Delirium Prevention,
Assessment and Management
Susan Schumacher, MS, G-CNS
Objectives
• Identify 3 differences in clinical presentation of delirium
versus underlying dementia.
• Explain how to perform the Confusion Assessment
Method (CAM).
• Identify at least 3 factors contributing to the development
of delirium.
• Identify appropriate interventions to prevent or shorten
the course of delirium.
• Describe pharmacological treatment of delirium.
What is Delirium?
A transient state of
cognitive impairment
manifested by
simultaneous disturbance
of behaviors that develop
abruptly and fluctuate
diurnally (daily)
Changes Observed in Delirium
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•
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Level of consciousness
Attention
Perception
Memory
Thinking
Orientation
Psychomotor behavior
Perceptions from Patients
• “I thought there were some photographers
and things around taking advantage of
people.”
• Felt like “someone had pulled a curtain.”
• Felt like “hospital staff were plotting
against me.”
– McCurren, Cronen (2003)
How Common is Delirium?
• Incidence within hospital 4-53.3%
• Complicates hospital stay for more than 2.3
million older persons annually
• Occurs in 5-61% of orthopedic patients,
especially those with hip fractures
• Between 22-89% of patients with delirium have
underlying dementia.
• Prevalence in patients receiving mechanical
ventilation is as high as 83%.
Differentiating Delirium and
Dementia
Delirium
Dementia
Onset
Acute, abrupt
Insidious
Duration
Hours to days, may last
months
Months to years
Course
Fluctuating course which
tends to be worse at
night
Steady decline; can be
stepwise decline with
vascular dementia.
Attention
Inattention present
No change
Differentiating Delirium and
Dementia
Delirium
Dementia
Consciousness
Changes- vigilant to
lethargic
No change until late in
the illness
Hallucinations/Delusions
Visual and auditory
hallucinations and
delusions
Delusions
Visual hallucinations with
Lewy body dementia
Sleep/wake cycle
Impaired, sleep schedule Fragmented; may
can become reversed
awaken frequently
Mood/Affect
Rapid swings; paranoid
Apathetic, depressed
Psychomotor behavior
Hypoactive, hyperactive
or mixed
No change
Outcomes Related to Delirium
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Length of stay
Higher level of care at discharge
Increased mortality after discharge
Increased risk of adverse events
Investigating the factors leading to
Delirium (Multi-factorial)
• Underlying risk factors: Factors that
cannot be changed which impact delirium.
• Precipitating factors: Factors that
contribute to development of delirium
which can be changed.
Underlying Risk Factors
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Dementia
Substance abuse
Parkinson’s disease
Sensory deficits
Age
Traumatic brain injury
Chronic kidney disease
Precipitating Factors
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Hypoxia
Infections
Electrolyte imbalances
Anemia
Medications
Uncontrolled pain
Constipation
Tethers (catheters)
What is Confusion Assessment
Method(CAM)?
• Diagnostic assessment tool for delirium
developed by Sharon Inouye (Yale)
• Assesses 4 features of delirium:
– Acute onset and fluctuating course
– Inattention
– Disorganized thinking
– Altered level of consciousness
Completion of CAM
• On admission for all patients greater than 70
years
• Every 8 hours for patients greater than 70 years
• Supportive information:
– Hours of sleep
– Agitation score
– Behaviors
– Nursing interventions
CAM Assessment on Admission
• Completed and documented within 4
hours of admission
– Baseline Cognitive Status Impairment
(dementia, traumatic brain injury, other
neurologic diseases impacting cognition)
– Admission Cognitive Status
– CAM completed by Surgery Center RN for
surgical patients (documented in PICIS)
Criteria for Patients Unable to
Complete the CAM
• Language Barrier (unable to speak
english)
• Receptive/Expressive Aphasia
• Unconscious or sedated (Use CAM-ICU)
• Severe stage of dementia or brain injury
What makes a positive CAM?
Feature I: Acute Onset of mental status changes
AND
Feature II: Inattention
AND
Feature III: Disorganized
Thinking
AND/
OR
Feature IV: Altered
Level of
Consciousness
ONE abnormal finding for each feature = a positive result for that feature
Confusion Assessment Method
(CAM)
• Criteria 1 (Acute onset and Fluctuating Course)- Has
patient changed from their baseline cognitive status?
Does the behavior fluctuate during the day, such as
worse in the evening or night?
Case Study- Criteria 1
• An 88 yr old woman who is admitted with an intracranial
bleed and has underlying mild cognitive impairment. She
has been alert and oriented to person, place and time.
She is cooperative with cares, but has a difficult time
remembering to use the call light. At 3am she wakes up
and cries out for help, pulls out her IV line, tries to push
nursing staff away and is paranoid about what the staff
are trying to do with her.
Case Study- Criteria 1
• A 79 yr old man admitted for total hip is POD #3. He
has underlying dementia (mild), CAD, Type II
diabetes, and osteoarthritis. Patient’s bed alarm is
going off 2-3 times/ shift, as he tries to get out of
bed to use bathroom and he forgets to use the call
light. He is alert and oriented to person and place,
slept well during the night and cooperates with
nursing cares. He asks the staff about calling his
wife several times every shift.
Confusion Assessment Method
(CAM)
Criteria 2-Inattention
• Does the patient have difficulty focusing attention, for
example, being easily distractible, or having difficulty
keeping track of what was being said?
Case Study- Criteria 2
• Talking with a patient
about his hospital stay,
patient gives eye contact
to the nurse initially, but
when an x-ray machine
moves past his door, his
focus shifts to the
hallway. Also, patient
unable to follow the
directions that nurse has
provided about using call
light when needing
assistance.
Confusion Assessment Method
(CAM)
• Criteria 3(Disorganized Thinking) Is the
patient’s speech disorganized or
incoherent, such as rambling or irrelevant
conversation, unclear or illogical flow of
ideas, or unpredictable switching from
subject to subject?
Confusion Assessment Method
(CAM)
Criteria 4
Levels of Consciousness
• Overall, how would you
rate this patient’s level of
consciousness?
• Alert (normal)
• Vigilant (hyperalert)
• Lethargic (drowsy, easily
aroused)
• Stupor (difficult to arouse)
• Coma (unarousable)
Richmond Agitation Sedation Scale (RASS)
Scor
e
Term
Description
+4
Combative
Overtly combative, violent, immediate danger to staff
+3
Very agitated
Pulls or removes tubes or catheters, aggressive
+2
Agitated
Frequent non-purposeful movement, fight ventilator
+1
Restless
Anxious but movements not aggressive, vigorous
0
Alert and calm
-1
Drowsy
Not fully alert, but has sustained awakening (eye opening/eye
contact) to voice (> 10 seconds)
-2
Light Sedation
Briefly awakens with eye contact to voice (< 10 seconds)
-3
Moderate
Sedation
Movement or eye opening to voice (but no eye contact)
-4
Deep Sedation
No response to voice, but movement or eye opening to physical
stimulation
What makes a positive CAM?
Feature I: Acute Onset of mental status changes
AND
Feature II: Inattention
AND
Feature III: Disorganized
Thinking
AND/
OR
Feature IV: Altered
Level of
Consciousness
ONE abnormal finding for each feature = a positive result for that feature
Let’s Practice!
E-paging a new Positive CAM
Delirium is an urgent medical condition. A positive CAM test should
be reported immediately so the patient can be evaluated for
delirium quickly.
Have this information ready when you page:
• BGM
• Last void/is patient retaining urine
• Oxygen saturation
• Last BM
If no response
• Pain status
within 10 mins,
• Temperature & Blood Pressure
call an RET
• I & O balance
• Latest labs if available (serum K, Na, Mg, Cr, etc)
• Agitation Score
Confirm your CAM POSITIVE result with the Charge
Nurse before paging.
Interventions to Prevent and
Manage Delirium
• Delirium Prevention Trial (Inouye)
– Patients in the highest adherence group
demonstrated an 89% reduction in delirium
risk compared with patients in the lowest
group.
– Protocols for orientation, therapeutic activities
and mobility make a significant difference
when implemented consistently!
Intervention Protocols
Protocols:
• Orientation
• Therapeutic activities
• Mobility
Interventions for Delirium
• Medication
management
– Review for culprit
medications
– Pharmacy consult
– Administer
medications for
delirium per order set
– Pain Management
Interventions for Preventing and
Resolving Delirium
• A2 Evidence
– Promotion of nutrition
– Removal of urinary catheter and
other tethers
– Early mobilization
– Glasses and hearing aides
– Pain management
– Bowel and bladder needs
– Fluids and electrolyte balance
– Adequate 02
Patient and Family Education
• Brochure/Booklet
– What is Delirium?
– Why is it occurring ?
– What can be done to
treat and resolve it?
– What can family
members do to help?
Comfort Measures and patients
with Dementia
• Temperature (hot or
cold?)
• Hungry or thirsty
• Over or under- stimulated
• Bowel or bladder needs
• Provide reassurance
• Personal items such as
family pictures
Hospital Elder Life Program (HELP)
• A comprehensive program of care for
hospitalized older patients, designed to
PREVENT delirium and functional decline.
• Target patient =>70 years old with a LOS > 2
days.
HELP® Goals
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Maintain physical and cognitive functioning throughout hospitalization
(through daily interventions)
Maximize independence at discharge
Assist with the appropriate transition from hospital to home or stepdown setting
Improve geriatric skills of staff throughout the general medicine units.
Hospital Elder Life Program (HELP)
Trained program volunteers: 100
Patient visits per
month: 400!!
Hospital Elder Life Program (HELP)
Key interventions of the program
• Daily visitor program with structured cognitive
orientation
• Therapeutic activities program
• Early mobilization
• Non-pharmacologic sleep protocol
• Hearing and vision protocol
• Feeding and fluid assistance
• Geriatric patient care education for unit nursing staff
How to order a HELP consult
Delirium Order set- Medications
• IV Haloperidol (Haldol) (Severe, Moderate
Hyperactive Delirium and Hypoactive Delirium)
– Scheduled doses of Haldol based on RASS score
– PRN doses to reduce agitation to 0 on RASS scale or until 8mg
given (moderate) 12mg (severe)
– Contact provider if Haldol every 30 minutes for 2hours is not
decreasing agitation.
– Weaning off Haldol (once pt goes 24 hours without prn dose)
– Try to avoid in patients with Parkinson’s disease
– Risk of prolongation of the QT/QTc interval (baseline and daily
EKG)
Why the daily EKG?
Prolongation of QT/QTc interval may occur with
any antipsychotic medication (Haldol) and
increases risk for Torsades de Pointes.
Delirium Order set- Medications
• QUEtiapine (Seroquel)
– Used for patients with
Parkinson’s disease
– May give Haldol and Ativan
additionally for RASS score
of +3. (Combative patient)
– Watch of orthostatic
hypotension
• LORazepam (Ativan)
– Given with IV Haldol for
very agitated patients
ONLY
Prevention of Delirium is Key!
References
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Inouye,S., Baker, D., Fugal, P. & Bradley, E. (2006). Dissemination of the hospital
elder life program: Implementation, adaptation, and successes. Journal of
Gerontological Society, 54:1492-1499.
Inouye,S., Bogardus,S., Williams,C. & Leo-Summers,L. (2003). The role of
adherence on the effectiveness of nonpharmacologic interventions. Archives of
Internal Medicine, 163: 958-964.
Robinson,S., Rich, C., Weitzel,T., Vollmer, C. & Eden,B. (2008). Delirium prevention
for cognitive, sensory, and mobility impairments. Research and Theory for
Nursing practice: An International Journal, 22(2): 103-113.
Sendelbach, S.& Finch Guthrie,P. (2009). Acute Confusion/Delirium. In M.G. Titler
(Series Ed.), Series on Evidence-Based Practice for Older Adults, Iowa City, IA:
The University of Iowa College of Nursing Interventions Research Center,
Research Translation and Dissemination Core.