Delirium & Dementia:

Double TroubleBy Denise L. Lyons, GCNS-BC, MSN; Shannon M. Grimley, GCP, PharmD; and Linda Sydnor, GCNS-BC, MSN

LPN2009, March/April 2009

2.3 ANCC contact hours

Online: www.lpnjournal.com

© 2009 by Lippincott Williams & Wilkins. All world rights reserved

Delirium’s long-lasting complications Decline in cognitive and physical function

Increased length of hospital stay

Greater need for nursing care

Delayed rehabilitation

Nursing home placement

Prevalence of delirium

In patients with dementia age 65 and older – 22% to 89%

May be underreported when patient also has dementia

Often diagnosed as worsening dementia

Prevalence of delirium

25% of older adults are hospitalized with delirium

56% develop delirium while hospitalized

What’s the difference?

Dementia is chronic, develops slowly, and isn’t reversible

Delirium is an acute change in mental status due to a reversible medical condition

What’s the difference?

Onset Delirium: Acute Dementia: Insidious

Course Delirium: Fluctuating, with lucid intervals; worse

at night Dementia: Slowly progressive

What’s the difference?

Duration Delirium: Hours to weeks Dementia: Months to years

Sleep/wake cycle Delirium: Always disrupted Dementia: Sleep fragmented

What’s the difference?

Illness or drug toxicity Delirium: Either or both present Dementia: Often absent, especially in Alzheimer’s

Level of consciousness Delirium: Disturbed. Patient is less clearly aware of the

environment and less able to focus, sustain, or shift attention

Dementia: Usually normal until late in illness

What’s the difference?

Behavior Delirium: Activity often abnormally decreased

(somnolence) or increased (agitation) Dementia: Normal to slow; behavior may be

inappropriate

Speech Delirium: Hesitant, slow, or rapid; incoherent Dementia: Difficulty finding words; aphasia

What’s the difference?

Mood Delirium: Fluctuating, labile, from fearful or

irritable to normal or depressed Dementia: Often flat, depressed

Thought processes Delirium: Disorganized; may be incoherent Dementia: Impoverished; speech gives little info

What’s the difference?

Thought content Delirium: Delusions common; often transient Dementia: Delusions may occur

Perceptions Delirium: Illusions, hallucinations (usually visual) Dementia: Hallucinations may occur

What’s the difference?

Judgment Delirium: Impaired, often to a varying degree Dementia: Increasingly impaired over illness

Orientation Delirium: Usually disoriented, especially for time. A

known place may seen unfamiliar Dementia: Fairly well maintained, but becomes

impaired in later stages of illness

What’s the difference?

Attention Delirium: Fluctuates. Patient is easily distracted and

unable to concentrate on tasks Dementia: Usually unaffected until late in illness

Memory Delirium: Immediate and recent memory impaired Dementia: Recent memory and new learning especially

impaired

Who’s at risk?

Predictable risk factors for developing delirium: Age older than 70 History of dementia Sleep deprivation Hearing or visual impairment Dehydration Severe illness or fractures Hospitalization

Who’s at risk?

Recent surgery Immobility Previous episodes of delirium Polypharmacy Alcoholism Multiple comorbidities

Common causes of delirium

Drugs prescribed, over-the-counter, and recreational alcohol withdrawal or intoxication polypharmacy (more than four medications) effects of anticholinergic drugs, psychoactive

drugs (anxiolytics, sedatives, hypnotics, antipsychotics, antidepressants), opioids, steroids

drug toxicity, drug withdrawal

Common causes of delirium

Elimination urinary retention fecal impaction or diarrhea

Liver and other organs liver failure, hepatitis, cirrhosis heart failure, MI, hypotension, dysrhythmia kidney dialysis, renal insufficiency

Common causes of delirium

GI bleeding, inflammation, infarction, infection stroke, cerebral edema, subdural hematoma, head

injury, hydrocephalus, encephalopathy, meningitis bone marrow disease (anemia)

Infection urinary tract or respiratory infection sepsis

Common causes of delirium

Respiratory hypoxia, pneumonia, pulmonary embolism,

chronic obstructive pulmonary disease, asthma abnormal arterial blood gases, carbon dioxide,

retention, hyperventilation

Injury trauma, pain, stress

Common causes of delirium

Unfamiliar environment restraint use, underlying dementia hospitalization or change in residence

Metabolic fluid/electrolyte disturbance dehydration/volume depletion abnormal blood glucose level

Common causes of delirium

elevated blood urea nitrogen or creatinine level vitamin B12/folate deficiency hypothyroidism, hyperthyroidism fever, hypothermia

Promoting prevention

Frequent bedside assessments of mental status noting any changes in inattention or unorganized thoughts

Manage patient’s environment: minimize noise, staff, room changes

Respond immediately to suspected physiologic causes of delirium: infection, medications etc.

Finding the cause

Observe the following: vital signs intake and output SpO2 level last bowel movement lung sound

medical device use pain level new medications blood glucose urinalysis

Medications that can cause problemsMany drugs can cause or exacerbate delirium: Alzheimer’s medications opioid analgesics nonopioid analgesics all anesthetics antianxiety/hypnotic agents, sedatives antiseizure drugs antidepressants

Medications that can cause problems antihistamines antihypertensives antimicrobials anti-Parkinson’s medications antispasmodics (urinary) cardiac medications glucocorticoids muscle relaxants

Diagnosing delirium

Two assessment tools may be helpful:

Confusion Assessment Method (CAM)

Neelon and Champagne Confusion Scale

Confusion Assessment Method (CAM) Available in long and short forms

Has 94% to 100% sensitivity rating

Key features include: acute onset, fluctuating course, inattention, disorganized thinking

Diagnosis by CAM requires first two features plus at least one of last two

Neelon and Champagne Confusion Scale Based on routine nursing assessments

Evaluates ten items divided into three levels: processing, behavior, physiologic functioning

Detects delirium in early stages

Medication management

National guidelines support using antipsychotic medications in patients with severe agitation or psychosis

Haloperidol (Haldol) is drug of choice; approved for oral and I.M. administration; has few anticholinergic effects; beware of QT changes when giving I.V.

Other drugs

Atypical antipsychotics may be given:

- risperidone (Risperdal)

- quetiapine (Seroquel)

- olanzapine (Zyprexa)

Effectiveness is uncertain; fewer adverse reactions

Benzodiazepines should only be used in alcohol withdrawal or as sedative-hypnotic

Supportive care

Maintain patient’s routine and have same care staff as much as possible

Create familiar environment with items from home

Eliminate stressors (bright lights, loud telephone)

Avoid invasive devices; remove as quickly as able

Supportive care Offer appropriate diversion activities

Communicate in a low, clear, calm voice

Be mindful of safety (bed in lowest position, area free from clutter)

Offer assistance to ambulate frequently

Use assistive devices (glasses hearing aids)

Dealing with agitation

Restraints are last resort

Be creative and remain calm

Modify environment so patient can move safely

Use of family member or staff as one-on-one if needed