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Delirium: suspect it, spot it and stop it.

Delirium is an acute confusional state common in older adults in hospital. Nurses must be alert to risk factors and act to prevent or manage this distressing but reversible condition.

Delirium is an acute and fluctuating confusional state which can occur when someone is ill or injured; it is regarded as acute brain failure, where a person's brain no longer functions as it usually would. Delirium is a serious condition, associated with poor outcomes^ but is potentially reversible if detected and treated. It is more common in older adults, but can occur at any age and should be considered a medical emergency.

Delirium is a common clinical syndrome characterised by:

* Acute onset, fluctuating through the course of the day.

* Decreased ability to maintain or shift attention.

* Changes in cognition or perception.

* Altered levels of consciousness. (2)

Although delirium is one of the most common complications for hospitalised older adults, it is often missed or misdiagnosed as dementia. By recognising risk, diagnosing promptly and managing modifiable risk factors, nurses can help ensure delirium is prevented, or its severity reduced and adverse outcomes mitigated. (1)

Suspect it

The best way to manage delirium is to prevent it. (1,4) Those most at risk are identified in Figure 1 (right).

The biggest problem with delirium is failure to recognise it. (5) This is because older adults, their families and, sometimes, health professionals believe that getting confused goes hand in hand with getting old. This is just not the case. Delirium is common, with up to 50 per cent of older adults experiencing it in their lifetimes. (4,8) It leads to poor outcomes, such as increased rates of admission to residential care, permanent functional and cognitive decline and increased mortality (see Figure 2, p14). (6) Delirium can develop over hours, days, and sometimes weeks, in older adults, (7) and may be the first sign that an older adult is becoming unwell. We need to suspect it, spot it and stop it. Flowever, recognition of delirium is not always straightforward.

Spot it

Delirium can present in many ways. People with delirium can be more confused than normal; they may be fidgety, agitated, or excessively drowsy. This pattern may fluctuate throughout the course of the day. Delirium can be classified into three subtypes--people may present with hyperactive symptoms, hypoactive symptoms or a mixture of the two states. Although the symptoms of hyperactive delirium are more readily identified, hypoactive delirium is the most common subtype--it is harder to spot, and often overlooked.

With hypoactive delirium, the person will be sleepy, drowsy or hard to wake. Nurses need to keep alert for the "good patient" - who is described as "no trouble" or is always asleep. You may notice they are quieter than usual, unable to respond, or have slower responses than normal. They can have difficulty following conversations or nod off when you are talking to them. They may even experience hallucinations but have difficulty communicating this. Often the person with delirium is unable to eat or drink independently and can quickly become dehydrated. People with hypoactive delirium tend to have worse outcomes and their delirium is often more severe and prolonged; they are prone to developing geriatric syndromes such as constipation, pressure injuries, deconditioning and falls. It is here that nursing care can have a significant influence on improving outcomes.

When experiencing hyperactive delirium, people become confused, agitated and sometimes aggressive. They are often hypervigilant, argumentative and suspicious, and could have changes to their sleep-wake cycle. They can be very mobile and prone to falling, if they are unsteady. You may notice they are distracted, plucking or pulling at clothes and bedding, or talking to someone who is not there. They may experience hallucinations or feel they are going mad. This can be frightening and distressing for patients, families, carers and staff. The best way to manage this is to reassure and distract them, using nonpharmacological strategies.

Delirium, dementia or something else?

It can be difficult, when meeting a confused patient, to know what is the cause of their confusion. One of the main characteristics of delirium is its sudden onset. Listening to and asking family members is important in recognising delirium. If you hear family say things like "This is not my mum", or "Dad is not himself--he's not normally like this", be alert to the possibility of delirium. Ask the question, "Is this an acute change?" If there is any doubt about diagnosis, it is recommended to treat as delirium in the first instance. (10,11) Table 1 (right) gives an overview of signs and symptoms of common differentials.

Causes

There may be one or many causes of delirium, including geriatric syndromes, medications or simply a change of environment. It is important to find and treat all identifiable causes (1,9,11). Patients with delirium, or at risk of developing it, should have modifiable risk factors assessed within 24 hours of admission (1) to prevent or reduce the severity of delirium.

There are many tools used to identify delirium--the most widely used are the confusion assessment method (CAM) or brief CAM (bCAM), 4AT, abbreviated mental test (AMT) with either four or 10 questions, months of the year backwards (MOTYB) and the single question in delirium (SQID).

Recent studies (12) indicated the AMT4/10 and the 4AT were all feasible and accurate in routinely identifying more than 86 per cent of patients with a diagnosis of delirium. (12) MOTYB, which is a component of both 4AT and bCAM, was also accurate. Whichever screening tool is used, identifying delirium is essential to enable best care for patients, and support for whanau, relatives and carers.

The pathophysiology of delirium is not well understood. (9) Research suggests mechanisms include inflammatory and stress responses, as well as the impact of direct brain insults, such as stroke, hypoxia, drugs and metabolic abnormalities. (9,13,13) A number of neurotransmitters are believed to be involved in the pathogenesis of delirium--these include acetylcholine, serotonin, dopamine and gamma-amino-butyric-acid (GABA). Up-regulation or down-regulation of these neurotransmitters leads to the symptoms of delirium. While anyone can experience delirium, advanced age and dementia are major risk factors, and vulnerable individuals can become delirious with a relatively small insult.5 Once delirium has been diagnosed, it is important to treat all potential causes, manage symptoms and reduce distress. (1)

Why suspecting, spotting and stopping is important

While delirium is potentially reversible, undiagnosed or severe delirium, or delirium occurring in vulnerable people, can often be prolonged, leading to permanent functional and cognitive decline. (1,5) It is not known how well a person with delirium will recover in these situations. (5)

Managing modifiable risk factors, such as polypharmacy, sensory impairment, dehydration, constipation, deconditioning and infection, has the biggest impact on preventing delirium and reducing severity and duration, once delirium has developed. (1, 11) To both prevent and manage delirium, nursing interventions should aim to optimise conditions for the brain by meeting basic care needs, managing modifiable risk factors such as sleep disturbance or sensory impairment, and addressing geriatric syndromes to reduce harm, (1,4,5,11, 15,16)

Recommended interventions

* Prevent deconditioning--mobilise, sit in chair for meals.

* Prevent dehydration--aim for fluid intake of [greater than or equal to]1.2L/24 hours unless otherwise indicated.

* Reduce constipation risk.

* Monitor and manage pain (consider Abbey pain scale).

* Reduce the risk of pressure injuries--monitor skin integrity.

* Reduce unnecessary line or catheter use where possible.

* Provide an environment conducive to sleep.

* Maintain or restore sleep-wake cycle patterns.

* Provide a low-stimulus, well-lit environment during waking hours.

* Reduce risk of falling--consider falls alarm and/or floor-line bed.

* Consider regular checks or close observation.

* Ensure visual/hearing aids are used where possible.

Delirium can be distressing for whanau. To reduce this distress, nurses should provide support and education about delirium. (15,16) Education could be in the form of information leaflets or brochures.

They should encourage family members to become involved in non-pharmacological management strategies, where possible. This could include bringing in personal items, such as familiar objects, blankets, clothes, books, photo albums and knitting to help prevent distress. Nurses can also encourage families to support the person's normal routine - such as taking short walks and getting out of bed before meals.

It is important to keep communication with the patient simple. Reorientation can be part of your usual conversation with them, such as "Good morning, it's time for breakfast", and opening curtains, using natural daylight. Encourage families to do the same. Use clocks, calendars, newspapers and notebooks or diaries as orientation strategies. Reassure patients by letting them know where they are, why they have been admitted, what is happening and how they are doing. It is best practice to avoid multiple ward transfers or transfers within a ward, (1) as this can be more disorientating. When patients are distressed or agitated, consider distraction techniques such as looking at family photographs or using books, magazines or "fiddle mitts" to get them talking. Promote relaxation and sufficient sleep, which can be encouraged with regular exercise, massage and wakefulness during the day.

A person with delirium will feel calmer if you and their family keep composed and try not to show distress. Tactfully disagree, distract or change the subject, if they display any unusual thoughts or ideas. The best way to manage a patient's distress is to have someone they know with them.

Medications should only be used if the patient is highly agitated or distressed, or a risk to themselves or others, (1,11,16) Start low and go slow with medications, for the shortest time possible, and observe for adverse reactions. Haloperidol can help diminish arousal, perceptual abnormalities and persecutory ideation. Newer antipsychotics, such as quetiapine and risperidone, should be considered. (4) The medical team may consider lorazepam for unremitting agitation; however, benzodiazepines should be avoided in the elderly. There may be a role for liaison psychiatry in unremitting or severe delirium, or where there are challenging behaviours that are difficult to manage.

Conclusion

Delirium is an acute and fluctuating confusional state which is common in older adults admitted to hospital. By understanding which patients are at risk of delirium, its causes, how to recognise it and putting interventions in place to either prevent or manage it, nurses are well placed to lead all aspects of delirium care. In essence, prevention is better than cure; delirium is distressing. To prevent adverse outcomes for patients, families and health-care providers, we need to suspect it, spot it and stop it.

* This article was reviewed by Auckland University professor of gerontology nursing Matthew Parsons, RN, MSc, PhD, and by the co-editors of Kai Tiaki Nursing New Zealand.

* The authors thank doctors M S Krishnan, Sophia Bennett and Eleni Fixter at Tees, Esk and Wear Valleys National Health Service Foundation Trust, United Kingdom, for use of images and resources.

Elaine Docherty, RN, PGDip(adv nurs prac), MHPrac, is a gerontology nurse specialist at Waitemata District Health Board.

Catherine Mounsey, RN, PGDip(adv nurs prac), MHPrac, is a clinical nurse co-ordinator for Health in Ageing at Bay of Plenty District Health Board.

References

(1) National Institute of Clinical Excellence. (2014). Delirium in Adults (QS63). UK: Author.

(2) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed). Washington, DC: Author.

(3) Gordon, S. J., Melillo, K. D., Nannini, A., & Lakatos, B. E. (2013). Bedside coaching to improve nurses' recognition of delirium. Journal of Neuroscience nursing, 45(5), 288-293. doi: 10.1097/JNN.0b013e31829d8c8

(4) Fong, T. G., Tulebaev, S. M., & Inouye, S. K. (2009). Delirium in elderly adults: Diagnosis, prevention and treatment. Nature Reviews Neurology, 5(4), 210-220. doi: 10.1038/nrneurol.2009.24

(5) Inouye, S. K., Westendorp, R. G. J., & Saczynski, J. S. (2014). Delirium in elderly people. The Lancet, 383(9920), 911-922. doi: 10.1016/ S0140-6736(13)60688-1

(6) Tan, A. H., & Scott, J. (2015). Association of point prevalence diagnosis of delirium on length of stay, 6-month mortality, and level of care on discharge at Waitemata District Health Board, Auckland. New Zealand Medical Journal, 128(1411), 68-76.

(7) Cerejeira, J. & Mukaetova-Ladinska, E. B. (2011). A clinical update on delirium: From early recognition to effective management. Nursing Research and Practice, 1-12. http://dx.doi.org/10.1155/2011/875196

(8) Martins, S. & Fernandes, L. (2012). Delirium in elderly people: A review. Frontiers in Neurology, 3, 1-12. http://dx.doi.org/10.3389/ fneur.2012.00101

(9) Maldonado, J. R. (2013). Neuropathogenesis of delirium: Review of current etiologic theories and common pathways. American Journal of Geriatric Psychiatry, 21(12), 1190-1222. doi: 10.1016/j.jagp.2013.09.005

(10) Purchas, M., Pollard, P., & Boyd, F. (2015). Clinical Guidelines for the Management of Delirium in Adults. United Kingdom: National Health Service Trust.

(11) Healthcare Improvement Scotland. (2014). Think Delirium: Improving the care for older people. Scotland: Author.

(12) Hendry, K., Quinn, T. J., Evans, 3., Scortichini, V., Miller, H., Burns, 3., Cunnington, A., & Stott, D. 3. (2016). Evaluation of delirium screening tools in geriatric medical inpatients: a diagnostic test accuracy study. Age and Ageing (advance online publication). doi:10.1093/ ageing/afwl30

(13) MacLullich, A. M. 3., Anand, A., Davis, D. H. 3., Jackson, T., Barugh, A. J., Hall, R. J.,... Cunningham, C. (2013). New horizons in the pathogenesis, assessment and management of delirium. Age and Ageing, 42(6), 667-674. doi: 10.1093/ageing/aftl48

(14) Cunningham, C. 8< MacLullich, A. M. (2013). At the extreme end of the psychoneuroimmunological spectrum: delirium as a maladaptive sickness behaviour response. Brain, Behavior and Immunity, 28, 1-13. doi: 10.1016/j.bbi.2012.07.012

(15) Bannon, L., McGaughey, J., Clarke, M., McAuley, D. F., & Blackwood, B. (2016) Impact of non-pharmacological interventions on prevention and treatment of delirium in critically ill patients: protocol for a systematic review of quantitative and qualitative research. Systematic Reviews, 5, 75. doi: 10.1186/sl3643-016-0254-0

(16) Martinez, F. T., Tobar, C., Beddings, C. I., Vallejo, G., & Fuentes, P. (2012). Preventing delirium in an acute hospital using a non-pharmacological intervention. Age and Ageing, 41(5), 629-634. doi: 10.1093/ageing/afs060

Table 1. Differentiating delirium from dementia and depression

              Delirium            Depression          Dementia

Definition    Acute fluctuating   A change of mood    Gradual and
              onset,              lasting at least    progressive
              disturbance in      two weeks with      decline in mental
              attention,          feelings of         processing
              disorganised        sadness,            ability affecting
              thinking, change    affecting all       memory,
              in level of         aspects of          communication,
              consciousness.      function and        language,
                                  cognition.          judgement and
                                                      abstract
                                                      thinking.

Onset         Hours to days.      Weeks to months.    Months to years.
Course,       Potentially         Usually             Progressive, may
progression   reversible.         reversible with     be slowed with
                                  treatment.          treatment but not
                                                      reversed.

Duration      Hours to months.    Months to years.    Months to years.

Memory        Impaired recent     Generally intact.   Impaired recent
              and immediate.                          and remote
                                                      memory.

Thinking      Fluctuating         Reduced             Difficulty with
and thought   alertness and       concentration,      executive
              cognition.          low self-esteem,    function,
                                  feelings of         processing and
                                  hopelessness.       communication,
                                                      which affects
                                                      function.

Speech        Disorganised,       Generally           Word finding
              rambling and/or     understandable.     difficulty.
              incoherent.

Sleep         Disturbed, but no   Disturbed, early    May have
patterns      set pattern; may    morning wakening    nocturnal
              have day/night      or hypersomnia.     wandering and
              reversal.                               confusion.

Behaviour     Behaviour           Withdrawn,          May include
              fluctuates or       decreased           delusions,
              varies.             motivation and      suspicions and
                                  interest.           paranoia.
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Title Annotation:practice
Author:Docherty, Elaine; Mounsey, Catherine
Publication:Kai Tiaki: Nursing New Zealand
Date:Nov 1, 2016
Words:2521
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