1. Hospital Acquired Delirium
Computer Tutorial and Presentation
Amy Gajkowski RN

2. Instructions
Use the purple navigation buttons at the bottom of the screen to move through the tutorial.
This button will go to the previous slide
This button will take you to the table of contents
This button will move you to the next slide
Click on any link on the table of contents to be directed to that section of the tutorial
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3. Expected Outcomes Understand the causes of hospital acquired delirium.
Recognize appropriate nursing interventions to prevent hospital acquired delirium
Understand that prevention is the best treatment for this medical condition.
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4. Table of Contents Stress/Inflammation Objectives Response (POD)
Pre Test
Quiz Three
Role of Genetics
Delirium Defined
Preventing Delirium
Hospital acquired
delirium
Managing Delirium
Quiz One
Post Test
Pathophysiology
References
Quiz Two
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5. Pre Test Delirium has a slow onset in patients True False
No. It has an abrupt onset
Yes! This is one way delirium
differs from dementia and Alzheimer’s

6. Pre Test Unlike dementia, delirium is reversible Yes! Unlike Dementia
and Alzheimer’s, it is reversible
True
No. You will learn through this tutorial
ways you can treat and prevent delirium!
False

7. Delirium Case Study
A 75 year old male was admitted to a medical unit around He presented with the police who brought him in after finding him wandering the streets around his home. When trying to take him home the man became abusive, confused, and frightened. The officers had stated that he “looked pale, ill, and agitated,” and they could find no identification. Upon the nurses’ assessment, it was very difficult to gain the man’s attention, and for him to focus on answering questions. Once he was able to answer, he rambled on in an incoherent, disorganized manner. The patient had intervals of agitation and was diaphoretic, and then would become very withdrawn. At times the man appeared to be falling asleep during the assessment, and could not describe where he was. His pulse was 94 and regular, BP 145/88. There was no evidence of injury or trauma.
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8. Delirium Case Study Think about this…
What interventions or investigations should be done?
If a family member is contacted, what questions would you want to ask?
The physician said the patient probably has Alzheimer’s; The nurse has five other patients, one needs to be discharged home, is this new patient urgent?
Yes No
Yes! This tutorial will explain
why this is a medical emergency!
Assume this is an emergency,
until proven otherwise
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9. Delirium Case Study
Delirium is often due to an acute illness or physiological change in the body.
It can be a presentation of many underlying diseases
It is often neglected as a medical emergency.
It is best to assume the onset of confusion is acute if there is no medical history available.
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10. Delirium Case Study What should be done?
CBC, electrolytes, renal/hepatic function, blood alcohol, chest x-ray, CT head.
Results: UTI and dehydration.
The patient improved, but was still confused.
His son stated that he was fully functional at home with no memory impairments/confusion.
The absence of history made it crucial to regard this patient as an emergency, and to observe him closely.
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11. Delirium defined
“Delirium is an acute decline of cognition and attention that represents a common and serious problem for older persons, particularly in times of acute illness and hospitalization” (Inouye, 2006 ).
Permission to use image granted from Nature Reviews Neurology.
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12. Delirium defined Clinical features of delirium…
Acute onset- occurs abruptly, over a period of hours or days.
Fluctuating course- increase/decrease in severity, symptoms may come or go. Lucid intervals are common in post op patients.
Inattention- shifting attention, difficulty focusing
Disorganized thinking- illogical flow of ideas, rambling
Altered level of consciousness- reduced clarity of environment, lethargy (Inouye, 2006).
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13. on quickly; sometimes as
Symptoms of delirium come on gradually over time.
True
False
No! It is an
abrupt onset
Yes! It usually comes
on quickly; sometimes as
fast as over a
couple of hours.

14. Delirium defined Clinical features of delirium… Cognitive deficits
Memory impairment
Disorientation
Perceptual disturbances
Hallucinations/illusions (Inyoue, 2006).
Psychomotor variants
Hyperactive- vigilance/agitation
Hypoactive- decreased motor ability/lethargy (Inyoue, 2006).
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15. Delirium defined Clinical features of delirium… Altered sleep cycle-
Insomnia/Sleep cycle reversal/Daytime sleeping /Fragmented patterns
Emotional disturbances-
Fear/Anxiety/Depression/Apathy/Anger/Euphoria/Paranoia/Irritability (Inyoue, 2006).
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16. Hospital acquired delirium
Delirium can be associated with substantial morbidity, functional decline, loss of independence, nursing home placement, and death (Jones, Metzger, Yang, Marcantonio, Gottlieb, 2009).
“Hospital costs are estimated to be greater than $8 billion annually, and post hospital costs are greater than $100 billion annually” (Jones, Metzger, Yang, Marcantonio, Gottlieb, 2009).
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17. Hospital acquired delirium
Prevalence increases with age.
“The mortality rate among hospitalized patients with delirium range from 22-76%” (Bryant, 2009 ).
The one year mortality rate associated with cases of delirium is 35-40%
(Jones, Metzger, Yang, Marcantonio, Gottlieb, 2009).
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18. Hospital acquired delirium
Delirium is often unrecognized due to
fluctuating nature
overlap with dementia
lack cognitive assessment
lack of knowledge of the consequences
The best treatment for delirium is prevention!
Risk Factors include:
Age >65
Neurodegenerative disease
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19. What is the best treatment for delirium?
Quiz one
What is the best treatment for delirium?
Medications
No, it is suggested to
avoid medications
Prevention
Yes, prevention!
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20. Pathophysiology of delirium
Theories of the causes of delirium
Acetylcholine deficiency
Alterations in pro-inflammatory markers
Permission to use image granted by Nature Reviews Neurology
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21. Pathophysiology of delirium
The exact pathophysiology is unknown
Theories: 1. Acetylcholine deficiency
2.Increase in pro-inflammatory markers circulating
(Both are related to stress/inflammation and aging.)
Acetylcholine (ACH)- regulation of mood, attention, memory, motor activity
Age dependent decrease of ACH neurotransmission. (Reduced cholinergic reserve)
Inflammation/Stress induced ACH-neurotransmission impairment (explains post-op delirium)
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22. Pathophysiology- Aging (Click to proceed)
-Age-associated decline
in acetylcholine
- Loss of cholinergic cell bodies
-Efficiency of proteins for the production
of acetylcholine decreases
-Number of acetylcholine receptors
decreases
-Reduced cholinergic reserve
-Acetylcholine deficiency is
linked to cognitive decline and
delirium.

23. Pathophysiology of delirium
With aging…
Blood brain barrier has structural/ functional changes
-Increases strength of the inflammation response
-“If the brain is inflamed due to a neurodegenerative disease, the CNS response is more severe” (Maclullich et.al, 2008).
Microglial cells are constantly activated by persistent neurodegeneration
-“Microglial cells produce low levels of pro inflammatory cytokines” (Maclullich et. al, 2008).
-Ready to respond intensely to stimulation/inflammation
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24. Pathophysiology of delirium
With the stress/inflammation response…
Increased amount of cytokines circulating which can lead to neurotransmission impairment.
-“Sickness behavior” (bodies’ way of trying to protect energy and reduce further injury)
- Trauma, surgery, infection/illness
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25. Pathophysiology of delirium
Sickness behavior
Adaptive behavioral/metabolic changes during infections/ immune stimulations.
CNS synthesis of cytokines/prostaglandins
Transduced without compromising the blood brain barrier (BBB)
Inflammatory mediators interact with neurons which do not have a BBB.
Activates endothelial cells of the brain
Releases prostaglandins into the parenchyma
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26. Pathophysiology-Stress/inflammation (Click to proceed)
Stress Response
(Illness/infection)
Microglia is activated.
(Pro inflammatory markers)
Which leads to an increased
level of cytokines circulating
Imbalance of neurotransmitters/
neurotransmission
Delirium

27. Quiz Two
Which of the reasons below, or both, can cause an increased level of cytokines seen in delirious patients?
Inflammation due to neuro-degeneration
with aging can cause an
increased level of cytokines.
Yes!
Patients with an inflammatory
Disease (Alzheimer’s) are
at an even greater risk!
An inflammatory response to an
illness or infection to further prevent any
further injury can cause an increase in
cytokines
Yes! This can be termed
“Sickness behavior” and it is seen
in many delirious patients
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28. Stress/Inflammation Response in Post-op patients
Surgery can cause a stress/inflammation response that increase inflammatory markers.
Patients undergoing major surgery are at a great risk for developing post-op delirium (POD).
There is an inflammation cascade response to the traumatized tissue that can lead to a delirious state.
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29. How does the stress/inflammation cause delirium? (Click to proceed)
Leukocytes adhere to
endothelial cells and activate
Free radicals are released after
degranulation
Endothelial cell
swelling/destruction
Capillary density due to narrowing
of the vessel walls/ edema
Longer distance for
O2 synthesis/ neurons cannot
keep up
No release of
neurospecific enzyme
Perfusion due to the
longer diffusion distance for O2
“Acetylcholine synthesis is sensitive to low O2 tension,
symptoms of deficiency will develop” = DELIRIUM (Hala, 2007).

30. Post-Op Delirium
After leukocyte-endothelial cell interaction, the inflammation process may lead to perfusion impairment.
Blood flow in the capillaries can become disrupted.
“This may hinder the organisms’ ability to heal. “No-reflow” phenomenon which can explain why some patients suffer from permanent cognitive impairments once they recover from a delirious state” (Barbosa, 2008).
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31. Pathophysiology of delirium
Direct brain insults (Hypotension, hypoxia, infarcts, hemorrhage etc.)
compromise brain function
energy depletion
changes in neurotransmitter levels
metabolic abnormalities
Permission to use image granted from Nature Reviews Neurology
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32. Quiz Three What is one of the theories of the cause of delirium?
Reduction of
inflammatory response
No. There is an extreme increase
in the severity of
the inflammation response
B. Acetylcholine
deficiency
Yes! It has been shown in
delirious pts that ACH deficiency causes
delirious behaviors
C. Decrease in cytokines
No. There is a marked increase
in the levels of cytokines in a delirious
Patient, due to the stress/inflammation response
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33. Post-Op Delirium Watch for symptoms on the second or third day!
Sometimes there can be a lucid interval for a post-op patient.
During the lucid interval, there may be no psychiatric symptoms.
Watch for symptoms on the second or third day!
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34. Role of genetics in delirium
Studies link apolipoprotein E4 allele (APOE) and delirium in elderly.
“linked to cognitive impairment in people with dementia.
role in neural plasticity, repairs damaged neurons, and aids in neural transmission” (Van Munster, 2009)
“APOE E4 genotype- increased inflammation, reduced cholinergic activity in the brain, increased cytokines and reduced acetylcholinergic pathways” (Van Munster, 2009).
According to the articles, more research is to come our way!
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35. Recognizing/Preventing Delirium
When a patient presents with confusion:
“Determining the acuity of the change in mental status is the essential first step” (Inouye, 2006).
Every older hospitalized patient should undergo formal cognitive testing. (Ex. CAM).
“Older adults should be aroused during rounds and evaluated if the hypoactive form of delirium is suspected” (Inouye, 2006).
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36. Recognizing/Preventing Delirium
Address risk factors
Provide orienting communication
Encourage mobilization
Use visual/ hearing aids
Prevent dehydration
Provide un-interrupted sleep time
Avoid psychoactive drugs
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37. Recognizing/preventing delirium
If there is a mental change that is acute…
“Perform a cognitive assessment and evaluation for delirium.
Rule out depression, mania, and acute psychosis” (Inouye, 2006).
In the case study, the nurse would have done a screening for delirium, such as a CAM score. The RN would have re-oriented the patient, and monitored his mental status closely.
If delirium is confirmed…
“Provide supportive care/ prevent complications” (Inouye, 2006).
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38. Managing delirium non-pharmacologically
Non-pharmacologic treatment strategies
Continue delirium prevention
Reorient patient, encourage family involvement
Use sitters/avoid physical restraints/foley catheters
Use music/massage/relaxation techniques for agitation
Use of hearing/ visual aids /interpreters
Maintain patient’s mobility
Normalize sleep/wake cycle
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39. What in this picture can lead to, or help prevent delirium
What in this picture can lead to, or help prevent delirium? (Use your mouse, there are 7)
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Images from clip art and Google Image

40. Managing delirium non-pharmacologically
Supportive care includes…
Protecting airway/preventing aspiration
Provide nutritional support
Provide skin care/prevent pressure sores
Mobilization/ prevent DVT, and PE
With the man from the case study, the RN would have checked a chest X-ray, EKG, other lab work, etc. to see if the patient had an infection or any other deficits that may be causing his delirium.
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41. CAM/CAM ICU CAM- Confusion Assessment Method
-Screens for overall cognitive impairment
-Screens for acute onset, inattention, disorganized thinking, altered level of consciousness
CAM ICU
The CAM ICU excludes verbal indicators because it’s intended for intubated/ventilated patients, or any patient who cannot speak or participate.
Click on the link below for a website on ICU delirium.
On the right, click on the video clip on CAM ICU in a clinical setting
Copyright ©2009 by Vanderbilt University Medical Center

42. Post Test 1.What is the best treatment for delirium?
2.What is one theory of the cause of delirium?
Medications
Antibiotics
Prevention
No, this is not
the recommended
treatment.
No, this will not
prevent delirium
Yes! This is the
best treatment
Reduced levels
of cytokines
ACH deficiency
ACH surplus
No, it’s an increased
amount of cytokines
Yes!
No, there is an
ACH deficiency
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43. Post Test
3.Which patient, or both, are at risk for developing delirium?
4.Re-orienting patients is one way of preventing delirium.
An elderly man
having a hip replacement
An elderly man
with pneumonia in the ICU
Yes this person is
a high risk due to POD
This man is a high risk due to his
infection and ICU stay
True
False
No. Orienting patients to their
surroundings prevents delirium
Yes! You can also
use familiar objects

44. Post Test 5.When would you watch for a delirium post-operatively?
2-3 days post-operative
Immediately after
the procedure
Yes! You may not see any
symptoms until then due to the
lucid interval
No. The lucid interval is
Sometime seen right after surgery

45. Congratulations! You have completed this tutorial. Further Questions?
Amy Gajkowski RN, BSN

46. References
Barbosa, F, Martins da Cunha, R, & Pinto, A. (2008). Postoperative delirium in the elderly [vol 58 no.6]. Retrieved from doi: /S0034
Bryant, C. (2010). Dementia, Delirium, Agitation, and Behavioural Problems. Journal of Psychosomatic Research, Wiley InterScience. Retrieved from:
Byrne, M, & Devine, E. (Ed.). (2009). Knowledge Based nursing initiative- risk for delirium in adults in intensive care . Milwaukee: Aurora Health Care.
Fong, T, Tulebaev, S, & Inouye, S. (2009). Delirium in elderly adults: diagnosis, prevention, and treatment. Nature Review, 5. Retrieved from doi: /nrneurol
Hala, M. (2007). Pathophysiology of postoperative delirium: Systemic inflammation as a response to surgical trauma causes diffuse microcirculatory impairment Medical Hypotheses, Volume 68, Issue 1, Pages
Ham, R, & Sloan, P. (2008). Primary care geriatrics. St. Louis, MI: Mosby.
Inouye, S. (2006). Delirium in older persons. The New England Journal of Medicine, 65. Retrieved from
Jaafar, A, Heycock, R, & George, J. (2008). Frailty- a clinical overview. Review in Clinical Gerontology, 17. doi: /S
Jones, R, Fong, T, Metzger, E, Tulebaev, S, & Yang, F. (2010). Aging, Brain disease, and Reserve: Implications for Delirium. American association for geriatric psychiatry . Retrieved (2010, March 23)
Leentjens, A, & Van der Mast, R. (2005). Delirium in elderly people: an update. Current Opinion in Psychiatry, 18. Retrieved from
Lemstra, A, kalisvaaart, K, Vreeswijk, R, Van Gool, W, & Eikelenboom, P. (2008). Pre-operative inflammatory markers and the risk of postoperative delirium in elderly patients. International Journal of Geriatric Psychiatry, 23. Retrieved from doi: /gps.2015
Luetz, A, Heymann, A, Radtke, F, Chenitir, C, & Heinz, A. (2010). Different assessment tools for intensive care unit delirium: which score to use? . Critical Care Medicine, 38(2),
Maclullich, A, Ferguson, K, Miller, T, Roolj, E, & Cunningham, C. (2008). Unravelling the pathophysiology of delirium: a focus on the role of aberrant stress response. Journal of Psychosomatic Research, 65(3), Retrieved from doi: /j.jpsychores
Rooji, S, Van Munster, B, Korevaar, J, & Levi, M. (2007). Cytokines and acute phase response in delirium. Journal of Psychosomatic Research, 62(5), Retrieved from doi: /j.jpschores
Van Munster, B, Rooij, S, & Korevaar, J. (2009). The Role of genetics in delirium in the elderly patient. Dementia and Geriatric Cognitive Disorders, 28. Retrieved from doi: /
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