what is delirium?
a common and serious medical condition characterised as an acute state of confusion
which age group is delirium most common in? why is this?
most common in older people due to their increased risk factors and comorbidities
older people with delirium are more likely to experience what sort of outcome?
an adverse one. more likely to be admitted permanently to a residential facility, to stay in hospital longer and experience iatrogenic complications, even more likely to die
two types of delirium
hypoactive and hyperactive
decreased physical activity, withdrawal, lethargy
hypoactive delirium
decreased speed and amount of speech, staring, listlessness
hypoactive delirium
drowsiness and reduced awareness of surroundings
hypoactive delirium
increased physical activity, hyper arousal, hyper alterness
hyperactive delirium
hallucinations, delusions and agitation
hyperactive delirium
rambling speech and restlessness
hyperactive delirium
onset of delirium
quickly, in days or hours
how long can delirium last for?
up to a month
what can make delirium difficult to catch on to?
it fluctuates throughout the day, and behaviours can change quickly
delirium can cause deterioration of what?
the memory
risk factors - demographic
over 65yrs
risk factors - cognitive state
prior episode of delirium, dementia or depression
risk factors - comorbidities
acute or chronic medical condition
risk factors - sensory impairment
visual or hearing loss
risk factors - surgery
procedure requiring general anaesthetic or sedation
risk factors - medications
polypharmacy, withdrawal from drugs or alcohol
risk factors - hospital related (iatrogenic)
overstimulation/understimulation, ICU admission, multiple ward changes
decreased sensation of thirst and chewing strength and taste can result in what?
dehydration and malnutrition, both which are risk factors for delirium
musculoskeletal degeneration and disturbed sleep patterns can result in what?
pain and mobility issues, lack of sleep > both which are risk factors for delirium
ineffective drug metabolism and suppressed immune response can result in what?
build up of toxins and hidden signs of infection > both which are risk factors for delirium
3 nursing interventions for delirium
- physical and verbal orientation cues
- assessing and treating pain regularly
- collaboration with multidisciplinary team
3 more nursing interventions for delirium
- supporting and educating family and friends
- assisting the person with eating and drinking
- managing surrounds (sound and lighting)
prolonged delirium can cause
a dementia process to develop in the brain
in older people, delirium may be the only sign of what?
an underlying acute medical condition
does a dementia diagnosis guarantee delirum?
no
the first step to recognising delirium is noticing what?
behavioural changes
2 most commonly use assessment tools for delirium
- confusion assessment tool (CAM)
- the 4AT
the recognition of delirium by CAM requires the presence of…
feature 1 and 2 AND either 3 or 4
feature 1 of CAM
acute onset and fluctuating course
acute onset and fluctuating course
- is there evidence of an acute change in mental status from the person’s usual state?
- does the behaviour fluctuate during the day, coming and going or decrease/increase in severity?
feature 2 of CAM
inattention
inattention
does the person have difficulty focusing their attention? are they easily distracted or having trouble keeping track of what is being said?
feature 3 of CAM
disorganised thinking
disorganised thinking
is the person’s thinking disorganised or incoherent? are they rambling? switching from subject to subject or showing an illogical flow of ideas?
feature 4 of CAM
altered level of consciousness
altered level of consciousness
any response other than ‘alert’ to rating consciousness
- alert: normal
- vigilant; hyper alert
- lethargic; drowsy, easily roused
- stupor; difficult to rouse
- coma; unrousable
the 4AT
score of 4 or more indicates delirium
causes of delirium - D
drugs; newly introduced ones, dosage changes or polypharmacy
causes of delirium - E
electrolyte abnormalities and pain
causes of delirium - L
lack of drugs; withdrawal from alcohol, nicotine, benzodiazepines
causes of delirium - I
infection; UTI, respiratory infections
causes of delirium - R
reduced sensory input; hearing/visual impairment, darkness, change in environment
causes of delirium - I (second one)
intracranial problems; stroke, meningitis, seizures, dementia
causes of delirium - U
urinary retention, constipation
causes of delirium - M
myocardial problems; myocardial infarction, heart failure and arrhythmia
what are the 5 P’s of delirium?
pee, poo, pain, pus, pills
PEE
UTIs, dehydration (leading to decreased urinary output), urinary retention, indewlling catheter insertion
POO
constipation and diarrhoea
PUS
infection of any kind can cause delirium
PAIN
unidentified/unmanaged pain can also cause delirium
PILLS
interactions and adverse effects of medications can bring on delirium
environment for those with hyperactive delirium
too much noise or overstimulation can induce/worse the symptoms. often need single room or quieter environment to foster recovery
in investigating delirium, what information should be gathered when obtaining the person’s history? (4 things)
- full head to toe assessment
- set of vitals
- identify recent medication changes
- identify any comorbidities
4 investigations used to screen for causes of delirium
- urinalysis, MSU
- blood tests
- chest x-ray
- electrocardiogram (ECG)
blood test to determine cause for delirium should test for?
- kidney function
- electrolytes
- glucose
- calcium
- liver function
- cardiac enzymes
- B12
- folate
- thyroid function
if a fever or cough is present (shown by chest x-ray or in chest ausculation), what order may be made?
blood or sputum cultures
if pt is SOB, has a cough, or pathology has detected anything abnormal in the chest, what order may be made?
arterial blood gases (ABGs)
if pt has a history of falls, is on anticoagulants, or has neurological signs present, what test may be ordered?
CT brain scane
if headache, fever and meningism are present, what may be ordered?
lumbar puncture
what test may assist in determining differential diagnosis such as a non-convulsive status epilepticus?
electroencephalogram (EEG)
