I have studied delirium through most of my nursing education as I have always had a focus on the older adult community. While in graduate school at The Pennsylvania State University to become a nurse practitioner (NP), I received a certificate in gerontology from the Geriatric Center of Nursing Excellence and learned about geriatric syndromes and person-centered care. I found delirium fascinating because it was something I saw regularly as a nurse, yet I never seemed to have a full understanding of it: the pathophysiology behind it, how it changed so rapidly for better or worse, and how I always believed not enough was being done to shine light on its seriousness. I believed the symptoms got dismissed or not taken seriously because “they [patients] were demented.” This is an important topic for another paper, but for the record, the preferred person-centered language is persons living with dementia, not “demented,” and delirium often occurs in persons with dementia.
In all my years of nursing, and through my schooling to become a NP, I had never seen delirium present so completely textbook as it did on this day. It was one of my last shifts in the emergency department (ED) before I graduated as a NP and I was training a new RN, right out of school. We received an ambulance patient to our room. “Gloria” was in her 80s, appeared to have a normal mental status and alertness, but occasionally repeated herself. She lived at home alone and had taken the bus to her primary care provider (PCP) for an appointment. Her PCP had referred her to the ED for further evaluation of her symptoms.
Upon first assessment, she was alert and oriented and understood our instructions and education about the ED process. She was pleasant, cooperative, calm, and relaxed. Fast forward 30 minutes to when a brand new (straight out of residency) ED physician went in to assess Gloria. He rather quickly came out and said, “I am ordering a head CT STAT, she isn't making any sense. She's incredibly anxious, and I can't get any answers from her. I want a CT of her brain before we do any further testing.”
Confused by this sudden change, both myself and my trainee went into the room to re-evaluate the patient, who was at this time acutely confused (delirious), nonsensically communicating, and repeating herself, essentially having “word salad.” Instead of jumping to conclusions, we listened patiently to Gloria and observed her behavior and finally understood that she needed to urinate. We helped her out of bed and walked her into the bathroom where she continued to be upset and had a meltdown. She was yelling out again and tearful, looking very frustrated. We could not understand anything she was saying and she appeared to be having a conversation in a different language. She was also observed to be looking for something, frantically rummaging through her clothes, eyes darting around the room, but it was impossible to understand what it was she was after. We decided to bring her purse to her while she was sitting on the toilet for comfort as she seemed to be holding it close to her from the moment she arrived in the ED. In a frenzy, she grasped onto it and dove into it, throwing everything out on the floor looking for something, but she could not verbalize what, nor could she find it. She was getting frustrated with herself at that point, becoming more and more agitated. My trainee looked at the orders while I stayed by her side and realized the ED physician ordered 0.5 mg intravenous Ativan®. I told her that I believed this was an episode of delirium and not to administer the Ativan as it would worsen her confusion and cover up the behavior or cause we needed to try and understand.
We sat with Gloria for 10 to 15 minutes, giving her time to look through her purse and try and verbalize her needs. She finally found a little hand sewn pouch that looked like a tiny sunglasses case and pulled out a catheter and immediately self-catheterized herself, overflowing the hat I had put in the toilet to collect a urine sample. She sat there for a few minutes and all of the sudden, as if a switch flipped, she said perfectly, “Thank you so much for being patient with me. I know I was a huge pain just then, but I just had to urinate so bad and I couldn't do that without self-cathing.”
We walked her back to bed, and her mentation cleared in minutes. We told the ED physician that we withheld the Ativan and explained that once Gloria had urinated, her mentation had cleared and I believed she most likely was having an episode of delirium to which he was intrigued. He asked how we knew it was delirium, how we knew she needed self-catheterization, and thanked us for being patient and not just jumping to medication even though he had ordered it. It was such an amazing experience, because not only did I get the chance to educate a new RN about delirium, but a new ED physician as well.
Having my geriatric training allowed me to see this situation and presentation in ways that others without the training did not. We took the time to understand her behavior while she told us “what matters” so that we were able to treat and resolve her delirium. Both bowel and bladder issues (e.g., retention, constipation/impaction) can cause delirium. Delirium can often have multiple causes and does not always clear up as rapidly as it did for Gloria (Oh et al., 2017). With my geriatric training, we were able to recognize that this was a rapid change in her mentation since she came to the ED, which is a classic red flag for diagnosing delirium. Understanding this presentation prevented ordering unnecessary tests and medications. I know that this woman and her story will remain in that physician's and RN's memories and make their practice more age-friendly in the future, as it certainly has for me. Had we given her the Ativan, she would have become more confused and may have become more immobile. In addition, she likely would have sat with a full bladder for several hours, which may have led to a bladder infection, or she could have had a fall while trying to get out of bed to go to the bathroom or search for her catheter. Failure to detect her delirium likely would have resulted in an iatrogenic hospital admission with an increased length of stay.
For Gloria, instead of encountering more harm in the ED, we recognized all behavior has meaning, we detected delirium's rapid onset (versus dementia or other conditions), and treated it appropriately with best practices instead of inappropriate medications that would have made it worse (American Geriatrics Society Beers® Criteria Update Expert Panel, 2019). Now as a NP, I realize that Gloria would likely benefit from further follow up for her mental status with regular screening for cognitive impairment so we can support her at home if needed (Fick, 2018; Fick et al., 2015). Gloria's story also shows the interaction and value of assessing and acting on the 4Ms of age-friendly care—What Matters, Mentation, Medications, and Mobility (access http://www.ihi.org/AgeFriendly).
Now, more than ever in the midst of a pandemic where delirium is often present in COVID-19 and is being managed in a crisis mode (with best practices sometimes thrown out the window), we need to take the time to communicate with and listen to older adults (Young & Fick, 2020). Prevention of delirium is more effective than treatment, but recognizing delirium is important as it can be a medical emergency, and in the case of Gloria, missing the cause could lead to more harm. Thankfully, this was a favorable outcome. Making facilities more age-friendly and assessing and speaking out about delirium can have a major positive impact on our communities and older adults and their caregivers.
Xenia Kugler, MS, CRNP
Mount Nittany Physician Group, Internal
- American Geriatrics Society Beers Criteria® Update Expert Panel. (2019). American Geriatrics Society 2019 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 67(4), 674–694. doi:10.1111/jgs.15767 [CrossRef]
- Fick, D. M. (2018). The critical vital sign of cognitive health and delirium: Whose responsibility is it?Journal of Gerontological Nursing, 44(8), 3–5 doi:10.3928/00989134-20180713-03 [CrossRef] PMID:30059132
- Fick, D. M., Inouye, S. K., Guess, J., Ngo, L. H., Jones, R. N., Saczynski, J. S. & Marcantonio, E. R. (2015). Preliminary development of an ultrabrief two-item bedside test for delirium. Journal of Hospital Medicine, 10(10), 645–650 doi:10.1002/jhm.2418 [CrossRef] PMID:26369992
- Oh, E. S., Fong, T. G., Hshieh, T. T. & Inouye, S. K. (2017). Delirium in older persons: Advances in diagnosis and treatment. Journal of the American Medical Association, 318(12), 1161–1174 doi:10.1001/jama.2017.12067 [CrossRef] PMID:28973626
- Young, H. M. & Fick, D. M. (2020). Public health and ethics intersect at new levels with gerontological nursing in COVID-19 pandemic. Journal of Gerontological Nursing, 46(5), 4–7 doi:10.3928/00989134-20200403-01 [CrossRef] PMID:32266947