In 2019/2020, based on the learning from three acute hospital projects funded by the HSE/Genio to develop integrated care pathways for a person with dementia presenting to their hospital, a national working group developed three pathways to guide the care of a person with dementia. These pathways can be modified by hospital groups or individual hospitals as needed for the local context.
In addition, two existing delirium algorithms developed by the National Clinical Programme for Older People were updated in 2019/2020 by the working group.
The Integrated Care Pathway for a person with known dementia who presents acutely or in potential crisis describes the integrated care pathway between the community and an acute hospital and back again. Please click on the links on this pathway to the in-hospital ED/AMAU and ward pathways/algorithms (pink and green boxes), or scroll down to read more about these individually:
Integrated Care Pathway for a person with known dementia who presents acutely or in potential crisis
Within this overarching pathway for a person with dementia, there are specific dementia pathways for use in the ED/AMAU. These are closely linked to the national delirium algorithm for use in the ED/AMAU. All older patients should follow the delirium algorithm, and depending on the results of this screening may also then follow a dementia pathway:
Early Identification and Management of Delirium in the Emergency Department/ Acute Medical Assessment Unit Algorithm
Dementia / Delirium Combined Pathway and Care Bundle for Emergency Department and Acute Medical Assessment Unit
These are designed to be used together- please print out as a two-sided A4 page for resource/pathway folders, or as two A3 posters for side-by-side display in the ED/AMAU. The delirium algorithm is updated from Version 1.0 in 2015, and has been nationally endorsed by all relevant national clinical programmes, and is based closely on a draft European guidance document. It should not be modified.
The result of the 4AT test in the delirium algorithm (page 1) indicates the pathway to be followed on page 2. Note that page 2 (reverse side) has a single dementia and/or delirium care bundle for simplicity, as a person with known or suspected dementia and/or delirium is cognitively vulnerable and the principles of care are the same regardless of the final diagnosis. This page can be locally modified as required.
Please see this example of a lanyard flash card which has the 4AT instructions/scoring on one side as a reminder for staff (This example has the useful 'PINCHME' delirium risk factor mnemonic on the other side, but the 4AT could also be put on the reverse of an ID badge)
Once a patient is transferred to (or admitted directly to) a ward, the algorithm Delirium on General Hospital Wards: Identifying Patients at Risk, Delirium Screening and Next Steps applies. This is updated from Version 1.0 in 2017, and has been nationally endorsed. It should not be modified.
Delirium on General Hospital Wards: Identifying Patients at Risk, Delirium Screening and Next Steps
You should also consider providing written information about delirium to the patient, if appropriate, and their family. This Delirium information leaflet was first developed in 2017 by the NCPOP (to support the implementation of the ward delirium algorithm) and was updated in 2020 by the national dementia pathways working group. It can be modified locally to suit the local context, or tailored for potential recipients (eg surgical patients, ICU patients, hip fracture patients, etc), applying local version control as appropriate.
Delirium Information Leaflet
Access a modifiable Delirium Information Leaflet here
All in-patients with known dementia will follow the delirium algorithm, but also the Integrated Dementia Care Pathway for Acute Hospital Wards (as in-patient dementia care is more than just delirium prevention):
Integrated Dementia Care Pathway for Acute Hospital Wards
A patient with suspected dementia is also treated according to the delirium algorithm, but in addition needs to follow the Diagnostic Pathway for Suspected Dementia on Acute Hospital Wards, to ensure that the person is assessed for possible dementia at an appropriate time.
Diagnostic Pathway for Suspected Dementia on Acute Hospital Wards
The two pathways (for known dementia and suspected dementia) are Designed to be printed as a two-sided A4 page for ward resource/pathway folders, or can be displayed as two A3 posters side-by-side on the ward.
These care pathways can be locally modified as needed to fit local resources/other pathways of care.
This may be useful for the particular needs of a person with delirium in the context of COVID-19.
Management Tips for Suspected Delirium in Patients with COVID-19