Delirium and related care

Gerontological Nursing BN Y4 NURS4201 Celia Chow, Assistant Professor (Nursing Practice) 5.11.2012
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Outline of today:
Objectives Overview of delirium & care Explore deeper : Facts and figures, definitions Delirium, dementia and depression Case scenarios Students presentation

Objectives
List definitions delirium Describe prevalence of delirium Recognise symptoms of delirium Name possible causes and risk factors of delirium Demonstrate awareness of 3Ds co-existence (delirium, dementia and depression) , by describing their clinical features. Implement appropriate, practical interventions by listing examples

Concept of delirium
1st used in medical by Celsus 1st century AD mental disorder during fever/head trauma Derives from Latin delirodelirare (de-lira: to go out of the furrow) To deviate from straight line, to be crazy, out of ones wits, to be silly (Lewis, Short & Andrews 1879)

Delirium : Overview
Disorder of attention and global cognitive function Acute and fluctuating course Treatable Often diagnosis is missed (>50%)

Major risk factors

Advancing age Pre-existing brain disease Medications Changing environment

Definition
Develops acutely and a disturbance of consciousness with impaired attention and disorganized thinking or perceptual disturbance that has a fluctuating course, and with evidence that there is an underlying physiologic or medical condition causing the disorder
- Tullmann et al. (2008)

Definition:
DSM IV criteria: Disturbed conciousness Cognitive change Perceptual disturbance Rapid onset (hours to days) & fluctuating daily course Evidence of causal physical condition

Pathophysiology
Not fully understood, may be cholinergic deficiency, dopamine excess, or cytokine activity - Inouye (2006) Multifactorial Predisposed patient + triggering factors Possible medical emergency e.g. Drug toxicity, hypoxia, hypoglycemia, liver failure renal insufficiency, fluid and electrolyte imbalance, cerebral edema/ischaemia

Elderly: Atypical Presentation

Atypical Presentation
Elderly may present with change in mental status, function or level of consciousness, confusion, falls, or agitation rather than typical signs of illness when an underlying acute problem is present!

Case scenario : 2 elders and CAM

http://consultgerirn.org/resources/media/?vid_id=4361983#player_container

STATISTICS ABOUT delirium

~ 30 % of cases of delirium are preventable 10-30% of older people admitted to acute medical wards (British Geriatric Society ) >50% ICU cases at T/O to general wards ~80% of mechanically-ventilated cases 22-89% incidence of delirium superimposed on dementia. Nursing: missed >50% of cases Sub acute/acute onset with fluctuations Mortality of hospitalized patients: 22%76% Miller (2008)

FACTS ABOUT delirium

Disturbance of consciousness Always related to underlying condition Cognitive changes (memory, orientation, language) +/-Psychotic symptoms e.g. hallucination Circadian disturbance (awake at night asleep day)

Causes (numerous)..
Medications Substance withdrawal Unfamiliar environment Infections Dehydration Hypoxia Electrolyte disorders (hyper/hypo Na), Anaemia, Hepatic/renal, lung, brain dysfunction Poisoning Injury, pain, stress Stroke Catheter, faecal impaction Genetic association (apolipoprotein E epsilon 4 allele identified

Medications
New medications Anticholinergic preparations
-thioridazine

Cardiovascular drugs
-nifedipine -quinidine -disopyramide -amiodarone -beta blockers

-amitriptaline -neuroleptics -tricyclic antidepressants -atropine -theophylline -diphenhydramine

Histamine-2 blocking agents

-cimetidine -ranitidine analgesics -meperidine -NSAIDs -opiates

Corticosteriods Anti-Parkinsonian agents

Sedative-hypnotics
-zolpidem -benzodiazepines

Substance abuse Alcohol withdrawal Opiods Analgesics Bath salts Drugs

Unfamiliar environment

What would you do?

Hospitalization Moving to a new place New resident of institution Change of room Change of caregiver Change in daily routine of institution

Infections

What would you do?

MOST COMMON: - UTI -Respiratory -Cellulitis MOST OVERLOOKED: -Mouth -Feet NB: Older adults may have infection without fever or elevated WBC.

Dehydration
Check for evidence and source I/O Dry mouth and tongue Lowish BP Weakness Oliguria Lethargy creatinine, urea, Na+

What would you do?

Hypoxia
Alert for:

Tachypnea Cyanosis (peripheral & central) Agitation Increased depth of respirations Decreased pO2 Accessory muscle use Paradoxical breathing pattern What would you do?

Electrolytes
Check for: Hypernatremia (>146mEq/L)/ Hyponatremia (< 136mEq/L) Physical findings : (HyperNa) Weakness ,Na + ,HCT, creatinine, serum osmolarity (HypoNa) Lethargy , nausea, malaise, Na+ , serum osmolarity

What are your nursing actions?

Further information
HyperNa Determine source of hypernatremia, e.g., increased water loss (fever, infection, vomiting, diarrhea), decreased water intake (physical or cognitive limitations), or increased sodium intake Check chemistry panel Prepare for possible fluid replacement Restrict activity to maintain energy balance Continue to monitor parameters q 2 h or as indicated by status of patient Refer to/notify appropriate advanced practice nurse or house officer Document actions and patient response in record HypoNa Determine source of hyponatremia, e.g., inadequate intake of sodium, renal disease, fluid restriction, SIADH, over-diuresis, low sodium tube feedings Prepare for electrolyte and possibly fluid replacement Restrict activity to maintain energy balance Continue to monitor parameters q 2 h or as indicated by status of patient Refer to/notify appropriate advanced practice nurse, house officer, MD Document actions and patient response in record

Pain
Check for: agitation, restlessness, moaning, grimacing, sighing, body rigidity (especially in dementia)

Essential features
Acute onset (hours/days) Fluctuating course Inattention or distraction Disorganized thinking or altered level of consciousness

Coexisting conditions
Advanced age (>70 y.o.) Alcoholism Depression Dementia Dehydration Fractures (4-53%) Infections Malnourishment Severe/ terminal illnesses e.g. AIDS, cancer, MI

Physical frailty Visual impairment Polypharmacy Renal impairment Pre-Post operative Sleep deprivation Sensory impairment Multiple comorbidities

Delirium Abrupt onset, usually at night Acute Duration: hours to weeks Impaired orientation usually for time; mistakes unfamiliar people/places

Dementia Gradual onset over months, years Chronic Progressive over weeks, months, years Disorientation in later stages

Tends to vary during the day, with lucid intervals, and be worse at night
LOC early Short attention span Disturbed sleep wake cycle Hallucinations common usually visual

Usually little variation across the day

No LOC until late Attention reduced Disturbed sleep wake cycle with reversed day and nights and not as variable Hallucinations common in Lewy body dementia and in advanced dementia of all types Psychomotor changes late Usually difficulty in finding words

Psychomotor changes early Speech incoherent, hesitant, low or rapid

Treatment

Non-pharmacological Pharmacological

Non-pharmacological
Optimize environment Personal belongings e.g. photos Quiet surroundings Sitter Follow a consistent routine Nutritionally balanced diet. Maintain hydration.

Safety
Keep the bed in the lowest possible position Avoid physical restraints. Safety alarm e.g. mattress sensor Use supportive aids e.g. glasses and hearing aids as appropriate for the person.

Pharmacological
Neuroleptics for hallucinations, delusions, agitation (chemical restrain) Lowest effective dose Low anticholinergic activity e.g. haloperidol, risperdone Careful use of benzodiazepine (more sedative, can make worse, LOC) *** look for hidden prescription.

Delirium: Prevention
Avoid psychoactive drugs Quiet environment Daytime activity Dark and quiet at night Visual and hearing assistive devices Orientation devices (clock, calendar) Avoid restraints

Delirium: Prevention
Environmental modification e.g. provide good lighting and signage Avoid sensory stimulation Avoid or secured catheter / IV Avoid constipation Keep mobile and assist toileting Adequate diet and hydration Adequate pain-relief Put on hearing aids and 33 spectacles

Delirium: Prevention & coping

Measures mentioned (previous slide) Communicate with clear, simple message Introduce yourself Explain what you are going to do Keep patient familiarize with few staff Keep a calm environment, minimize noises from TV, visitors and staff Engage patient in simple conversation and orient them within the environment

Dementia+ Delirium+Depression happens in 50% of psychosomatic medical cases KEYWORDS

Dementia Delirium Depression

Progressive deterioration, Alert Memory loss Cognitive deficit(s) Irreversible MMSE

Acute /sub acute Fluctuating consciousness Underlying condition Mortality 30% avoidable Drugs

Pseudo-Dementia, Labile Life events stressors Pain Weight-loss Drugs GDS

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 Delirium and dementia are prevalent in geriatric patients presenting to acute-care medical unit, but remain under-recognized and under-diagnosed. Patients with delirium tended to have poorer outcomes in term of length hospital stay, no. of unplanned readmission, and mortality within one year. (Leung et al
2011)

Case sharing: A 68 year old female with no significant past medical hx. She is confused and is seeing a man who is not there. WHAT WOULD YOU DO?

References
Hindle A & Coates (2011) Nursing Care of Older People. Oxford University Press

Inouye, S. K. (2006). Delirium in older persons. New England Journal of Medicine, 354, 11571165. Evidence Level VI: Expert Opinion.
Leung JLM, Lee GTH, Chan CC, Sim TC, Sha KY, Lam YH, Wu JYM (2011). The use of digit span test in screening for cognitive impairment in acute geriatric inpatients and 1-year follow-up for patients with delirium. Asian Journal of Gerontology & Geriatrics 6(2) P. 112.
Leis, CT, Short C and Andrews EA (1879) Harpers Latin dictionary. A New Latin Dictionary Founded on the Translation of Freunds Latin-German Lexicon, edited by E.A. Andrews. New York, Harper & Brothers; Oxford: Clarendon Press. Miller M. Evaluation and management of delirium in hospitalized older patients. American Family Physician. 2008;78(11):1265-1270.

Ragain M. (2010) Dementia vs. Delirium . Texas Tech University HSC Geriatric Education Center Web Training for Intern http://www.youtube.com/watch?feature=endscreen&v=vEOpLueoR4&NR=1 Tullmann DF, Mion LC, Fletcher K, & Foreman MD (2012) Consider: Delirium. http://consultgerirn.org/topics/delirium/need_help_stat Retrieved 30 Oct 2012