Delirium Tullman et al1

CHAPTER 7

DELIRIUM: PREVENTION, EARLY RECOGNITION, AND TREATMENT

Dorothy F. Tullmann, Lorraine C. Mion, Kathleen Fletcher, and Marquis D. Foreman

EDUCATIONAL OBJECTIVES

On completion of this chapter, the reader should be able to

1.Describe hospitalized older adults at risk for delirium.

2.Discuss the importance of early recognition of delirium.

3.Identify four clinical characteristics of delirium.

4.Develop a plan to prevent or treat delirium.

5. List five outcomes associated with delirium.

(for description of Evidence Levels cited in this chapter, see Chapter, Evaluating Clinical Practice Guidelines, page ??) [PUBLISHER PLEASE INSERT PAGE NUMBER]

OVERVIEW

Delirium is a common syndrome in hospitalized older adults. Sometimes reversible, delirium is one of the major contributors to poor outcomes of health care and institutionalization for older patients. A significant proportion of delirium cases has been shown to be preventable by identifying modifiable risk factors and utilizing a standardized nursing practice protocol. If delirium does develop, early recognition is of paramount importance in order to treat the underlying pathology and minimize delirium’s sequelae. Nurses play a key role in both the prevention and early recognition of this potentially devastating condition.

Background and Statement of Problem

Delirium is a disturbance of consciousness with impaired attention and disorganized thinking that develops rapidly and with evidence of an underlying physiologic or medical condition (American Psychiatric Association, 2000). Delirium is characterized by a reduced ability to focus, sustain, or shift attention, memory impairment, disorientation, and/or illusions, visual or other hallucinations, or misperceptions of stimuli. Delusional thinking may also occur. Unlike other chronic cognitive impairments, delirium develops over a short period of time and tends to fluctuate during the course of the day. A patient may present with either hyperactive, hypoactive, or mixed subtypes of delirium (de Rooij, Schuurmans, van der Mast, & Levi, 2005 [Level I]). Nurses typically associate delirium with hyperactivity and distressing, time-consuming, harmful patient behaviors. However, the hypoactive subtype with its lack of overt psychomotor activity is also common (O’Keeffe & Lavan, 1999 [Level IV]).

Delirium is present on admission (prevalence) to the hospital in 10% to 15% of older patients; and the in-hospital incidence (new onset) is 10% to 40% in older medical and surgical patients (Fann, 2000 [Level I]). Among hip surgery patients alone the incidence of delirium is 43% to 61% (Holmes & House, 2000 [Level I]). Older adults admitted to intensive care units (ICUs) have a both a prevalent and incident delirium of 31% (McNicoll et al., 2003 [Level IV]) and up to 83% of mechanically ventilated patients (all ages) experience delirium (Ely et al., 2001a [Level IV]). The incidence of delirium superimposed on dementia ranges from 22% to 89% (Fick, Agostini, & Inouye, 2002 [Level I]). The onset of delirium generally occurs shortly after admission, has a varied and unpredictable course, and may persist for several weeks after hospital discharge (Kiely et al., 2003 [Level IV]; Marcantonio et al., 2003 [Level IV]; Rudberg, Pompei, Foreman, Ross, & Cassel, 1997 [Level IV]).

The pathophysiology of delirium is not well understood (Trzepacz & van der Mast, 2002 [Level VI]) and a number of risk factors have been identified suggesting that the etiology of delirium is multifactorial (Inouye, 1998 [Level VI]). The most common risk factors for delirium include dementia, male gender, advanced age, and medical illness (Elie, Cole, Primeau, & Bellavance, 1998 [Level I]). Other predisposing risk factors identified are poor functional status, alcohol abuse, depression (Fann, 2000 [Level I]) as well as dehydration and sensory impairment (Inouye, Viscoli, Horwitz, Hurst, & Tinetti, 1993 [Level IV]).

Precipitating risk factors occurring during hospitalization include: polypharmacy, malnutrition, physical restraints, a bladder catheter or any iatrogenic event (Inouye & Charpentier, 1996 [Level IV]). Multiple medications have been implicated as precipitating factors for delirium. These include, but are not limited to: anticholinergics, narcotics (meperidine), sedative hypnotics (benzodiazepines), histamine (H2) receptor antagonists, corticosteroids, centrally-acting antihypertensives, and antiparkinsonian drugs (Fann, 2000 [Level I]). Other precipitating factors include undertreated pain (Morrison et al., 2003 [Level IV]) and care setting relocation (especially to ICU) (McCusker et al., 2001 [Level IV]).

Delirium results in significant distress for the patient, their family members, and nurses (Breitbart, Gibson, & Tremblay, 2002 [Level IV]). In addition, delirium is associated with increased mortality, increased post-operative complications, longer hospital stay, functional decline, and new nursing home placement (Fann, 2000 [Level I]). Long-term cognitive decline (Ely et al., 2004a [Level IV]; McCusker, Cole, Dendukuri, Blezile, & Primeau, 2001 [Level IV]) and increased health care costs (Inouye, 2006 [Level VI]; Milbrandt et al., 2004 [Level IV]) have also been associated with delirium. Clearly, delirium is a high-priority nursing challenge for all who care for older adults.

PARAMETERS OF ASSESSMENT

Identifying the risk factors for delirium (above) is critically important. Eliminating or reducing these risk factors can prevent delirium in many cases (Milisen, Lemiengre, Braes, & Foreman, 2001 [Level I]).

Recognizing the first signs of delirium is also important in order to further identify, eliminate or reduce the precipitating factor(s) such as pain, infection, or other acute illnesses. The criteria used to distinguish delirium or acute confusion from other changes in mental status include the following:

  • Disturbance of consciousness (reduced clarity and awareness of the environment), with reduced ability to focus, sustain, and shift attention. Patients have trouble following instructions or making sense of their environment, even with cues. They may also get “stuck” on a particular concern or thought.
  • A change in cognition: memory deficit, disorientation, language disturbance, and/or perceptual disturbance. Symptoms are often associated with disturbances in the sleep/wake cycle and rapidly shifting emotional disturbances, with escalation of the disturbed behavior at night (sundowning). Hallucinations and delusions are common. Patients can be hyperactive and agitated or lethargic and less active. The latter presentation is particularly concerning because it is often not recognized by health care providers as delirium. The presentation may also be mixed, with the patient fluctuating from one to the other.
  • The cardinal sign of delirium is that the above changes occur rapidly over several hours or days.

It is important to remember that delirium may occur concurrently with dementia or depression. In fact, those patients are at increased risk to develop delirium. Family and caregivers can be invaluable in helping to distinguish cognitive changes in those circumstances when the patient is not well known to you.

Despite its importance, delirium is under recognized by nurses and physicians (Ely et al., 2004b [Level IV]; Fick & Foreman, 2000 [Level IV]; Inouye, Foreman, Mion, Katz, & Cooney, Jr., 2001 [Level IV]). Personal philosophies about aging are a factor in nurses’ inability to distinguish delirium from dementia (McCarthy, 2003 [Level IV]). In addition, the hypoactive subtype of delirium, with no agitated behavior to alert physicians and nurses to its presence, is another reason why delirium is not identified. Failure to recognize delirium means that the underlying cause cannot be identified and treated in a timely manner, contributing to the sequelae associated with delirium.

Nurses are in the best position to recognize delirium. Screening tools have been developed to assist nurses in their assessment (Schuurmans, Deschamps, Markham, Shortridge-Baggett, & Duursman, 2003 [Level V]; see Resources). Experienced clinicians can train nurses to use these instruments in their routine assessment of older adults (Pun et al., 2005 [Level IV]). In the absence of such training, however, nurses can identify the clinical features of delirium and alert the physician or nurse practitioner to continue the diagnostic process (see Sec IV, Parameters of Assessment in Table 1, Nursing Standard of Practice Protocol).

INTERVENTION/CARE STRATEGIES

Multicomponent nursing interventions, guided by the multiple risk factors for delirium, are modestly successful in preventing delirium (Cole, Primeau, & McCusker, 1996 [Level I]; Milisen et al., 2005 [Level I]). However, such multicomponent interventions are not effective for treating delirium once it has developed (Milisen et al., 2005 [Level I]; Pitkala et al., 2006 [Level II]) and are possibly less effective for older medical than surgical patients (Cole, Primeau, & Elie, 1998 [Level I]). None of the multicomponent intervention studies focused on patients with chronic cognitive impairment--- patients at greatest risk for delirium (Britton, & Russell, 2005 [Level I]). Medications are not effective in preventing delirium (Kalisvaart et al., 2005 [Level II]).

Once it has been determined that the patient is either at risk for or has already developed delirium, a standardized delirium protocol should be initiated immediately. Protocols tested in two multicomponent interventions effectively prevented delirium (Inouye et al., 1999 [Level II]; Marcantonio, Flacker, Wright, & Resnick, 2001 [Level II]). The protocols varied somewhat but two principles emerged from the research: (1) minimize the risk for delirium by preventing or eliminating the etiologic agent(s); provide a therapeutic environment and general supportive nursing care (see Section V, Nursing Care Strategies, in Table 1, Protocol for details).

While nonpharmacologic interventions are preferred, medications are also used in the treatment of delirium (Meagher, 2001 [Level VI]). Antipsychotics (such as haloperidol) are frequently used although the efficacy and safety has not been established by double-blind, randomized, placebo-controlled trials (Seitz, Gill, & van Zyl, 2007 [Level I]). Medications such as diazepam to enhance post-laparotomy sleep in older patients (Aizawa et al., 2002 [Level II]), risperidone (Parellada, Baesa, de Pablo, & Martinez, 2004 [Level II]), and olanzapine (Skrobik, Bergeron, Dumont, & Gottfried, 2004 [Level II]) may prevent delirium but more robust studies are needed. Diazepam should not be used in older adults (Fick et al., 2003 [Level IV]) and given the adverse affects in older adults with many medications (see chapter on Adverse Drug Events in this text); any new medication approved for delirium should be used with extreme caution in these patients.

CASE STUDY WITH DISCUSSION

Mr. Z is a 82-year-old patient admitted to your unit for prostate surgery. He is a retired accountant, lives with his wife, and is very active. He drives a car, plays golf, and regularly participates in activities at the senior center. His Type II diabetes is well controlled on Actoplus- met (pioglitazone hydrochloride and metformin hydrochloride). Mr. Z reports that he has decreased his fluid intake so he can avoid waking several times during the night to urinate. He also has a history of hypertension, moderate hearing loss (hearing aids bilaterally), and previous surgery for inguinalhernia repair. He wears bifocal glasses for distance and reading. He is alert, oriented, and expresses a good understanding of his upcoming surgery. His preoperative laboratory values are within normal limits except for a hematocrit of 28% and a blood urea nitrogen/creatinine (BUN/Cr) ratio slightly elevated at 21:1. His medications include for Actoplus-met (pioglitazone hydrocloride and metformin hydrochloride) for hisdiabetes and verapamil for hypertension.

What factors present on admission to the hospital put Mr. Z at risk for developing delirium?

  • Age. Older adults are at greater risk for delirium, particularly if they have underlying dementia or depression. Physiologic changes that occur with aging can affect the ability of older adults to respond to physical and physiologic stress and to maintain homeostasis.
  • Dehydration. An elevated BUN/Cr ratio indicates dehydration (from decreased fluid intake), a frequent contributing factor (along with electrolyte imbalance) to delirium of hospitalized older adults.
  • Anemia. Because of a low hematocrit, the body has diminished ability to deliver adequate oxygen to the brain, making delirium more likely.
  • Sensory deficits. Those with vision and hearing loss are more likely to misinterpret sensory input which places them at increased risk for delirium.
  • It is important to understand that it might not be one particular factor but the interplay of patient vulnerability (predisposing factors) and precipitating factors—common during hospitalization—which place the older adult at risk for delirium.

What can you do to help prevent delirium in Mr. Z?

  • If possible, consult with a geriatric specialist (physician or nurse) for a thorough geriatric assessment of Mr. Z.
  • Make sure his glasses and hearing aids are on and functioning.
  • Explore reasons for the low hematocrit.

You provide care for Mr. Z again two days after surgery. He is confused and picking at the air and oriented to self only. An indwelling urinary catheter and peripheral intravenous line are in place. In his report, the day shift nurse mentioned considering a physical restraint because Mr. Z was increasingly restless and might be delirious.

What are the clinical features of delirium?

  • Disturbance of consciousness characterized by reduced clarity and awareness of the environment: reduced ability to focus, sustain, and shift attention. Patients have trouble following instructions or making sense of their environment, even with cues. They may also get “stuck” on a particular concern or thought.
  • Cognitive changes: memory deficit, disorientation, language disturbance, and/or perceptual disturbance.
  • Perceptual disturbances: Hallucinations and delusions are common. Patients can be hyperactive and agitated or lethargic (hypoactive) and less active. The latter presentation is of particular concern because it is often not recognized by health care providers as delirium. The presentation may also be mixed, with the patient fluctuating from one to the other behavioral state.
  • Delirium can be characterized bydisturbances in the sleep/wake cycle and rapidly shifting emotional disturbances, with escalation of the disturbed behavior at night (sundowning).
  • The cardinal sign of delirium is that the above changes occur rapidly over several hours or days.

It is also important to consider that delirium may occur concurrently with dementia or depression. In fact, these patients are at increased risk to develop delirium. Family and caregivers can be invaluable in helping to identify or distinguish cognitive changes in circumstances when the patient is not well known to you.

What additional factors may now be contributing to Mr. Z’s delirium?

  • Anesthesia and other medications. It takes several hours for the body to clear the effects of anesthesia. Inasmuch as older adults have a larger percentage of body fat than younger persons, and many drugs are fat-soluble, drug effects will last longer. Also, older adults tend to have less cellular water; hence, water-soluble drugs will be more concentrated and have a more pronounced effect. Nurses need to ask the patient or family if any new drugs other than pain medication have been added. What is the dose and frequency of the pain medications? Is the dose appropriate?
  • Pain. What is Mr. Z’s pain control regimen and status? Poor pain control contributes to restlessness and is associated with delirium. Is the current drug the best for good pain relief in this patient?
  • Hypoxemia. Mr. Z is at risk because of limited mobility and possible atelectasis after surgery. What is his oxygen saturation (SpO2)? Does he have crackles or diminished breath sounds?
  • Infection, inflammation, or other medical illness. Postoperative infections, intraoperative myocardial infarctions (MIs), or strokes are possible causes of delirium in this case. Could Mr. Z. have a urinary tract infection (UTI) since he is post-prostate surgery and particularly since he has a Foley catheter? An inflammatory response to a new medical problem may be the cause of the delirium.
  • Unfamiliar surroundings. Particularly for those with sensory deficits, unfamiliar environments can lead to misinterpretations of information which may contribute delirium.

What steps should be taken now?

  • Avoid the use of restraints which could worsen Mr. Z’s agitation.
  • Call the physician or nurse practitioner (NP) immediately and report your findings; request that he or she come and evaluate the patient to determine the underlying cause of the delirium. If Mr. Z’s delirium worsens, he may also need medication (e.g. haloperidol) to control his symptoms.
  • Frequent reality orientation. Frequent orientation, reassurance, and helping Mr. Z interpret his environment and what is happening to him should be helpful. (Monitor the patient’s reaction. If the patient becomes upset or angry, you will need to modify your approach to that of more reassurance and validating the patient’s experience rather than reorienting).
  • Are Mr. Z’s hearing aids and glasses in place and clean? functioning? Impaired sensory input contributes significantly to delirium. Also, he may seem more confused than he really is if he is not able to hear what you are saying.
  • Invite family/significant others to stay as much as they are able to assist with his orientation, reassurance, and sense of well-being.Monitor the effect of family visitation. If the patient has increased agitation or anxiety, then limit the visitation of the individual who seems to be triggering Mr. Z’s upset.
  • Mobilize the patient. Mobility assists with orientation and helps prevent problems associated with immobility, such as atelectasis and deep venous thrombosis.
  • Judicious use of medications for pain, sleep, or anxiety. Drugs used to address these issues can exacerbate the delirium. Try nonpharmacologic approaches for sleep and anxiety first. If Mr. Z is having pain, are the drug and dose appropriate for him? A regular schedule of a smaller dose or nonnarcotic pain medication almost always is better than prn dosing.
  • Try to provide for adequate sleep: noise reduction at night, soft, relaxing music, warm milk, herbal tea, massage, and rescheduling care in order not to interrupt sleep.
  • Make sure the patient is well hydrated.
  • Talk to the doctor or NP about removing the indwelling urinary catheter. Because of his surgery, Mr. Z may need it immediately post-op, but it should be removed as soon as possible. Additionally, recommend a urinalysis to rule out UTI.
  • Address safety concerns (e.g., increase surveillance). Mr. Z is now also at risk for falls and/or pressure ulcers.

SUMMARY

Delirium is a common occurrence in hospitalized older adults and contributes to poor outcomes. Thus, it is important to promptly identify those patients at risk for delirium and implement preventive measures as well as promptly recognize delirium when it appears. Nursing assessments using validated delirium screening instruments must become routine. A standard of practice protocol provides concise information to guide nursing care of individuals at risk of or experiencing delirium.

ACKNOWLEDGEMENTS

Our thanks to Suzann Rosenthal-Williams, MSN, GNP for her real-life experiences in helping to prevent and treat delirium in older adults and Naomi Gorton, Clinical Nurse Leader student, for her assistance in preparing the references.