Elderly individuals in the United States are living longer, healthier lives than ever before. Community health care agencies help moderately-ill elders remain at home and receive the nursing and supportive care they require. Therefore, by the time nursing home placement becomes inevitable, the elder is older, frailer, and more vulnerable to a multitude of biopsychosocial Stressors. As such, these individuals are at high risk for the development of cognitive impairments, most specifically delirium (Gómez, 1987; Lipowski, 1980, 1987).
To emphasize the prevalence and transient nature of delirium, it has been referred to as "everyman's psychosis" by Aita (1968) and as a "reversible madness" by Stead (1966). Its highest incidence is among elderly individuals, and this reversible syndrome is often misdiagnosed or entirely missed in this population (Foreman, 1992; Lipowski, 1987; Lyness, 1990; WuIs, 1986). Because the onset of delirium often appears very much like a psychiatrie illness, misd iagnosis usually results in the inference that the elderly person has developed a psychosis, or, in individuals with preexisting dementia, that he/she is experiencing a normal progression of the illness. Psychotropic medications are then prescribed with little or no attention paid to the reversible underlying cause of the delirium. The prescription of psychotropics without further exploration of physiological causes can lead to further morbidity, and even mortality, from the underlying untreated illness (Lyness, 1990; Weddington, 1982). Furthermore, although no strong evidence exists to substantiate it, there remains speculation that dementia is a consequence of untreated delirium (Lipowski, 1983, 1987; WUIs, 1993).
Nurses frequently are the first to recognize the subtle changes in mental status and physical functioning that accompany delirium (Foreman, 1986). Because consultation with physicians outside a nursing home setting is often difficult, nurses are compelled to manage these health care problems autonomously. To aid nurses working in nursing homes in better assessing and advocating for appropriate management of delirium, the clinical features of the condition will be discussed, and a nursing protocol for assessment will be presented.
Delirium is a cluster of symptoms that serves as a harbinger of a myriad of physical illnesses in the frail elder. The initial psychological dysfunction often signals that compromised physiologic function will soon follow. Delirium is transient in nature and manifests itself as an acute impairment in cognition and attention, with concomitant alterations in the sleep-wake cycle and psychomotor behavior. The behavioral manifestations of delirium can be extremely varied and, as such, are confusing to caregivers. A classic example of delirium involves a patient who is disoriented, agitated, emotionally labile, and experiencing hallucinations and delusions (Gómez, 1987; Lipowski, 1983, 1987; Lyness, 1990). But as Lyness (1990) points out, elderly patients may experience a "quiet delirium" where they exhibit atypical behaviors, such as withdrawal, or manifest classic symptoms to a lesser degree. These atypical cases are frequently misdiagnosed as psychiatric disorders, specifically depression.
Little is validated about the pathogenesis of delirium. However, exploring several of the more accepted hypotheses of pathogenesis may help nurses become more vigilant toward the possible development of delirium in frail elderly residents.
Engel and Romano (1959) postulated that a general reduction in cerebral oxidative metabolism accounted for the global cognitive impairment seen in delirium. Therefore, "any factor that causes reduction of the supply, uptake or utilization of substrates for brain metabolic activity could lead to delirium" (Lipowski, 1987). An addition to this hypothesis was contributed by Blass and Plum (1983), who proposed that decreased cerebral oxidative metabolism resulted in the reduction of acetylcholine synthesis, thus causing delirium. This finding was supported by studies demonstrating that the administration of anticholinergic agents could induce delirium and be reversed by the administration of a cholinesterase inhibitor (!til, 1966; Lipowski, 1980). Further development of this hypothesis of pathogenesis as a pathophysiologic explanation for delirium includes the concept that reduced cerebral oxidative metabolism creates an imbalance between, rather than a simple reduction of, neurotransmitters.
Another distinctly different hypothesis is held by Krai (1975). He proposed that delirium in elderly patients represents a reaction to acute stress that is mediated by elevated levels of plasma cortisol. The elevated cortisol levels are known to cause the attention and information processing aberrations associated with delirium.
Using the hypothesis for pathogenesis discussed above, causative factors that may decrease the supply or utilization of oxygen in the brain or cause a stress reaction in the frail elderly are numerous. One way to categorize causal factors of delirium are systemic, mechanical, and psychosocial-environmental (Foreman, 1984). Systemic causes refer to those conditions which interrupt normal brain functioning by altering brain metabolic processes. Mechanical causes refer to blockage or restriction of normal brain functioning, such as vascular obstruction. Psychosocial-environmental causes refer to external, nonbiologic factors that diminish personal meaning (Figure 1). In addition, elders almost universally experience age-associated physiologic and psychosocial changes that can increase their risk for developing delirium. For example, physiologic changes that predispose a frail elder include sensory changes, specifically changes in sight and hearing; reduced synthesis of neurotransmitters; changes in the pharmacokinetics and pharmacodynamics of drugs; decreased immune function; and reduced capacity for homeostatic regulation (Lipowski, 1983, 1987). Psychosocial causes include bereavement; abrupt changes in the living environment; and cognitive changes of aging, such as slower reaction and recall times (Ebersole, 1990).
The multifactorial causes of delirium in frail elders, when combined with the influencing factors of ageassociated changes, make assessments of these individuals difficult. Nurses are in the best position to make such assessments because of the consistent contact and holistic perspective they bring to the care of elders in their practice.
Examples of Causes of Delirium in Frail Elders
THE NURSING PROTOCOL
The purpose of the nursing assessment protocol is to provide nurses working in nursing homes with a structured framework to assess causative factors of delirium in frail nursing home residents. Nurses can then be proactive in requesting further diagnostic testing, in altering the elder's current treatment or autonomously managing the elder's environment.
In attempting to construct the protocol for the assessment of delirium in frail elders, all efforts have been made toward integrating the literature and the author's practice experience. Specific attention was focused on the most common causes of delirium in this population, such as the exacerbation of preexisting disease, drug toxicity/ interactions, and infections (Ebersole, 1989; Gómez, 1987; Grossberg, 1990; Lipowski, 1987; Lyness, 1990; Schaffer, 1983). These causes are given priority in the protocol and should be ruled out in every elder who is assessed as being delirious. Because delirium is an incredibly complex health issue for frail nursing home elders who are the focus of this protocol, certain causative factors will not be addressed. For example, postsurgical delirium would not be as relevant to this pop ulation.
USING THE PROTOCOL
The protocol is divided into two basic assessments: determining that a resident is indeed delirious; and exploring potential underlying causes of the delirium in a logical manner. Six areas for suspecting underlying causes are numbered according to the most common causes of delirium and indicate the flow of the assessment (Figure 2). Each of the six areas contain more specific criteria that help the nurse decide whether a given area could be the cause for the delirium and what further specific autonomous or collaborative laboratory /diagnostic testing is indicated.
In reality, many of these steps occur simultaneously and more than one causative factor may be operating to create a delirium. Therefore, this protocol serves primarily as an orderly framework to guide the nurse in the assessment of a complex problem.
IMPLICATIONS FOR NURSING
Prompt identification of delirium and its underlying causes can improve outcomes for frail elders in nursing homes. Nurses who identify and take appropriate actions toward resolving the multiple causative factors of delirium will decrease further morbidity and loss of function in their elderly patients. Good assessments of these elders should include careful attention to baseline vital signs, orner physiologic parameters, and psychosocial patterns. Such timely and sensitive assessment not only improves the quality of life for patients by preserving functional abilities, but can decrease the frustration and stress experienced by nurses caring for a delirious patient. This job frustration can be minimized when the nurse is empowered through the use of a structured assessment protocol for delirium.
Six Areas for Suspecting Underlying Causes of Delirium
Nursing home nurses have the potential to be frail elders' most powerful advocates in the treatment of delirium. This advocacy can be accomplished when nurses relay specific assessments and make concise recommendations for treatment to physicians, nurse practitioners, or other primary health care providers. It will be the nurse's assessment that most influences the outcome of delirium in the frail elderly. A logical nursing protocol can assist in such assessments.
Although the incidence of delirium in nursing home elders is not well documented, nurses practicing in such settings indicate that it is a most common occurrence - an occurrence that is stressful for residents and staff alike. Therefore, a review of the clinical features of delirium was discussed, and a nursing protocol for assessment of causative factors of delirium was presented. It is proposed that the use of such a protocol can improve outcomes for elders and empower their nurses.
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