LTC 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.  Those who practice in long-term care must be knowledgeable about the risk factors for the disorder, know how to recognize, diagnose, prevent, and treat it. (1)

Why is it important?

  • 50% of affected individuals have delirium on discharge from hospital, or transfer to LTC
  • Incidence in LTCH varies from 1% to 14% and is increasing as length of hospital stays are reduced
  • Increased mortality due to post-operative complications and functional decline
  • Increased likelihood of long-term cognitive impairment
  • Those already experiencing dementia, can develop a hypoactive (apathetic) subtype of delirium

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-delirium%20

 3.  Delirium – Preventing and Managing (2012). Retrieved Feb 14. 2014 from:
     http://seniorfriendlyhospitals.ca/toolkit/processes-care/delirium/preventing-and-managing 

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