Hospital Resources - Delirium

Delirium is a disturbance of consciousness with reduced ability to focus, sustain, or shift attention.  It is a change in cognition that occurs over a short period of time and tends to fluctuate over the course of the day. Symptoms include problems with attention, thinking, memory, psychomotor changes and disruption of the sleep-wake cycle.  Delirium is usually triggered by acute medical or surgical illness, or by certain medications.

Why is it important?

  • 10 - 15% of older people admitted to acute care are admitted with delirium (2)
  • 10 - 40% develop delirium over the course of a hospital stay (2)
  • Increased mortality due to post-operative complications and functional decline
  • Increased likelihood of institutionalization and long-term cognitive impairment, and increased health care costs
  • Often missed: up to 66% of cases are unrecognized (3)
  • 50% of affected individuals have delirium on discharge (1)
  • Delirium is a marker of an increased risk of the development of a dementia, even in older people without previous cognitive or functional impairment

Common Causes

  • Predisposing factors include: previous cognitive problems, sensory deficits, frailty, depression, dehydration and polypharmacy
  • There are many precipitating causes especially infections, drugs, cardio-respiratory disease, metabolic disturbances and pain

Key Considerations

  • Important to consider the possibility that delirium might occur
  • Monitoring is crucial (e.g. use of CAM, DOS),routinely screen for delirium/changes in cognition
  • Recovery may takes weeks to months
  • Reducing risk factors is the most effective strategy to prevent and manage delirium:
    • Ensure adequate intake, including use of dentures, proper positioning, nutrition supplements
    • Correct fluid and electrolyte imbalances
    • Provide regular bowel routines to avoid constipation, avoid use of indwelling catheters
    • Use patients vision and hearing aids
    • Avoid use of physical restraints & mobilize
    • Encourage independence in activities of daily living
    • Promote relaxation and sleep
  • Obtain medication history, reconcile, review, and optimize medications
  • Pharmacological treatments should be used only for marked agitation/restlessness while avoiding psychoactive drugs when possible
  • Manage pain and discomfort
  • Provide information to family regarding delirium 

References

1.  American Medical Directors Association (2008). Delirium and acute problematic behavior in the long-term care
     setting. Columbia (MD): American Medical Directors Association (AMDA); 2008. 36 p. Retrieved Feb. 2014 from:
     http://www.guideline.gov/content.aspx?id=12379%20

2.  Chan, P. (2011). Clarifying the confusion about confusion: Current practices in managing geriatric delirium.
     BCMJ, Vol. 53, No. 8, October 2011, page(s) 409-415 Articles. Retrieved Feb. 2014 from:
     http://www.bcmj.org/articles/clarifying-confusion-about-confusion-current-practices-managing-geriatric-

 

Recommended Readings / Guidelines

1.   Canadian Coalition for Seniors’ Mental Health.  (2006).  National Guidelines for Seniors' Mental Health:
      The Assessment and Treatment of Delirium
.  Retrieved March 2014 from:
      ccsmh.ca/wp-content/uploads/2016/03/NatlGuideline_Delirium.pdf

2.   National Institute for Health and Clinical Excellence.  (2010).  Delirium, diagnosis, prevention and management
      Retrieved March 2014 from: 
      http://www.nice.org.uk/nicemedia/live/13060/49909/49909.pdf

3.   Registered Nurses’ Association of Ontario.  (2003).  Screening for Delirium, Dementia and Depression in the
      Older Adult
.  Retrieved March 2014 from:
      http://rnao.ca/bpg/guidelines/screening-delirium-dementia-and-depression-older-adult

4.   Registered Nurses’ Association of Ontario.  (2004). Caregiving Strategies for Older Adults with Delirium, Dementia
      and Depression
.  Retrieved March 2014 from: 
      http://rnao.ca/bpg/guidelines/caregiving-strategies-old