Differentiating between delirium and dementia: New Zealand's ageing population is increasing rapidly. Delirium and dementia are two common aged-related conditions. It is important nurses can differentiate between them.[ILLUSTRATION OMITTED] The number of New Zealanders This is a list of well-known people associated with New Zealand. Art A
Condition of disorientation, confused thinking, and rapid alternation between mental states. The patient is restless, cannot concentrate, and undergoes emotional changes (e.g., anxiety, apathy, euphoria), sometimes with hallucinations. and dementia are two common age-related health conditions. The prevalence of delirium is estimated to be from five percent to 80 percent in ill, older adults, depending on health care settings. (2,3) The prevalence of dementia doubles every five years from the age of 65 until 85 and older. At least 22 percent of people over the age of 85 have dementia in New Zealand New Zealand (zē`lənd), island country (2005 est. pop. 4,035,000), 104,454 sq mi (270,534 sq km), in the S Pacific Ocean, over 1,000 mi (1,600 km) SE of Australia. The capital is Wellington; the largest city and leading port is Auckland. . (4) Nurses provide the majority of health care to older adults across all health care settings. In hospitals, nurses provide round-the-clock patient surveillance and are the primary source of information about changes in an older person's health status to other health professionals. (5) Similarly, in primary health care, nurses are likely to know older people and their families well and are in a position to note health changes and advocate for referral to specialist medical care. Given the social, health and financial implications associated with delirium and dementia, it is crucial that nurses maintain a high Level of vigilance for these conditions when coming in contact with ill, confused older people. (6,7) Older people with delirium or dementia frequently present with confusion. Determining the cause of the confusion requires careful assessment. Nurses need to ask: "What is causing the confusion?" Is it delirium? Dementia? A combination of the two? Or something entirely different? Determining the cause of the confusion is important. Incorrect or delayed diagnoses can increase hospital stays, result in inappropriate placement into residential care, and cause intentional and/or unintentional injury unintentional injury Accidental injury Public health Any injury caused by an accident. See Injury. , premature death Premature Death occurs when a living thing dies of a cause other than old age. A premature death can be the result of injury, illness, violence, suicide, poor nutrition (often stemming from low income), starvation, dehydration, or other factors. and an increased use of already scarce health resources. (7) Accurate nursing assessment is a critical element in the identification of health problems and treatment strategies for older adults who have delirium and/or dementia. This practice update provides information on the differentiation between these two debilitating de·bil·i·tat·ing adj. Causing a loss of strength or energy. Debilitating Weakening, or reducing the strength of. Mentioned in: Stress Reduction and adverse health events, along with some useful assessment frameworks and other resources. Comments from people with delirium and dementia are interspersed throughout the article to draw attention to the impact of these conditions on people's lives and well-being. Definitions of delirium and dementia Delirium is a temporary and acute state of confusion, also referred to as an acute confusional state. The American Psychiatric Association The American Psychiatric Association (APA) is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential world-wide. Its some 148,000 members are mainly American but some are international. identifies delirium as a transient organic mental syndrome organic mental syndrome n. Abbr. OMS See organic brain syndrome. characterised by a reduced Level of consciousness, reduced ability to focus, perceptual disturbances and memory impairment. (8) Common causes of delirium include infection, neurological, cardiological and respiratory events, electrolyte imbalance electrolyte imbalance Critical care A general term for a derangement of major electrolytes–Na+, K+, chloride; thus defined, EI is common; in practice, EIs are only of interest if they cause clinical disease , an alteration in the endocrine and metabolic systems and the side effects Side effects Effects of a proposed project on other parts of the firm. of drug therapy including poly-pharmacy. Other risk factors include older age, the use of restraints, visual and/or hearing impairment hearing impairment n. A reduction or defect in the ability to perceive sound. , the presence of another cognitive disorder (for example dementia), alcoholism and changes to routines and the environment. (3) These causes of delirium are unsurprising when considered alongside the physiological processes associated with ageing. For example, age-related changes affect the body's ability to detect fever as a response to infection, the ability to regulate the amount and make-up of body fluids and a decrease in the ability to detect thirst, as well as the age-related alterations associated with changes in vision and hearing. Delirium subtypes are classified as hyperactive hy·per·ac·tive adj. 1. Highly or excessively active, as a gland. 2. Having behavior characterized by constant overactivity. 3. Afflicted with attention deficit disorder. , hypoactive and mixed delirium types. (9,10) With a hyperactive delirium, the older person presents not only with increased psychomotor psychomotor /psy·cho·mo·tor/ (si?ko-mo´ter) pertaining to motor effects of cerebral or psychic activity. psy·cho·mo·tor adj. 1. activity but is also irritable and overly responsive to stimuli. On the other hand, a hypoactive delirium is characterised by reduced psychomotor activity and drowsiness drows·i·ness n. A state of impaired awareness associated with a desire or inclination to sleep. Also called hypnesthesia. drowsiness Medtalk Semiconsciousness; grogginess, sleepiness . Due to its subtle presentation, a hypoactive delirium is the most difficult to detect. Mixed presentations include, as the name suggests, aspects of both the hyperactive and hypoactive types. Lily, a 76-year-old woman describes the physiological changes that resulted in her delirium. "I kept getting this really bad pain ... It got so bad, I kept vomiting. All of the vomiting left me dehydrated ... they x-rayed me while I was in the throes of pain, you see, so they knew what to do then. So the next night, the next afternoon, he operated and that is when I sort of passed out and everything went wrong and what have you." (2) The dementias are grouped in categories related to causation, such as dementia of the Alzheimer's type, vascular dementia vascular dementia n. A steplike deterioration in intellectual functions that result from multiple infarctions of the cerebral hemispheres. Also called multi-infarct dementia. and dementia due to other medical conditions See carpal tunnel syndrome, computer vision syndrome, dry eyes and deep vein thrombosis. such as Parkinson's disease Parkinson's disease or Parkinsonism, degenerative brain disorder first described by the English surgeon James Parkinson in 1817. When there is no known cause, the disease usually appears after age 40 and is referred to as Parkinson's disease. and Huntington's disease Huntington's disease, hereditary, acute disturbance of the central nervous system usually beginning in middle age and characterized by involuntary muscular movements and progressive intellectual deterioration; formerly called Huntington's chorea. . (8) Dementia of the Alzheimer's type is the most common form of dementia, and has a gradual onset, in contrast to delirium. There are initial memory problems and later development of aphasia aphasia (əfā`zhə), language disturbance caused by a lesion of the brain, making an individual partially or totally impaired in his ability to speak, write, or comprehend the meaning of spoken or written words. (language deterioration), apraxia apraxia Disturbance in carrying out skilled acts, caused by a lesion in the cerebral cortex; motor power and mental capacity remain intact. Motor apraxia is the inability to perform fine motor acts. Ideational apraxia is loss of the ability to plan even a simple action. (impaired motor function ability despite intact motor ability), agnosia Agnosia An impairment in the recognition of stimuli in a particular sensory modality. True agnosias are associative defects, where the perceived stimulus fails to arouse a meaningful state. (loss of ability to identify objects) and disturbances in executive functioning In neuropsychology and cognitive psychology, executive functioning is the mental capacity to control and purposefully apply one's own mental skills. Different executive functions may include: the ability to sustain or flexibly redirect attention, the inhibition of inappropriate (as demonstrated in problems related to abstract thought and the management of complex behaviour). The course of the disease is generally over eight to 10 years with continuing cognitive decline, measurable on assessment instruments such as the Mini-Mental State Exam (MMSE MMSE Mini Mental State Examination MMSE Minimum Mean Squared Error MMSE Mini-Mental Status Examination MMSE Multiuse Mission Support Equipment MMSE Multimission Support Equipment MMSE Multi Media Service Environment ), and the development of motor and gait disturbances in the later stages leading to profound disability. Alzheimer's disease Alzheimer's disease (ăls`hī'mərz, ôls–), degenerative disease of nerve cells in the cerebral cortex that leads to atrophy of the brain and senile dementia. is diagnosed by a process of exclusion of all other causes for the dementia. (8) Some factors have the potential to complicate the diagnostic process of differentiating between delirium and dementia. Firstly, an older person who has been hospitalised is more likely to experience an episode of delirium if they already have dementia. (12) Secondly, links have been made suggesting an increased occurrence of dementia following an episode of delirium. (13) Finally, Insel and Badger assert that cognitive decline (for example, not remembering names or phone numbers) can be an expected component of the normal ageing process and needs to be differentiated from delirium and dementia. (14) Diana McGowin wrote about her fears at the time of her diagnosis of Alzheimer's disease. She reveals the human impact of diagnosis invisible in medical and clinical descriptions and her need for ongoing support. "What I wanted, no, what I needed, was someone to assure me that no matter what my future held, they would stand beside me, fight my battles with me, or, if need be, for me. I wanted an assurance from someone that I would not be abandoned to shrivel away. They would give me encouragement, love, moral support and if necessary take care of me." (11) Furthermore, although dementia and delirium have been recognised as two separate entities, there are points where the two conditions overlap. It has been noted that delirium resolves over a period of time but these times vary from hours, weeks, days, through to months. For example, in one study it was reported that approximately 80 percent of participants still had a resolving delirium up to six months post discharge from hospital. (15) The potential for 'terminological, confusion' is therefore apparent, with research identifying that there is an increased incidence of misdiagnosis mis·di·ag·no·sis n. pl. mis·di·ag·no·ses An incorrect diagnosis. mis·di  ag·nose as welt weltn. 1. A ridge or bump on the skin caused by a lash or blow or sometimes by an allergic reaction. 2. See wheal. as an under detection of delirium and dementia. (2,12) Nursing assessment strategies When a person presents with a confusional state, a detailed history is required. If the person is unable to provide the information him or herself, then the involvement of family members and/or significant others is pivotal. (2) If the person is presenting to the health service for the first time, then an 'investigating a presenting concern framework' such as PQRST PQRST Palliative/Provoking, Quality, Radiation, Severity, Timing (Chest Pain Evaluation) or COLDSPA COLDSPA Character, Onset, Location, Duration, Severity, Pattern and Associated Factors (illness assessment) should be used. (16) (See Table 1.) These frameworks are useful mnemonic Pronounced "ni-mon-ic." A memory aid. In programming, it is a name assigned to a machine function. For example, COM1 is the mnemonic assigned to serial port #1 on a PC. Programming languages are almost entirely mnemonics. devices to help nurses assess an older person who may have delirium or dementia. Other assessment data to gather include: * Past and most recent health history, as well as family history, including any mental health problems. * Social history, including any recent changes in the person's environment and alcohol consumption. * Nutritional intake. * The use of prescription and over-the-counter medication, as well as recreational drugs. If, during the interview process, it has been revealed that, for example, the person has recently been unwell with a cold, then physical examination of the chest should be undertaken using the assessment skills of auscultation auscultation Procedure for detecting certain defects or conditions by listening for normal and abnormal heart, breath, bowel, fetal, and other sounds in the body. The invention of the stethoscope in 1819 improved and expanded this practice, still very useful despite the and percussion to determine if there is any underlying physical health issue that is causing the confusional state. The assessment findings should be documented in the clinical notes and followed up. This might mean suggesting and ensuring that further investigations such as urinalysis, full blood count, blood chemistry profiling and a chest x-ray chest x-ray, n an examination of the chest using x-rays. Routinely performed in patients complaining of chest pain to rule out respiratory or heart disease. chest X-ray Chest film, see there be done. In addition, a structured mental status assessment should be undertaken to form the foundation for further more focused cognitive assessments. The MMSE is a general cognitive screening test ideally suited for this function, measuring memory, orientation, language, attention, visuospatial visuospatial /vis·uo·spa·tial/ (-spa´shal) pertaining to the ability to understand visual representations and their spatial relationships. vis·u·o·spa·tial adj. and constructional skills. (17) The MMSE is widely utilised and research has shown that lower scores on this tool are indicative but not conclusive of delirium and/or dementia. (7) Several instruments are available to assist with a diagnosis of delirium in the older adult. Of these the most widely used is the Confusion Assessment Method (CAM). (18) Another scale commonly used is the Neecham Confusion Scale, a delirium focused tool. (19) Neville identifies the CAM as being both expedient and effective to use in the older population across health care settings in New Zealand. (2) The ease of use enables people without formal mental health education, for example, general nurses working in an acute medical or surgical unit, health personnel in the residential care sector and general physicians to undertake an assessment of delirium in about five minutes. Harry, a 72-year-old man who identifies himself as having a strong Christian faith explains his experience of being delirious in the following way "... To my mind I was being attacked by the prince of darkness ... his force was sucking at me and everything was distorted. It was as though there was a barrier which I couldn't get through ... and the nurse gave me the impression that she was demonic. It drove me nuts." (2) When a dementing illness is suspected, referral to a medical specialist is necessary for the diagnostic investigations required to exclude any treatable causes of the symptoms, such as depression and delirium. Early diagnosis is also important to ensure people with a dementia such as Alzheimer's disease have access to pharmaceutical treatments, cholinesterase inhibitors and memantine, which maintain cognitive functioning in some people for a limited time. (20) There is also increasing interest in reducing the impact of dementia through addressing risk factors such as cardiovascular disease Cardiovascular disease Disease that affects the heart and blood vessels. Mentioned in: Lipoproteins Test cardiovascular disease . (21) Nursing responsibilities in relation to dementia include timely assessment of health status, advocating for prompt referral and diagnosis, helping people to adjust to the diagnosis and providing ongoing and well-paced education about disease management strategies, financial entitlements and care-giving support to the person, family and friends. (22) Table 2 lists some useful online sites for further information about assessment frameworks, and educational and community resources for delirium and dementia. Conclusion Nurses, along with other health professionals have a critical rote to play in maximising health and family well-being through working knowledgably with people and their families. The ability to discriminate between delirium and dementia and to provide competent nursing care is based on a range of attributes. Knowledge is required about age-related change and likely disease processes, along with an understanding of the difference between delirium and dementia and the appropriate nursing interventions. Nursing skills include the ability to collect relevant data, along with effective communication with the patient, family and other health professionals. An attitude of vigilance, along with an acceptance of the need for advocacy for high quality health care for older people and their families, is the foundation for effective nursing action. References (1) Statistics New Zealand Statistics New Zealand (In Māori, Tatauranga Aotearoa) is the state sector organisation of New Zealand which is responsible for the country's official statistics, under the authority of the 1975 Statistics Act. . (2004) Older New Zealanders-65 and beyond. Wellington: Statistics New Zealand. (2) Neville, S. (2005) Delirium in the older adult: A critical gerontological ger·on·tol·o·gy n. The scientific study of the biological, psychological, and sociological phenomena associated with old age and aging. ge·ron approach. Unpublished doctoral dissertation, Massey University Massey University (Māori: Te Kunenga ki Purehuroa) is New Zealand's largest university with approximately 40,000 students. It has campuses in Palmerston North (sites at Turitea and Hokowhitu), Wellington (in the suburb of Mt Cook) and , Palmerston North Palmerston North, city (1996 pop. 73,095), S North Island, New Zealand. It is a transportation and farm-marketing center with diverse industries. The city's agricultural college, founded in 1926, became Massey Univ. in 1964. . (3) Siddiqi, N. and House, A. (2006) Delirium: An update on diagnosis, treatment and prevention. Clinical Medicine; 6: 6, 540-543. (4) Ferri, C.L., Prince, M., Brayne, C., Brodaty, H., Fratiglioni, L., Ganguli, M., Hall, K., Hasegawa, K., Hendie, H., Huang, Y, Jorm, A., Mathers, C., Menezes, P.R., Rimmer, E. and Scazufca, M. (2005) Global prevalence of dementia: A Delphi consensus study. The Lancet: 366, 2112-2117. (5) Neville, S., Gillon, D. and Milligan, K. (2006) New Zealand registered nurses' use of physical assessment skills. Vision. A Journal of Nursing; 14:1, 13-19. (6) New Zealand Guidelines Group. (2003) Assessment processes for people aged 65 years and over. Wellington: New Zealand Guidelines Group. (7) Virani, T., Santos, J. McConnell, H., Mason, M., Scott, C., Gergolas, E. and Powell, K. (2003) Nursing best practice guidelines practice guidelines Medical practice A set of recommendations for Pt management that identifies a specific or range of range of management strategies. See Peer review organization, Practice standards. Cf 'Cookbook' medicine. . Screening for delirium, dementia and depression in older adults. Ontario: Registered Nurses Association of Ontario. 8) American Psychiatric Association. (2000) Diagnostic end statistical manual of mental disorders mental disorders: see bipolar disorder; paranoia; psychiatry; psychosis; schizophrenia. : DSM-IV-TR DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (Text Revision) (American Psychiatric Association) . Washington, DC: Author. (9) Lipowski, Z. (1990) Delirium: Acute confusional states. Oxford: Oxford University Press, (10) Schuurmans, M,, Duursma, S. and Shortridge-Baggett, L. (2001.). Early recognition of delirium: Review of the literature. Journal of Clinical Nursing; 30, 721-729. (11) McGowin, D. (1994) Living in the Labyrinth. Cambridge: Mainsail Press. (12) Irving, K., Fick, D. and Foreman, M. (2006) Delirium: A new appraisal of an old problem, International Journal of Older People Nursing; 1, 106-112. (13) Fick, D. and Foreman, M. (2000) Consequences of not recognizing delirium superimposed su·per·im·pose tr.v. su·per·im·posed, su·per·im·pos·ing, su·per·im·pos·es 1. To lay or place (something) on or over something else. 2. on dementia in hospitalized elderly individuals. Journal of Gerontological Nursing; 26: 1., 30-40. (14) Insel, K. and Badger, r. (2002). Deciphering the 4 D's: Cognitive decline, delirium, depression and dementia--a review. Journal of Advanced Nursing; 38: 4, 360-368. (15) Inouye, S. (1994) The dilemma of delirium: Clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients. The American Journal of Medicine; 97, 278-288. (16) Weber, J. and Kelley, J. (2007) Health assessment in nursing (3rd ed.). Philadelphia: Lippincott, Williams & Wilkins. (17) Folstein, M., Folstein, S. and McHugh, P. (1975) "Mini Mental State": A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatry and Research; 12, 189-198. (18) Inouye, S., van Dyck, C., Alessi, C,, Batkin, S., Siegal, A. and Horwitz, R. (1990) Clarifying confusion: The Confusion Assessment Method. Annal An´nal n. 1. See Annals. of Internal Medicine; 113, 941-948. (19) Neelon, V., Champagne, M., Carlson, J. and Funk, S. (1996) The Neecham Confusion Scale: Construction, validation, and clinical testing, Nursing Research; 45, 324-330. (20) Waldemar, G., Dubois, B., Emre, M., Georges, J., McKeith, I. G., Rossor, M., Scheltens, P., Tariska, P. and Winblad, B. (2007) Recommendations for the diagnosis and management of Alzheimer's disease and other disorders associated with dementia: EFNS EFNS Educational Foundation for Nuclear Science EFNS European Federation of Neurological Societies guideline. European Journal of Neurology; 14, e1-e26. (21) Cooper, 8. (2002) Thinking preventively about dementia: A review. International Journal of Geriatric Psychiatry; 17, 895-906. (22) Gilmour. J. A. and Huntington, A. D. (2005) Finding the balance: Living with memory loss. International Journal of Nursing Practice; 11, 118-124. This article was reviewed by Kai Tiaki Nursing New Zealand's practice article review committee in August 2007. Stephen Neville, RN, PhD, and Jean Gilmour, RN, PhD, are both senior lecturers in the School of Health Sciences--Auckland, Massey University. Table 1 'A PRESENTING CONCERN FRAMEWORK' P = provocative/palliative (what makes it worse/better, what causes it?) Q = quality/quantity (how much does it feel, look, sound, how much is there?) R = region/radiation (where is it and does it spread?) S = severity (rate on a scale) T = timing (when did it begin, how often does it occur, is it sudden or gradual?). C = character (describe the sign/symptom, how does it feel, took etc?) O = onset (when did it begin?) L = rotation (where is it, does it radiate?) D = duration (how long does it last?) S = severity (rate on a scale) P = pattern (what makes it better/worse?) A = associated factors (are there any other signs or symptoms?) Table 2 USEFUL ONLINE RESOURCES * Comparison of the clinical features of acute confusion, dementia and depression. National guidelines for the support and management of people with dementia. Available on line at http://www.nzgg.org.nz/ guidelines/0045/Guidelines_For_People_With_Dementia.pdf * Mini Mental State ExaminationNational guidelines for the support and management of people with dementia. Available at: http:// www.nzgg.org.nz/guidelines/0045/Guidelines_For_People_With_Dementia.pdf * SPICES: An Overall Assessment Toot of Older Adults ;The Geriatric Depression Scale (GDS); Confusion Assessment Method (CAM); Recognition of Dementia in Hospitalized Older Adults; Assessing and Managing Delirium in people with Dementia. Available at: http:// www.geronurseonline.org/index.cfm?section_id=7 * On -line information sheets about dementia with topics including Alzheimer's disease, communication, understanding behaviours, dementia and driving, legal matters, and younger people with memory loss. Available at Alzheimers New Zealand at http://www.alzheimers.org.nz/ resources.php * Practice guideline for the treatment of people with delirium: http://www.mentalhealth.com/dis/p20-or01.html * Dementia Advocacy and Support Network International: An international group for people with dementia. Has numerous educational resources and a chat group for people with dementia: http://www.dasninternational.org/ * Contacts for the 23 member organisations of Alzheimers New Zealand. These organisations support all people with dementia, their family and friends, through services such as support groups, caregiver education, educational resources, day care and advocacy: http:// www.alzheimers.org.nz/contactus.php |
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