Ms. Flanagan is a doctoral candidate and part-time faculty, Decker School of Nursing, Binghamton University, Binghamton, New York, and Dr. Fick is Professor of Nursing, School of Nursing, and Professor of Medicine, Department of Psychiatry, The Pennsylvania State University, University Park, Pennsylvania.
The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity. Dr. Fick acknowledges partial support for this work by award number R01 NR011042 from the National Institute of Nursing Research (NINR). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NINR or the National Institutes of Health.
Address correspondence to Nina M. Flanagan, GNP-BC, APMH-BC, MS, Doctoral Candidate, Decker School of Nursing, Binghamton University, 440 Vestal Parkway, Binghamton, NY 13902; e-mail: email@example.com.
Delirium is defined as an acute change in mental status with features of inattention, disorganized thinking, and alteration in level of consciousness (American Psychiatric Association, 2000). Delirium remains a significant risk for hospitalized older adults and has been shown to be a persistent risk posthospitalization as well (Marcantonio et al., 2005). Dementia is a major risk factor for delirium. The prevalence of delirium superimposed on dementia (DSD) ranges from 22% to 89% in hospitalized and community-dwelling individuals 65 and older. Individuals with DSD have been found to have accelerated decline in cognitive and functional abilities, greater need for institutionalization, rehospitalization risk, and increased mortality (Fick, Agostini, & Inouye, 2002). In addition, delirium can accelerate the trajectory of cognitive decline in patients with Alzheimer’s disease (Fong et al., 2009). The purpose of this article is to describe and define DSD, outline assessment tools for its identification, and provide appropriate nursing interventions. An individual example is interspersed throughout the text to highlight the changes seen in DSD with nursing interventions.
Delirium Superimposed on Dementia
DSD occurs when an individual with a pre-existing dementia develops delirium. Delirium continues to be underrecognized and undertreated in hospitalized older adults with dementia. There are three motoric subtypes of delirium (APA, 2000). The hyperactive form is characterized by restlessness, increased psychomotor activity, and irritability. The hypoactive form of delirium is much more difficult to recognize, as the symptoms are less obvious. Individuals with this form can be more passive, drowsy, withdrawn, or lethargic. The third motoric subtype is a mixed form (Peterson et al., 2006). Inouye, Foreman, Mion, Katz, and Cooney (2001) identified four independent risk factors for underrecognition of delirium by nurses: presence of the hypoactive form of delirium, age 80 and older, vision impairment, and dementia.
Marjorie, 78 years old, is admitted to the hospital with urinary sepsis and dehydration. She lives at home with her daughter and can independently perform her activities of daily living and ambulates with a walker. Marjorie’s medical history includes Alzheimer’s dementia and hypertension. Today, she is quiet and refuses to eat her breakfast, bathe, and participate in physical therapy. Is Marjorie experiencing delirium? How can you assess Marjorie for DSD?
Assessment for DSD
The most important aspect of assessment is to determine the baseline mental status of the person with dementia. Ideally, cognitive assessment should be completed on admission and repeated with a change in mental status. Screening for delirium should be done on every shift and documented. Has Marjorie received a baseline cognitive assessment? If not, now is a good time to do one and communicate your findings in the chart and shift report.
The Mini-Cog, which includes a clock-drawing component, is a short test that measures orientation, registration, and recall (Borson, Scanlan, Brush, Vitaliano, & Dokmak, 2000). The Mini-Cog is an excellent screening tool for dementia and can be used to assess baseline mental status. It requires minimal training to administer and requires minimal language interpretation. The Mini-Cog test and instructions are available online at http://www.hospitalmedicine.org/geriresource/toolbox/mini_cog.htm.
The Modified Blessed Dementia Scale (Blessed, Tomlinson, & Roth, 1968) uses information from informal caregivers to help determine an individual’s level of functioning during the 6 months prior to hospitalization. The goal of this scale is to assess a person’s competence in handling household tasks and finances. Examples of questions you could ask Marjorie’s daughter include “During the 6 months prior to her hospitalization, have you noticed any problems with Marjorie’s ability to cope with small amounts of money? What about grasping situations or recognizing surroundings or people?
The Mini-Mental State Examination (MMSE) consists of questions that measure orientation, registration, recall, calculation, and visual perception (Folstein, Folstein, & McHugh, 1975). The examination takes at least 10 to 15 minutes to complete and requires training to administer. The total score for the MMSE is 30 points; lower scores indicate greater impairment.
The most widely validated instrument for delirium screening is the Confusion Assessment Method (CAM). The CAM was developed by Inouye et al. (1990) to detect delirium in hospitalized older adults. The CAM includes an instrument and diagnostic algorithm for identification of delirium. Originally developed through literature review and expert panel consensus, the CAM assesses the presence of four key delirium features: acute onset and fluctuation, inattention, disorganized thinking, and altered level of consciousness (Wei, Fearing, Sternberg, & Inouye, 2008). Questions to address CAM features can be found in Table 1. The CAM requires training and takes 10 to 15 minutes to administer. Using the Modified Blessed Dementia Scale with Marjorie’s daughter, you will be able to determine Marjorie’s baseline cognitive status and accurately determine what is different. This information and the CAM will provide a guideline for assessment of cognitive status and documentation from nurse to nurse, hour to hour, and shift to shift.
Table 1: Guide to Assessing Delirium Using the Confusion Assessment Method
The NEECHAM is a 9-item scale used as a primary observation tool for detecting the presence and severity of acute confusion in hospitalized older adults. This tool addresses cognitive processing, behavior, and physiological control and is strongly correlated with the MMSE (Neelon, Champagne, Carlson, & Funk, 1996). The tool can be completed in 8 to 10 minutes by nurses while obtaining vital signs and does not challenge patients or make them acutely aware of their cognitive deficits (Rapp et al., 2000).
Clear communication and consistent use of an assessment tool are key to identifying those individuals with DSD. The inclusion of family in determining baseline mental status is crucial to identification of delirium. Caregivers may assume these changes are normal for individuals with dementia and do not always alert health care providers of cognitive changes, underscoring the importance of educating caregivers about delirium and its symptoms.
Determine Marjorie’s baseline status with her family and document and communicate your findings. After your assessment using the CAM and discussion with her daughter, you conclude that Marjorie is experiencing delirium. Once delirium has been identified, assessment for possible causes is the next step. The cause of delirium is often multifactorial and a systematic approach to identifying possible causes is essential. Possible causes of delirium are listed in Table 2. Collaborate with Marjorie’s health care provider or other members of the health care team on your findings and review possible causes.
Table 2: Potential Causes of Delirium
Nursing Interventions for DSD
Now that you have determined Marjorie has delirium, how can you keep her safe and prevent it from worsening? The nursing interventions listed below are not only important for those individuals with DSD; they can be implemented for any hospitalized older adult. The nursing interventions were adapted from the Hospital Elder Life Program developed by Inouye, Schlesinger, and Lydon (1999), designed to prevent delirium and functional decline in hospitalized older adults. Interventions target risk factors for delirium and stress an interdisciplinary approach to care.
The goals of intervention are to (a) detect delirium and treat causes, (b) promote safety and prevent injury, (c) manage complications, and (d) decrease severity and re-occurrence. Marjorie initially exhibits signs of the hypoactive form of delirium. She may benefit from cognitive stimulation such as puzzles or reading. Find out what kinds of leisure activities Marjorie enjoyed. To decrease sensory deprivation, be sure she has any necessary assistive aids such as eyeglasses or hearing aids. Encourage Marjorie’s family to participate in her care, and educate the family on activities appropriate for cognitive stimulation. This will give Marjorie a sense of security as well as an opportunity to interact with her family.
The following is a 10-step approach to address Marjorie’s delirium:
Share information with others. Interdisciplinary communication with care providers, physicians, occupational and physical therapists, and geriatric pharmacists can help identify changes in cognitive and physical function and determine potential causes for delirium.
Minimize medications. Eliminate unnecessary medications and avoid adding others, especially benzodiazepine and antipsychotic medications. Have Marjorie’s medications at the hospital been reconciled with the medications she was taking at home? Have any new medications been added to her regimen?
Communicate calmly and slowly. Avoid having multiple caregivers talk to the patient at once.
Avoid physical restraints. Consider the use of bed and chair alarms for fall prevention. If a sitter is involved, consider involving him or her in delirium care and cognitive stimulation.
Address hydration needs. Closely monitor intake and output. Be sure the patient has access to fluids at the bedside. Marjorie was dehydrated on admission; this is very important in her case.
Regulate sleep-wake cycles using nonpharmacological measures. Avoid sedative and hypnotic agents. Has Marjorie been ordered to take any sleep medications? Avoid the use of caffeine. Maintain cognitive stimulation and activity throughout the day to avoid sleeping for prolonged intervals.
Assess for pain and treat promptly. Consider the use of pain scales such as the Pain Assessment in Advanced Dementia (PAINAD; Warden, Hurley, & Volicer, 2003). The PAINAD assesses pain in individuals with cognitive impairment using observations of breathing, body language, vocalization, facial expressions, and consolability. Is Marjorie grimacing or moaning? Is she tense or fidgety? Is there a source for pain?
Educate the family about delirium and encourage them to participate in care.
Mobilize the patient as soon as possible to avoid iatrogenic illness such as pneumonia, urinary tract infection, and deep vein thrombosis. Obtain physical and occupational therapy orders as soon as possible.
Regulate excretory function with implementation of bowel and bladder programs. Marjorie has a urinary tract infection. She may require frequent and scheduled toileting.
DSD is a serious complication for older adults. Baseline cognitive assessment and continual re-assessment will identify those individuals at risk for delirium and alert nurses to a change in cognition, which may indicate onset of delirium. Initial assessment must involve caregivers most familiar with the patient’s baseline cognitive function. The use of a delirium screening tool and early identification of delirium is crucial in care planning and intervention. Nurses play a pivotal role in identifying those individuals with DSD and can provide leadership to the interdisciplinary team. The need for nursing research that includes questions specific for delirium, as well as family participation in interventions, is needed to improve delirium detection and treatment in individuals with dementia.
- American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). doi:10.1176/appi.books.9780890423349
- Blessed, G., Tomlinson, B.E. & Roth, M. (1968). The association between quantitative measures of dementia and of the senile change in the cerebral grey matter of subjects. British Journal of Psychiatry, 114, 797–811. doi:10.1192/bjp.114.512.797 [CrossRef]
- Borson, S., Scanlan, J., Brush, M., Vitaliano, P. & Dokmak, A. (2000). The Mini-Cog: A cognitive “vital signs” measure for dementia screening in multi-lingual elderly. International Journal of Geriatric Psychiatry, 15, 1021–1027. doi:10.1002/1099-1166(200011)15:11<1021::AID-GPS234>3.0.CO;2-6 [CrossRef]
- Fick, D.M., Agostini, J.V. & Inouye, S.K. (2002). Delirium superimposed on dementia: A systematic review. Journal of the American Geriatrics Society, 50, 1723–1732. doi:10.1046/j.1532-5415.2002.50468.x [CrossRef]
- Fick, D.M. & Mion, L. (2007). Assessing and managing delirium in older adults with dementia. Try This: Best Practices in Nursing Care to Older Adults with Dementia, Issue D8. Retrieved from the ConsultGeriRN.org website: http://consultgerirn.org/uploads/File/trythis/try_this_d8.pdf
- Folstein, M.F., Folstein, S.E. & McHugh, P.R. (1975). “Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189–198. doi:10.1016/0022-3956(75)90026-6 [CrossRef]
- Fong, T.G., Jones, R.N., Shi, P., Marcantonio, E.R., Yap, L. & Rudolph, J.L. et al. (2009). Delirium accelerates cognitive decline in Alzheimer disease. Neurology, 72, 1570–1575. doi:10.1212/WNL.0b013e3181a4129a [CrossRef]
- Inouye, S.K. (2003). Confusion Assessment Method (CAM): Training manual and coding guide. New Haven, CT: Yale University School of Medicine.
- Inouye, S.K., Foreman, M.D., Mion, L.C., Katz, K.H. & Cooney, L.M. Jr.. (2001). Nurses’ recognition of delirium and its symptoms: Comparison of nurse and researcher ratings. Archives of Internal Medicine, 161, 2467–2473. doi:10.1001/archinte.161.20.2467 [CrossRef]
- Inouye, S.K., Schlesinger, M.J. & Lydon, T.J. (1999). Delirium: A symptom of how hospital care is failing older persons and a window to improve quality of hospital care. American Journal of Medicine, 106, 565–573. doi:10.1016/S0002-9343(99)00070-4 [CrossRef]
- Inouye, S.K., van Dyck, C.H., Alessi, C.A., Balkin, S., Siegal, A.P. & Horwitz, R.I. (1990). Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Annals of Internal Medicine, 113, 941–948.
- Marcantonio, E.R., Kiely, D.K., Simon, S.E., Orav, E., Jones, R. & Murphy, K.M. et al. (2005). Outcomes of older people admitted to postacute care facilities with delirium. Journal of the American Geriatrics Society, 53, 963–969. doi:10.1111/j.1532-5415.2005.53305.x [CrossRef]
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Guide to Assessing Delirium Using the Confusion Assessment Method
|Acute onset and fluctuating course|
Staff from prior living facility
Nurse from prior shift or admitting nurse
|If patient is exhibiting confusion, ask family and/or caregiver:|
Is this a change from the patient’s normal behavior?
Is this a change in the patient’s usual mental status, and what is different?
Note that change can be prior to hospitalization, day to day, hour to hour, or shift to shift.
|If patient is exhibiting inattention, observe the following:|
Is the patient easily distractible?
Does the patient have trouble keeping track of what is said or following directions?
Ask the patient to spell world backward or recall digits backward and forward (e.g., telephone number).
Prior shift communication
|If patient is exhibiting irregular thought patterns, observe patient or ask family and/or caregiver:|
Is the patient rambling or having irrelevant conversation (e.g., jumping from topic to topic without making sense)?
Is the patient showing signs of incoherent thought processing?
|Altered level of consciousness|
Observe patient (wake patient up if he or she is excessively sleepy during the day)
|If patient is exhibiting a change from his or her normal level of consciousness, observe the following:|
Is the patient hyperalert, drowsy but easy to arouse, or unarousable?
Potential Causes of Delirium
Were any new medications added to patient’s regimen?
Have there been any recent increases or decreases in dosages?
Has the patient exhibited fever, urinary, or respiratory symptoms?
Is the patient’s white blood cell count elevated?
|Dehydration; electrolyte disturbances|
What are the patient’s most recent blood urea nitrogen, creatinine, and sodium levels?
|Lack of medication|
Are the patient’s symptoms due to withdrawal from medication or alcohol?
Are the patient’s pain symptoms well controlled?
Does the patient have vision or hearing loss?
Are the patient’s eyeglasses on and/or hearing aids in?
Is there evidence of neurological changes (e.g., aphasia, hemiparesis, drowsiness, lethargy)?
Has the patient fallen recently?
Does the patient have urinary retention or incontinence?
When was the patient’s last bowel movement (i.e., possible fecal impaction)?
Has the patient’s cardiopulmonary status (e.g., heart rate, lung sounds, pulse oximetry) been assessed?
Have patient’s blood sugar levels been checked?
Is there adequate glucose control?