Delirium: A Medical Emergency

Linda Hassler, RN, MS, GCNS-BC Ann May Center for Nursing

3 Cirquedu soleil “Delirium” A live music concert

4 Objectives Define delirium and causes Define delirium and causes Discuss assessment techniques Discuss assessment techniques Review the “Three D’s” Review the “Three D’s” Summarizes interventions for delirium Summarizes interventions for delirium Describe the CAM assessment tool Describe the CAM assessment tool Discuss delirium in the hospital setting Discuss delirium in the hospital setting Define delirium and causes Define delirium and causes Discuss assessment techniques Discuss assessment techniques Review the “Three D’s” Review the “Three D’s” Summarizes interventions for delirium Summarizes interventions for delirium Describe the CAM assessment tool Describe the CAM assessment tool Discuss delirium in the hospital setting Discuss delirium in the hospital setting

5 Definition of Delirium Delirium – Delirium – a reversible confusional state a reversible confusional state AKA acute confusional state AKA acute confusional state a mental disturbance characterized by: a mental disturbance characterized by: Acute, sudden onset Acute, sudden onset Disturbed consciousness Disturbed consciousness Impaired cognition, inattention is the hallmark Impaired cognition, inattention is the hallmark Identifiable underlying medical cause Identifiable underlying medical cause Disruption of higher cortical functions, seen on EEG waves Disruption of higher cortical functions, seen on EEG waves

6 Reversible causes of DELIRIUM D= Drugs, Drugs, Drugs (handout) E= Eyes and ears L= Lack of drug/alcohol (withdrawal), Low oxygen levels I= Infection R= Retention of urine or stool, Restraints I= Intracranial (think falls, seizures) U= Undernutrition/underhydration M= Metabolic, electrolytes S= Sleep deprivation

Searching for the Cause of Delirium Handout

8 Prevalence of Delirium 4 to 5 million elders (over age 65) are estimated to have cognitive disorders 4 to 5 million elders (over age 65) are estimated to have cognitive disorders Often misdiagnosed as depression, psychosis, or dementia Often misdiagnosed as depression, psychosis, or dementia 32% were unrecognized by physician 32% were unrecognized by physician 40-80% elders admitted to hospital with delirium disorder or may have onset within three days 40-80% elders admitted to hospital with delirium disorder or may have onset within three days 56% medical unit 56% medical unit 70-87% ICU 70-87% ICU 61% surgical 61% surgical

9 Consequences of Delirium Cost up to $8 billion per year Cost up to $8 billion per year Associated with Associated with Increased complications Increased complications Increased morbidity Increased morbidity Increased length of stay Increased length of stay Increased nursing home admission Increased nursing home admission Increased risk of functional decline Increased risk of functional decline Increased caregiver burden Increased caregiver burden Increased mortality Increased mortality Co-morbid condition with underlying dementia Co-morbid condition with underlying dementia 40% will develop delirium 40% will develop delirium

10 Whose at Risk? Over age 80 Over age 80 Men Men Isolated Isolated Disrupted sleep cycle and usual patterns Disrupted sleep cycle and usual patterns Confinement to a small area Confinement to a small area New medications – polypharmacy New medications – polypharmacy Pain Pain Restraints and/or bed rest Restraints and/or bed rest Sensory deprivation – lack of glasses, hearing aide, dentures Sensory deprivation – lack of glasses, hearing aide, dentures Loss of control Loss of control Previous history of delirium Previous history of delirium

The 3 D’s Handout

12 Three types of Delirium 1. Hyperactive 30% - repetitive behaviors, plucking sheets, picking, wandering, illusions, hallucinations 2. Hypoactive 25% - quiet, withdrawn, misdiagnosed as depression 3. Mixed 45% - fluctuates and includes lucid periods

13 Assessment of Delirium History and Physical Current medication review Tests: chemistries, EKG, CXR, ABGs, oxygen saturation, u/a, thyroid function tests, cultures, drug levels, folate levels, pulse oximetry, EEG, lumbar puncture, serum B12 Confusion Assessment Method (CAM) – developed in 1988 for non-psychiatrically trained clinicians to identify delirium quickly and accurately

14 CAM NINE operationalzed criteria from DSM-III-R, omitted organic etiology NINE operationalzed criteria from DSM-III-R, omitted organic etiology TWO cardinal elements: TWO cardinal elements: Acute onset and fluctuating course Acute onset and fluctuating course Inattention Inattention TWO complimentary designations TWO complimentary designations Disorganized thinking Disorganized thinking Alter level of consciousness Alter level of consciousness Remaining FIVE features are not in algorism as they add nothing to the sensitivity and specificity of the tool Remaining FIVE features are not in algorism as they add nothing to the sensitivity and specificity of the tool Takes 5 minutes Takes 5 minutes If diagnosis of Delirium suspected, further work- up necessary If diagnosis of Delirium suspected, further work- up necessary

15 CAM long version Five other features: Five other features: Disorientation Disorientation Memory impairment Memory impairment Perceptual disturbances Perceptual disturbances Psychomotor Psychomotor Agitation Agitation Retardation Retardation Altered sleep-wake cycle Altered sleep-wake cycle

16 The Short CAM BOX 1: BOX 1: ACUTE ONSET AND FLUCTUATING COURSE ACUTE ONSET AND FLUCTUATING COURSE a) Is there evidence of an acute change in mental status from the person’s baseline? No YES b) Did the (abnormal) behavior fluctuate during the day, that is, tend to come and go or increase and decrease in severity? No YES

17 The Short CAM INATTENTION INATTENTION Did the person have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said? No YES Did the person have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said? No YES Are all three items in box 1 are checked YES? Are all three items in box 1 are checked YES?

18 The Short CAM BOX 2 BOX 2 DISORGANIZED THINKING DISORGANIZED THINKING Was the person’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? No YES Was the person’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? No YES

19 The Short CAM ALTERED LEVEL OF CONSCIOUSNESS ALTERED LEVEL OF CONSCIOUSNESS Overall, how would you rate the person’s level of consciousness? ALERT Overall, how would you rate the person’s level of consciousness? ALERT Small box: Small box: Vigilant Vigilant Lethargic Lethargic Stupor Stupor Coma Coma Did any checks appear in the small box? No YES Did any checks appear in the small box? No YES

20 The Short CAM = Scoring If all items in Box 1 are checked YES If all items in Box 1 are checked YES AND AND At least one item is Box 2 is checked YES At least one item is Box 2 is checked YES THEN THEN A diagnosis of Delirium is suggested A diagnosis of Delirium is suggested

Try this: Best Practices in Nursing Care to Older Adults The Confusion Assessment Method “CAM”

22 Treatment of Delirium Failure to treat delays recovery and can worsen the older person’s health and function. Treat the cause! Reassure family! Psychiatric Management: identify and treat underlying etiology intervene immediately for urgent medical conditions ongoing monitoring of psychiatric status

23 Treatment of Delirium Environmental and supportive interventions:  all environmental factors that exacerbate delirium Make environment more familiar Reorient and reassure Inform to  fear or demoralization Somatic Interventions: antipsychotic; benzodiazepines Good news is that they may have little memory of delirious episode once resolved Relapse rate is 35-40%

24 Best treatment is PREVENTION! Orientation and therapeutic activities for cognitively impaired Orientation and therapeutic activities for cognitively impaired Early mobilization Early mobilization Non-pharmacologic approaches to behavior problems Non-pharmacologic approaches to behavior problems Better sleep hygiene practices Better sleep hygiene practices Appropriate communication techniques Appropriate communication techniques Early intervention for dehydration Early intervention for dehydration (Yale Delirium Prevention Trail, Inouye, 1999)

Searching for Solutions Handout

26 Delirium DVD

Delirium: Best Practice Quick Reference Guide for Care of Older Persons Care of Older Persons

28 The Delirium Puzzle

29 References See handout list and also: See handout list and also: Vancouver Island Health Authority (2006) Delirium: A Medical Emergency DVD and supporting documents. Vancouver Island Health Authority (2006) Delirium: A Medical Emergency DVD and supporting documents. Laplante, J, Cole, M (September 2001). Detection of Delirium using the Confusion Assessment Method. Journal of Gerontological Nursing, pg Laplante, J, Cole, M (September 2001). Detection of Delirium using the Confusion Assessment Method. Journal of Gerontological Nursing, pg Delirium strategies for assessing and treating. Retrieved: 10/12/07. Delirium strategies for assessing and treating. Retrieved: 10/12/ Topic: Delirium. Retrieved: 10/12/07. Topic: Delirium. Retrieved: 10/12/07.

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