Chapter 13: Delirium

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Chapter 13 Delirium
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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.

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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

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Definition and Etiology (contd)

• 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
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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 confusion
• Many treatable causes
• Need to distinguish delirium, depression, and
  dementia

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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

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Risk Factors

• Presdisposing factors baseline vulnerabilities
  that the patient already has prior to
  hospitalization
• Precipitating factors events or conditions
  occuring during hospitalization that trigger
  delirium
• Beers List of potential inappropriate medications

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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

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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

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Assessment

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

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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
• Abdominal series

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Diagnosis (contd)

• Chest X-ray
• Electrocardiogram
• Swallowing evaluation
• Medication review
• I WATCH DEATH
• Infection, Withdrawal, Acute metabolic, Trauma,
  CNS pathology, Hypoxia, Deficiencies,
  Endocrinopathies, Acute vascular, Toxins or
  drugs, Heavy metals

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Interventions

• ADVISE Advocacy, Diligence, Vigilance,
  Integration, Support, Education (Table 13-6,
  P.499)
• Pain
• Agitation
• Combativeness
• Inattentiveness
• Wandering and exit seeking
• Sleep
• When a Sitter is the Wrong Approach
• Safety concerns
• Home management after discharge
• Prognosis

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Sundowner syndrome

• 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

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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