Cover Article
Management of
Delirium in
Critically Ill
Older Adults
Michele C. Balas, RN, PhD, APRN-NP, CCRN
Michael Rice, RN, PhD, APRN-NP
Claudia Chaperon, PhD, APRN-NP
Heather Smith, PT, MHS, MPH
Maureen Disbot, RN, MS, CCRN
Barry Fuchs, MD
Delirium in older adults in critical care is associated with poor outcomes, including longer stays, higher costs, increased mortality, greater use of continuous sedation
and physical restraints, increased unintended removal of catheters and self-extubation,
functional decline, new institutionalization, and new onset of cognitive impairment.
Diagnosing delirium is complicated because many critically ill older adults cannot
communicate their needs effectively. Manifestations include reduced ability to focus
attention, disorientation, memory impairment, and perceptual disturbances. Nurses
often have primary responsibility for detecting and treating delirium, which can be
extraordinarily complicated because patients are often voiceless, extremely ill, and
require high levels of sedatives to facilitate mechanical ventilation. An aggressive,
appropriate, and compassionate management strategy may reduce the suffering and
adverse outcomes associated with delirium and improve relationships between nurses,
patients, and patients’ family members. (Critical Care Nurse. 2012;32[4]:15-26)
CNEContinuing Nursing Education
This article has been designated for CNE credit.
A closed-book, multiple-choice examination
follows this article, which tests your knowledge
of the following objectives:
1. Identify risk factors for delirium in critically
ill older adults and the common barriers
to its early recognition
2. Describe the symptoms, possible causes,
and potential clinical consequences of
delirium in critically ill older adults
3. Discuss the nursing implications associated
with both pharmacological and nonpharmacological methods of prevention and management of delirium in critically ill older adults
©2012 American Association of Critical-Care Nurses
doi: http://dx.doi.org/10.4037/ccn2012480
www.ccnonline.org
M
ore than one-half
of all intensive care
unit (ICU) days are
incurred by adults
65 years and older.1
Unfortunately, once admitted to an
ICU, older adults are at high risk for
delirium.2,3 Often referred to as “acute
cognitive dysfunction,”4 delirium is
a common and serious geriatric syndrome in the ICU. Formally, delirium
is defined as an acute but temporary
state of fluctuating levels of consciousness and pervasive impairment in
mental, behavioral, and emotional
functioning.5 The manifestations can
be extremely upsetting to patients,
patients’ families, and nursing staff.
Delirious patients may experience
visual and auditory hallucinations,
are impulsive, are often disoriented,
and often have self-injurious behaviors.6 These behaviors potentially
increase the risk for poor outcomes.
Nurses play an essential role in
the management of delirious, critically ill older adults. Nurses are often
the interdisciplinary team members
who first notice that an elderly patient
is experiencing a change in mental
status; determine whether the patient
is experiencing other indications of
distress such as pain, anxiety, or
dyspnea that may cause or contribute
to the behavioral changes; and intervene by using the best available evidence to promote the comfort, safety,
and welfare of the patient. This
process is extraordinarily complicated because many older adults are
voiceless due to their critical illness,
CriticalCareNurse Vol 32, No. 4, AUGUST 2012 15
et al3 found that
Table 1 Outcomes associated with delirium in the intensive
62% of the
care unit (ICU)
patients had
Higher ICU and hospital costs
evidence of
Longer ICU and hospital length of stay
delirium during
Greater use of continuous sedation and physical restraints
the ICU stay. In
2
a similar study
Increased unintended self-removal of catheters and self-extubation
of older adults
Higher ICU, hospital, and 6-month mortality rates
in a surgical
ICU, 30% of
to extend to the time after discharge
patients experienced delirium sometime during their ICU stay. Of note, in from the hospital. In a surgical ICU,
older patients with delirium were
both of these studies, older adults
more likely than patients without
were screened not only for delirium
delirium to be discharged to a place
(via the Confusion Assessment
other than home (61.3% vs 20.5%; P
Method for the Intensive Care Unit;
12
<.001) and have greater functional
CAM-ICU ) but also for preexisting
decline, as measured by the Index of
cognitive impairment, which is now
Frequency and Outcomes
ADL,22 (67.7% vs 43.6%; P=.02).23 In
recognized as an important predictor
Associated With Delirium
this study,23 delirium was strongly
of delirium.13 These reports suggest
Delirium is a common and frequent manifestation of acute brain
that delirium rates in older patients in and independently associated with
9
greater odds of being discharged to
dysfunction. The reported prevamedical and surgical ICUs may vary
widely, depending on the type of unit. any place other than home (odds
lence of delirium in critically ill adults
10,11
ratio, 7.20; 95% CI, 1.93-26.82). In
Further study is warranted to deterranges widely, from 11% to 87%.
another study24 of older medical
mine if these variations persist.
Few investigators have exclusively
ICU patients, after adjustments
Delirium in the ICU is associated
examined the occurrence and durawith a wide array of poor patient out- were made for relevant covariates,
tion of delirium in critically ill older
including age, severity of illness,
comes (Table 1). The effect of deliradults. In a study of older adults
ium on critically ill older adults seems comorbid conditions, use of psyadmitted to medical ICUs, McNicoll
choactive medication while in the
ICU, and baseline cognitive and
functional status, the number of
Authors
Michele C. Balas is an assistant professor at the University of Nebraska Medical Center,
days of ICU delirium was signifiCollege of Nursing, Omaha, Nebraska.
cantly associated with time to death
Michael J. Rice is a professor of psychiatric nursing and the associate medical director of
within 1 year after admission to the
the Behavioral Health Education Center for Nebraska at the University of Nebraska MedICU (hazard ratio, 1.10; 95% CI,
ical Center, College of Nursing.
1.02-1.18). These findings indicate
Claudia Chaperon is an assistant professor at the University of Nebraska Medical Center,
that delirium is a burden not only
College of Nursing.
for critically ill older adults, who
Heather Smith was manager of core measures at New York Presbyterian Hospital, New York,
New York, when this study was done. She is now program director for quality at the American
face marked disability and altered
Physical Therapy Association in Alexandria, Virginia.
quality of life, but also for the
Maureen Disbot is vice president of quality operations, Methodist Hospital, Houston, Texas.
patients’ family caregivers.
mechanical ventilation, and the sedative effects of medications used in
the ICU to facilitate care.7 Furthermore, critical care nurses are practicing in an environment where
health care providers are just beginning to fully appreciate the prognostic importance of delirium.8
In this article, we review current
evidence pertinent to delirium in
critically ill older adults and describe
pharmacological and nonpharmacological approaches nurses can use to
manage the distressing physical, psychological, and emotional manifestations of delirium in older patients.
Barry Fuchs is an associate professor, Department of Medicine, Perlman College of Medicine,
University of Pennsylvania, Philadelphia, Pennsylvania.
Corresponding author: Michele Christina Balas, RN, PhD, APRN-NP, CCRN, 4903 N 142nd St, Omaha, NE 68164
(e-mail: mbalas@unmc.edu).
To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.
Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.
16 CriticalCareNurse Vol 32, No. 4, AUGUST 2012
14
2,15-17
18
19
16,20,21
Risk Factors
Delirium in ICUs was originally
thought to be caused by environmental factors unique to the units,
www.ccnonline.org
Table 2
Risk factors for delirium
Risk factors
Setting (population)
Nonmodifiable
Potentially modifiable
Hospital (older adults)5,27-30
Dementia/cognitive impairment
Severity of illness
Advanced age
Male sex
Preadmission institutionalization
Social isolation
History of depression
Fever, low blood pressure
Hearing and visual impairments
Diminished activities of daily living
Multiple abnormal results of laboratory tests
Unplanned surgery/type of surgery
Alcohol abuse
Fracture at time of admission
Increased number of admissions in the past year
Preadmission malnutrition
Use of physical restraints
Medication use (see following)
Low mobility after surgery
Malnutrition
Sensory impairment
Iatrogenic events (defined as cardiopulmonary
complications, hospital-acquired infections,
medication related, complications of diagnostic
or therapeutic procedures, unintentional injury)
Critical care (adults)5,10,19,25
Comorbid conditions
Preoperative psychiatric illness
History of smoking
Multiple abnormal results on laboratory tests
Infections
Fever
Advanced age
Severity of illness
Medications (eg, mean daily dose of morphine,
larger daily doses of both fentanyl and midazolam)
Windowless units
Intensive care unit (ICU) length of stay
Sleep deprivation
Infections
Critical care (older adults)13,31,32 Dementia
Receipt of benzodiazepines before ICU admission
Elevated creatinine levels
Low arterial pH
Severity of illness
such as sleep deprivation, sensory
overload, and lack of windows.16,25-27
More recent evidence5,10,19,25,27-30 suggests that risk factors associated with
delirium in critical care are similar
to those in other hospitalized older
adults (Tables 2 and 3). Of note,
some of these variables are fixed (eg,
age, diagnosis), whereas others may
be amenable to nursing intervention.
Several interrelated patient characteristics are associated with delirium in older ICU patients. Pisani et
al31 identified 4 preexisting risk factors for delirium in older patients
admitted to medical ICUs: dementia,
administration of benzodiazepines
before ICU admission, elevated serum
creatinine levels, and low arterial pH.
The relationship among medications,
www.ccnonline.org
Receipt of a benzodiazepine, an opioid, or
haloperidol
physiological
Table 3 Medications associated with deliriuma
derangements,
Anesthetics
and delirium in
Analgesics
older ICU
Antiasthmatic agents
Anticonvulsants
patients was
Antihistamines
also reported
Antihypertensive and cardiovascular medications
for another
Antimicrobials
Antiparkinsonian medications
study32 by
Benzodiazepines
Pisani and colCorticosteroids
Gastrointestinal medications
leagues. These
Muscle relaxants
researchers
Immunosuppressive agents
were interested
Lithium
Psychotropic medications with anticholinergic properties
in examining
a Based on information from American Psychiatric Association.
modifiable risk
factors for delirdelirium in older ICU patients.
ium in the ICU. They found that
These findings indicate the need
administration of a benzodiazepine,
for screening for preexisting cognian opioid, or haloperidol; preexisttive impairment, judicious use of
ing dementia; and severity of illness
medications, and prevention of
were associated with the duration of
5
CriticalCareNurse Vol 32, No. 4, AUGUST 2012 17
secondary physiological injuries in
critically ill older adults.
Definition and Clinical
Manifestations
The gold standard for diagnosis
of delirium is the Diagnostic and Statistical Manual of Mental Disorders
(Fourth Edition, Text Revision;
DSM-IV-TR).5 The DSM-IV-TR defines
delirium as a disturbance of consciousness, attention, and perception that
develops over a short time (usually
hours to days) that can fluctuate during the course of the day.5 The manual emphasizes that delirium often
develops as a sudden decline from
the previous level of functioning rather
than with the gradual decline associated with dementia. The 4 DSM-IV-TR
diagnostic criteria for delirium are
given in Table 4.
Delirium is manifested by disturbances in consciousness, orientation,
speech, and perception and by neurological abnormalities. The disturbance in consciousness is manifested
as a reduced ability to focus, sustain, or
shift attention. Behaviorally, a patient
with delirium is easily distracted and
often difficult to engage in conversation. In contrast, cognitive changes
associated with delirium are characterized by impaired memory, visual
spatial impairment, disorientation,
and language disturbances. Progressive
loss of orientation is often a cardinal
indication of the onset of delirium.
Disorientation to time is one of the
first indications of cognitive decline;
next are disorientations to place, person, and self. Speech and language
disturbances can also occur in delirium, and include dysarthria, dysnomia, dysgraphia, and even aphasia.5
Perceptual disturbances involve
3 main areas: misinterpretations,
18 CriticalCareNurse Vol 32, No. 4, AUGUST 2012
Table 4 Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition,
Text Revision) criteria for deliriuma
1. Disturbance of consciousness with reduced ability to focus, sustain, or shift attention.
2. A change in cognition or the development of a perceptual disturbance that is not
accounted for by a preexisting, established, or evolving dementia.
3. The disturbance develops over a short time (usually hours to days) and
tends to fluctuate during the course of the day.
4. Evidence from the history, physical examination, or laboratory findings indicates that
the disturbance is caused by some direct physiological consequences of a general
medical condition, by a toxic substance, by use of medications, or by more than
one cause.
a Based
on information from American Psychiatric Association.5
illusions, and hallucinations. Although
visual hallucinations are common,33
misperceptions associated with other
senses, including auditory, tactile,
and olfactory, also occur. Initial neurological manifestations of delirium
include disturbances in the sleep-wake
cycle, activity levels, and emotional
responses and multiple nonspecific
neurological abnormalities (eg, tremor,
myoclonus, asterixis, reflex changes,
and electroencephalographic abnormalities).5,33 Neurological disturbances
are often dramatic, fluctuating, and
disturbing to witness.
The psychomotor behaviors of
delirious patients are often classified
into 3 subtypes: hyperactive,
hypoactive, and mixed.34-37 Behaviors
associated with the hyperactive form
may be particularly disturbing; these
include screaming out in fear,
describing hallucinations, pulling at
tubes, trying to climb out of bed,
and attempting to hit staff. In stark
contrast, the hypoactive form of
delirium may be missed in the
absence of active monitoring and is
more common in older, seriously ill
patients. Elderly patients with the
hypoactive form may be deemed
“easier to care for” because they
often lie quietly in their bed and are
withdrawn or lethargic. In one study35
in an ICU, the purely hyperactive
form of delirium was rare (1.6%); the
hypoactive (43.5%) and mixed (54.9%)
forms were far more common. The
transient nature and multiple manifestations of delirium often complicate accurate diagnosis.
Challenges in Diagnosis
Intensive care providers have
historically observed dramatic
changes in cognitive and neurobiological function in critically ill
older adults. Unfortunately, a lack
of conceptual clarity continues to
exist in describing the exact nature
of these changes. For example, delirium in the critical care setting often
is referred to as ICU psychosis, ICU
syndrome, or sundowning.38 The
variable definitions and terminology
used to describe delirium inhibit
effective communication and
research on this condition.38 Delirium continues to be overlooked,
misdiagnosed as dementia (a more
chronic form of cognitive dysfunction), psychiatric illnesses such as
depression, and decline attributed
to normal aging.28 A lack of familiarity with valid and reliable screening
tools used to diagnose delirium in
the ICU may also contribute to either
missed diagnosis or underdiagnosis.
www.ccnonline.org
In the ICU, voicelessness, or
the inability to speak, is often due
to the effects of intubation and
mechanical ventilation, sedation,
or the frequent cognitive, sensory,
and physiological imbalances that
often accompany critical illness.39-41
These effects make it difficult to
detect delirium in voiceless
patients. Restrictions in the
amount of time family members of
critically ill older patients can
spend with the patients also potentially influence delirium detection
rates, because a patient’s family
members are often the first to recognize the patient is experiencing
a change in mental status. Not
having the same patient on a consistent basis and the multiple
changes in caregivers that occur in
the ICU environment are also inherent problems in the recognition of
delirium. These barriers impede
early recognition, delaying timely
and appropriate intervention.
Detection of Delirium
Screening for Preexisting
Cognitive Impairment
Several tools42-59 are available
to nurses to aid in the differential
diagnosis of delirium in critically
ill older patients (Table 5—available
online only, at www.ccnonline.org).
Because dementia is a known risk
factor for delirium in the ICU and
the development of delirium may
actually hasten or accelerate the
development of dementia-like syndromes,60 ICU clinicians should
consider routinely screening
patients for evidence of preexisting
cognitive impairment.31 Pisani et al31
suggest that knowledge of a patient’s
dementia status will not only make
ICU staff more cognizant of the
www.ccnonline.org
risk for delirium but also alert them
to factors that contribute to delirium, such as use of physical
restraints and use of certain anticholenergic medications. Effective
screening instruments for detection
of preexisting cognitive impairment
in older critically ill patients include
the short form of the Informant
Questionnaire on Cognitive Decline
in the Elderly42 and the Modified
Blessed Dementia Rating Scale.43
Monitoring for
Contr ibutor y Symptoms
Critically ill older adults experience several other symptoms and
syndromes that may contribute to
the development of delirium. The
contribution of these other entities
is reflected in the clinical practice
guidelines of the Society of Critical
Care Medicine61 for the sustained
use of sedatives and analgesics in
critically ill adults. The guidelines
state that all ICU patients should be
regularly assessed for pain, sedation,
delirium, and sleep disturbances by
using scales or tools that are both
validated and appropriate to older
patients. The society further recommends that this assessment be performed sequentially; that is, providers
should first assess and treat pain,
and the sedation of agitated critically
ill patients should be started only
after the patients have been provided
adequate pain relief and treatment
of reversible physiological causes.
Performing Regular Assessments
Several delirium detection tools
have been validated in critically ill
populations (see Table 5—online
only). Of note, however, the scales
differ substantially in the quality
and extent of validation efforts, the
specific components of the delirium
syndrome addressed, the ability to
differentiate between the forms of
delirium, and the ease of use.57,62 One
of the most established and widely
used tools is the CAM-ICU. This
tool11,12 is a modified version of the
CAM developed to assist in diagnosing delirium in nonverbal, critically ill patients. The CAM-ICU
criteria for a diagnosis of delirium
are the same as in the CAM, although
some components have been modified. Features 1 (acute onset of mental status change or fluctuating
course), 3 (disorganized thinking),
and 4 (altered level of consciousness)
remain the same. However, for
assessment of feature 2 (inattention),
the CAM-ICU uses either the Visual
(Picture) or the Auditory (Letter)
Attention Screening Examination.
The CAM-ICU can be administered
in less than 2 minutes and is valid
and reliable in different ICU settings. More information about the
CAM-ICU is available online.38
Another useful tool for evaluating delirium is the Intensive Care
Delirium Screening Checklist.55
This tool consists of 8 items based
on the DSM-IV-TR criteria for delirium: altered level of consciousness,
inattention, disorientation, hallucination or delusion, psychomotor
agitation or retardation, inappropriate mood or speech, sleep-wake cycle
disturbance, and symptom fluctuation. Scores range from 0 to 8. A
total score of 4 or greater has 99%
sensitivity for a psychiatric diagnosis of delirium.
Treatment Options
The exact pathophysiology of
ICU delirium remains unclear. Its
development is thought to be related
CriticalCareNurse Vol 32, No. 4, AUGUST 2012 19
to anatomical deficits; imbalances in
the neurotransmitters that modulate
control of cognitive function, behavior,
and mood; and various inflammatory mechanisms.38 Neurotransmitters, including the monoamines (eg,
serotonin, dopamine, norepinephrine), and imbalances in acetylcholine,
glutamate, and γ-aminobutyric acid
are postulated to be involved in
delirium.9 Pharmacological treatment of delirium is usually directed
toward decreasing agitation and
psychotic symptoms.5
Pharmacological Methods
A thorough discussion of medication management in critically ill
older adults is beyond the scope of
this article. A few caveats, however,
warrant special attention. First, many
medications are associated with the
onset of delirium (Table 3). Almost
every medication used in the ICU
can potentially predispose an older
patient to delirium. Ironically, many
of the medications used to treat the
symptoms of delirium (eg, restlessness, altered sleep cycle) have anticipated side effects that may actually
make the symptoms worse. Nurses
caring for delirious, older patients
should critically review each patient’s
record of medications administered
for the number and type of medications the patient is receiving and
should discuss with the patient’s
physician or nurse practitioner the
possibility of discontinuing all
nonessential medications to limit
the total number of drugs administered.7 Implementation of many of
the standard geriatric principles of
medication management (eg, frequent review of medications used,
avoidance of polypharmacy, application of the Beers Criteria and
20 CriticalCareNurse Vol 32, No. 4, AUGUST 2012
concepts)63 may reduce the incidence and severity of delirium in
critically ill older patients.
Antipsychotic medications are
commonly used in the ICU to treat
the symptoms of delirium.64 According to the most recent guidelines61 of
the Society of Critical Care Medicine,
haloperidol is still the preferred
agent for the treatment of delirium
in critically ill patients. Although
the optimal dose and regimen of
haloperidol have not been well
defined, the guidelines suggest
using a loading regimen, starting
with a 2-mg dose and then giving
doses (double the previous dose)
every 15 to 20 minutes while agitation persists. Of note, however, the
safety and efficacy of antipsychotic
medications, particularly in older
adults, have recently been questioned. The level of risk is reflected
in the “black box” warning65 of the
Food and Drug Administration for
use of antipsychotics in elderly
patients. This class of medications
is not approved for dementiarelated psychosis because of
increased mortality risk in
elderly patients on conventional or atypical antipsychotics. Most of the deaths
are associated with use due
to cardiovascular or infectious
events. The extent to which
the increased mortality can
be clearly attributed to antipsychotic vs some patient
characteristic(s) is not clear.65
Because of the lack of supporting evidence for the use of antipsychotic medications for delirium in
critically ill patients and the potentially life-threatening adverse effects
of these medications (eg, torsades
de pointes, neuroleptic malignant
syndrome, sudden cardiac death),
Girard et al66 recently conducted a
ground-breaking study to determine
the feasibility, efficacy, and safety of
antipsychotics for treatment of ICU
delirium. The hypothesis behind
the Modifying the Incidence of
Delirium randomized, multicenter,
placebo-controlled trial was that
use of antipsychotics would improve
days alive without delirium or coma.
A total of 101 patients were randomly assigned to receive haloperidol, ziprasidone, or placebo every 6
hours for up to 14 days. The patients
were 35 to 68 years old. Frequency
of administration of medication
was adjusted twice daily according
to each patient’s status. The results
indicated that compared with
placebo, neither haloperidol nor
ziprasidone significantly reduced
the duration of delirium. Further,
patients in the 3 treatment groups
spent a similar number of days alive
without delirium and coma. Because
of the surprising efficacy findings, the
researchers66 suggest that more trials
are needed to determine whether
use of antipsychotics for treatment
of delirium in the ICU is appropriate.
In another clinically relevant,
prospective, randomized study,
Devlin et al67 compared the efficacy
and safety of scheduled quetiapine
to placebo for the treatment of delirium in critically ill patients receiving as-needed haloperidol. The
results indicated that use of quetiapine (when added to as-needed
haloperidol) resulted in slightly
faster resolution of delirium, less
agitation, and a greater rate of
transfer to home or rehabilitation
centers versus other settings. Of
note, however, the sample size of
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this study was small (only 36
patients), a characteristic that may,
as the investigators acknowledge,
limit the ability to reliably detect
differences in any of the efficacy or
safety outcomes. Because of these
concerns about safety and efficacy,
nurses should consider several
things before administering antipsychotic medications to delirious, critically ill older patients68 (Table 6).
Use of sedatives and analgesics is
ubiquitous in the ICU.61 Although
often necessary, medications such
as benzodiazepines and opioids may
increase the risk for delirium,69-71
particularly in critically ill older
patients.13,31-32 Because these medications themselves contribute to
worsening clinical outcomes, an
evidence-based organizational
approach referred to as the ABCDE
bundle (Awakening and Breathing
Coordination, Delirium monitoring
and management, and Early mobility and exercise) has recently been
suggested.72,73 The goal of this
approach is to liberate critically ill
adults from the harmful effects of
exposure to sedatives by using targetbased sedation protocols, spontaneous awakening trials, and proper
choice of sedatives.73 An additional
goal is early mobilization,73 which
will hopefully reduce delirium and
improve neurocognitive outcomes.
Nonpharmacological Methods
The unstable physiological condition that often precedes or exists
at the time of admission of older
adults to the ICU is often a nurse’s
top priority. One of the most important nonpharmacological interventions nurses can use when caring for
a delirious, critically ill older adult
is preventing and/or correcting the
www.ccnonline.org
Table 6 Points to consider when administering antipsychotic medications to
critically ill older adults
What is the goal of treatment?
Is there a particular behavior, such as pulling at tubes, that is being targeted by the
antipsychotic medication?
If behavior is the target symptom, is the cause of the behavior identifiable and
manageable?
Does a nonpharmacological approach exist that would be more effective at treating
that specific behavior?
Does the patient have a contraindication for typical or atypical use of antipsychotic
medication ?
Has a psychiatric consultation been obtained?
Is the medication approved by the Food and Drug Administration for the target
symptoms for elders?
Do the side effects of the medication compromise the nutritional or electrolyte status
of the patient?
What is the patient’s QT interval?
unstable physiological and hemodynamic conditions that accompany
many of the disorders associated
with acute change in mental status
(eg, early sepsis).74-77 Removal or
reversal and recognition of the underlying cause of delirium remain the
cornerstone of treatment.5
Nurses who provide care to an
older adult experiencing an acute
change in mental status need to
mobilize all of their available resources
early on. If the patient is not yet in
the ICU, mobilization may include
activating the hospital’s rapid-response
team, immediately notifying the
patient’s physician of the change in
mental status, and increasing the
level of care. Precautions to prevent
aspiration and falls and ensure safety
should also be started to protect the
patient from harm.76 Mobilization of
resources is important because a
nurse caring for a delirious, critically
ill older patient will need to work
with other members of the ICU team
to determine the cause of delirium.
Common tools used in the differential
diagnosis of delirium include assessment of vital signs, blood glucose
levels, pulse oximetry monitoring,
laboratory profiles (eg, chemistry
studies, drug levels, urinalysis, and
arterial blood gas analysis), chest
radiographs and electrocardiograms.75,76 Keeping the patient safe
and preventing secondary physiological injury is a top priority in
effective management of delirium.
Another major obstacle to
effectively managing delirium in
critically ill, older patients is the
major communication challenges
experienced by these patients.
Recent evidence78 suggests that
patients with impaired communication may be at elevated risk for
poor outcomes. The inability to
communicate one’s needs effectively
can be associated with feelings of
panic, insecurity, stress, anger,
worry, and fear,79,80 feelings that
may result in further hormonal
and physiological abnormalities.
Older adults appear to be at
particularly high risk for impaired
CriticalCareNurse Vol 32, No. 4, AUGUST 2012 21
communication in the ICU. In a
study by Happ et al41 that included
18 older ICU patients, all 18 patients
had impaired vision or wore glasses,
but more than half (10) did not
have their glasses with them in the
ICU. In addition, none of the 3
patients who reported wearing
hearing aids had their devices in
the ICU. Older adults in this study41
were also more likely to have
impaired communication (eg, difficulties with speech, word recall,
writing) before hospitalization and
were more often delirious and sedated
at the time of enrollment in the study
than were younger patients. Critically
ill, older patients need to be provided
with their glasses, hearing aids, or
other assistive devices to facilitate
early mobilization and safe performance of their activities of daily living.
Establishing an effective means
of communication with critically ill
older patients, their families, and
other staff members will provide
nurses the opportunity to create the
strong social network needed for
successful, healthy patient outcomes.
Methods of providing critically ill,
older patients a way to communicate their needs to staff and family
members while the patients are in
the ICU include using body language
or gestures, touching or pointing,
lipreading or using mime, using yesno questions, providing a pencil
and paper, establishing eye contact,
using blinking, using communica-
To learn more about delirium in the critical
care setting, read “Impact of a Delirium
Screening Tool and Multifaceted Education
on Nurses’ Knowledge of Delirium and Ability to Evaluate It Correctly” by Gesin et al in
the American Journal of Critical Care, 2012;
21:e1-e11. Available at www.ajcconline.org.
22 CriticalCareNurse Vol 32, No. 4, AUGUST 2012
tion boards, consulting speech language pathologists for speaking
valves and other augmentative and
alternative communication systems,
and encouraging family presence
during weaning from prolonged
mechanical ventilation.39,40,81,82
Several other strategies for
improving communication with
delirious patients have been offered.
These techniques include using
short, simple sentences; speaking
slowly and clearly; identifying oneself by name and calling patients by
their preferred names; repeating
questions as needed; allowing time
for patients to respond; and listening and observing patients’ behavior.74-77,83,84 Encouraging patients to
be involved in and in control of as
much of their care as possible, using
reminiscing, acknowledging
patients’ feelings and fears, and providing reassurance not only facilitate effective communication83 but
also provide reassurance and
increase patients’ self-esteem.
In addition, nurses providing
care for a critically ill older patient
must remember that the patient is
not the only person who suffers
when the patient becomes delirious.
Seeing a loved one confused is often
devastating to a patient’s family
members. Involving and informing
a patient’s significant other of the
patient’s change in mental status as
early as possible is important.75
Providing emotional support to a
patient’s family members is paramount. Family members should be
encouraged to visit frequently with
the patient and to assist in reorientation and nursing care. Family
members are also a vital source of
information for determining a
patient’s baseline mental functioning
and behavior and often are important team members in surveillance of
patients.40
Although nursing interventions
for delirious hospitalized older
patients have been reported recently,85,86
the effect of these interventions on
the incidence, duration, and outcomes
of delirium have not been determined.
Nonpharmacological strategies that
may be applicable to delirious, critically ill, older patients are presented
in Table 7. Health care providers
have called for programs such as the
Hospital Elder Life Program to be
modified in a way that would benefit
critically ill older adults.87,88 Since it
was first described in 2000, the Hospital Elder Life Program89 is often
used as a strategy of improving inpatient care of older adults. This
evidence-based, multicomponent,
interdisciplinary program has been
successful not only in reducing the
incidence of delirium in hospitalized
older adults but also as an educational
resource, improving hospital outcomes (eg, functional decline), providing nursing education, improving
retention of nurses, enhancing the
satisfaction of patients and their families, and improving quality of care.90
Conclusion
Delirium occurs frequently in
critically ill, older patients and is
associated with numerous adverse
outcomes during and after hospitalization. The safety and efficacy of
antipsychotic medications in older
adults is questionable, and studies
raise the issue of whether this class of
medications is appropriate for treatment of delirium in the ICU. Existing
evidence also suggests that the use of
benzodiazepines may further increase
the risk for delirium in critically ill
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Table 7
Additional nonpharmacological interventions to prevent and manage delirium in critically ill older adults
Avoid malnutrition and vitamin deficiencies75,83
Avoid use of physical restraints75,76
Discontinue or remove all unnecessary catheters, tubes, and equipment75,76,83
Keep call bell within patient’s reach at all times
Consider “camouflaging” catheters and tubes
Provide adequate lighting and limit noise levels75,77
Keep environment calm and uncluttered; avoid overstimulation and unnecessary room changes74-76
Consider moving patient closer to nurse’s station, using a “low” bed and/or constant observation76,77
Consider using distraction techniques such as an activity belt; frequent personal contact with family, friends, and staff; or television
programs or music with personal significance to the patient76
Use nonpharmacological strategies for sleep promotion; for example, relaxation tapes, massage75,76,83
Encourage early and frequent mobilization/avoid immobilization74-76
Allow activities that decrease anxiety
Encourage participation in activities of daily living75; teach appropriate exercises or strength-training activities
Consult physical, occupational, and speech therapy personnel as needed76
Provide patients with a way of communicating their needs to staff and family83
Use reality orientation76; repeat information as necessary; explain the situation, environment, and equipment; listen and observe behavior;
acknowledge patients’ feelings and fears76
Provide cognitively stimulating activities adapted to each patient75
Interview consistent caregivers and patient’s family to determine patient’s baseline mental status75
Involve and inform significant other of patient’s change in mental status75 (provide emotional support)
Encourage scheduled visits by patient’s family and friends (may be helpful to call in family 24/7)74-76
Treat pain75,76
Consult psychiatry service as needed75,84
older patients. These findings suggest a need to provide ICU nurses
with alternatives to sedation that
will keep patients from becoming
delirious. Although a wide variety of
nonpharmacological interventions
to prevent and treat delirium in hospitalized older adults have been
offered, these interventions have
not been tested in an ICU. Removal,
reversal, and recognition of the
underlying causes of delirium are
essential components in its treatment. Critical care nurses who provide care for older adults should use
all available resources to establish
an effective communication network with the patients, the patients’
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family members, and other health
care providers to achieve successful,
healthy outcomes for patients. CCN
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Financial Disclosures
None reported.
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