DELIRIUM

Delirium is characterized by an acute state of confusion that is transient and fluctuates over the course of a day. It is associated with disturbances of consciousness, attention, cognition, and perception. It may further be manifested by abnormal sleep patterns, alterations in psychomotor behavior, and language or perceptual disturbances. Delirium is a common, but often overlooked syndrome in the elderly. If left misdiagnosed or untreated, it can have a significant impact on the well-being of the older population. The nursing home environment serves as a particularly vulnerable setting, thereby accentuating the need for education to enhance the detection and subsequent therapeutic treatment of delirium.

The prevalence of delirium in hospitalized Consequences patients ranges from 10 to 30% with even higher occurrence among those with post- The consequences of delirium are high operative and cancer diagnoses (Smith et al., morbidity and mortality, along with an 1995). Even more alarming is that an enormous financial burden for the healthcare estimated 15 to 26% of elderly patients with system. More specifically, delirium is delirium die, usually due to the underlying responsible for increased length of hospital pathologic process (Espino et al., 1998). The stays, increased nursing care, decreased etiology of delirium is multi-factorial, ability to function, delayed rehabilitation, complex, and poorly understood by many and more frequent institutionalization (Fick healthcare providers. Yet it is considered a and Foreman, 2000). While the majority of medical emergency and early recognition of patients recover, full recovery by the elderly symptoms correlates with most favorable is estimated at only 4 to 40% by the time of outcomes for patients (Chan and Brennan, discharge from a hospitalization per year 1999). Unfortunately, due to its broad (Practice Guideline, 1999). Although the spectrum of signs and symptoms, delirium is data on health outcomes are of greatest often misdiagnosed as a psychosis, concern, the financial implications are depression, or dementia. Subsequently, it staggering. It has been reported that delirium may be overlooked or go mistreated. involves more than 17.5 million inpatient Patients who develop delirium during days and over $4 billion (in 1994 dollars) of hospitalization are more likely to be Medicare expenditures (Inouye et al., 1999). admitted to a long-term care facility after Improving the chance for full recovery relies discharge (Rapp, 1998). The prevalence of on early detection and appropriate delirium in nursing home residents is not management of delirium. well documented, although nurses working in the long-term care setting indicate it is a fairly common occurrence (Mentes, 1995).

Delirium 1 Pathophysiology reversible cause of delirium, accounting for 22 to 39% of all cases. Schuurmans et al. The pathophysiology of delirium is poorly (2001) corroborate this finding by noting understood. According to Smith et al. that medication toxicity, dehydration, and (1995), delirium involves widespread other metabolic disturbances are the most metabolic cerebral dysfunction. It may be frequent causes of delirium in older the result of a global, nonspecific disorder of hospitalized patients. Inouye and brain function as the result of systemic Charpentier (1996) support the hypothesis processes such as acid-base imbalances, that delirium is multi-factoral, resulting from hypoxia, hypotension, or hypothermia. the complex interrelationship between Another view proposes that delirium is predisposing factors and precipitating caused by cerebral oxidative metabolism factors. resulting in the reduction of acetylcholine synthesis (Mentes, 1995). This finding has It is commonly accepted that certain patient been substantiated by Lipowski (Mentes, populations are more predisposed to the 1995) through studies that demonstrated the development of delirium. Advanced age is inducement of delirium following one of the most significant risk factors, with administration of anticholinergic agents. an age of 80 or older being at greatest risk Still another theory hypothesized by Kral (Weinberger and Carnes, 1997). Another (Mentes, 1995) proposes delirium is the significant risk factor is the presence of result of elevated plasma cortisol levels existing baseline cognitive impairment. A brought on by acute stress. patient with dementia has a two to three times greater risk of developing delirium Causes and Risk Factors than a patient with normal mental status (Shua-Haim et al., 2000). Additional risk Causes of delirium are usually multiple in factors include hypothermia, low serum origin. Mentes (1995) refers to categorizing albumin, visual impairment, limited social causal factors of delirium by systemic, interactions, and multiple prescription mechanical, and psychosocial- medications (Chan and Brennan, 1999). environmental factors. In this categorization, systemic causes are those that alter brain Clinical Presentation metabolic processes such as infections, drug toxicity, elimination problems, or electrolyte Essential clinical criteria for delirium are imbalances. Mechanical causes are outlined by the American Psychiatric conditions that block or restrict normal brain Association’s Diagnostic and Statistical function such as vascular obstruction due to Manual of Mental Disorders, DSM-IV. cardiac dysfunction, brain trauma, As outlined by Jacobson and cardiovascular accident, or cancer. Schreibman (1997), these criteria Psychosocial-environmental causes refer to include: external, non-biologic factors that impact a person’s well-being. This category includes  Disturbance of consciousness (i.e., factors such as sensory deprivation or over- reduced clarity of awareness of the stimulation, personal losses, and age- environment) with reduced ability to associated physiologic and psychosocial focus, sustain, or shift attention; changes. Chan and Brennan (1999) report  A change in cognition (e.g., memory that medications are the most common deficit, disorientation, or language

Delirium 2 disturbance) or the development of a morning. Weinberger and Carnes (1997) perceptual disturbance that is not better state that symptoms tend to fluctuate during accounted for by a pre-existing, the course of the day and are most severe at established, or evolving dementia; night. They additionally report that a high  A disturbance develops over a short percentage of patients experience a period of time (usually hours to days) prodromal period where sleep abnormalities and tends to fluctuate during the course in the form of vivid dreams, nightmares, of the day; and and/or sleep-wake cycle disruptions occur.  Evidence from the history, physician examination, or laboratory findings that In addition to the manifestations described the disturbance is caused by the direct previously, patients may suffer from physiologic consequences of a general impairment of memory in the form of medical condition. registration, retention, and recall, with many of the patients remaining amnesic of the Most sources recognize two subtypes of episode following recovery from the delirium, those being the hyperactive type or delirium (Weinberger and Carnes, 1997). the hypoactive type, while others also Language almost always is abnormal with include a “mixed” delirium. According to speech being slurred, rambling, and/or the Practice Guideline for Treatment of incoherent. Usually, the patient is Patients with Delirium (1999), the disoriented to time and place, but rarely to hyperactive type is characterized by person. Finally, psychomotor activity may hallucinations, delusions, agitation, and be either reduced or increased. The disorientation. In contrast, the hypoactive hyperactive form is associated with form is manifested by confusion and diaphoresis, tachycardia, flushing, and sedation with infrequent involvement of tremors along with disruptive behavior. In hallucinations, delusions, or illusions. Often, contrast, patients with hypoactive delirium a patient may revert from one state to are often seen as depressed, uncooperative, another within the course of a delirious or sleepy. episode. Hyperactive delirium is often linked with withdrawal syndromes and Lack of Recognition by anticholinergic-induced onset, while Caregivers hypoactive delirium is usually associated with metabolic and hepatic Despite its life-threatening potential and encephalopathies, acute intoxications, or frequent occurrence, delirium is often hypoxia (Smith et al., 1995). misdiagnosed or attributed erroneously to the aging process, dementia, or a normal The clinical features of delirium cover a progression of a preexisting illness. broad spectrum of signs and symptoms. According to Inouye, Schlesinger, and Delirium occurs most commonly in the late Lydon (1999), delirium is unrecognized by afternoon and is characterized by a rapid the clinicians caring for the patient one-third onset of hours to days (Sandberg et al., to two-thirds of the time. Recognition of 1999). However in a study by Sandberg et delirium when superimposed on dementia al. (1999), 315 out of 717 patients with creates an even greater recognition problem. delirium manifested the symptoms only 37% In a study by Fick and Foreman (2000), of the time in the afternoon, evening, or failure to recognize delirium in dementia night and 47% experienced delirium in the

Delirium 3 patients was a recurrent problem for both should be given to the causes and risk physicians and nurses. factors of delirium, use of clear and There are multiple reasons that healthcare consistent terminology regarding mental providers fail to recognize delirium. status, and knowledge of the normal aging Knowledge and awareness of delirium has process. Additionally, consideration should been hindered by the use of vague be given to the routine use of screening or terminology within the medical community, evaluation instruments to assist in the need for useful and uncomplicated detection and ongoing monitoring of diagnostic tools, and preconceived notions delirium. by healthcare providers about the aging process. Screening Instruments

Because nurses are the front-line caregivers There are multitudes of screening or 24 hours a day, 7 days a week, they are in evaluation tools that are helpful in the the best position to detect subtle changes in assessment for delirium. Since tests vary in patient’s mental status. Schuurmans et al. length, complexity of administration, and (2001) cite numerous studies indicating that reliability and validity, discussion here will nurses are the most likely caregivers to center on those identified as most valuable recognize delirium. Yet, awareness and for identification of delirium. Instruments understanding of delirium by nurses is are primarily classified into cognitive minimal at best. This fact is evidenced screening tests, delirium rating scales, and through the many studies reviewed by diagnosis tools. Some of these instruments Schuurmans et al. These studies indicate are more reliable in the detection of delirium disorientation is detected best by nurses, than others and each type of instrument has however detection of other symptoms such its own benefits and limitations. as sleep disturbances, abnormal psychomotor activity, perceptual problems, The most widely accepted and utilized or language disturbances is inconsistent. In cognitive screening instrument is the Mini another cited study by McCarthy Mental Status Exam (MMSE). It includes (Schuurmans et al., 2001), it was found that eleven simple questions, including two the ability to recognize acute confusion was written answers that assess the patient’s influenced by the philosophical attitude of orientation, instant recall, short-term the nurse about healthy aging. Lastly, lack memory, language, calculation, and of a thorough patient assessment by both constructional abilities (Smith et al., 1995). physicians and nurses contributes to the poor Its advantages are that it can be conducted in detection of delirium. One study (Fick and less than 10 minutes and is easily Foreman, 2000) found that observation and administered (Weinberger and Carnes, documentation of mental status by providers 1997). These authors identify the was minimal. The study revealed that disadvantages as its relative insensitivity to providers spent little time with patients, mild cognitive impairments, its inability to failed to acknowledge family input distinguish between delirium and dementia, regarding mental status, and did not and its limited value with patients with recognize changing mental function. Hence, minimal education (Smith et al., 1995). it appears that accurate detection of delirium Other recognized cognitive instruments is contingent on better education and include the Cognitive-Capacity Screening training of caregivers. Educational emphasis Examination (CCSE), the Blessed

Delirium 4 Orientation-Memory-Concentration Test altered level of consciousness. Advantages (BOMC) and the Short Mental-Status Test of this tool are that it can be administered (SMST). While utilized less frequently, quickly with excellent validity and these instruments offer essentially the same reliability (Smith et al., 1995). Its benefits and limitations as the MMSE. disadvantage is that it requires trained interviewers and although it can be Delirium rating scales are instruments that administered quickly, it is valid only after help in determining the severity and first completing a thorough mental status symptoms of delirium and can be used to evaluation. The DSI is a fairly common follow the course of the syndrome. The alternative but is long, somewhat difficult to Confusion-Rating Scale (CRS) is a three- administer, and also requires rater training. point judgment instrument developed by and According to Smith et al. (1995), it detects for nurses that evaluates patient behavior the presence or absence of the seven criteria based on four domains (Smith et al., 1995). of DSM-III and is probably the best choice The instrument, which is utilized each shift, to evaluate behavioral signs associated with evaluates orientation, communication, delirium. In summary, screening tools are an behavior, and presence of perceptual important component of detecting, disturbances. The pro is that the tool is both monitoring, and managing delirium. quick and easy. The con is that validity is Particularly in the nursing home setting, unknown and administration requires trained consideration should be given to the length raters. Another common rating scale of the instrument, the ease of administration, instrument is the NEECHAM Confusion and the amount of required rater training. It Scale which is a nine-item observation scale is important to consider the shortcomings of with good validity and reliability current assessment tools in the development (Schuurmans et al., 2001). This rating scale of an effective intervention strategy. is a nurse-oriented instrument that facilitates rapid bedside documentation of normal Interventions functioning. Its disadvantage is that it is long and requires measurement of physical Once delirium is recognized, appropriate parameters. Other less frequently utilized interventions are necessary. Interventions rating instruments are the Delirium Scale essentially can be categorized into those that (D-Scale), Delirium-Rating Scale (DRS), treat the physical symptoms or underlying and the Memorial Delirium-Assessment causes and those that are supportive in Scale (MDAS). nature. Since delirium is an acute medical emergency, initial and prompt treatment of Common diagnostic instruments include the the cause is imperative. In addition, medical Confusion-Assessment Method (CAM) and care should include maintaining hydration, the Delirium Symptom Interview (DSI). The nutrition, and avoidance of hypothermic or CAM which is based on Diagnostic and hypoxic states. Close observation and Statistical Manual of Mental Disorders monitoring of physiologic and psychosocial (DSM-III R), is helpful in differentiating status including vital signs, fluid intake and between delirium, dementia, and depression output, and oxygenation should be done. All (Shua-Haim et al., 2000). It is designed to current drugs that the patient is taking detect the four cardinal elements of should be reviewed and discontinued unless delirium: acute onset and fluctuating course, deemed absolutely necessary (Weinberger disorganized thinking, inattention, and and Carnes, 1997). Anticholinergics,

Delirium 5 narcotics, analgesics, antihistamines, personal objects, and controlled family cardiovascular drugs, antihypertensives, and visits. From a professional standpoint, benzodiazepines can all precipitate consistency of caregivers should be confusion and should be suspect (Espino et maintained. Avoidance of physical restraints al., 1998). If excessive agitation or psychotic is recommended by all sources. To foster behavior, pharmacologic therapy may be accurate perceptual experiences, it is indicated. important to ensure that patients utilize their eyeglasses, hearing aids, and other assistive Most physicians agree that Haloperidol is devices. the drug of choice (Shua-Haim et al., 2000; Weinberger and Carnes, 1997; Jacobson and Other supportive measures are focused at Schreibman, 1997; Chan and Brennan, managing cognitive impairments. Jacobson 1999; Practice Guideline, 1999), although and Schreibman (1997) suggest that tactics the use of risperidone is increasing in of reorientation, verification, explanation, frequency. Loxapine is an older atypical and repetition are extremely helpful. anti-psychotic drug that may also be helpful Reorientation can be accomplished both in the management of agitation/anxiety in verbally and by displaying a clock or delirium (McElhaney, 2002). Use of low calendar in the patient’s room. Inouye et al. dose benzodiazepines is controversial and (1999) studied a multicomponent most practitioners recommend intervention strategy called the Elder Life administration only when delirium is Program that was found effective in the associated with alcohol or sedative prevention of delirium in hospitalized older withdrawal (Chan and Brennan, 1999; medical patients. This program established Weinberger and Carnes, 1997). Lorazepam, protocols that address many of the delirium oxazepam, and diazepam are cited as the risk factors identified thus far including most frequently utilized agents (Shua-Haim orientation, sleep enhancement, dehydration, et al., 2000; Jacobson and Schreibman, hearing and visual impairment, and 1997; Chan and Brennan, 1999; Practice cognitive activities. Finally, attention to Guideline, 1999). preventive measures such as scheduled toileting, adequate hygiene, and regular Supportive measures are an integral exercise are important to minimizing the component of effectively helping the patient occurrence of delirium (Jacobson and with delirium. Creation of an optimal Schreibman, 1997). environment is essential. Efforts should be directed at minimizing both overstimulation Summary and understimulation, maintaining safety, maximizing the patient’s ability to perceive Delirium is a common, yet misunderstood the environment correctly, and creating syndrome in the elderly. Through preventive familiarity and consistency (Jacobson and measures and increased education regarding Schreibman, 1997; Shua-Haim et al., 2000; the causes, signs, and treatment of delirium, Chan and Brennan, 1999; Weinberger and caregivers in the long-term care setting have Carnes, 1997). Maintaining low levels of the potential to significantly impact patient lighting and noise is important, however it is outcomes and reduce patient/family also important to simulate a normal day- suffering. night cycle. Familiar items should be incorporated such as pictures of loved ones,

Delirium 6 Inouye S and Charpentier P. Precipitating Factors for Delirium in Hospitalized Elderly. JAMA 1996; 275: 852-857. References Inouye S, Schlesinger MJ, and Lydon TJ. Bair BD. Presentation and recognition of Delirium: A symptom of how hospital care common psychiatric disorders in the elderly. is failing older persons and a window to Clinical Geriatrics. 2000. improve quality of hospital care. American Journal of Medicine May 1999; 106: 565- Chan D and Brennan NJ. Delirium: Making 573. the diagnosis, improving the prognosis. Geriatrics Mar 1999; 54: 28-42. Marcantonio E. Merk Manual of Geriatrics, Third Ed. Whitehouse Station, NJ: Merk Diagnostic medical testing in psychiatric Research Lab. disorders; Delirium; UPCMD Home; Psychiatry testing; University Pathology Mentes JC. A nursing protocol to assess Consortium, LLC, 1998-2002. causes Of delirium: Identifying delirium in nursing home residents. Journal of Espino DV, Jules-Bradley ACA, Johnston Gerontological Nursing Feb 1995; 26-30. DL, and Mouton CP. Diagnostic approach to the confused elderly patient. American Practice Guideline for the Treatment of Family Physician Mar 1998; 57(6). Patients With Delirium. The American Journal of Psychiatry May 1999; 156: 5. Fick D and Foreman M. Consequences of not recognizing delirium superimposed on Rapp CG and The Iowa Veterans Affairs dementia in hospitalized elderly individuals. Nursing Research Consortium. Research- Journal of Gerontological Nursing Jan based protocol: Acute confusion / delirium. 2000. 1998.

Jacobson S and Schreibman B. Behavioral Resnick B. Dementia, delirium and and Pharmacologic Treatment of Delirium. depression in older adults. Advance for American Family Physician 1997; 56: 2005- Nurses 2002 - Online edition. 12. Schuurmans MJ, Duursma SA, and Inouye SK. Assessment and management of Shortridge-Baggett LM. Early recognition of delirium in hospitalized older patients. delirium: A review of the literature. Journal Annals of Long Term Care: Clinical Care of Clinical Nursing 2001; 10: 721-729. and Aging 2000; 8(12): 53-9. Shua-Haim JR, Sabo MR, and Ross JS. Inouye SK, Bogardus ST Jr, Charpentier Delirium in the elderly. Home Health Care PA, et al. A multicomponent intervention to Consultant Sep 2000; 7: 28-33. prevent delirium in hospitalized older patients. The New England Journal of Smith MJ, Breitbart WS, and Platt MM. A Medicine Mar 1999; 340(9). critique of instruments and methods to detect, diagnose, and rate delirium. Journal

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MO-02-01-NHD December 2002 This material was prepared by Primaris under contract with the Centers for Medicare & Medicaid Services (CMS). The contents presented do not necessarily reflect CMS policy. Version 12/20/2002

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