1. Delirium & Dementia: Double Trouble By Denise L. Lyons, GCNS-BC, MSN; Shannon M. Grimley, GCP, PharmD; and Linda Sydnor, GCNS-BC, MSN LPN2009, March/April 2009 2.3 ANCC contact hours Online: www.lpnjournal.com © 2009 by Lippincott Williams & Wilkins. All world rights reserved

2. Delirium’s long-lasting complications Decline in cognitive and physical function Increased length of hospital stay Greater need for nursing care Delayed rehabilitation Nursing home placement

3. Prevalence of delirium In patients with dementia age 65 and older – 22% to 89% May be underreported when patient also has dementia Often diagnosed as worsening dementia

4. Prevalence of delirium 25% of older adults are hospitalized with delirium 56% develop delirium while hospitalized

5. What’s the difference? Dementia is chronic, develops slowly, and isn’t reversible Delirium is an acute change in mental status due to a reversible medical condition

6. What’s the difference? Onset Delirium: Acute Dementia: Insidious Course Delirium: Fluctuating, with lucid intervals; worse at night Dementia: Slowly progressive

7. What’s the difference? Duration Delirium: Hours to weeks Dementia: Months to years Sleep/wake cycle Delirium: Always disrupted Dementia: Sleep fragmented

8. What’s the difference? Illness or drug toxicity Delirium: Either or both present Dementia: Often absent, especially in Alzheimer’s Level of consciousness Delirium: Disturbed. Patient is less clearly aware of the environment and less able to focus, sustain, or shift attention Dementia: Usually normal until late in illness

9. What’s the difference? Behavior Delirium: Activity often abnormally decreased (somnolence) or increased (agitation) Dementia: Normal to slow; behavior may be inappropriate Speech Delirium: Hesitant, slow, or rapid; incoherent Dementia: Difficulty finding words; aphasia

10. What’s the difference? Mood Delirium: Fluctuating, labile, from fearful or irritable to normal or depressed Dementia: Often flat, depressed Thought processes Delirium: Disorganized; may be incoherent Dementia: Impoverished; speech gives little info

11. What’s the difference? Thought content Delirium: Delusions common; often transient Dementia: Delusions may occur Perceptions Delirium: Illusions, hallucinations (usually visual) Dementia: Hallucinations may occur

12. What’s the difference? Judgment Delirium: Impaired, often to a varying degree Dementia: Increasingly impaired over illness Orientation Delirium: Usually disoriented, especially for time. A known place may seen unfamiliar Dementia: Fairly well maintained, but becomes impaired in later stages of illness

13. What’s the difference? Attention Delirium: Fluctuates. Patient is easily distracted and unable to concentrate on tasks Dementia: Usually unaffected until late in illness Memory Delirium: Immediate and recent memory impaired Dementia: Recent memory and new learning especially impaired

14. Who’s at risk? Predictable risk factors for developing delirium: Age older than 70 History of dementia Sleep deprivation Hearing or visual impairment Dehydration Severe illness or fractures Hospitalization

15. Who’s at risk? Recent surgery Immobility Previous episodes of delirium Polypharmacy Alcoholism Multiple comorbidities

16. Common causes of delirium Drugs prescribed, over-the-counter, and recreational alcohol withdrawal or intoxication polypharmacy (more than four medications) effects of anticholinergic drugs, psychoactive drugs (anxiolytics, sedatives, hypnotics, antipsychotics, antidepressants), opioids, steroids drug toxicity, drug withdrawal

17. Common causes of delirium Elimination urinary retention fecal impaction or diarrhea Liver and other organs liver failure, hepatitis, cirrhosis heart failure, MI, hypotension, dysrhythmia kidney dialysis, renal insufficiency

18. Common causes of delirium GI bleeding, inflammation, infarction, infection stroke, cerebral edema, subdural hematoma, head injury, hydrocephalus, encephalopathy, meningitis bone marrow disease (anemia) Infection urinary tract or respiratory infection sepsis

19. Common causes of delirium Respiratory hypoxia, pneumonia, pulmonary embolism, chronic obstructive pulmonary disease, asthma abnormal arterial blood gases, carbon dioxide, retention, hyperventilation Injury trauma, pain, stress

20. Common causes of delirium Unfamiliar environment restraint use, underlying dementia hospitalization or change in residence Metabolic fluid/electrolyte disturbance dehydration/volume depletion abnormal blood glucose level

21. Common causes of delirium elevated blood urea nitrogen or creatinine level vitamin B 12 /folate deficiency hypothyroidism, hyperthyroidism fever, hypothermia

22. Promoting prevention Frequent bedside assessments of mental status noting any changes in inattention or unorganized thoughts Manage patient’s environment: minimize noise, staff, room changes Respond immediately to suspected physiologic causes of delirium: infection, medications etc.

23. Finding the cause Observe the following: vital signs intake and output SpO 2 level last bowel movement lung sound medical device use pain level new medications blood glucose urinalysis

24. Medications that can cause problems Many drugs can cause or exacerbate delirium: Alzheimer’s medications opioid analgesics nonopioid analgesics all anesthetics antianxiety/hypnotic agents, sedatives antiseizure drugs antidepressants

25. Medications that can cause problems antihistamines antihypertensives antimicrobials anti-Parkinson’s medications antispasmodics (urinary) cardiac medications glucocorticoids muscle relaxants

26. Diagnosing delirium Two assessment tools may be helpful: Confusion Assessment Method (CAM) Neelon and Champagne Confusion Scale

27. Confusion Assessment Method (CAM) Available in long and short forms Has 94% to 100% sensitivity rating Key features include: acute onset, fluctuating course, inattention, disorganized thinking Diagnosis by CAM requires first two features plus at least one of last two

28. Neelon and Champagne Confusion Scale Based on routine nursing assessments Evaluates ten items divided into three levels: processing, behavior, physiologic functioning Detects delirium in early stages

29. Medication management National guidelines support using antipsychotic medications in patients with severe agitation or psychosis Haloperidol (Haldol) is drug of choice; approved for oral and I.M. administration; has few anticholinergic effects; beware of QT changes when giving I.V.

30. Other drugs Atypical antipsychotics may be given: - risperidone (Risperdal) - quetiapine (Seroquel) - olanzapine (Zyprexa) Effectiveness is uncertain; fewer adverse reactions Benzodiazepines should only be used in alcohol withdrawal or as sedative-hypnotic

31. Supportive care Maintain patient’s routine and have same care staff as much as possible Create familiar environment with items from home Eliminate stressors (bright lights, loud telephone) Avoid invasive devices; remove as quickly as able

32. Supportive care Offer appropriate diversion activities Communicate in a low, clear, calm voice Be mindful of safety (bed in lowest position, area free from clutter) Offer assistance to ambulate frequently Use assistive devices (glasses hearing aids)

33. Dealing with agitation Restraints are last resort Be creative and remain calm Modify environment so patient can move safely Use of family member or staff as one-on-one if needed