Dr. Steis is Community Health Nurse, Orlando Veterans Affairs Medical Center, Viera, Florida; Dr. Shaughnessy is Associate Director for Education/Evaluation, Baltimore Veterans Affairs Geriatric Research Education and Clinical Centers, and Associate Professor, University of Maryland School of Nursing, Baltimore, Maryland; and Dr. Gordon is Assistant Clinical Professor, Department of Psychiatry, Vanderbilt University School of Medicine, and Chief of Psychology, Mental Health Care Line, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee.
The authors have disclosed no potential conflicts of interest, financial or otherwise.
Address correspondence to Melinda R. Steis, PhD, RN, Community Health Nurse, Orlando Veterans Affairs Medical Center, 2900 Veterans Way, Viera, FL 32940; e-mail: firstname.lastname@example.org.
Your patient, Mr. Jones, is a 72-year-old man admitted from home who has a long history of depression and more recent early-stage, mild vascular dementia. He was brought to the hospital for colon cancer surgery. On admission assessment, he was alert; oriented to person, place, and time; had a pleasant affect; and joked with the nursing staff. After returning to the floor following an uneventful surgery, he began to hallucinate, became disoriented and agitated, and had to be physically restrained from pulling out his tubes and lines. The nursing staff reported this to the attending physician who ordered a psychiatric consultation. The consulting psychiatrist attributed Mr. Jones’ agitation to anxiety and dementia and recommended a benzodiazepine agent. Although Mr. Jones seemed calmer, the hallucinations and disorientation continued, requiring ongoing physical restraints. On Day 3 post operation, Mr. Jones was discharged to a nursing home for rehabilitation therapy, and the family was told that he would need permanent placement in long-term care, as the original plan for him to return home was no longer realistic.
This scenario is not uncommon. Older adults with multiple pre-existing conditions are admitted to hospitals with acute illnesses and injuries every day. With awareness of risk factors and knowledge of delirium, nurses can play a pivotal role in the early identification, treatment, and, most important, prevention of delirium in older adults.
Delirium is an acute, fluctuating confusional state that often signals an emergent decline in health (American Psychiatric Association [APA], 2000; Inouye et al., 1990). It is a condition characterized by a disturbance of consciousness and a change in cognition that develops over a short period of time. Delirium has four components: (a) disturbance of consciousness with decreased ability to focus, sustain, or shift attention; (b) change in cognition or development of a perceptual disturbance that is not better accounted for by a pre-existing, established, or evolving dementia; (c) development of disturbance over a short period of time and tendency to fluctuate during the course of the day; and (d) evidence that the disturbance is directly caused by the effects of a medical condition (APA, 2000).
Delirium is remarkably common. The prevalence of delirium on hospital admission has been reported to be between 14% and 24% (Agostini & Inouye, 2003), and the incidence of developing delirium during hospitalization has been reported to be between 6% and 56% (Agostini & Inouye, 2003). Common outcomes for individuals who experience delirium include persistently lowered levels of cognition and function, such as with ambulation, feeding, and toileting. These same symptoms are also associated with the decision to institutionalize (Boockvar & Lachs, 2003). Other negative outcomes linked to those who experience delirium include longer hospital stays, discharge from acute care before full recovery from the delirium, accelerated functional decline, increased rate of re-admission to acute care, and death within 1 year (Edlund et al., 2006; Fick & Foreman, 2000). These consequences as a whole mean a higher human cost from delirium and much higher costs to the health care system. Current estimates indicate that annual health care costs directly linked to delirium range from $143 billion to $152 billion nationally (Leslie & Inouye, 2011).
Recognition of Delirium
So, why is delirium not recognized by clinicians across health care settings (Voyer, Richard, Doucet, Danjou, & Carmichael, 2008)? Health care professionals may have difficulty identifying delirium because of their lack of knowledge related to delirium and the complex symptoms that appear differently in the presence of other complicating comorbid conditions such as dementia, depression, and the effects of medications (Voyer et al., 2008). One of the hallmarks of delirium is an acute change in mental status that fluctuates over time, making it hard to recognize in an environment where lengths of stay become ever shorter. In addition, if individual patient-nurse interactions are brief, it can often be difficult to document baseline mental status. In an effort to manage multiple complex medical problems in today’s busy health care settings, changes in mental status may not be readily assessed or noticed, but these are often the first sign of acute illness in older adults (Boockvar & Lachs, 2003).
Identification of delirium becomes even more complex in the context of dementia, as in the case of Mr. Jones. Individuals with dementia are more vulnerable to delirium, and the onset of delirium in these individuals can sometimes be confused with natural fluctuations. However, delirium has several features that are not consistent with dementia and are potentially more easily recognized by care providers; these include an acute change in mental status, impaired attention, symptom fluctuation, and altered level of consciousness. Of these, acute mental status change and inattention are hallmarks of delirium (APA, 2000). For example, over the course of a shift, a patient with dementia, who was earlier able to understand and follow simple verbal commands, now seems not to hear you or appears incapable of performing simple tasks he or she was previously able to do.
Except for individuals at the end of life, level of consciousness should not be impaired in older adults with dementia and is an important indicator of a change in mental status (Boettger, Passik, & Breitbart, 2011). Early detection and treatment of delirium superimposed on dementia could slow its progression and prevent complications, both critical to remaining in the community. Those who experience delirium superimposed on dementia have a two-fold increase of death within 1 year of a delirious episode (Bellelli, Speciale, Barisione, & Trabucchi, 2007).
Addressing the Problem
The first strategy to address the problem is to identify those at risk. Risk factors for delirium include predisposing factors and precipitating factors. Predisposing factors are those baseline traits or conditions that render a person at risk of developing delirium (Inouye, Schlesinger, & Lydon, 1999). Precipitating factors are conditions that act as triggers to the development of delirium (Inouye et al., 1999). Drugs can be considered both predisposing and precipitating factors. The most significant predisposing factor for older adults to develop delirium is dementia (Iseli, Brand, Telford, & LoGiudice, 2007), followed by advancing age, neuroleptic drugs, functional impairment, and impaired vision (Edlund et al., 2006). Inouye (2006) proposed that there is a complicated relationship between patients who exhibit predisposing risk factors and are therefore vulnerable to develop delirium and known precipitating factors in the development of delirium such as drugs, primary neurological diseases, acute comorbidities, surgery, environmental issues, and sleep deprivation.
Once the risk factors have been identified, the index of suspicion for delirium should be raised, and the next step is to initiate an assessment. Several valid and reliable instruments can be used for this purpose, including the Confusion Assessment Method (CAM) (Inouye et al., 1990), the CAM for the Intensive Care Unit (ICU) (Ely et al., 2001), the Delirium Rating Scale–Revised–98 (Trzepacz et al., 2001), and the Nursing Delirium Screening Scale (Gaudreau, Gagnon, Harel, Tremblay, & Roy, 2005). If time or circumstances do not allow for a formal screening, nurses should assess the patient’s attention simply by asking him or her to name the days of the week backward. If the patient completes this successfully, the nurse should ask for the months of the year backward. If the patient is too lethargic to attend to the task or responds inappropriately and no other obvious cause is present, delirium should be considered and reported to the team immediately. A change in mental status identified and addressed early can often identify an acute problem before it becomes more serious or life threatening.
In patients with baseline cognitive impairment such as dementia, it is imperative to ascertain and document their baseline mental status by interviewing their informal caregivers to determine their baseline level of day-to-day functioning and mental status before the current illness. This will facilitate comparing any perceived changes with that baseline (Boettger et al., 2011). Individuals with mild to moderate dementia are capable of being attentive and engaged during communication exchanges. It is also not “normal” to fluctuate between levels of consciousness. Delirium screening tools are just as effective with individuals with dementia as they are with those without dementia (Fick & Foreman, 2000).
When caring for a patient suspected to have delirium, the mnemonic DELIRIUM (Table) may be helpful to guide nurses’ next steps to identify the specific cause of the change in status and direct them to corrective actions. It is important to remember that delirium usually has more than one cause.
Table: Delirium Mnemonic
Individual Example: Alternative Scenario
The nurse in the post-operative ward knew that Mr. Jones’ age and early-stage dementia placed him at risk for developing delirium (predisposing factors). The nurse also knew that acute illness (colon cancer), anesthesia, and Foley catheter placement for surgery were precipitating factors. The nurse put into action a plan that called for discontinuing the Foley catheter promptly following surgery, reviewed all ordered medications to check for potential impact on mental status, and monitored Mr. Jones’ cognition carefully during his post-operative period. Preventive strategies, such as making sure his eyeglasses were handy, mobilizing him early, and keeping his environment conducive to orientation during the day and to sleep at night would lessen his delirium risk. In this alternative scenario, Mr. Jones has a successful post-operative course and is discharged directly to home with short-term skilled home care services to monitor his vital signs, attend to his surgical wound, and provide bathing and dressing assistance until he can manage again on his own.
Nurses play a crucial role in keeping patients safe and ensuring optimal outcomes, regardless of the setting. With the growing population of older adults and the expected increases in chronic illness and dementia, delirium is a problem nurses are likely to experience in all practice settings. Knowing what to look for helps nurses recognize the risk and act early to minimize (or even prevent) delirium in their patients. For more information on delirium, assessment, and research updates, the following websites are recommended: the American Delirium Society ( http://www.americandeliriumsociety.org), Vanderbilt University Medical Center’s ICU Delirium and Cognitive Impairment Study Group ( http://www.mc.vanderbilt.edu/icudelirium), and the Hospital Elder Life Program ( http://www.hospitalelderlifeprogram.org).
- Agostini, J.V. & Inouye, S.K. (2003). Delirium. In Hazzard, W.R., Blass, J P., Halter, J.B., Ouslander, J.G. & Tinetti, M.E. (Eds.), Principles of geriatric medicine and gerontology (5th ed., pp. 1503–1515). New York: McGraw-Hill.
- American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
- Bellelli, G., Speciale, S., Barisione, E. & Trabucchi, M. (2007). Delirium subtypes and 1-year mortality among elderly patients discharged from a post-acute rehabilitation facility. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 62, 1182–1183. doi:10.1093/gerona/62.10.1182 [CrossRef]
- Boettger, S., Passik, S. & Breitbart, W. (2011). Treatment characteristics of delirium superimposed on dementia. International Psychogeriatrics, 23, 1671–1676. doi:10.1017/S1041610211000998 [CrossRef]
- Boockvar, K.S. & Lachs, M.S. (2003). Predictive value of nonspecific symptoms for acute illness in nursing home residents. Journal of the American Geriatrics Society, 51, 1111–1115. doi:10.1046/j.1532-5415.2003.51360.x [CrossRef]
- Edlund, A., Lundström, M., Karlsson, S., Brännström, B., Bucht, G. & Gustafson, Y. (2006). Delirium in older patients admitted to general internal medicine. Journal of Geriatric Psychiatry and Neurology, 19, 83–90. doi:10.1177/0891988706286509 [CrossRef]
- Ely, E.W., Margolin, R., Francis, J., May, L., Truman, B., Dittus, R. & Inouye, S.K. (2001). Evaluation of delirium in critically ill patients: Validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Critical Care Medicine, 29, 1370–1379. doi:10.1097/00003246-200107000-00012 [CrossRef]
- Fick, D. & Foreman, M. (2000). Consequences of not recognizing delirium superimposed on dementia in hospitalized elderly individuals. Journal of Gerontological Nursing, 26(1), 30–40.
- Gaudreau, J.D., Gagnon, P., Harel, F., Tremblay, A. & Roy, M.A. (2005). Fast, systematic, and continuous delirium assessment in hospitalized patients: The nursing delirium screening scale. Journal of Pain and Symptom Management, 29, 368–375. doi:10.1016/j.jpainsymman.2004.07.009 [CrossRef]
- Inouye, S.K. (2006). Delirium in older persons. New England Journal of Medicine, 354, 1157–1165. doi:10.1056/NEJMra052321 [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.
- Iseli, R.K., Brand, C., Telford, M. & LoGiudice, D. (2007). Delirium in elderly general medical inpatients: a prospective study. Internal Medicine Journal, 37, 806–811. doi:10.1111/j.1445-5994.2007.01386.x [CrossRef]
- Leslie, D.L. & Inouye, S.K. (2011). The importance of delirium: Economic and societal costs. Journal of the American Geriatrics Society, 59(Suppl. 2), S241–S243. doi:10.1111/j.1532-5415.2011.03671.x [CrossRef]
- Trzepacz, P.T., Mittal, D., Torres, R., Kanary, K., Norton, J. & Jimerson, N. (2001). Validation of the Delirium Rating Scale-Revised-98: Comparison with the Delirium Rating Scale and the Cognitive Test for Delirium. Journal of Neuropsychiatry and Clinical Neurosciences, 13, 229–242. doi:10.1176/appi.neuropsych.13.2.229 [CrossRef]
- Voyer, P., Richard, S., Doucet, L., Danjou, C. & Carmichael, P.H. (2008). Detection of delirium by nurses among long-term care residents with dementia. BMC Nursing, 7, 4. Retrieved from http://www.biomedcentral.com/1472-6955/7/4. doi:10.1186/1472-6955-7-4 [CrossRef]
||Drugs, drugs, drugs
||Low 02 states (MI, ARDS, PE, CHF, COPD)b
||Retention (of urine or stool), Restraints
||Subdural, Sleep deprivation