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 stateAbrupt onset (hours to days)Impaired attention and focusFluctuating mentation and cognitionPotentially reversible

Chronic confusional stateGradual decline (months to years)Attention fairly preservedMentation is generally constantIrreversible

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

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

• 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• Abdominal series

Diagnosis (cont’d)• 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

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

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

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