

Evidence of local arrangements to ensure that adults newly admitted to hospital for long-term care who are at risk of delirium are assessed for recent changes in behaviour, including cognition, perception, physical function and social behaviour.

Interventions to prevent delirium

Adults newly admitted to hospital or long-term care who are at risk of delirium receive a range of tailored interventions to prevent delirium.

Use of antipsychotic medication for people who are distressed

Adults with delirium in hospital or long-term care who are distressed or are a risk to themselves or others are not prescribed antipsychotic medication unless de-escalation techniques are ineffective or inappropriate.

Information and support

Adults with delirium in hospital or long-term care, and their family members and carers, are given information that explains the condition and describes other people's experiences of delirium.

Communication of diagnosis to GPs

Improving communication between hospitals and GPs, and within hospital departments, may help people who are recovering from or who still have delirium to receive adequate follow-up care once they are back in the community or a long-term care home. Follow-up care may include treatment for reversible causes, investigation for possible dementia and a greater emphasis on preventing delirium recurring. A person's diagnosis of delirium may not be communicated to their GP because it is usually secondary to their main reason for admission, and it also may not be communicated between hospital wards when the person is transferred. A person's diagnosis of delirium during a hospital stay should be formally included in the discharge summary sent to their GP, and the term 'delirium' should be used.

The quality standard is expected to contribute to improvements in the following outcomes:

• Length of hospital stay.
• Detection of delirium.
• Incidence of delirium.
• Falls in hospital.
• Mortality.
• Adults' experience of hospital care.
• Carer involvement in healthcare.

NICE quality standard on transient loss of consciousness

NICE has published a quality standard on Transient loss of consciousness ('blackouts') in over 16s.

Transient loss of consciousness is very common, affecting up to half the population in the UK at some point in their lives. It is defined as spontaneous loss of consciousness with complete recovery. In this context, complete recovery would involve full recovery of consciousness without any residual neurological deficit. An episode is often described as a 'blackout' or a 'collapse', but some people collapse without transient loss of consciousness; this quality standard does not cover that situation. There are various causes of transient loss of consciousness, including cardiovascular disorders (which are the most common), neurological conditions such as epilepsy, and psychogenic attacks.

Approximately 3–5 per cent of adults who attend accident and emergency departments do so because of transient loss of consciousness; this accounts for up to 6 per cent of urgent hospital admissions. It is particularly common in people aged 65 and older; it has been estimated that up to 23 per cent of this group experience syncope (transient loss of consciousness due to a reduction in blood supply to the brain) over a 10‑year period, and there is a high rate of recurrence. Reflex (vasovagal) syncope (which is usually benign) is common in younger people. Many younger people who have a vasovagal syncope episode may not seek medical help, so the true incidence of transient losses of consciousness – especially in younger people – is uncertain.

Accuracy of diagnosis

The diagnosis of the underlying cause of transient loss of consciousness is often inaccurate, inefficient and delayed. In addition, there is huge variation in the management of transient loss of consciousness. A substantial proportion of people initially diagnosed with and treated for epilepsy in fact have a cardiovascular cause for transient loss of consciousness. Some people have expensive or inappropriate tests, unnecessary referral or referral to the wrong specialty; whereas others with potentially dangerous conditions may not receive the correct assessment, diagnosis and treatment.

The aim of initial assessment, diagnosis and specialist referral of people who have had a transient loss of consciousness is to ensure that that they receive the correct diagnosis quickly, efficiently and cost effectively, leading to a suitable management plan for the underlying cause.

The quality standard is expected to contribute to improvements in the following outcomes:

• Emergency hospital admissions.
• Specialist referrals.
• Mortality from causes considered preventable.
• Patient experience of clinical care.
• Misdiagnosis of the cause of transient loss of consciousness.