Delirium:Delirium:A Medical A Medical EmergencyEmergency

Linda Hassler, Linda Hassler, RN, MS, GCNS-BCRN, MS, GCNS-BC

Ann May Center for NursingAnn May Center for Nursing

732-776-2480732-776-2480

lhassler@meridianhealth.comlhassler@meridianhealth.com

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Cirquedu soleil “Delirium”Cirquedu soleil “Delirium”A live music concertA live music concert

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ObjectivesObjectives

Define delirium and causesDefine delirium and causes Discuss assessment techniquesDiscuss assessment techniques Review the “Three D’s”Review the “Three D’s” Summarizes interventions for Summarizes interventions for

deliriumdelirium Describe the CAM assessment toolDescribe the CAM assessment tool Discuss delirium in the hospital Discuss delirium in the hospital

settingsetting

Define delirium and causesDefine delirium and causes Discuss assessment techniquesDiscuss assessment techniques Review the “Three D’s”Review the “Three D’s” Summarizes interventions for Summarizes interventions for

deliriumdelirium Describe the CAM assessment toolDescribe the CAM assessment tool Discuss delirium in the hospital Discuss delirium in the hospital

settingsetting

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Definition of DeliriumDefinition of Delirium

Delirium – Delirium – a a reversible confusional statereversible confusional state AKA acute confusional stateAKA acute confusional state a mental disturbance characterized by:a mental disturbance characterized by:

Acute, sudden onsetAcute, sudden onset Disturbed consciousness Disturbed consciousness Impaired cognition, inattention is the Impaired cognition, inattention is the

hallmarkhallmark Identifiable underlying medical causeIdentifiable underlying medical cause Disruption of higher cortical functions, seen Disruption of higher cortical functions, seen

on EEG waveson EEG waves

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Reversible causes of Reversible causes of DELIRIUMDELIRIUM

D= D= Drugs, Drugs, Drugs Drugs, Drugs, Drugs (handout)(handout)E= E= Eyes and earsEyes and earsL= L= Lack of drug/alcohol (withdrawal), Low Lack of drug/alcohol (withdrawal), Low

oxygen levelsoxygen levelsI= I= InfectionInfectionR= R= Retention of urine or stool, RestraintsRetention of urine or stool, RestraintsI= I= Intracranial (think falls, seizures)Intracranial (think falls, seizures)U= U= Undernutrition/underhydrationUndernutrition/underhydrationM= M= Metabolic, electrolytes Metabolic, electrolytes S= S= Sleep deprivationSleep deprivation

Searching for the Searching for the Cause of Cause of DeliriumDelirium

Handout Handout

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Prevalence of DeliriumPrevalence of Delirium

4 to 5 million elders (over age 65) are estimated 4 to 5 million elders (over age 65) are estimated to have cognitive disordersto have cognitive disorders

Often misdiagnosed as depression, psychosis, or Often misdiagnosed as depression, psychosis, or dementiadementia

32% were unrecognized by physician32% were unrecognized by physician

40-80% elders admitted to hospital with delirium 40-80% elders admitted to hospital with delirium disorder or may have onset within three daysdisorder or may have onset within three days

56% medical unit56% medical unit

70-87% ICU70-87% ICU

61% surgical61% surgical

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Consequences of Consequences of DeliriumDelirium

Cost up to $8 billion per yearCost up to $8 billion per year Associated withAssociated with

Increased complicationsIncreased complications Increased morbidityIncreased morbidity Increased length of stay Increased length of stay Increased nursing home admissionIncreased nursing home admission Increased risk of functional declineIncreased risk of functional decline Increased caregiver burdenIncreased caregiver burden Increased mortality Increased mortality

Co-morbid condition with underlying Co-morbid condition with underlying dementiadementia 40% will develop delirium40% will develop delirium

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Whose at Risk?Whose at Risk? Over age 80Over age 80 MenMen IsolatedIsolated Disrupted sleep cycle and usual patternsDisrupted sleep cycle and usual patterns Confinement to a small areaConfinement to a small area New medications – polypharmacyNew medications – polypharmacy PainPain Restraints and/or bed restRestraints and/or bed rest Sensory deprivation – lack of glasses, hearing aide, Sensory deprivation – lack of glasses, hearing aide,

denturesdentures Loss of controlLoss of control Previous history of deliriumPrevious history of delirium

The 3 D’sThe 3 D’s

Handout Handout

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Three types of DeliriumThree types of Delirium

1.1. HyperactiveHyperactive 30% - repetitive 30% - repetitive behaviors, plucking sheets, picking, behaviors, plucking sheets, picking, wandering, illusions, hallucinationswandering, illusions, hallucinations

2.2. HypoactiveHypoactive 25% - quiet, 25% - quiet, withdrawn, misdiagnosed as withdrawn, misdiagnosed as depressiondepression

3.3. MixedMixed 45% - fluctuates and 45% - fluctuates and includes lucid periodsincludes lucid periods

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Assessment of DeliriumAssessment of Delirium History and PhysicalHistory and Physical

Current medication reviewCurrent medication review

Tests:Tests: chemistries, EKG, CXR, ABGs, chemistries, EKG, CXR, ABGs, oxygen saturation, u/a, thyroid function oxygen saturation, u/a, thyroid function tests, cultures, drug levels, folate levels, tests, cultures, drug levels, folate levels, pulse oximetry, EEG, lumbar puncture, pulse oximetry, EEG, lumbar puncture, serum B12serum B12

Confusion Assessment Method (CAM)Confusion Assessment Method (CAM) – – developed in 1988 for non-psychiatrically developed in 1988 for non-psychiatrically trained clinicians to identify delirium trained clinicians to identify delirium quickly and accuratelyquickly and accurately

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CAMCAM NINE operationalzed criteria from DSM-III-R, NINE operationalzed criteria from DSM-III-R,

omitted organic etiologyomitted organic etiology TWO cardinal elements:TWO cardinal elements:

Acute onset and fluctuating courseAcute onset and fluctuating course InattentionInattention

TWO complimentary designationsTWO complimentary designations Disorganized thinkingDisorganized thinking Alter level of consciousnessAlter level of consciousness

Remaining FIVE features are not in algorism as Remaining FIVE features are not in algorism as they add nothing to the sensitivity and they add nothing to the sensitivity and specificity of the tool specificity of the tool

Takes 5 minutesTakes 5 minutes If diagnosis of Delirium suspected, further If diagnosis of Delirium suspected, further

work-up necessarywork-up necessary

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CAM long versionCAM long version

Five other features:Five other features: DisorientationDisorientation Memory impairmentMemory impairment Perceptual disturbancesPerceptual disturbances PsychomotorPsychomotor

AgitationAgitation RetardationRetardation

Altered sleep-wake cycleAltered sleep-wake cycle

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The Short CAMThe Short CAM

BOX 1:BOX 1: ACUTE ONSET AND FLUCTUATING ACUTE ONSET AND FLUCTUATING

COURSECOURSEa)a) Is there evidence of an acute change in Is there evidence of an acute change in

mental status from the person’s mental status from the person’s baseline? No baseline? No YESYES

b)b) Did the (abnormal) behavior fluctuate Did the (abnormal) behavior fluctuate during the day, that is, tend to come during the day, that is, tend to come and go or increase and decrease in and go or increase and decrease in severity? No severity? No YESYES

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The Short CAMThe Short CAM

INATTENTIONINATTENTION Did the person have difficulty focusing Did the person have difficulty focusing

attention, for example, being easily attention, for example, being easily distractible or having difficulty keeping distractible or having difficulty keeping track of what was being said? No track of what was being said? No YESYES

Are all three items in box 1 are Are all three items in box 1 are checked YES?checked YES?

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The Short CAMThe Short CAM

BOX 2BOX 2 DISORGANIZED THINKINGDISORGANIZED THINKING

Was the person’s thinking disorganized Was the person’s thinking disorganized or incoherent, such as rambling or or incoherent, such as rambling or irrelevant conversation, unclear or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable illogical flow of ideas, or unpredictable switching from subject to subject? No switching from subject to subject? No YESYES

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The Short CAMThe Short CAM

ALTERED LEVEL OF CONSCIOUSNESSALTERED LEVEL OF CONSCIOUSNESS Overall, how would you rate the Overall, how would you rate the

person’s level of consciousness? ALERTperson’s level of consciousness? ALERT Small box:Small box:

VigilantVigilant LethargicLethargic StuporStupor Coma Coma

Did any checks appear in the small box? No Did any checks appear in the small box? No YESYES

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The Short CAM = The Short CAM = ScoringScoring

If all items in Box 1 are checked If all items in Box 1 are checked YESYES ANDAND At least one item is Box 2 is checked At least one item is Box 2 is checked

YESYES THENTHEN A diagnosis of Delirium is suggestedA diagnosis of Delirium is suggested

Try this: Best Try this: Best Practices in Practices in

Nursing Care to Nursing Care to Older AdultsOlder Adults

The Confusion Assessment The Confusion Assessment MethodMethod

““CAM”CAM”

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Treatment of DeliriumTreatment of Delirium Failure to treat delays recovery and can

worsen the older person’s health and function.

Treat the cause!

Reassure family!

Psychiatric Management: identify and treat underlying etiology

intervene immediately for urgent medical conditions

ongoing monitoring of psychiatric status

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Treatment of DeliriumTreatment of Delirium Environmental and supportive interventions:

all environmental factors that exacerbate delirium Make environment more familiar Reorient and reassure Inform to fear or demoralization

Somatic Interventions: antipsychotic; benzodiazepines

Good news is that they may have little memory of delirious episode once resolved

Relapse rate is 35-40%

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Best treatment isBest treatment isPREVENTION!PREVENTION!

Orientation and therapeutic Orientation and therapeutic activities for cognitively impairedactivities for cognitively impaired

Early mobilizationEarly mobilization Non-pharmacologic approaches to Non-pharmacologic approaches to

behavior problemsbehavior problems Better sleep hygiene practicesBetter sleep hygiene practices Appropriate communication Appropriate communication

techniquestechniques Early intervention for dehydrationEarly intervention for dehydration(Yale Delirium Prevention Trail, Inouye, 1999)(Yale Delirium Prevention Trail, Inouye, 1999)

Searching for Searching for SolutionsSolutions

Handout Handout

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Delirium DVDDelirium DVD

Delirium: Best Delirium: Best PracticePractice

Quick Reference Guide forQuick Reference Guide for

Care of Older PersonsCare of Older Persons

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The Delirium PuzzleThe Delirium Puzzle

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ReferencesReferences See handout list and also:See handout list and also:

Vancouver Island Health Authority (2006) Vancouver Island Health Authority (2006) Delirium: Delirium: A Medical EmergencyA Medical Emergency DVD and supporting DVD and supporting documents. documents. www.viha.ca/ppo/learningwww.viha.ca/ppo/learning

Laplante, J, Cole, M (September 2001). Detection of Laplante, J, Cole, M (September 2001). Detection of Delirium using the Confusion Assessment Method. Delirium using the Confusion Assessment Method. Journal of Gerontological NursingJournal of Gerontological Nursing, pg 16-23., pg 16-23.

www.Guideline.govwww.Guideline.gov Delirium strategies for Delirium strategies for assessing and treating. Retrieved: 10/12/07.assessing and treating. Retrieved: 10/12/07.

www.consultgerirn.orgwww.consultgerirn.org Topic: Delirium. Retrieved: Topic: Delirium. Retrieved: 10/12/07.10/12/07.

Thank you!Thank you!

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