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Delirium Tullman et al 1 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. Delirium Tullman et al 2 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 Delirium Tullman et al 3 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 Delirium Tullman et al 4 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 Delirium Tullman et al 5 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 Delirium Tullman et al 6 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 Delirium Tullman et al 7 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 Delirium Tullman et al 8 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 9 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 Delirium Tullman et al 10 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 11 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 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. 12 Delirium Tullman et al 13 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 Delirium Tullman et al 14 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 15 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]) Delirium Tullman et al Additional Online Information about Delirium http://www.icudelirium.org/delirium/ http://elderlife.med.yale.edu/public/pubs.php?pageid=01.03.07 16 Delirium Tullman et al 17 REFERENCES Agostini, J. V., Leo-Summers, L. S., & Inouye, S. K. (2001). Cognitive and other adverse effects of diphenhydramine use in hospitalized older patients. Archives of Internal Medicine, 161, 2091-2097. Evidence Level IV: Non-experimental Study. Aizawa, K., Kanai, T., Saikawa, Y., Takabayashi, T., Kawano, Y., Miyazawa, N., et al. (2002). A novel approach to the prevention of postoperative delirium in the elderly after gastrointestinal surgery. Surgery Today, 32, 310-314. Evidence Level II: Single Experimental Study. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author. Breitbart, W., Gibson, C., & Tremblay, A. (2002). The delirium experience: delirium recall and delirium-related distress in hospitalized patients with cancer, their spouses/caregivers, and their nurses. Psychosomatics, 43, 183-194. Evidence Level IV: Non-experimental Study. Britton, A., & Russell, R. (2004). Multidisciplinary team interventions for delirium in patients with chronic cognitive impairment. Cochrane Data Base Systematic Reviews, 2, CD000395. Evidence Level I: Systematic Review. Cole, M. G., McCusker, J., Bellavance, F., Primeau, F. J., Bailey, R. F., Bonycastle, J. J., et al. (2002). Systematic detection and multidisciplinary care of delirium in older medical inpatients: a randomized trial. CMAJ Canadian Medical Association Journal, 167(7), 753-759. Evidence Level II: Single Experimental Study. Delirium Tullman et al 18 Cole, M. G., Primeau F. J., & Elie, L. M. (1998). Delirium: prevention, treatment, and outcome studies. Journal of Geriatric Psychiatry and Neurology, 11,126-137. Evidence Level I: Systematic Review. Cole, M. G., Primeau, F., & McCusker, J. (1996). Effectiveness of interventions to prevent delirium in hospitalized patients: a systematic review. Canadian Medical Association Journal, 155, 1263-1268. Evidence Level I: Systematic Review. de Jonge, J. F. M., Kalisvarrt, K. J., Timmers, J. F. M., Kat, M.G., & Jackson, J. C. (2005). Delirium-O-Meter: a nurses’ rating scale for monitoring delirium severity in geriatric patients. 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W., Margolin, R., Francis, J., May, L., Truman, B., Dittus, R., et al. (2001b). Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Critical Care Medicine, 29, 2091-2097. Evidence Level IV: Non-experimental Study. Ely, E. W., Shintani, A., Truman, B., Speroff, T., Gordon, S.M., Harrell, F. E., Jr., et al. (2004a). Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. Journal of the American Medical Association, 291, 17531762. Evidence Level IV: Non-experimental Study. Ely, E. W., Stephens, R. K., Jackson, J. C., Thomason, J. W., Truman, B., Gordon, S., et al. (2004b). Current opinions regarding the importance, diagnosis, and management of delirium in the intensive care unit: a survey of 912 healthcare professionals. Critical Care Medicine, 32, 106-112. Evidence Level IV: Non-experimental Study. Fann, J. R. (2000). The epidemiology of delirium: a review of studies and methodological issues. Seminars in Clinical Neuropsychiatry, 5, 64-74. Evidence Level I: Systematic Review. Fick, D. M., Agostini, J.V., & Inouye, S.K. (2002). Delirium superimposed on dementia: a systematic review. Journal of the American Geriatric Society, 50, 1723-1732. Evidence Level I: Systematic Review. Fick, D. M., Cooper, J.W., Wade, W.E., Waller, J.L., Maclean, J.R., & Beers, M.H. (2003). Updating the Beers criteria for potentially inappropriate medication use in older adults: Results of a U.S. consensus panel of experts. Archives of Internal Medicine 163, 2716-2724. Evidence Level IV: Non-experimental Study. Delirium Tullman et al 20 Fick, D., & Foreman, M. (2000). Consequences of not recognizing delirium superimposed on dementia in hospitalized elderly individuals. Journal of Gerontological Nursing, 26, 30-40. Evidence Level IV: Non-experimental Study. Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). “Mini-Mental State”: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189-198. Evidence IV: Non-experimental Study. Holmes, J. D., & House, A. O. (2000). Psychiatric illness in hip fracture. Age & Ageing, 29, 537-546. Evidence Level I: Systematic Review. Inouye, S. K. (2003). The Confusion Assessment Method (CAM): training manual and coding guide. Yale University School of Medicine. Retrieved September 15, 2006 from:http://elderlife.med.yale.edu/pdf/The%20Confusion%20Assessment%20Metho d.pdf Inouye, S. K. (2006). Delirium in older persons. New England Journal of Medicine, 354, 1157-1165. Evidence Level VI: Expert Opinion. Inouye, S. K., Bogardus, S. T., Charpentier, P. A., Leo-Summers, Acampora, D., Holford, T. R., et al. (1999). A multicomponent intervention to prevent delirium in hospitalized older patients. The New England Journal of Medicine, 340, 669-676. Evidence Level II: Single Experimental Study. Inouye, S. K., & Charpentier, P. A., (1996). Precipitating factors for delirium in hospitalized elderly persons: predictive model and interrelationship with baseline vulnerability. Journal of American Medical Association, 275, 852-857. Evidence Level IV: Non-experimental Study. Delirium Tullman et al 21 Inouye, S. K., Foreman, M. D., Mion, L. C., Katz, K. H., & Cooney, Jr., L. M. (2001). Nurses’ recognition of delirium and its symptoms: comparison of nurse and researcher ratings. Archives of Internal Medicine, 161, 2467-2473. Evidence Level IV: Non-experimental Study. Inouye, S. K., VanDyck, C. H., Alessi, C. A., Balkin, S., Siegel, A. P., et al. (1990). Clarifying confusion: The Confusion Assessment Method. A new method for detecting delirium. Annals of Internal Medicine, 113(12), 941-948. Evidence Level IV: Non-experimental Study. Inouye, S. K., Viscoli, C. M., Horwitz, R. I., Hurst, L. D., & Tinetti, M. E. (1993). A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics. Annals of Internal Medicine, 119, 474-481. Evidence Level IV: Non-experimental Study. Kalisvaart, K. J., de Jonghe, J. F., Bogaards, M. J., Vreeswijk, R., Egberts, T. C., Burger, B. J., et al. (2005). Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-controlled study. Journal of the American Geriatrics Society, 53, 1658-1666. Evidence Level II: Single Experimental Study. Kiely, D. K., Bergmann, M. A., Murphy, K. M, Jones, R. N., Orav, E. J., & Marcantonio, E.R. (2003). Delirium among newly admitted post-acute facility patients: prevalence, symptoms and severity. Journal of Gerontology Medical Sciences, 58A (5), 441-445. Evidence Level IV: Non-experimental Study. Laurila, J. V., Pitkala, K. H, Strandberg, T. E., & Tilvis, R. S. (2002). Confusion assessment method in the diagnostics of delirium among aged hospital patients: Delirium Tullman et al 22 would it serve better in screening than as a diagnostic instrument? International Journal of Geriatric Psychiatry, 18(12) 1112-1119. Evidence Level IV: Nonexperimental Study. Marcantonio, E. R., Flacker, J. M., Wright, R. J., & Resnick, N. M. (2001). Reducing delirium after hip fracture: a randomized trial. Journal of the American Geriatrics Society, 49(3) 516-679. Evidence Level II: Non-experimental Study. Marcantonio, E. R., Simon, S. E., Bergmann, M. A., Jones, R. N., Murphy, K. M., & Morris, J. N. (2003). Delirium symptoms in post-acute care: Prevalent, persistent, and associated with poor functional recovery. Journal of the American Geriatrics Society, 51, 4-9. Evidence Level IV: Non-experimental Study. McCarthy, M. C. (2003). Detecting acute confusion in older adults: Comparing clinical reasoning of nurses working in acute, long-term, and community health care environments. Research in Nursing and Health, 26, 203-212. Evidence Level II: Single Experimental Study. McCusker, J., Cole, M., Abrahamowicz, M., Han, L., Podoba, J. E., & Ramman-Haddad, L. (2001). Environmental risk factors for delirium in hospitalized older people. Journal of the American Geriatrics Society, 49, 1327-1334. Evidence Level IV: Nonexperimental Study. McCusker, J., Cole, M., Dendukuri, N., Belzile, E., & Primeau, F. (2001). Delirium in older medical inpatients and subsequent cognitive and functional status: a prospective study. Canadian Medical Association Journal, 165, 575-583. Evidence Level IV: Non-experimental Study. Delirium Tullman et al 23 McNicoll, L., Pisani, M. A., Zhang, Y., Ely, E. W., Siegel, M. D., & Inouye, S. K. (2003). Delirium in the intensive care unit: occurrence and clinical course in older patients. Journal of the American Geriatrics Society, 51, 591-598. Evidence Level IV: Non-experimental Study. Meagher, D. J. (2001). Delirium: optimizing management. British Medical Journal, 322(7279), 144-149. Evidence Level VI: Expert Opinion. Milbrandt, E. B., Deppen, S., Harrison, P. L., Shintani, A. K., Speroff, T., Stiles, R. A., et al. (2004). Costs associated with delirium in mechanically ventilated patients. Critical Care Medicine, 32, 955-962. Evidence Level IV: Non-experimental Study. Milisen, K., Lemiengre, J., Braes, T., & Foreman, M. D. (2005). Multicomponent intervention strategies for managing delirium in hospitalized older people: systematic review. Journal of Advanced Nursing, 52, 79-90. Evidence Level I: Systematic Review. Morrison, R. S., Magaziner, J., Gilbert, M., Koval, K. J., McLaughlin, M. A., Orosz, G., et al. (2003). Relationship between pain and opioid analgesics on the development of delirium following hip fracture. Journals of Gerontology Series A-Biological Sciences & Medical Sciences. 58(1):76-81. Evidence Level IV: Non-experimental Study. O’Keeffe, S. T., & Lavan, J. N. (1999). Clinical significance of delirium subtypes in older people. Age and Ageing, 28, 115-119. Evidence Level IV: Non-experimental Study. O’Keeffe, S. T., Mulkerrin, E. C., Nayeem, K., Varughese, M., & Pillay, I. (2005). Use of serial Mini-Mental State Examinations to diagnose and monitor delirium in elderly Delirium Tullman et al 24 hospital patients. Journal of the American Geriatrics Society, 53, 867-870. Evidence Level IV: Non-experimental Study. Pitkala, K. H., Laurila, J. V., Strandberg, T. E., & Tilvis, R. S. (2006). Multicomponent geriatric intervention for elderly inpatients with delirium: A randomized, controlled trial. Journals of Gerontology A, Biologic Sciences & Medical Sciences 61(2), 176181. Evidence Level II: Single Experimental Study. Parellada, E., Baeza, I., de Pablo, J., & Martinez, G. (2004, March). Risperidone in the treatment of patients with delirium. Journal of Clinical Psychiatry, 65,(3), 348-353. Evidence Level II: Single Experimental Study. Pompei, P., Foreman, M., Rudberg, M. A., Inouye, S. K., Braund, V., & Cassel, C. K. (1994). Delirium in hospitalized older persons: outcomes and predictors. Journal of the America Geriatrics Society, 42, 809-815. Evidence Level IV: Non-experimental Study. Pun, B. T., Gordon, S. M., Peterson, J. F., Shintani, A. K., Jackson, J. C., Foss, J., et al. (2005). Large-scale implementation of sedation and delirium monitoring in the intensive care unit: A report from two medical centers. Critical Care Medicine, 33, 1199-1205. Evidence Level IV: Non-experimental Study. Rudberg, M. A., Pompei, P., Foreman, M. D., Ross, R. E., & Cassel, C. K. (1997). The natural history of delirium in older hospitalized patients: a syndrome of heterogeneity. Age and Ageing, 26, 169-174. Evidence Level IV: Non-experimental Study. Delirium Tullman et al 25 Schuurmans, M. J., Deschamps, P. I., Markham, S. W., Shortridge-Baggett, L. M., & Duursma, S. A. (2003). The measurement of delirium: review of scales.Research Theory in Nursing Practice, 17, 207-224. Evidence Level V: Literature Review. Seitz, D. P., Gill, S. S., & van Zyl, L. T. (2007). Antipsychotics in the treatment of delirium: A systematic review. Journal of Clinical Psychiatry, 68(1), 11-21. Evidence Level I: Systematic Review. Skrobik, Y. K., Bergeron, N., Dumont, M., & Gottfried, S. B. (2004). Olanzapine vs haloperidol: treating delirium in a critical care setting. Intensive Care Medicine, 30, 444-449. Evidence Level II: Single Experimental Study. Trzepacz, P. T., & van der Mast, R. C. (2002). The neuropathophysiology of delirium. In J. Lindesay, K. Rockwood, & A. Macdonald (Eds.), Delirium in old age (pp. 51100). New York: Oxford University Press. Evidence Level VI: Expert Opinion. Trzepacz, P. T., Mittal, D., Torres, R., et al. (2001). Validation of the Delirium Rating Scale-revised-98: comparison with the delriium rating scale and the cognitive test for delirium. Journal of Neuropsychiatry and Clinical Neuroscience 13(3), 229-242. Evidence Level IV: Non-experimental Study. Delirium Tullman et al 26 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]) Delirium Tullman et al 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 Delirium Tullman et al 28 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) Delirium Tullman et al 29 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. Delirium Tullman et al 30 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 Delirium Tullman et al 31 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 Delirium Tullman et al 32 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