Want to know more

DELIRIUM

The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:

Definitions

Delirium: A disturbance in consciousness with reduced ability to focus, sustain, or shift attention; a change in cognition or the development of a perceptual disturbance that develops over a short period of time and tend to fluctuate during the course of the day (American Psychiatric Association, 2000).

Acute change in mental status that is characterized by a sudden onset of impaired attention disorganized thinking or incoherent speech. The patient usually has clouded consciousnesses, perceptual disturbances, sleep-wake problems, psychomotor agitation or lethargy and is disoriented (Flaherty, J., 1998).

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Background

Epidemiology

  • Prevalence upon admission to hospital: 16%
  • Incidence during hospitalization: 6%-55%, typically about 20%
  • Postoperative incidence: 15%-72%
  • Incidence at hospital discharge: 30%-60%
  • Onset: About 3rd day of hospitalization
  • Duration: Typically less than 5 days. Symptoms can last 3-6 months

Consequences

  • Loss of independence, diminished ability to participated in own care, and loss of ability for self-determination
  • Morbidity: Delirious patients are more likely to develop pressure ulcers, fall, have adverse reactions to medications, develop infections, become institutionalized, and have continued cognitive impairment.
  • Mortality given equivalent severity of illness: delirious patients are 6 times more likely to die than nondelirious patients.
  • For Health care professionals and institutions, acutely confused patients are hospitalized for longer periods of time and post an increased demand for intensity of nursing care for which institutions tend not to be adequately reimbursed. Hospitals lose on average $30,000 per confused patient.

Risk Factors

  • Increasing age
  • Increasing severity of illness
  • Multiple chronic illnesses with multiple medications
  • History of dementia, depression, and/or previous delirium
  • Substance and alcohol use
  • Sleep deprivation
  • Immobility
  • Sensory impairment
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Assessment/Screening Tools

Atypical Presentation: Elderly may present with change in function or level of consciousness, confusion, falls, or agitation rather than typical signs of illness when an underlying acute problem is present.

For patients not in an acute care facility: If source of delirium cannot be quickly identified and treated and/or if the patient is rapidly declining in health and/or function related to the delirium-Transfer patient to acute care facility.

It is not unusual for patients with dementia to also be delirious. Agitation thus may be a manifestation of dementia alone, or it may be caused or made worse by delirium.

In addition to using standardized assessment instruments, assessment of delirium should include the following:

  • Obtain baseline or premorbid cognitive functioning from family, significant other(s), or another intimate source.
  • Ask patients the following questions when assessing cognitive functioning:
  • Have you noticed any changes in your thinking or memory recently?
  • Recently, have you experienced any strange thoughts?
  • Affirmative responses should arouse suspicion of the risk for delirium.
  • Review Features for delirium:
    • Alertness
      • Alert (normal)
      • Vigilant (hyperalert)
      • Lethargic (drowsy but easily aroused)
      • Stupor (difficult to arouse)
      • Coma (unarouseable)
    • Attention
      • Digit span, forward and backward
      • Serial subtraction
      • Spelling backwards
      • Clock Drawing Test
    • Orientation
      • Person (should not be disoriented here)
      • Place
      • Time
    • Memory
      • Recent and remote events
    • Thinking
      • Logical versus disorganized, rambling, irrelevant
    • Perception
      • Recognition of objects and people
      • Clock Drawing Test
    • Psychomotor behavior
      • Hypo- or Hyperkinetic
      • Unusual or inappropriate

    Source: Adapted from Foreman and Zane (1996).

  • Differentiate Delirium from dementia and depression (See: Comparison of the Clinical Features of Delirium, Dementia, Depression table)
  • Review current laboratory values, medications, monitor vital signs, and fluid intake and output, to identify the possible etiologic factors: acute illness, infection (e.g., UTI, URI), medication (e.g. anticholinergics, sedatives, psychotropics, narcotics H2 Blockers), altered homeostasis (e.g. dehydrations, and electrolyte imbalance, hemodynamic status, (e.g., hypovolemia, hypoxia), and environmental challenge (sensory overload or deprivation).


Depression Dementia Delirium Table - 3ds.pdf
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Nursing Care Strategies/Treatment/Management

The most likely causes of delirium by etiologic agents, including physical findings and nursing actions are summarized in the Table Most likely Causes of Delirium by Etiologic Agent: Assessment and Interventions

Most Likely Causes of Delirium by Etiologic Agent: Assessment & Interventions
Etiologic Agent Physical Findings Nursing Actions
Hypoxia
  • Tachypnea
  • Cyanosis (peripheral & central)
  • Agitation
  • Increased depth of respirations
  • Decreased pO2
  • Accessory muscle use
  • Paradoxical breathing pattern
    		•
  • Determine source of hypoxia, e.g., infection, COPD, PE, bronchospasm, anemia
  • Position patient to facilitate air exchange, e.g., high Fowler's as tolerated by patient
  • Restrict/pace activity to reduce additional oxygen requirements
  • Monitor blood gas results or that of pulse oximetry
  • Continue to monitor parameters q 2 h or as indicated by status of patient
  • Prepare for oxygen administration, use long tubing to maintain mobilization
  • Document actions and patient response in hospital record
    		•
    Infection

    MOST COMMON:

  • Urinary tract
  • Respiratory
  • Cellulitis


    • MOST OVERLOOKED:

  • Mouth
  • Feet
    		•  Note: Older adults may have infection without fever or elevated WBC.

    Urinary:

    • Dysuria is frequently absent
    • Frequency
    • Urgency
    • Nocturia
    • Incontinence
    • Anorexia
    • Cultures may be negative
    • Protein and/or blood dipstick

    Respiratory:

    • Chills, fever, and elevated WBC (may be absent)
    • Cough may be dry, productive, or absent
    • Slight cyanosis
    • Anorexia
    • Nausea
    • Vomiting
    • Tachycardia/tachypnea
    • Cultures may be negative
    • Breath sounds: wheezes, crackles, or rhonchi possible
    • Change in patient's functional level often seen as first sign of infection in elderly
  • Determine source and site of infection
  • Provide adequate fluids, 2000 ml per day, unless otherwise contraindicated
  • Refer to/notify appropriate advanced practice nurse or house officer
  • Apply cooling techniques as needed and indicated, e.g., remove covers or use cooling mattress/blanket
  • Monitor for flushed hot skin, tachycardia, seizures, changes in body temperature, and breath sounds q 2 h or as indicted by status of the patient
  • Monitor intake and output
  • For respiratory infections provide humidified air, cough and deep breath PRN, provide frequent oral hygiene; chest physiotherapy to mobilize secretions
  • Refer to/notify appropriate advanced practice nurse, house officer, MD
  • Document actions and patient response in hospital record
    		•
    Etiologic Agent Physical Findings Nursing Actions
    Dehydration
  • Hypotension with orthostatic changes evident
  • Weakness
  • Nausea
  • Oliguria
  • Dry mucous membranes and skin
  • Poor skin turgor over sternum
  • Lethargy
  • Lightheadedness
  • Elevations in hematocrit, blood urea nitrogen, and creatinine may occur
    		•
  • Determine source of dehydration, e.g., decreased fluid intake or increased fluid output, increased demand (infection)
  • Prepare for fluid replacement and additional diagnostic and therapeutic actions (check BUN, creatinine)
  • Check medications as a cause for increased loss of fluids, e.g., diuretics
  • Check person's ability to swallow or for mechanical problems preventing fluid intake
  • Determine individual's daily fluid needs, and develop a fluid schedule
  • Make sure water is in easy reach of the individual
  • Determine if individual can independently meet fluid needs, if not, place on a fluid schedule
  • Refer to/notify appropriate advanced practice nurse, house officer, MD
  • Continue surveillance of patient q 2-6 hours as indicated by patient status
  • Document actions and patient response in hospital record
    		•
    Etiologic Agent Physical Findings Nursing Actions
    Hypernatremia
    (> 146 mEq/L)
  • Weakness
  • Focal neurological deficits
  • Obtundation/Lethargic
  • Elevated HCT, BUN, creatinine, and serum osmolarity, urine sodium
    		•
  • Determine source of hypernatremia, e.g., increased water loss (fever, infection, vomiting, diarrhea), decreased water intake (physical or cognitive limitations), or increased sodium intake
  • Check chemistry panel
  • Prepare for possible fluid replacement
  • Restrict activity to maintain energy balance
  • Continue to monitor parameters q 2 h or as indicated by status of patient
  • Refer to/notify appropriate advanced practice nurse or house officer
  • Document actions and patient response in record
    		•
    Hyponatremia
    (< 136 mEq/L)
  • Hypotension
  • Hypothermia
  • Nausea
  • Malaise
  • Lethargy
  • Somnolence
  • Decreased serum sodium and osmolality
    		•
  • Determine source of hyponatremia, e.g., inadequate intake of sodium, renal disease, fluid restriction, SIADH, over-diuresis, low sodium tube feedings
  • Prepare for electrolyte and possibly fluid replacement
  • Restrict activity to maintain energy balance
  • Continue to monitor parameters q 2 h or as indicated by status of patient
  • Refer to/notify appropriate advanced practice nurse, house officer, MD
  • Document actions and patient response in record
    		•
    Etiologic Agent Physical Findings Nursing Actions
    Cognitive impairment
  • Impaired cognitive function(s)
  • Positive CAM screen (See: Try This - Confusion Assessment Method)
    		•
  • Assess for seizure, stroke/TIA, head injury (recent fall). May need head CT.
  • Offer orienting information as a normal part of daily care and activities
  • Work with patient to correctly interpret the environment
  • (See Dementia Topic)
    		•
    Medications
    Special attention to:
  • New medications
  • Anticholinergic preparations
    -thioridazine
    -amitriptyline
    -neuroleptics
    -tricyclic antidepressants
    -atropine
    -theophylline
    -diphenhydramine
  • histamine-2 blocking agents
    -cimetidine
    -ranitidine
  • analgesics
    -meperidine
    -non-steroidal anti
    -inflammatory agents
    -opiates
  • sedative-hypnotics
    -zolpidem
    -benzodiazepines
  • cardiovascular drugs
    -nifedipine
    -quinidine
    -disopyramide
    -amiodarone
    -beta blockers
  • Corticosteriods
  • Anti-Parkinsonian agents
    		•
  • Variable, depending upon the specific medication, drug-drug interactions, and the person's underlying health problems and health status.
    		•
  • Monitor the effects (intended and adverse) of medications. Be especially vigilant for drug interactions. With the onset of any new symptom, first consider it an adverse reaction to a new medication. (See Medications Topic)
  • Check drug levels as indicated
  • Evaluate each medication; use only those medications indicated by the patient's status, thereby keeping medication to a minimum.
  • Monitor for adverse effects, drug-drug, drug-disease, and drug-nutrient interactions
  • Avoid the use of meperidine, & NSAIDs for more than 2 weeks at a time
  • Use nonpharmacologic sleep enhancing protocols. (See Sleep Topic)
  • Taper or discontinue drugs that cause delirium
    		•
    Etiologic Agent Physical Findings Nursing Actions
    Pain
  • Agitation, restlessness, moaning, grimacing, sighing, body rigidity (especially in dementia)
    		•
  • Assess for pain (See Try This: Assessing Pain & Assessing Pain in Persons with Dementia)
  • Treat and evaluate pain
  • Collaborate with pain team
  • Relieve pain through adequate and appropriate administration of analgesia and alternative nonpharmacologic therapies (See Pain Topic).


    • General Nursing Strategies:

  • Collaborate with interdisciplinary team members.
  • Monitor vital signs, including pain
  • Prevent falls (See Falls Topic
  • Protect from hazards of immobility
  • Consider companion with patient.
  • Avoid restraints (See Physical Restraint Topic)
    		•



    In addition to the specific strategies by etiology outlined in the Table: Most likely Causes of Delirium by Etiologic Agent: Assessment and Interventions, nursing care for patients with delirium should include the following care strategies

    • Treat underlying pathology and contributing factors:
      • Administer medications judiciously
      • Prevent or promptly and appropriately treat infections
      • Maintain fluid balance
      • Promote electrolyte balance
    • Provide a therapeutic environment
      • Provide appropriate sensory stimulation
      • Reassure and reorient patient
      • Maintain consistency of caregivers
      • Encourage family members or significant others to be at bedside
      • Use sensory aids as appropriate
      • Minimize abrupt relocations
    • Provide general supportive nursing care
      • Provide comfort measures
      • Protect from hazards of immobility and mobilization
      • Provide supportive nursing care for meeting basic needs (e.g., toileting, feeding, hydrations, pain, etc.)
      • Communicate clearly; provide explanations
      • Reassure and educate family
      • Minimize invasive procedures
    • Refer to appropriate advanced practitioners (e.g., geriatric resource nurse, geriatric or psychiatric clinical nurse specialist or nurse practitioner, or consultation-liason service)

    For patients not in an acute care facility

    • If source of delirium cannot be quickly identified and treated and/or if the patient is rapidly declining in health and/or function related to the delirium-Transfer patient to acute care facility.
    • Prevent falls: Good footwear. Remove throw rugs. Have a non-skid mat in bathroom. Install chair/rail in tub/shower. Good lighting. (See Falls Topic)
    • Minimize changes in location, e.g., moving rooms in LTC
    • Communicate/Educate patient and family/caregivers regularly.
    • Avoid restraints as this may worsen delirium and injure patient. Try alternative measures to restraint use and least restrictive devices. Use nonpharmacological measures prior to giving antipsychotics. If absolutely necessary and the patient does not calm down, give lowest dose of an antipsychotic (i.e.: Risperdal m tab may be give sublingually and patient does not need to swallow). (See Physical Restraint Topic)

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    Evaluation/Outcomes

    Patient

    • Lowered incidence, duration, severity, and recurrence of delirium
    • Increased functional status
    • Decreased mortality
    • Return to baseline mental status
    • Discharge to pre-hospital setting/Remain at home/remain at institution

    Provider

    • Increased detection of delirium
    • Prompt implementation of appropriate interventions
    • Improved satisfaction of care of elderly

    Institution

    • Decreased overall cost
    • Decreased length of stay in acute/critical care settings
    • Decreased transfer from home environment/long term care setting
    • Decreased morbidity and mortality
    • Increased referrals and consultation to specialists
    • Increased provision of quality care
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    Follow-up

    • Documentation of prompt recognition of delirium
    • Documentation of interventions for delirium
    • Continued decrease in incidence, duration, severity of delirium
    • Prevention of recurrence of delirium
    • Staff competence in recognition and treatment of delirium

    Reprinted with permission from Springer publishing company. Foreman, F. D., Mion, L. C., Trygstad, L., & Fletcher, K. (2003). Delirium: Strategies for Assessing and Treating. In M. Mezey, T. Fulmer, I. Abraham (Eds.), D. Zwicker (Managing Ed.), Geriatric nursing protocols for best practice (2nd ed., pp. 116-140). New York: Springer Publishing Company, Inc.

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