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Nursing Management of Delirium
This page was last updated on September 19, 2013

Introduction

Organic mental disorders are behavioral or psychological disorders associated with transient or permanent brain dysfunction and include only those mental and behavioral disorders that are due to demonstrable cerebral disease or disorder either primary or secondary.

The presence of following features requires special attention in identifying organic mental disorders:

  • First episode
  • Sudden onset
  • Older age of onset
  • History of drug and alcohol use disorders
  • Concurrent medical or neurological disorder
  • Neurological signs or symptoms like seizure ,impairment in consciousness, head injury, sensory or motor disturbances
  • Presence of confusion , disorientation ,memory impairment or soft neurological sign.
  • Prominent visual or other non auditory hallucinations.

 The disorder can be subcategorized into the following categories :

  • Delirium
  • Dementia
  • Organic amnestic syndrome
  • Other organic mental disorders

Definition

Delirium is not a clinical entity but a symptom-complex of manifold etiology. Its presence signifies acute cerebral insufficiency and often represents a medical and/or psychiatric emergency.Though some forms of delirium have distinctive features, the fundamental phenomena are common to all, with clouding of consciousness the sine qua non. The condition has two major components: (1) the basic "acute brain syndrome" and (2) associated release phenomena.Clinicians must first make the vital differentiation between delirium and "functional" mental disorder, then proceed with the elucidation of the underlying diagnosis and the concurrent organization of symptomatic and etiologic treatment.Proper treatment combines management of the acute brain syndrome with general and specific procedures for control of the underlying condition. Dealing with the symptom-complex itself involves the principles and practice of sedation, hydration, and nutrition, nursing care and supportive measures. Provided the basic organic condition is treatable, the prognosis today is usually good.

According to DSM IV TR delirium is characterized by a disturbance of consciousness and a change in cognition that develop rapidly over a period of time.

History:

In the English literature delirium was applied to an organic brain syndrome with impaired consciousness. In contrast, in France délire was originally used to describe a primary disturbance of perception. In 1909 Bonhoeffer defined delirium as a clinical pattern of acute brain failure.  In the past it was known in different names such as acute confusional state, acute brain syndrome, acute organic reaction , toxic psychosis, metabolic encephalopathies  .

Epidemiology:
Delirium is a common problem in all health care settings, with a prevalence of 0.4% in general population, 1.1% in general population aged >55 years, 9–30% in general hospital admissions and 5–55% in elderly general hospital admissions.

Predisposing factors :
A.  Metabolic causes:

  • Hypoxia
  • Hypoglycemia
  • Hepatic encephalopathy, uremic encephalopathy
  • Cardiac failure ,cardiac arrhythmias
  • Water and electrolyte imbalance(water ,Na+,K+, Mg ++,Ca++)
  • Metabolic acidosis
  • Fever, anemia, hypovolemic shock

B. Endocrine causes

  • Hypo-hyper pitutairism
  • Hypo-hyper –thyroidism
  • Hypo-hyper –parathyroidism
  • Hypo-hyper –adrenalism

C. Drugs (both ingestion and withdrawal causes delirium) and poisons

  • Digitalis ,quinidine ,anti-hypertensive’s
  • Alcohol, sedatives ,hypnonitics
  • Tri cyclic antidepressants  and antipsychotics
  • Anti convulsants –levo dopa
  • Salicylates ,steroids ,pencillin,insulin
  • Methyl alcohol ,heavy metals

D. Nutritional deficiencies

  • Thiamin, niacin, pyridoxine ,folic acid ,B12

E. Systemic infections:

  • Acute and chronic (e.g. septicemia, pneumonia and endocarditis)

F. Intracranial causes:

  • Epilepsy
  • Head injury, subarachnoid hemorrhage ,sub dural hematoma
  • Intracranial infections e.g. meningitis, encephalitis cerebral malaria
  • Stroke ,hypertensive encephalopathy
  • Focal lesions e.g. right parietal lesions

G. Miscellaneous

  • Post operative states
  • Sleep deprivation
  • Heat ,electricity and radiation

Possible causes of delirium, can be described with  the well-known I WATCH DEATH mnemonic.

The DSM IV TR differentiates between the disorders of delirium by their etiology ,although they share a common symptom presentation . Categories of delirium includes :

  • Delirium due to general medical condition
  • Substance induced delirium
  • Substance intoxication delirium
  • Substance withdrawal delirium
  • Delirium due to multiple etiologies

1. Delirium due to general medical condition : In this type the delirium is due to direct result of the physiological consequences of a general medical condition. Such conditions include systemic infections, metabolic disorders, fluid or electrolyte imbalances, hepatic or renal disease ,thiamine deficiency, post operative states, hypertensive encephalopathy, postictal states and sequelae of  head trauma.

2. Substance induced delirium:   this disorder is characterized by the symptoms of delirium  that are attributed to medication side effects or exposure to a toxin.  The following medications are reported to cause substance induced delirium : anesthetics, analgesics, antiasthamatic drugs ,anticonvulsants ,antihistamines, antihypertensive, antimicrobials, antiparkinsonian drugs immunosuppressive agents ,lithium ,muscle relaxants and psychotropic medications .

3. Substance induced delirium : Delirium may arise within minutes to hours after taking relatively high dose of certain drugs such as cannabis ,cocaine and hallucinogens . 

4. Substance withdrawal delirium:  it occurs after reduction or termination of sustained usually high dose use of certain substances such as alcohol, sedatives, hypnotics or anxiolytics. 

5. Delirium due to multiple etiologies : It is associated with more than one cause. It may be the result of combined effect of general medication ad substance use.

Clinical features:  

Delirium is characterized by the following features:

  • Impairment of consciousness is the key feature that separates delirium from most other psychiatric disorders. There is a continuum between mild impairment of consciousness and near unconsciousness. There is fluctuation in intensity, and symptoms are often worse at night. The patient may be unmistakably drowsy, but milder states are easy to miss, especially by those who are unfamiliar with the patient's normal intellectual performance. They may be apparent only in reduced or slowed performance on bedside cognitive testing. There is disorientation in time, place, and the identity of other people.
  • Appearance and behaviour: the patient looks unwell and behaviour may be marked by agitation or hypoactivity, by a fluctuation between these states, or by a mixture of them—for example, a drowsy patient plucking aimlessly at the bedclothes.
  • Mood is frequently labile, with perplexity, intermittent periods of anxiety or depression, or occasionally of other mood states such as elation and irritability. Usually, the mood states have an empty and transitory quality.
  • Speech: the patient may mumble and be incoherent.
  • Perception: visual perception is the modality most often affected. Illusions and misinterpretations are frequent. For example, a patient may become agitated and fearful, believing that a shadow in a dark room is actually an attacker. Visual hallucinations also occur. The small living creatures which may be seen in delirium tremens are the best-known example. Auditory and tactile hallucinations also occur. Complex sensory distortions, such as colours being experienced as tastes, would suggest intoxication with hallucinogens.
  • Cognition: there are abnormalities in all areas of cognitive function. Memory registration, retention, and recall are all affected. Mild cases may show their most pronounced abnormalities in slow performance on tasks or in the wandering of attention away from the task at hand.
  • Orientation: in obvious cases, orientation in person, time, and place will all be disturbed. Milder degrees of disorientation will need to be interpreted in the context of the individual patient. For example, it may be considered not abnormal for a person who has been seriously ill in hospital for a long time to be unaware of the day of the month.
  • Concentration is impaired, for example, on tests such as ‘serial sevens' or ‘days of the week backwards'.
  • Memory disturbances are seen, with impaired registration (e.g. digit span), short-term recall (e.g. name and address), and long-term recall (e.g. current news items). After recovery from the illness there is usually (but not always) amnesia for the illness.
  • Insight is usually impaired. The patient will have no understanding of why a psychiatric assessment has been requested
  • The disturbance of sleep wake cycle most commonly insomnia at night with day time drowsiness
  • Diurnal variation is marked usually with worsening of symptoms in the evening and night (called sun downing )

Diagnosis

ICD 10  diagnostic criteria : According ICD 10 , for definite diagnosis of delirium ,symptoms should be present in each one of the following areas .

  • Impairment of the consciousness and attention (on a continuum from clouding to coma, reduced ability to direct ,focus ,sustain and shift attention )
  • Global disturbance of cognition ( perceptual distortions: illusions and hallucinations most often visual ; impairment of abstract thinking and comprehension with or with out transient delusions ,but typically with some degree of incoherence ,impairment of immediate recall  and of recent memory but relatively intact remote memory ;disorientation for time as well as  in more severe cases for place and person.
  • Psychomotor disturbances ( hypo or hyper activity and unpredictable shifts from one to one another ;increased reaction time increased or decreased flow of speech and enhanced startle reactions )
  • Disturbance of sleep walk cycle (insomnia or in severe cases total sleep loss or reversal of the sleep walk cycle ;day time drowsiness ,nocturnal worsening of symptoms ,disturbing dream or nightmares  which may continue as hallucinations after awakening)
  • Emotional disturbances .e.g. depression, anxiety or fear, irritability ,euphoria ,apathy.
  • The onset is usually rapid and the course diurnally fluctuating and total duration of the condition much less than 6 months .

Differential diagnosis of delirium

  • Functional psychotic disorders can mimic the positive features of delirium, such as hallucinations.
  • Stupor due to severe depression or mania can be mistaken for a diminished level of consciousness.
  • Dementia
  • Amnestic disorders, such as Korsakov's syndrome, also occur in clear consciousness, but the cognitive deficits are concentrated in short-term memory. Immediate recall (e.g. digit span) is normal in amnestic disorders, and long-term memory is relatively preserved: both are impaired in delirium.
  • Sleep disorders (e.g. narcolepsy) and various forms of epilepsy (e.g. the rare petit mal status epilepticus in children) may also need to be excluded.

Physical and laboratory examinations :

  • A bedside mental status examination or Mini Mental Status Examination or neurological signs can be used to document the cognitive impairment and to provide a base line from which to measure the patients clinical course .
  • The Confusion Assessment Method is also widely used because it is reliable, brief, and applicable to a variety of settings

Confusion Assessment Method

  • Delirium diagnosed if (a) + (b) + one of either (c) or (d):
  • Acute onset and fluctuating course: Evidence of an acute change in mental status from the patient's baseline that changes in severity during the day
  • Inattention: Patient has difficulty focusing attention, e.g. is easily distractible or has difficulty keeping track of conversation
  • Disorganized thinking: Patient's thinking is disorganized or incoherent, as evidenced by rambling or irrelevant conversation and unclear or illogical flow of ideas
  • Altered consciousness: A rating of a patient's level of consciousness as other than alert (normal) i.e. vigilant or hyper alert, lethargic or drowsy, stuporus  or comatose
  • Physical examination reveals the cause of delirium
  • Laboratory work up include CBP, electrolytes, thyroid function tests, ECG , EEG  ,chest x ray ,blood ,urine , and CSF cultures .
  • EEG:  It shows a generalized slowing of activity

Management :
Four key steps in management of delirium are –

  • Addressing the underlying causes,
  • Maintaining behavioural control,
  • Preventing complications,
  • Supporting functional needs

The  management strategies include both nonpharmacologic and pharmacologic interventions.

Nonpharmacologic Interventions
Physical Interventions:

  • Initial interventions include general measures to support cerebral function, such as intravenous hydration and appropriate nourishment.
  • Supplemental oxygen has been found to be highly effective in patients who develop delirium with pneumonia.
  • Physical restraints, once a mainstay in the treatment of delirium, are now used only when all pharmacologic and nonpharmacologic interventions have failed.

 Environmental Interventions:

  • The hospital environment is a significant factor in the management of delirium. Environmental manipulations are directed toward providing the right amount of stimulation for the patient, encouraging sleep, maximizing the patient's ability to perceive the environment accurately, maintaining safety, and achieving familiarity and consistency for the patient.
  • Over stimulation should be avoided, because it contributes to both confusion and insomnia
  • Under stimulation is probably a more common problem and is perhaps equally injurious. Delirious patients who are left alone without stimulation often withdraw and begin to respond more to internal stimuli than external stimuli. In such situations, regular interaction with hospital staff can be helpful. It is often appropriate to place the delirious patient in a room close to the nursing station or other workstation
  • Sun downing can be lessened by leaving a radio on in the patient's room
  • It has long been recognized that, in certain cases, the hallucinations of delirium can be specifically treated: visual hallucinations by controlled visual stimuli, auditory hallucinations by music and other meaningful external sounds, and olfactory hallucinations by the introduction of odors or scents
  • To help the patient perceive the environment accurately, adequate daytime lighting and a night light should be provided
  • Hearing aids, eyeglasses and other devices that assist sensory perception should be used whenever possible and should not be put away during a delirious episode
  • One of the most helpful interventions is having family members stay with the patient. Family members should also be encouraged to bring personal effects from home, because some patients with delirium are greatly comforted by the presence of familiar photographs or objects.

Cognitive Interventions:

Reorientation is one of the most easily accomplished cognitive interventions. The first step is to place a clock and a calendar where the patient can see them easily. The patient should then be verbally reoriented to time and place several times over the course of the day. Repetition is recommended to compensate for memory impairment in the delirious patient.

Psychologic Interventions:
The delusions expressed by a patient should not be directly disputed. Instead, alternative explanations of events should be offered, and frequent reassurance should be given.

Pharmacologic Interventions

  • 100 mg of B1 IV for thiamine deficiency and IV fluids for fluid and electrolyte imbalances
  • Symptomatic management: as many patients are agitated , emergency psychiatric treatments may be needed. Small doses of benzodiazepines (lorazepam or diazepam)  or antipsychotics (haloperidol)  may be given orally or parenterally.

Prognosis:

Resolution of symptoms may take longer in patients with poor pre morbid cognitive function, incorrect or incomplete diagnosis of contributing factors, and structural brain diseases treated with large doses of psychoactive medications prior to the onset of acute medical illness. For some patients, the cognitive effects of delirium may resolve slowly or not at all.

Patient Education

  • Educating families and patients regarding the etiology and course of disease is an important role for physicians.
  • Educate the patient, family, and primary caregivers about future risk factors.
  • Families may worry that the patient has brain damage or a permanent psychiatric illness. Providing reassurance that delirium often is temporary and is the result of a medical condition may be beneficial to both patients and their families.
  • Suggest that family members or friends visit the patient, usually one at a time, and provide a calm and structured environment. Encourage them to furnish some familiar objects, such as photos or a favorite blanket, to help reorient the patient and make the patient feel more secure.

Nursing management :
Assessment

  • Client history : from the clients history ,nurses should assess the following areas of concern.
  • Type ,frequency, and severity of mood swings,
  • Personality  and behavioral changes
  • Catastrophic emotional reactions   
  • Cognitive changes such as problems with attention span ,thinking process ,problem –solving
  • Language difficulties
  • Orientation to person ,place, date and situation
  • Appropriateness of social behavior

Physical assessment :
Assessment should focus on two main areas

  • Signs of damage to the nervous system
  • Evidence of diseases of other organs

Nursing diagnoses :
1. Risk for trauma related to impairment in cognitive and psychomotor function

Outcome criteria : Client will not experience injury
Interventions:

  • Arrange furniture and other items in the room to accommodate clients disabilities
  • Store frequently used items within easy access
  • Do not keep bed in elevated position
  • Assist the client with ambulation
  • Keep a dim light on at night
  • Frequently orient the client to place ,time and situation
  • Soft restraints may be required if client is very disoriented and hyperactive

2. Disturbed thought process related to cerebral degeneration as evidenced by disorientation, confusion, memory deficits  and inaccurate interpretation of the environment

Outcome criteria: client will interpret the environment accurately and maintain reality orientation to the best of his or her cognitive ability
Interventions:

  • Frequently orient the client to reality. Use clock and calendars with large numbers that are easy to read
  • Notes and large bold signs may be used as reminders
  • Keep explanation simple
  • Discourage rumination of delusional thinking
  • Talk about real people and real events
  • Monitor for medication side effect

3. Self care deficit related to disorientation ,confusion and memory deficits as evidenced by inability to fulfill the ADL

Outcome criteria: client will accomplish the ADLs to the best of his or her ability. Unfulfilled activities may be kept by caregivers

Interventions:

  • Identify the self care deficits and provide assistance as required
  • Provide guidance and assistance for independent actions
  • Provide a structured schedule of activities that does not change from day to day
  • Provide for consistency in assignment of daily caregivers
  • Perform ongoing assessment of clients ability to fulfill nutritional needs ,ensure personal safety ,follow medication regimen and communicate need for assistance with activities that she or he cannot accomplish independently
  • Involve the family members in the care of the patient

Conclusion

Delirium or acute confusional state is a transient global disorder of cognition. The condition is a medical emergency associated with increased morbidity and mortality rates. Early diagnosis and resolution of symptoms are correlated with the most favorable outcomes. Therefore, it must be treated as a medical emergency.

References

  1. Henry WD, Mann AM. Diagnosis and treatment of delirium.. Can Med Assoc J. 1965 Nov 27;93(22):1156-66.
  2. Mary TC. Psychiatric Mental Health Nursing –Concept of Care.3rd ed. Philadelphia: F.A. Davis Publishers; 2005
  3. Fortinash K M, Worret P H. Psychiatric Nursing Care Plans.5th ed. Philadelphia: Mosby Publications; 2007.
  4. Kaplan HI, Sadock BJ. Synopsis of Psychiatry, Behavioral Sciences/ Clinical Psychiatry .9th ed. Hong Kong: William and Wilkinson Publishers ;1998
  5. Gelder M G, López-Ibor J J, and Andreasen N. New Oxford Textbook of Psychiatry .London Oxford University Press ;2000
  6. Stuart GW, Laria MT. Principles and Practices of Psychiatric Nursing. Ist ed. Philadelphia: Mosby Publishers; 2001.
  7. The ICD 10 Classification of Mental and Behavioral Disorders .World Health Organization.Geneva.1992.
   
 
     
     

 
 
 
 
 
             
 

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