DELIRIUM
Nursing Standard of Practice Protocol: Delirium: Prevention, Early Recognition, and Treatment

Dorothy F. Tullmann, PhD, RN, Lorraine C. Mion, PhD, RN, FAAN, Kathleen Fletcher, RN, MSN, APRN-BC, GNP, FAAN, Marquis D. Foreman, PhD, RN, FAAN

The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:

• Goal
• Overview
• Background
• Parameters of Assessment
• Nursing Care Strategies
• Evaluation/Expected Outcomes
• Follow-up Monitoring of Condition
• References

Goal

To reduce the incidence of delirium in hospitalized older adults.

Overview

A. Delirium is a common syndrome in hospitalized older adults.

B. Although sometimes reversible, delirium is associated with increased mortality, increased hospital costs, and long-term cognitive and functional impairment.

C. Delirium can be prevented with recognition of high-risk patients and the implementation of a standardized protocol.

D. Delirium, when it develops, may be under-recognized by physicians and nurses.

E. Routine screening for delirium should be part of comprehensive nursing care of older adults.

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Background

A. Definition: Delirium is a disturbance of consciousness with impaired attention and disorganized thinking or perceptual disturbance that develops acutely, has a fluctuating course, and with evidence that there is an underlying physiologic or medical condition causing the disorder.

B. Epidemiology

1. Prevalence (present on admission): 10% to 15% in acute care 1 and 31% in ICU.²
2. Incidence (new onset): 10% to 40% in acute care,1 43% to 61% post– hip surgery,3 31% in ICU,2 and 83% of mechanically ventilated patients.⁴
3. Duration: May resolve in a few hours to days or persist for weeks to months. ¹

C. Etiology

1. Pathophysiologic mechanisms unclear ⁵

2. Risk factors for delirium are mulitifactorial:

a. Advanced age ¹
b. Dementia ⁶
c. Medical illness ⁶
d. Multiple medications ⁶
e. Alcohol abuse ⁶
f. Male gender ⁶
g. Poor functional status ¹
h. Depression ¹
i. Pain ¹
j. Increased blood urea nitrogen/creatinine (BUN/Cr) ratio ⁷
k. Sensory impairment ⁷

3. Potential outcomes of delirium:

a. Increased mortality ¹
b. Increased morbidity ¹

i. Long-term cognitive impairment ⁸, ⁹
ii. Postoperative complications ¹
iii. Decreased functional ability ¹
iv. Increased hospital length of stay ⁸, ¹⁰
v. Institutionalization ¹
vi. Increased health care costs ¹¹

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Parameters of Assessment

A. Assess for risk factors

1. Baseline or pre-morbid cognitive impairment
2. Medications review
3. Pain
4. Metabolic disturbances (i.e., hypoglycemia, hypercalcemia, hyponatremia, hypokalemia)
5. Dehydration (physical signs/symptoms, intake/output, Na+, BUN/Cr)
6. Infection (fever, WBCs with differential, cultures)
7. Environment (sensory overload or deprivation)
8. Impaired mobility

B. Features of delirium should be assessed every shift (see Try This CAM and Try This CAM-ICU and Resources section for validated instruments)

1. Acute onset; evidence of underlying medical condition
2. Alertness: Fluctuates from stuporous to hypervigilant
3. Attention: Inattentive, easily distractible, and may have difficulty shifting attention from one focus to another; has difficulty keeping track of what is being said
4. Orientation: Disoriented to time and place; should not be disoriented to person
5. Memory: Inability to recall events of hospitalization and current illness; unable to remember instructions; forgetful of names, events, activities, current news, and so on
6. Thinking: Disorganized thinking; rambling, irrelevant, incoherent conversation; unclear or illogical flow of ideas; or unpredictable switching from topic to topic; difficulty in expressing needs and concerns; speech may be garbled
7. Perception: Perceptual disturbances such as illusions and visual or auditory hallucinations; and misperceptions such as calling a stranger by a relative’s name
8. Psychomotor activity: May fluctuate between hypoactive, hyperactive, and mixed subtypes

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Nursing Care Strategies

Based on protocols in multicomponent delirium prevention studies ¹², ¹³

A. Collaborate with physician/nurse practitioner to treat the underlying pathology and contributing factors. If available, consult with geriatrician and/or Geriatric Nurse Practitioner or Clinical Nurse Specialist.

B. Eliminate or minimize risk factors

1. Administer medications judiciously; avoid high-risk medications.
2. Prevent/promptly and appropriately treat infections.
3. Prevent/promptly treat dehydration and electrolyte disturbances.
4. Provide adequate pain control.
5. Maximize oxygen delivery (supplemental oxygen, blood, and BP support as needed).
6. Use sensory aids as appropriate.
7. Regulate bowel/bladder function.
8. Provide adequate nutrition.

C. Provide a therapeutic environment.

1. Foster orientation: frequently reassure and reorient patient (unless patient becomes agitated); utilize easily visible calendars, clocks, caregiver identification; carefully explain all activities; communicate clearly
2. Provide appropriate sensory stimulation: quiet room; adequate light; one task at a time; noise-reduction strategies
3. Facilitate sleep: back massage, warm milk or herbal tea at bedtime; relaxation music/tapes; noise-reduction measures; avoid awakening patient 4. Foster familiarity: encourage family/friends to stay at bedside; bring familiar objects from home; maintain consistency of caregivers; minimize relocations
5. Maximize mobility: avoid restraints and urinary catheters; ambulate or active range of motion three times daily
6. Communicate clearly, provide explanations
7. Reassure and educate family
8. Minimize invasive interventions
9. Consider psychotropic medication as a last resort

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Evaluation/Expected Outcomes

A. Patient

1. Absence of delirium or
2. Cognitive status returned to baseline (prior to delirium)
3. Functional status returned to baseline (prior to delirium)
4. Discharged to same destination as prehospitalization

B. Health Care Provider

1. Increased detection of delirium
2. Implementation of appropriate interventions to prevent/treat delirium
3. Use of standardized delirium-prevention protocol
4. Decreased use of physical restraints
5. Decreased use of antipsychotic medications
6. Increased satisfaction in care of hospitalized elderly

C. Institution

1. Decreased overall cost
2. Decreased length of stays
3. Decreased morbidity and mortality
4. Increased referrals and consultation to the specified specialists
5. Improved satisfaction of patients, families, nursing staff

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Follow-up Monitoring of Condition

A. Decreased delirium to become a measure of quality care

B. Incidence of delirium to decrease

C. Patient days with delirium to decrease

D. Staff competence in recognition and treatment of acute confusion/delirium

E. Documentation of a variety of interventions for acute confusion/delirium

Na+ = sodium; BUN/Cr = blood urea nitrogen/creatinine ratio; BP = blood pressure;
Hgb/Hct = hemoglobin and hematocrit; SpO2 = pulse oxygen saturation;
WBCs = white blood cells; URI = upper respiratory infection; UTI = urinary tract infection

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For Definition of Levels of Quantitative Evidence Click Here

Reprinted with permission from Springer Publishing Company.  Tullman, D. F., Mion, L. C., Fletcher, K., & Foreman, M. D.  (2008).  Delirium: Prevention, early recognition, and treatment.  In E. Capezuti, D. Zwicker, M. Mezey, & T. Fulmer (Eds.)  Evidence-Based Geriatric Nursing Protocols for Best Practice (3^rd ed.). (pp. 111-125).  New York: Springer Publishing Company, Inc.
 

References

For definition of Levels of Quantitative Evidence click here.

1. Fann, J. R. (2000). The epidemiology of delirium: A review of studies and methodological issues. Seminars in Clinical Neuropsychiatry, 5, 64–74. Evidence Level I: Systematic Review.

2. McNicoll, L., Pisani, M. A., Zhang, Y., Ely, E. W., Siegel, M. D., & Inouye, S. K. (2003). Delirium in the intensive care unit: Occurrence and clinical course in older patients. Journal of the American Geriatrics Society, 51, 591–598. Evidence Level IV: Nonexperimental Study.

3. Holmes, J. D., & House, A. O. (2000). Psychiatric illness in hip fracture. Age & Ageing , 29 , 537–546. Evidence Level I: Systematic Review.

4. Ely, E. W., Inouye, S. K., Bernard, G. R., Gordon, S., Francis, J., May, L., et al. (2001). Delirium in mechanically ventilated patients: Validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). Journal of the American Medical Association, 286, 2703–2710. Evidence Level IV: Nonexperimental Study.

5. Trzepacz, P. T., & van der Mast, R. C. (2002). The neuropathophysiology of delirium. In J. Lindesay, K. Rockwood, & A. Macdonald (Eds.), Delirium in old age (pp. 51–100). New York: Oxford University Press. Evidence Level VI: Expert Opinion.

6. Elie, M., Cole, M. G., Primeau, F. J., & Bellavance, F. (1998). Delirium risk factors in elderly hospitalized patients. Journal of General Internal Medicine, 13, 204–212. Evidence Level I: Systematic Review.

7. Inouye, S. K., & Charpentier, P. A. (1996). Precipitating factors for delirium in hospitalized elderly persons: Predictive model and interrelationship with baseline vulnerability. Journal of American Medical Association, 275, 852–857. Evidence Level IV: Nonexperimental Study.

8. Ely, E. W., Shintani, A., Truman, B., Speroff, T., Gordon, S. M., Harrell, F. E., Jr., et al. (2004). Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. Journal of the American Medical Association, 291, 1753–1762. Evidence Level IV: Nonexperimental Study.

9. McCusker, J., Cole, M., Dendukuri, N., Belzile, E., & Primeau, F. (2001). Delirium in older medical inpatients and subsequent cognitive and functional status: A prospective study. Canadian Medical Association Journal, 165, 575–583. Evidence Level IV: Nonexperimental Study.

10. Pompei, P., Foreman, M., Rudberg, M. A., Inouye, S. K., Braund, V., & Cassel, C. K. (1994). Delirium in hospitalized older persons: Outcomes and predictors. Journal of the America Geriatrics Society, 42, 809–815. Evidence Level IV: Nonexperimental Study.

11. Inouye, S. K. (2006). Delirium in older persons. New England Journal of Medicine, 354, 1157–1165. Evidence Level VI: Expert Opinion.

12. Inouye, S. K., Bogardus, S. T., Charpentier, P. A., Leo-Summers, L., Acampora, D., Holford, T. R., et al. (1999). A multicomponent intervention to prevent delirium in hospitalized older patients. The New England Journal of Medicine, 340, 669–676. Evidence Level II: Single Experimental Study.

13. Marcantonio, E. R., Flacker, J. M., Wright, R. J., & Resnick, N. M. (2001). Reducing delirium after hip fracture: A randomized trial. Journal of the American Geriatrics Society, 49(3) 516–679. Evidence Level II: Nonexperimental Study.

Reprinted with permission from Springer Publishing Company. Tullman, D. F., Mion, L. C., Fletcher, K., & Foreman, M. D. 2008. Delirium: Prevention, Early Recognition, and Treatment. In E. Capezuti, D. Zwicker, M. Mezey, & T. Fulmer (Eds.) Evidence-Based Geriatric Nursing Protocols for Best Practice (3^rd ed.). New York: Springer Publishing Company, Inc.

Last updated - January 2008

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