Delirium Study Notes

Delirium

Definition and Overview

• Delirium: A state of confusion that develops over hours to days.

• Presentation may include:

  • Decreased ability to direct, focus, sustain, and shift attention and awareness.

  • Deficiency in memory, orientation, language, visuospatial ability, or perception.

  • Hypoactivity or hyperactivity.

  • Emotional problems such as fear, depression, euphoria, or perplexity.

  • Sleep problems.

Symptoms of Delirium

• Symptoms represent a change from baseline and may fluctuate.

• Symptoms do not occur due to changes in level of arousal and cannot be explained by another preexisting, evolving, or established neurocognitive disorder.

Etiology and Pathophysiology

General Characteristics

• Exact cause of delirium is unknown.

• Main contributing factor: Impairment of cerebral oxidative metabolism.

• Other contributing factors:

  • Multiple neurotransmitter abnormalities.

  • Proinflammatory cytokines.

Contributing Factors

• Delirium is rarely caused by a single factor.

• Major risk factors:

  • Increased age.

  • Preexisting dementia.

  • Hypertension.

  • Alcohol use.

  • Severe illness.

Mnemonic for Causes

• Mnemonic: DELIRIUM

  • D: Dementia, dehydration

  • E: Electrolyte imbalances, emotional stress

  • L: Lung, liver, heart, kidney, brain issues

  • I: Infection, intensive care unit (ICU)

  • R: Prescription drugs

  • I: Injury, immobility

  • U: Untreated pain, unfamiliar environment

  • M: Metabolic disorders.

Precipitating Factors for Delirium

• Dementia is the leading risk factor for delirium.

• Delirium can lead to subsequent development of dementia due to permanent neuronal damage.

• Environmental factors:

  • Sleep deprivation.

  • Stress.

  • Sensory overload.

  • Immobilization.

• Physical conditions:

  • Electrolyte imbalances.

  • Severe infections.

• Drugs:

  • Especially in older or vulnerable patients, drugs such as sedatives, opioids, etc.

  • Up to 60% of older adults experience delirium during hospitalization for a medical condition.

  • Delirium is the most common surgical complication in older adults.

• ICU Statistics:

  • 87% of patients in the ICU experience delirium.

  • Delirium may be the first symptom of life-threatening problems (e.g., pneumonia, urosepsis, meningitis).

  • It can occur after a minor insult in a vulnerable patient.

  • Pain and depression significantly contribute to delirium, particularly among older adults.

Clinical Manifestations

General Manifestations

• Can present with various manifestations ranging from hypoactive and lethargic states to hyperactive, agitated, and hallucinating states.

• Symptoms can be mixed, and delirium usually develops over a 2- to 3-day period, but can develop within hours.

• Duration can range from 1 to 7 days, and in some cases, can persist for months or years with some patients not fully recovering.

Symptoms During Delirium

• In a delirious state, patients may exhibit:

  • Reduced ability to focus, sustain, or shift attention.

  • Impaired memory, judgment, and orientation.

• Speech may be rapid, rambling, and/or incoherent.

• Other manifestations may include:

  • Disorganized thinking.

  • Irritability.

  • Insomnia.

  • Loss of appetite.

  • Restlessness.

Later Manifestations

• Later manifestations may include:

  • Agitation.

  • Misperception.

  • Misinterpretation.

  • Hallucinations.

Distinctions from Dementia

• Manifestations of delirium are often confused with dementia, but key distinctions include:

  • Sudden cognitive impairment.

  • Disorientation.

  • Clouded sensorium.

Case Study

Patient Profile

• 84-year-old K.P. has been in the ICU for 3 days following unexpected major abdominal surgery.

  • Underwent partial removal of descending colon for obstruction due to diverticula.

• K.P. exhibits increasing confusion and agitation.

  • Vital signs are within normal limits.

  • Abdominal incision healing without redness or drainage.

  • Starting to tolerate an oral diet.

Pre-surgery Condition

• Before surgery, K.P. was sad but alert and oriented.

  • He is now trying to climb out of bed and expresses a need to leave, showing anger towards family for not taking him home.

  • Family members express concern regarding his confusion.

Diagnostic Studies

Challenges in Diagnosis

• Diagnosis complicated by the inability to communicate, especially in critically ill patients.

Assessment Components

• Medical history.

• Psychological history.

• Physical assessment.

• Careful attention to medications.

• Use of the Confusion Assessment Method (CAM).

Confusion Assessment Method (CAM)

• CAM features for assessing delirium:

  • Feature 1: Acute onset OR fluctuation in mental status.

  • Evidence of acute change in mental status from the baseline? Is there fluctuation in behavior?

  • Feature 2: Disturbance in attention.

  • Difficulty directing, sustaining, or shifting attention?

  • Feature 3: Disorganized thinking.

  • Is the patient's thinking incoherent or disorganized?

  • Feature 4: Altered level of consciousness.

  • Is the patient's level of consciousness different from alertness (e.g., lethargic, drowsy, stupor, or coma)?

Laboratory Tests

• To explore the cause of delirium, the following laboratory tests may be done:

  • CBC (Complete Blood Count).

  • Serum electrolytes.

  • BUN (Blood Urea Nitrogen).

  • Creatinine level.

  • Drug and alcohol levels.

  • Electrocardiogram (ECG).

  • Urinalysis.

  • Liver and thyroid function tests.

  • O2 saturation.

  • Lumbar puncture if fever or nuchal rigidity is present, to check for meningitis or encephalitis.

  • CSF (Cerebrospinal Fluid) examined for glucose, protein, and bacteria.

  • Brain imaging may be conducted for head injury evaluation.

Treatment and Management

Overall Strategies

• Treatment is important as many cases are potentially reversible.

  • Nursing role includes:

  • Prevention: Identify high-risk patients.

  • Early recognition: Eliminate precipitating factors.

  • Treatment: Address underlying causes.

Nursing Care

• Protect the patient from harm.

  • Presence of a caregiver may help; providing familiar objects and photos can reduce anxiety.

  • Prefer a private room or one nearby the nurses’ station for monitoring.

  • Consistent staffing to foster familiarity and trust.

  • Reduce environmental stimuli.

Reorientation and Behavioral Interventions

• Create a calm and safe environment, providing reassurance.

  • Use clocks, calendars, and lists of scheduled activities for reorientation.

  • Remove lines not needed and manage environmental stimuli related to noise and light levels.

• Personal Contact: Offer comfort and direction through touch and verbal communication.

  • Ensure the use of the patient's glasses and hearing aids to reduce sensory limitations.

  • Encourage early mobility and minimize the use of restraints.

  • Introduce relaxation techniques as needed.

Health Team Interventions

• Address factors such as polypharmacy, pain, nutrition, elimination issues, immobility, skin breakdown, and exercise.

Family and Caregiver Support

• The nurse should focus on supporting the family and caregivers throughout the care process.

• Patient Education: Visit www.ICUdelirium.org for resources.

Drug Therapy

Indications for Medication

• Drug therapy is reserved for patients with severe agitation that:

  • Interferes with necessary medical therapy.

  • Increases risk for falls and injury.

  • Occurs after nonpharmacologic interventions have failed.

Specific Medications

• Dexmedetomidine (Precedex): Considered for sedation in ICU settings.

• Antipsychotics (controversial; monitoring side effects required):

  • Haloperidol (Haldol).

  • Risperidone (Risperdal).

• Short-acting benzodiazepines (used cautiously due to potential to worsen delirium):

  • Lorazepam (Ativan).

Follow-up Case Study Questions

• Considerations regarding K.P.’s mental status and the next priority action in his care.

• Evaluate priorities concerning family concerns and anxiety.