Delirium

A.  Delirium is a common syndrome in hospitalized older adults and is associated with increased mortality, hospital costs, and long-term cognitive and functional impairment.

B.  Delirium may be prevented or diminished with the recognition of high-risk patients and the implementation of a standardized multicomponent delirium-reduction protocol.

C.  Recognition of risk factors and routine screening for delirium should be part of comprehensive nursing care for older adults.

BACKGROUND

A.  Delirium is a neurocognitive disorder that develops over a short period of time (hours to days), fluctuates in severity throughout the day, and is primarily a disturbance of attention. Delirium is a physiological consequence of another underlying disorder (APA, 2013).

B.  Prevalence and incidence: In 8% to 17% of older medical patients, 31% of ICU patients, and 26% to 62% of palliative care patients, delirium is present on admission (Inouye et al., 2014; Siddiqi et al., 2006). Delirium develops in 11% to 42% of medical (Siddiqi et al., 2006), 4% to 53% of hip surgery (Bruce et al., 2007), 31% of medical ICU (McNicoll et al., 2003; Salluh et al., 2010), 24.4% to 28.3% of surgical ICU (Balas et al., 2007; Chaiwat et al., 2019), up to 81.7% of mechanically ventilated (Ely et al., 2004; Pisani et al., 2010), and 26% to 88% of palliative care patients (Hosie et al., 2013; Mosk et al., 2017).

C.  Risk factors: The most common risk factors for delirium in acute hospital units are dementia, older age, comorbid illness, severity of medical illness, infection, “high-risk” medication use, postoperative status, diminished activities of daily living, immobility, sensory impairment, urinary catheterization, urea and electrolyte imbalance, metabolic acidosis, and malnutrition (Abraha et al., 2016; Ahmed et al., 2014; Zaal et al., 2015). Other possible risk factors include sleep deprivation (Weinhouse et al., 2009), polypharmacy, physical restraints, and anemia (Inouye et al., 1990, 1993; O’Keeffe & Lavan, 1996).

D.  Outcomes: The outcomes of delirium in hospitalized older adults are increased mortality (Schubert et al., 2018; Witlox et al., 2010), hospital length of stay, transfer to long-term care facilities (Shi et al., 2012; Witlox et al., 2013), depression, decreased functional and cognitive status, increased geriatric syndrome complications, and dementia (Anderson et al., 2012; Cole et al., 2008; Jackson et al., 2014; Witlox et al., 2010, 2013). From 22% to 89% of older hospitalized adults with dementia also have delirium superimposed on the dementia (Fick et al., 2002), are at increased risk for developing delirium, and experience worse outcomes if it occurs (Ford, 2016; Morandi et al., 2014; Yang et al., 2009).

PARAMETERS OF ASSESSMENT

A.  Assess for common and other risk factors (Ahmed et al., 2014; Halladay et al., 2018).

  1. Cognitive dysfunction
  2. Illness severity
  3. Comorbidities
  4. Infection
  5. Postoperative status
  6. High-risk medication use (e.g., benzodiazepines)
  7. Immobility
  8. Decreased activities of daily living
  9. Urinary catheterization
  10. Urea and electrolyte imbalance and dehydration
  11. Malnutrition
  12. Physical restraints
  13. Anemia
  14. Metabolic acidosis

B.  Assess for delirium using a validated screening tool (see “Resources”)  

  1. Key features of delirium (CAM, CAM-ICU, bCAM)
    • Acute onset and fluctuating course
    • Inattention
    • Disorganized thinking
    • Altered level of consciousness
  2. Delirium symptoms (Nu-DESC)
    • Disorientation
    • Inappropriate behavior
    • Inappropriate communication
    • Illusions or hallucinations
    • Psychomotor hypoactivity

NURSING CARE STRATEGIES

A.  Eliminate or minimize risk factors

  1. Administer medications judiciously; avoid high-risk medications.
  2. Prevent and/or promptly and appropriately treat infections.
  3. Prevent and/or promptly treat dehydration and electrolyte disturbances.
  4. Provide adequate pain control.
  5. Maximize oxygen delivery (supplemental oxygen, blood, and BP support as needed).
  6. Use sensory aids as appropriate.
  7. Regulate bowel/bladder function.
  8. Provide adequate nutrition.

B.  Provide a therapeutic environment.  

  1. Foster orientation: Frequently reassure and reorient patient (unless patient becomes agitated); use easily visible calendars, clocks, caregiver identification; carefully explain all activities; communicate clearly.
  2. Provide appropriate sensory stimulation: quiet room, adequate light, pursue one task at a time, use noise-reduction strategies.
  3. Facilitate sleep: Offer back massage, warm milk, or herbal tea at bedtime; play relaxation music/tapes; employ noise-reduction measures; avoid awaking patient.
  4. Foster familiarity: Encourage family/friends to stay at bedside, bring familiar objects from home, maintain consistency of caregivers, minimize relocations.
  5. Maximize mobility: Avoid restraints and urinary catheters; ambulate or perform active ROM exercises three times daily.
  6. Provide appropriate cognitive stimulation.
  7. Communicate clearly, provide explanations.
  8. Reassure and educate family.
  9. Minimize invasive interventions.
  10. Consult with a geriatric specialist.
  11. Consider psychotropic medication as a last resort for agitation (Neufeld, Yue, Robinson, Inouye, & Needham, 2016; Patel, Baldwin, Bunting, & Laha, 2014; Zaubler et al., 2013).

EVALUATION/EXPECTED OUTCOMES

A.  Patient

  1. Absence of delirium
  2. Cognitive status returned to baseline (before delirium)
  3. Functional status returned to baseline (before delirium)
  4. Discharged to same destination as prehospitalization

B.  Healthcare provider

  1. Regular use of delirium screening tool
  2. Increased detection of delirium
  3. Implementation of appropriate interventions to prevent/treat delirium from standardized protocol
  4. Decreased use of physical restraints
  5. Decreased use of antipsychotic medications
  6. Increased satisfaction in care of hospitalized older adults

C.  Institution

  1. Staff education and interprofessional care planning
  2. Implementation of standardized delirium screening protocol
  3. Decreased overall cost
  4. Decreased length of stay
  5. Decreased morbidity and mortality
  6. Increased referrals and consultation to earlier specified specialists
  7. Improved satisfaction of patients, families, and nursing staff

FOLLOW-UP MONITORING OF CONDITION

A.  Decreased delirium to become a measure of quality care

B.  Incidence of delirium to decrease

C.  Patient days with delirium to decrease

D.  Staff competence in recognition and treatment of delirium

E.  Documentation of a variety of interventions for delirium

ABBREVIATIONS

BCAM        Brief Confusion Assessment Method

CAM           Confusion Assessment Method

CAM-ICU   CAM for patients in intensive care unit

Nu-DESC    Nursing Delirium Screening Scale

ROM           Range of motion

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Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description

Chapter 20:  Blevins, C. (2021) Delirium: Prevention, Early Recognition, and Treatment.  In M. Boltz, E. Capezuti, D. Zwicker & T. Fulmer (eds.).  Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed. pp 317-329).  New York: Springer.

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