1. Chapter 13: Delirium

2. 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.

3. 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

4. Definition and Etiology (cont’d)
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

5. Background Mechanism of delirium not fully understood
Occurs in % 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 acute confusion
Many treatable causes
Need to distinguish delirium, depression, and dementia

6. 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

7. Risk Factors
Presdisposing factors: baseline vulnerabilities that the patient already has prior to hospitalization (Box 13-1, p. 489)
Precipitating factors: events or conditions occuring during hospitalization that trigger delirium
Beer’s List of potential inappropriate medications

8. 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

9. 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

10. Assessment Mental Status Examination Attention Orientation Language
Memory
Reasoning
Thought process
Thought content

11. 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 to determine the presence of stroke
Abdominal series to rule out constipation

12. Diagnosis (cont’d) Chest X-ray Electrocardiogram Swallowing evaluation
Medication review
I WATCH DEATH: contributing factors of delirium
(p. 498)
Infection, Withdrawal, Acute metabolic, Trauma, CNS pathology, Hypoxia, Deficiencies, Endocrinopathies, Acute vascular, Toxins or drugs, Heavy metals

13. Interventions
ADVISE: Advocacy, Diligence, Vigilance, Integration, Support, Education (Table 13-6, P.499)
Pain: scheduled analgesia
Agitation: remove excess stimulation
Combativeness: prevention & tx of constipation…
Inattentiveness: simple & repetitive activities
Wandering and exit seeking: frequent toileting…
Sleep: darkening the room etc…
When a “Sitter” is the Wrong Approach: family member or familiar friends…
Safety concerns:
Home management after discharge: need 24 hrs. supervision
Prognosis

14. Sundowner syndrome Management: 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

15. 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