Chapter 13: Delirium

Learning Objectives Define delirium. Explain common causes of delirium in older adults. Describe signs and symptoms of delirium. Distinguish between delirium and dementia. Discuss appropriate treatment of delirium in a variety of settings.

Definition and Etiology DSM-IV Criteria for Delirium Disturbance of consciousness with reduced ability to focus, sustain, or shift attention. Change in cognition or development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia Disturbance develops over a short period of time (hours to days) and tends to fluctuate during the course of the day Evidence from the history, physical examination, or laboratory findings that disturbance is caused by the direct physiological consequences of a general medical condition

Definition and Etiology (cont’d) Differentiating Delirium from Dementia Delirium Dementia Acute confusional state Abrupt onset (hours to days) Impaired attention and focus Fluctuating mentation and cognition Potentially reversible Chronic confusional state Gradual decline (months to years) Attention fairly preserved Mentation is generally constant Irreversible

Background Mechanism of delirium not fully understood Occurs in 22- 38% of older patients in the hospital As many as 40% of long-term care residents Associated with increased length of stays in the hospital and higher mortality rates Altered consciousness Temporary Also called acute confusion Many treatable causes Need to distinguish delirium, depression, and dementia

Significance of the Problem Medical emergency associated with increased morbidity and mortality Wide variation in the numbers underscores difficulty recognizing delirium due to its fluctuating nature Postoperative delirium Peaks on 2nd post-op day Orthopedic surgery patients most at risk

Risk Factors Presdisposing factors: baseline vulnerabilities that the patient already has prior to hospitalization (Box 13-1, p. 489) Precipitating factors: events or conditions occuring during hospitalization that trigger delirium Beer’s List of potential inappropriate medications

Risk Factors Fluid and electrolyte imbalances, CHF Medications, Pain, Emotional stress Impaired cardiac or respiratory function Unfamiliar surroundings Malnutrition Anemia Dehydration Alcoholism Hypoxia Infection Trauma

Warning Signs 1 to 3 days prior to onset of delirium Agitation, restlessness, anxiety, irritability, distractibility, and sleep disruption that may progress to daytime somnolence and nighttime wakefulness Post-op - 6 hours prior to onset of delirium anxiety, disorientation, urgent calls for attention, memory impairment, incoherence, disorientation, and underlying somatic illness

Assessment Mental Status Examination Attention Orientation Language Memory Reasoning Thought process Thought content

Diagnosis Acute episode of delirium requires clinical evaluation by physician or nurse practitioner Monitor vital signs and signs of infection Delirium labs Complete blood count (CBC) Comprehensive metabolic panel Urinalysis Neuroimaging to determine the presence of stroke Abdominal series to rule out constipation

Diagnosis (cont’d) Chest X-ray Electrocardiogram Swallowing evaluation Medication review I WATCH DEATH: contributing factors of delirium (p. 498) Infection, Withdrawal, Acute metabolic, Trauma, CNS pathology, Hypoxia, Deficiencies, Endocrinopathies, Acute vascular, Toxins or drugs, Heavy metals

Interventions ADVISE: Advocacy, Diligence, Vigilance, Integration, Support, Education (Table 13-6, P.499) Pain: scheduled analgesia Agitation: remove excess stimulation Combativeness: prevention & tx of constipation… Inattentiveness: simple & repetitive activities Wandering and exit seeking: frequent toileting… Sleep: darkening the room etc… When a “Sitter” is the Wrong Approach: family member or familiar friends… Safety concerns: Home management after discharge: need 24 hrs. supervision Prognosis

Sundowner syndrome Management: A form of delirium Nocturnal confusion Confusion “as the sun goes down” Increased with unfamiliar surrounding Often disturbed sleep patterns May result from excess sensory stimulation or deprivation Management: Keep familiar objects in view Provide physical activity during the day Avoid napping during day Use a night light in room Provide human contact and touch for reassurance Meet basic needs for fluids, food, toileting Control noise and visitors in evening

Summary Delirium is a common problem among older adults, especially those frail and compromised Nursing care for individual with delirium is aimed at discovering and treating underlying causes May be simple, such as a urinary tract infection or complex and multifaceted Most delirium is an acute geriatric syndrome, but untreated it can have harmful effects on health and quality of life