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Delirium Tullman et al
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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.
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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
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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
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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
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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
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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
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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 inguinal hernia repair. He wears
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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 his diabetes 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.
Delirium Tullman et al
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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
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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 by disturbances 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?
Delirium Tullman et al
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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.
Delirium Tullman et al
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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.
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
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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
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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.
Delirium Tullman et al
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RESOURCES
Recommended Delirium Screening Instruments
Confusion Assessment Method (CAM) (Inouye, 2003; Inouye et al., 1990 [Level IV]).
Recommended for verbal patients by Laurila, Pitkala, Strandberg, & Tilvis, (2002 [Level
IV])
Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) (Ely et al., 2001a
[Level IV]; Ely et al., 2001b [Level IV]). Recommended for non-verbal patients by
Schuurmans et al. (2003 [Level V]).
Other Delirium Screening Instruments
Delirium-O-Meter (deJonge, Kalisvarrt, Timmers, Kat, & Jackson, 2005 [Level VI]) may
be used for monitoring the different characteristics and the severity of delirium in
geriatric patients
Delirium Rating Scale (DRS)-98 (Trzepacz et al., 2001 [Level IV]) may be used to assess
delirium severity.
Mini-Mental State Examination (MMSE) (Folstein, Folstein, & McHugh, 1975 [Level
IV]) may be used to monitor course of delirium in hospitalized patients according to
O’Keeffe, Mulkerrin, Nayeem, Varughese, & Pillay (2005 [Level IV])
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Additional Online Information about Delirium
http://www.icudelirium.org/delirium/
http://elderlife.med.yale.edu/public/pubs.php?pageid=01.03.07
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BOX 7.1 TABLE 1. NURSING STANDARD OF PRACTICE PROTOCOL:
DELIRIUM, PREVENTION, EARLY RECOGNITION AND TREATMENT
I.
GOAL To reduce the incidence of delirium in hospitalized older adults.
II. OVERVIEW
A. Delirium is a common syndrome in hospitalized older adults.
B. Although sometimes reversible, delirium is associated with increased mortality,
increased hospital costs, and long-term cognitive and functional impairment.
C. Delirium can be prevented with recognition of high-risk patients and the
implementation of a standardized protocol.
D. Delirium, when it develops, may be underrecognized by physicians and nurses.
E. Routine screening for delirium should be part of comprehensive nursing care of
older adults.
III. BACKGROUND
A. Definition: Delirium is a disturbance of consciousness with impaired attention and
disorganized thinking or perceptual disturbance that develops acutely, has a
fluctuating course and with evidence that there is an underlying physiologic or
medical condition causing the disorder.
B. Epidemiology
1. Prevalence (present on admission): 10%-15% in acute care (Fann, 2000 [Level
I]); 31% in ICU (McNicoll et al., 2003 [Level IV])
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2. Incidence (new onset): 10%-40% in acute care (Fann, 2000 [Level I]); 43%61% post hip surgery (Holmes & House, 2000 [Level I]); 31% in ICU
(McNicoll et al., 2003 [Level IV]); 83% of mechanically ventilated patients
(Ely et al., 2001a [Level IV]).
3. Duration: may resolve in a few hours to days or persist for weeks to months
(Fann, 2000 [Level I])
C. Etiology
1. Pathophysiologic mechanisms unclear (Trzepacz & Van der Mast, 2002
[Level VI])
2. Risk factors for delirium are multifactorial
a. Advanced age (Fann, 2000 [Level I])
b. Dementia (Elie et al., 1998 [Level I])
c. Medical illness (Elie et al., 1998 [Level I])
d. Multiple medications (Elie et al., 1998 [Level I]; see Reducing Adverse
Drug Events in this text)
e. Alcohol abuse (Elie et al., 1998 [Level I])
f. Male gender (Elie et al., 1998 [Level I])
g. Poor functional status (Fann, 2000 [Level I])
h. Depression (Fann, 2000 [Level I])
i. Pain (Fann, 2000 [Level I])
j. Increased blood urea nitrogen/creatinine (BUN/Cr) ratio (Inouye &
27
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Charpentier, 1996 [Level IV])
k. Sensory impairment (Inouye & Charpentier, 1996 [Level IV])
3. Potential outcomes of delirium
a. Increased mortality (Fann, 2000 [Level I])
b. Increased morbidity (Fann, 2000 [Level I])
i. Long-term cognitive impairment (Ely et al., 2004a; McCusker et al.,
2001 [Level IV])
ii. Post-operative complications (Fann, 2000 [Level I])
iii. Decreased functional ability (Fann, 2000 [Level I])
iv. Increased hospital length of stay (Ely et al., 2004a; Pompei et al., 1994
[Level IV])
v. Institutionalization (Fann, 2000 [Level I])
vi. Increased healthcare costs (Inouye, 2006 [Level VI])
IV. PARAMETERS OF ASSESSMENT
A. Assess for risk factors
1. Baseline or pre-morbid cognitive impairment (see Assessing Cognitive
Function in this text)
2. Medications review (see Reducing Adverse Drug Events in this text)
3. Pain
4. Metabolic disturbances (hypoglycemia, hypercalcemia, hyponatremia,
hypokalemia)
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5. Dehydration (physical signs/symptoms, intake/output, Na+, BUN/Cr)
6. Infection (fever, WBCs with differential, cultures)
7. Environment (sensory overload or deprivation)
8. Impaired mobility
B. Features of delirium—assess every shift (see Resources for validated instruments)
1. Acute onset; evidence of underlying medical condition
2. Alertness: Fluctuates from stuporous to hypervigilant
3. Attention: Inattentive, easily distractible, and may have difficulty shifting
attention from one focus to another; has difficulty keeping track of what is
being said
4. Orientation: Disoriented to time and place; should not be disoriented to person
5. Memory: Inability to recall events of hospitalization and current illness;
unable to remember instructions; forgetful of names, events, activities, current
news, etc.
6. Thinking: Disorganized thinking; rambling, irrelevant, incoherent
conversation; unclear or illogical flow of ideas; or unpredictable switching
from topic to topic; difficulty in expressing needs and concerns; speech may
be garbled
7. Perception: Perceptual disturbances such as illusions and visual or auditory
hallucinations; and misperceptions such as calling a stranger by a relative's
name.
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8. Psychomotor activity: May fluctuate between hypoactive, hyperactive, mixed
subtypes
V. NURSING CARE STRATEGIES (based on protocols in multicomponent delirium
prevention studies (Inouye, et al., 1999; Marcantonio, et al., 2001 [Level II])
A. Collaborate with physician/nurse practitioner to treat the underlying pathology and
contributing factors. If available, consult with geriatrician and/or Geriatric Nurse
Practitioner or Clinical Nurse Specialist.
B. Eliminate or minimize risk factors
1. Administer medications judiciously; avoid high-risk medications (see
Reducing Adverse Drug Events in this text).
2. Prevent/promptly and appropriately treat infections.
3. Prevent/promptly treat dehydration and electrolyte disturbances.
4. Provide adequate pain control (see Pain Management in this text).
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.
C. Provide a therapeutic environment.
1. Foster orientation: frequently reassure and reorient patient (unless patient
becomes agitated); utilize easily visible calendars, clocks, caregiver
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identification; carefully explain all activities; communicate clearly
2. Provide appropriate sensory stimulation: quiet room; adequate light; one task
at a time; noise reduction strategies
3. Facilitate sleep: back massage, warm milk or herbal tea at bedtime; relaxation
music/tapes; 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 (see Chapter Use of Physical Restraints)
and urinary catheters; ambulate or active ROM three times daily;
6. Communicate clearly, provide explanations
7. Reassure and educate family
8. Minimize invasive interventions.
9. Consider psychotropic medication as a last resort
VI. EVALUATION/EXPECTED OUTCOMES
A. Patient
1. Absence of delirium or
2. Cognitive status returned to baseline (prior to delirium)
3. Functional status returned to baseline (prior to delirium)
4. Discharged to same destination as pre-hospitalization
B. Health Care Provider
1. Increased detection of delirium
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2. Implementation of appropriate interventions to prevent/treat delirium
3. Use of standardized delirium prevention protocol
4. Decreased use of physical restraints
5. Decreased use of antipsychotic medications
6. Increased satisfaction in care of hospitalized elderly.
C. Institution
1. Decreased overall cost
2. Decreased length of stays
3. Decreased morbidity and mortality
4. Increased referrals and consultation to above specified specialists
5. Improved satisfaction of patients, families, nursing staff
VII. 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 acute confusion/delirium
E. Documentation of a variety of interventions for acute confusion/delirium.
Na+ = sodium; BUN/Cr = blood urea nitrogen/creatinine ratio; BP = blood pressure;
Hgb/Hct = hemoglobin and hematocrit; SpO2 = pulse oxygen saturation; WBCs = white
blood cells; URI = upper respiratory infection; UTI = urinary tract infection; ROM =
range of motion