Delirium, also known as "brain failure," is characterized by dramatic behavioral changes.
It is similar to heart failure in that it has varied causes (Fong et al., 2009).
The hallmark of delirium is its acute onset, often indicating a serious underlying illness.
Inouye (2006) identifies delirium as the most common complication of hospitalization, also referred to as ICU psychosis.
Delirium is frequently linked to illnesses such as pneumonia, myocardial infarction, and urinary tract infections.
Definition
Delirium is an acute disorder of cognition characterized by disturbances in attention, perception, thinking, memory, psychomotor behavior, and the sleep-wake cycle.
It is a time-limited syndrome of acute onset that is highly treatable when recognized in time.
This acute confusional state impairs all mental processes and can result from any condition that disrupts the metabolic or structural integrity of the brain.
Incidence
Delirium has the highest incidence among organic mental disorders.
About 10 to 25% of medical-surgical inpatients meet the criteria for delirium during hospitalization.
About 20 to 40% of geriatric patients meet the criteria for delirium during hospitalization.
The percentage is higher in post-operative patients.
Types of Delirium
Hypoactive delirium: Includes inactivity or reduced motor activity, sluggishness, and abnormal drowsiness.
Hyperactive delirium: Includes restlessness, agitation, rapid mood changes, or hallucinations.
Mixed delirium: Includes both hyperactive and hypoactive symptoms; the person may quickly switch between these states.
Clinical Features and Findings
Impairment of consciousness: Clouding of consciousness ranging from drowsiness to stupor and coma.
Impairment of attention: Difficulty in shifting, focusing, and sustaining attention.
Perceptual disturbances: Illusions and hallucinations, most often visual.
Disturbance of cognition:
Impairment of abstract thinking and comprehension.
Impairment of recent and immediate memory.
Increased reaction time.
Psychomotor disturbances: Hypo- or hyperactivity, aimless groping or picking at bedclothes (flocculation), enhanced startle reaction.
Disturbance of sleep cycle: Insomnia or total sleep loss in severe cases, daytime drowsiness, disturbing dreams or nightmares.
Biologic Assessment: Symptoms often begin with an acute change in behavior. Nurses must understand the individual's baseline. Input from caregivers, family, or significant others is crucial.
Current and Past Health Status: Assess the onset, duration, range, and intensity of symptoms. Identify any history of chronic illnesses, dementia, depression, or other psychiatric conditions.
Physical Examination and Review of Systems: Conduct a physical exam and review of systems for patients with suspected delirium or organic mental disorders. Assess vital signs, laboratory data (CBC, glucose, BUN, creatinine, electrolytes, liver function, oxygen saturation), fluid balance, and any signs of constipation or recent diarrhea to identify underlying causes.
Physical Functions: Assess physical functional status (ADLs), use of sensory aids, usual activity level, recent changes, and pain. Evaluate sleep patterns, including typical and recent changes, as sleep disturbances are common in delirium. Reversed sleep-wake cycles are frequent, and restoring normal sleep is essential to reduce confusion.
Safety Interventions: Protect delirious patients from harm due to hallucinations, delusions, illusions, aggression, or agitation. Use low beds, guardrails, and close supervision to ensure safety.
Psychological Domain:
Assessment: Mental Status Examination.
Interventions: Maintain frequent interaction with patients to support them during confusion or hallucinations. Encourage them to express fears and discomfort. Use adequate lighting, readable calendars and clocks, reasonable noise levels, and verbal orientation to ease distress. Ensure eyeglasses and hearing aids are used and include familiar personal belongings in the environment.
Social Domain:
Family Roles: Assess family support, understanding of delirium, and interactions with the patient. Delirium-related behaviors may confuse or frighten family members, and some may inadvertently increase agitation. Family presence, when appropriate, can help calm and reassure the patient.
Interventions: Create a safe, predictable environment to protect the patient and restore order. Use calendars, clocks, and orienting items to aid in reorientation. For agitation, apply de-escalation techniques and avoid physical restraints.
Support from Families: Encourage families to collaborate with staff in reorienting the patient and creating a supportive environment. Advise delaying important decisions requiring the patient's input until recovery. If decisions are made, involve multiple witnesses, as the patient may not recall them later.
Evaluation and Treatment Outcomes:
The primary treatment goal is prevention or resolution of the delirious episode with return to previous cognitive status.
Outcome measures include:
Correction of the underlying physiological alteration.
Resolution of confusion.
Family member verbalization of understanding of confusion.
Prevention of injury.
Conclusion
Delirium leads to increased mortality and morbidity and longer hospital stays.
Many patients with delirium will not return to their pre-hospitalized functional status and will require long-term care.
Questions and Answers
Which patient group is more prone to delirium?
A. post-operative patients
Answer: A
Which of the following is NOT a type of delirium?
D. Neurogenic delirium
Answer: D
Which type of delirium is characterized by restlessness and agitation?
B. Hyperactive
Answer: B
Which of the following is a common cause of delirium?