1. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Focus on Delirium
(Relates to Chapter 60, “Nursing Management: Alzheimer’s Disease, Dementia, and Delirium” in the textbook)
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Delirium
Three most common cognitive problems in adults
Delirium (acute confusion)
Dementia
Depression
These problems often occur together.
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Delirium
State of temporary but acute mental confusion
Common problem
Life threatening
Possibly preventable syndrome
Highest in hospitalized older adults
In the hospital setting, 15% to 53% of older adults experience delirium postoperatively, and 70% to 87% experience delirium in the intensive care setting.
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Delirium
Common in older adults who have a short-term illness such as
Lung or heart disease
Infection
Poor nutrition
Drug interaction
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Delirium
Patients who experience delirium are at increased risk for
Longer hospitalization
Further functional decline
Institutionalization
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6. Delirium Etiology and Pathophysiology
Poorly understood
Contributors
Cholinergic deficiency
Excess release of dopamine
↑ and ↓ in serotonergic activity
Chronic stress
Clinically, delirium is rarely caused by a single factor. It is often the result of the interaction of the patient’s underlying condition with a precipitating event.
For example, the patient with underlying health problems such as heart failure, cancer, cognitive impairment, or sensory limitations may develop delirium in response to a relatively minor change (e.g., use of a sleeping medication).
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7. Delirium Etiology and Pathophysiology
Neuroimaging studies indicate that both cortical and subcortical structures are involved.
Thalamus
Basal ganglia
Pontine reticular formation
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8. Delirium Etiology and Pathophysiology
Acetylcholine may be a critical factor in the development of delirium.
Anticholinergic drugs can precipitate delirium in older adults.
Anticholinesterase agents can reverse delirium caused by anticholinergic drugs.
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9. Delirium Etiology and Pathophysiology
Neurotransmitter acetylcholine (cont’d)
Hypoglycemia, hypoxia, and thiamine deficiency ↓ the CNS production of acetylcholine.
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10. Delirium Precipitating Factors
Demographic characteristics
Age 65 or older
Male gender
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11. Delirium Precipitating Factors
Cognitive status
Dementia
Cognitive impairment
History of delirium
Depression
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12. Delirium Precipitating Factors
Environmental
Admission to ICU
Use of physical restraints
Pain (especially untreated)
Emotional stress
Prolonged sleep deprivation
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13. Delirium Precipitating Factors
Functional status
Functional dependence
Immobility
History of falls
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14. Delirium Precipitating Factors
Sensory
Sensory deprivation
Sensory overload
Decreased oral intake
Dehydration
Malnutrition
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15. Delirium Precipitating Factors
Drugs
Sedative-hypnotics
Opioids
Anticholinergic drugs
Treatment with multiple drugs
Alcohol or drug withdrawal
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16. Delirium Precipitating Factors
Coexisting medical conditions
Severe acute or terminal illness
Chronic renal or hepatic disease
History of stroke
Neurologic disease
Infection/sepsis
Fracture or trauma
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17. Delirium Precipitating Factors
Surgery
Orthopedic surgery
Cardiac surgery
Prolonged cardiopulmonary bypass
Noncardiac surgery
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18. Delirium Clinical Manifestations
Can present with a variety of manifestations
Delirium usually develops over a 2- to 3-day period
Patients with delirium can present with a variety of manifestations ranging from hypoactivity and lethargy to hyperactivity, including agitation and hallucinations.
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19. Delirium Clinical Manifestations
Early manifestations often include
Inability to concentrate
Irritability
Insomnia
Loss of appetite
Restlessness
Confusion
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20. Delirium Clinical Manifestations
Later manifestations may include
Agitation
Misperception
Misinterpretation
Hallucinations
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21. Delirium Clinical Manifestations
Acute delirium occurs frequently in hospitalized older adults.
Lasts from 1 to 7 days
May persist up to and after discharge
Most frequent consequence following unscheduled surgery on older adults
Patient at increased risk for falls
This transient condition is characterized by disorganized thinking, difficulty concentrating, and sensory misperceptions.
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22. Delirium Clinical Manifestations
Manifestations are sometimes confused with dementia and depression.
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23. Delirium Clinical Manifestations
Key distinction is patient with delirium who exhibits sudden
Cognitive impairment
Disorientation
Clouded sensorium
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24. Delirium Diagnostic Studies
Medical history
Psychologic history
Physical examination
Careful attention to medications
Cognitive measures (e.g., Confusion Assessment Method [CAM])
The Confusion Assessment Method (CAM) tool has been extensively studied and is a reliable method of assessing for delirium (see Table 60-13).
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25. Delirium Diagnostic Studies
Laboratory tests to explore the cause
Serum electrolytes
Blood urea nitrogen level
Creatinine level
Complete blood count (CBC)
Drug and alcohol levels
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26. Delirium Diagnostic Studies
Laboratory tests (cont’d)
Electrocardiogram (ECG)
Urine analysis
Liver and thyroid function tests
Oxygen saturation level
Lumbar puncture
Drug and alcohol levels may be obtained.
If unexplained fever or nuchal rigidity is present, and meningitis or encephalitis is suspected, a lumbar puncture may be performed.
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27. Delirium Nursing Management
Nurse’s role
Prevention
Early recognition
Treatment
Prevention of delirium involves recognition of high-risk patients.
Patient groups at risk include those with neurologic disorders (e.g., stroke, dementia, CNS infection, Parkinson’s disease), sensory impairment, and advanced age.
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28. Delirium Nursing Management
Focus on eliminating precipitating factors.
Protect patient from harm.
Encourage family members to stay at bedside.
If delirium is secondary to infection, antibiotic therapy is started.
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29. Delirium Nursing Management
Reorientation and behavioral interventions—used in all patients with delirium
Create a safe and quiet environment.
Provide reassurance.
Pay attention to environmental stimuli.
Clocks, calendars, noise, and light levels
If the patient uses eyeglasses or a hearing aid, these should be made readily available because sensory deprivation can precipitate delirium.
Avoid the use of restraints.
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30. Delirium Nursing Management
Patient experiencing delirium is also at risk for
Immobility
Skin breakdown
Nurse should also focus on supporting the family and caregivers.
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Delirium Drug Therapy
Reserved for those patients with severe agitation
Interferes with needed medical therapy
Puts patient at increased risk for falls and injury
Drug therapy is used cautiously because many of the drugs used to manage agitation have psychoactive properties.
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Delirium Drug Therapy
Treated with low-dose antipsychotics
Haloperidol (Haldol)
Risperidone (Risperdal)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Short-acting benzodiazepines (e.g., lorazepam [Ativan])
In addition to sedation, other side effects with antipsychotics include hypotension; extrapyramidal side effects, including tardive dyskinesia (involuntary muscle movements of the face, trunk, and arms) and athetosis (involuntary writhing movements of the limbs); muscle tone changes; and anticholinergic effects.
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33. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Audience Response Question
A 69-year-old patient is admitted to the hospital with a urinary infection and possible bacterial sepsis. The patient is disoriented and has a disturbed sleep-wake cycle. The nurse administers the Confusion Assessment Method (CAM) tool to differentiate among various cognitive disorders, primarily because:
1. Delirium can be reversed by treating the underlying causes.
2. Depression is a common cause of dementia in older adults.
3. Nursing care should be based on the cause of the cognitive impairment.
4. Drug therapy with antipsychotic agents is indicated in the treatment of dementia.
Answer: 1
Rationale: Delirium, a state of temporary but acute mental confusion, is a common, life-threatening, and possibly preventable syndrome in older adults. Clinically, delirium is rarely caused by a single factor. It is often the result of the interaction of the patient’s underlying condition with a precipitating event.
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Case Study
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Case Study
84-year-old man has been in the intensive care unit for 3 days after unexpected major abdominal surgery.
He is becoming increasingly confused and agitated.
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Case Study
His vital signs are within normal limits.
His abdominal incision is healing with no redness or drainage.
He is starting to tolerate an oral diet.
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Case Study
He is repeatedly trying to climb out of bed.
He was alert and oriented before surgery.
States he needs to “get out of here”
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Case Study
Angry at family members for not “taking me home”
Family members are very upset about his confusion.
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Discussion Questions
What type of cognitive impairment does he have?
What is your priority regarding his mental status?
1. He exhibits symptoms of delirium. Delirium is a temporary but acute mental confusion that is common in the hospitalized elderly.
Safety is the nurse’s first concern. The nurse needs to provide a safe and calming environment. Reorienting strategies should be used. These may include reassurance, reorienting information, personal contact, and contact with family members.
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40. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Discussion Questions
What is the next priority for you while caring for him?
Regarding his family and their anxiety, what is your priority?
3. The next priority is to determine the cause of the delirium. This process includes review of medical and psychologic history, and physical examination. Also included is review of medications and of laboratory data.
4. The family needs reassurance that delirium is typically an acute condition. If no other medical problems are encountered, he is likely to return to his former mental state after his condition stabilizes and/or he transfers from the ICU. Family members are encouraged to continue reorientation activities and not to react to his inappropriate statements.
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