Delirium Prevention and Management

 

OVERVIEW

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 the 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 and 31% of ICU 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 (Salluh et al., 2010), 24.4% to 28.3% of SICU (Balas et al., 2007; Chaiwat et al., 2019), and up to 81.7% of mechanically ventilated patients (Ely et al., 2004; Pisani et al., 2010), and 22% to 89% of patients have DSD (Fick et al., 2002; Han et al., 2022; 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 (Ahmed et al., 2014; Zaal et al., 2015). Other possible risk factors include sleep deprivation, polypharmacy, physical restraints, and anemia (Inouye et al., 1990, 1993).

D. Outcomes: The outcomes of delirium in hospitalized older adults are increased mortality (Schubert et al., 2018; Witlox et al., 2010) and 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; 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).

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. Use of high-risk medication (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
  15. Uncontrolled pain
  16. Constipation

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

  1. Key features of delirium (CAM, CAM-ICU, bCAM)
    • Acute onset and fluctuating mental status
    • 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 blood pressure 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 the patient (unless the patient becomes agitated); use easily visible calendars, clocks, caregiver identification; carefully explain all activities; and communicate clearly.
  2. Provide appropriate sensory stimulation, including quiet room, adequate light, pursuing one task at a time, and using noise reduction strategies.
  3. Facilitate sleep. Offer back massage, warm milk, or herbal tea at bedtime; play relaxation music/tapes; employ noise reduction measures; and avoid awaking the patient.
  4. Foster familiarity. Encourage family/friends to stay at bedside, bring familiar objects from home, maintain consistency of caregivers, and 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 et al., 2016; 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. Recognition of delirium risk
  2. Regular use of delirium screening tool
  3. Implementation of appropriate interventions to prevent/treat delirium from standardized protocol
  4. Increased detection of delirium
  5. Decreased use of physical restraints
  6. Decreased use of antipsychotic medications
  7. 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           Confusion Assessment Method for the Intensive Care Unit

DSD                   delirium superimposed on dementia

Nu-DESC           Nursing Delirium Screening Scale

ROM                  range of motion

SICU                  surgical ICU

----

Updated: January 2025

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti, PhD, RN, FAAN, E.A., & Fulmer PhD, RN, FAAN, T. T. (2025). Evidence-Based Geriatric Nursing Protocols for Best Practice (7th ed.). Springer Publishing. Retrieved December 17, 2024, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826152763.html#tableofcontents

Chapter 21, Blevin, C. & Longley, M. (2025) Delirium

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Witlox, J., Slor, C. J., Jansen, R. W. M. M., Kalisvaart, K. J., van Stijn, M. F. M., Houdijk, A. P. J., Eikelenboom, P., van Gool, W. A., & de Jonghe, J. F. M. (2013). The neuropsychological sequelae of delirium in elderly patients with hip fracture three months after hospital discharge. International Psychogeriatrics, 25(9), 1521–1531. https://doi.org/10.1017/S1041610213000574.Evidence Level IV.

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Zaal, I. J., Devlin, J. W., Peelen, L. M., & Slooter, A. J. C. (2015). A systematic review of risk factors for delirium in the ICU. Critical Care Medicine, 43(1), 40–47. https://doi.org/10.1097/CCM.0000000000000625. Evidence Level I.

Zaubler, T., Murphy, K., Rizzuto, L., Santos, R., Skotzko, C., Giordano, J., Bustami, R., & Inouye, S. (2013). Quality improvement and cost savings with multicomponent delirium interventions; replication of the hospital elder life program in a community hospital. Psychosomatics,54(3), 219–226. https://doi.org/10.1016/j.psym.2013.01.010.Evidence Level IV.

Zhang, Z., Pan, L., & Ni, H. (2013). Impact of delirium on clinical outcome in critically ill patients: A meta-analysis. General Hospital Psychiatry, 35(2), 105–111. https://doi.org/10.1016/j.genhosp psych.2012.11.003. Evidence Level I.

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