Overview

Delirium is a common syndrome in hospitalized older adults and is one of the major contributors to poor outcomes of health care and institutionalization for older patients (Siddiqi, House, & Holmes, 2006).  Delirium has been shown to be preventable by identifying modifiable risk factors and using a standardized nursing practice protocol (Milisen, Lemiengre, Braes, & Foreman, 2005) and involving a geriatric specialist (Siddiqi, Stockdale, Britton, & Holmes, 2007).  If delirium does develop, early recognition is of paramount importance in order to treat the underlying pathology and minimize delirium's sequelae.  Nurses play a key role in both the prevention and early recognition of this potentially devastating condition in older hospitalized adults (Milisen et al., 2005).  

Nursing Standard of Practice Protocol: Delirium

Dorothy F. Tullmann, PhD, RN, Kathleen Fletcher, RN, MSN, APRN-BC, GNP, FAAN, Marquis D. Foreman, PhD, RN, FAAN

Evidence-Based Content - Updated July 2012
Reprinted with permission from Springer Publishing Company. Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition, © Springer Publishing Company, LLC. The text is available here.

The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:

Goal
Overview
Background
Parameters of Assessment
Nursing Care Strategies
Evaluation/Expected Outcomes
Follow-up Monitoring of Condition
References

Goal

To reduce the incidence of delirium in hospitalized older adults.

Overview

A. Delirium is a common syndrome in hospitalized older adults and is associated with increased mortality, hospital costs, and long-term cognitive and functional impairment. (Ref 1)

B. Delirium can sometimes be prevented with recognition of high-risk patients, implementation of a standardized delirirum-reduction protocol, and proactive geriatric consultation. (Ref 2)

C. Recognition of risk factors and routine screening for delirium should be part of comprehensive nursing care of older adults. (Ref 3)

Background and Statement of Problem

A. Definition: Delirium is a disturbance of consciousness with impaired attention and disorganized thinking or perceptual disturbance that develops acutely, has a fluctuating course, and with evidence that there is an underlying physiologic or medical condition causing the disorder. (Ref 4)

B. Etiology and epidemiology

1. Prevalence and incidence: Medical inpatients, prevalence is 10% to 31%; incidence is 3% to 29% (Ref 1). Hip surgery patients, incidence of delirium is 4% to 53% with hip fractures and cognitive causing higher risk of delirium (Ref 5). Medical ICUs, prevalence and incidence both 31% (Ref 6). Surgical ICUs, prevalence 2.6%, incidence 28.3% (Ref 7). Mechanically ventilated patients in ICU, up to 83% during ICU stay (Ref 8), more than 50% of medical ICU patients still have delirium when transferred (Ref 9). Incidence of delirium superimposed on dementia, 22% to 89% (Ref 10).
2. Pathophysiology: Unclear, may be cholinergic deficiency, dopamine excess, or cytokine activity (Ref 11). A genetic association with apolipoprotein E epsilon 4 allele identified (Ref 12).
3. Risk factors: Predisposing, age (70 years and older), severity of illness and cognitive impairment; also depression, sensory impairment, fluid and electrolyte disturbances and polypharmacy (especially psychotropics). Precipitating, central nervous system pathology (such as stroke), metabolic, electrolyte and/or endocrine disturbances, infection and drug toxicity or withdrawal; also pain, hypoperfusion/hypoxia, number of drugs, (especially psychotropic and anti-cholinergic) and restraints. Environmental factors, ICU admission, multiple room changes, and an absence of a clock or glasses (Ref 13).
4. Outcomes: Increased mortality, nursing home placement, and decreased functional status and cognition (Ref 14; 15). Distress for the patient, their family members, and nurses(Ref 16; 2).

Parameters of Assessment

A. Assess for risk factors (Ref 13)

1. Baseline or pre-morbid cognitive impairment (see Chapter 8, Assessing Cognitive Function)
2. Medications review (see Chapter 17, Reducing Adverse Drug Events)
3. Pain (see Chapter 14, Pain Management)
4. Metabolic disturbances (hypoglycemia, hypercalcemia, hyponatremia, hypokalemia)
5. Hypoperfusion/hyponoxemia (BP, capillary refill, SpO2)6. Dehydration (physical signs/symptoms, intake/output, Na+, BUN/Cr)
7. Infection (fever, WBCs with differential, cultures)
8. Environment (sensory overload or deprivation, restraints)
9. Impaired mobility10. Sensory impairment (vision, hearing)

B. Features of delirium (Ref 4; 17)--assess every shift (see "Resources" for validated instruments)

1. Acute onset; evidence of underlying medical condition
2. Alertness: Fluctuates from stuporous to hypervigilant
3. Attention: Inattentive, easily distractible, and may have difficulty shifting attention from one focus to another; has difficulty keeping track of what is being said
4. Orientation: Disoriented to time and place; should not be disoriented to person
5. Memory: Inability to recall events of hospitalization and current illness; unable to remember instructions; forgetful of names, events, activities, current news, and so on
6. Thinking: Disorganized thinking; rambling, irrelevant, incoherent conversation; unclear or illogical flow of ideas; or unpredictable switching from topic to topic; difficulty in expressing needs and concerns; speech may be garbled
7. Perception: Perceptual disturbances such as illusions and visual or auditory hallucinations; and misperceptions such as calling a stranger by a relative’s name
8. Psychomotor activity: May fluctuate between hypoactive, hyperactive, and mixed subtypes

Nursing Care Strategies

(based on protocols in multicomponent delirium prevention studies) (Ref 18; 19; 20)

A. Obtain geriatric consultation.

B. Eliminate or minimize risk factors

1. Administer medications judiciously; avoid high-risk medications (see Chapter 17, Reducing Adverse Drug Events).
2. Prevent/promptly and appropriately treat infections.
3. Prevent/promptly treat dehydration and electrolyte disturbances.
4. Provide adequate pain control (see Chapter 14, Pain Management).
5. Maximize oxygen delivery (supplemental oxygen, blood, and BP support as needed).
6. Use sensory aids as appropriate.
7. Regulate bowel/bladder function.
8. Provide adequate nutrition (see Chapter 22, Nutrition).

C. Provide a therapeutic environment.

1. Foster orientation: frequently reassure and reorient patient (unless patient becomes agitated); use easily visible calendars, clocks, caregiver identification; carefully explain all activities; communicate clearly
2. Provide appropriate sensory stimulation: quiet room; adequate light; one task at a time; noise-reduction strategies
3. Facilitate sleep: back massage, warm milk or herbal tea at bedtime; relaxation music/tapes; noise-reduction measures; avoid awakening patient 4. Foster familiarity: encourage family/friends to stay at bedside; bring familiar objects from home; maintain consistency of caregivers; minimize relocations
5. Maximize mobility: avoid restraints (see Chapter 13, Physical Restraints and Side Rails in Acute and Critical Care Settings) and urinary catheters; ambulate or active ROM three times daily
6. Communicate clearly, provide explanations
7. Reassure and educate family (see Chapter 24, Family Caregiving)
8. Minimize invasive interventions
9. Consider psychotropic medication as a last resort for agitation

Evaluation/Expected Outcomes

A. Patient

1. Absence of delirium or
2. Cognitive status returned to baseline (prior to delirium)
3. Functional status returned to baseline (prior to delirium)
4. Discharged to same destination as prehospitalization

B. Health Care Provider

1. Regular use of delirium screening tool
2. Increased detection of delirium
3. Implementation of appropriate interventions to prevent/treat delirium from standardized protocol
4. Decreased use of physical restraints
5. Decreased use of antipsychotic medications
6. Increased satisfaction in care of hospitalized older adults

C. Institution

1. Staff education and interprofessional care planning
2. Implementation of standardized delirium screening protocol
3. Decreased overall cost
4. Decreased length of stays
5. Decreased morbidity and mortality
6. Increased referrals and consultation to above specified specialists
7. Improved satisfaction of patients, families, and nursing staff

Follow-up Monitoring of Condition

A. Decreased delirium to become a measure of quality care

B. Incidence of delirium to decrease

C. Patient days with delirium to decrease

D. Staff competence in recognition and treatment of acute confusion/delirium

E. Documentation of a variety of interventions for acute confusion/delirium

Na+ = sodium; BUN/Cr = blood urea nitrogen/creatinine ratio; BP = blood pressure;
Hgb/Hct = hemoglobin and hematocrit; SpO2 = pulse oxygen saturation;
WBCs = white blood cells; URI = upper respiratory infection; UTI = urinary tract infection; ROM= range of motion

For Definition of Levels of Quantitative Evidence Click Here

From Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition, © Springer Publishing Company, LLC.

References

For definition of Levels of Quantitative Evidence click here.

1. Siddiqi, N., House, A.O., & Holmes, J.D. (2006). Occurrence and outcome of delirium in medical in-patients: A systematic literature review. Age and Ageing, 35(4), 350-364. Evidence Level V.

2. Bruera, E., Bush, S.H., Willey, J., Paraskevopoulos, T., Li, Z., Palmer, J.L., ...Elsayem, A. (2009). Impact of delirium and recall on the level of distress in patients with advanced cancer and their family caregivers. Cancer, 115(9), 2004-2012. Evidence Level IV.

3. Milisen, K., Lemiengre, J., Braes, T., & Foreman, M.D. (2005). Multicomponent intervention strategies for managing delirium in hospitalized older people: Systematic review. Journal of Advanced Nursing, 52(1), 79-90. Evidence Level V.

4. American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR (4th ed.). Washington, DC: Author.

5. Bruce, A.J., Ritchie, C.W., Blizard, R., Lai, R., & Raven, P. (2007). The incidence of delirium associated with orthopedic surgery: A meta-analytic review.International Psychogeriatrics, 19(2), 197-214. Evidence Level I.

6. McNicoll, L., Pisani, M. A., Zhang, Y., Ely, E. W., Siegel, M. D., & Inouye, S. K. (2003). Delirium in the intensive care unit: Occurrence and clinical course in older patients. Journal of the American Geriatrics Society, 51, 591–598. Evidence Level IV.

7. Balas, M.C., Deutschman, C.S., Sullivan-Marx, E.M., Strumpf, N.E., Alston, R.P., & Richmond, T.S. (2007). Delirium in older patients in surgical intensive care units. Journal of Nursing Scholarship, 39(2), 147-154. Evidence Level IV.

8. Ely, E. W., Inouye, S. K., Bernard, G. R., Gordon, S., Francis, J., May, L., et al. (2001). Delirium in mechanically ventilated patients: Validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). Journal of the American Medical Association, 286, 2703–2710. Evidence Level IV.

9. Pisani, M.A., Murphy, T.E., Araujo, K.L., & Van Ness, P.H. (2010). Factors associated with persistent delirium after intensive care unit admission in an older medical patient population. Journal of Critical Care, 25(3), 540.el-540.e7. Evidence Level IV.

10. Fick, D.M., Agostini, J.V., & Inouye, S.K. (2002). Delirium superimposed on dementia: A systematic review. Journal of the American Geriatrics Society, 50(10), 1723-1732. Evidence Level IV.

11. Inouye, S. K. (2006). Delirium in older persons. New England Journal of Medicine, 354, 1157–1165. Evidence Level VI: Expert Opinion.

12. van Munster, B.C., Korevaar, J.C., Zwinderman, A.H., Leeflang, M.M., & de Rooij, S.E. (2009). The association between delirium and the apolipoprotein E epsilon 4 allele: New study results and a meta-analysis. The American Journal of Geriatric Psychiatry, 17(10), 856-862. Evidence Level I.

13. Michaud, L., Büla, C. Berney, A., Camus, V., Voellinger, R., Stiefel, F., & Burnand, B. (2007). Delirium: Guidelines for general hospitals. Journal of Psychosomatic Research, 62(3), 371-383. Evidence Level V.

14. Cole, M.G., Ciampi, A., Belzile, E., & Zhong, L. (2009). Persistent delirium in older hospital patients: A systematic review of frequency and prognosis. Age and Ageing, 38(1), 19-26. Evidence Level I.

15. Witlox, J., Eurelings, L.S., de Jonghe, J.F., Kalisvaart, K.J., Eikelenboom, P., & van Gool, W.A. (2010). Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: A meta-analysis. The Journal of the American Medical Association, 304(4), 443-451. Evidence Level I.

16. Cohen, M.Z., Pace, E.A., Kaur, G., & Bruera, E. (2009). Delirium in advanced cancer leading to distress in patients and family caregivers. Journal of Palliative Care, 25(3), 164-171. Evidence Level IV.

17. 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(12), 941-948. Evidence Level IV.

18. Inouye, S. K., Bogardus, S. T., Charpentier, P. A., Leo-Summers, L., Acampora, D., Holford, T. R., et al. (1999). A multicomponent intervention to prevent delirium in hospitalized older patients. The New England Journal of Medicine, 340, 669–676. Evidence Level II.

19. Lundström, M., Olofsson, B., Stenvall, M., Karlsson, S., Nyberg, L., Englund, U., ...Gustafson, Y. (2007). Postoperative delirium in old patients with femoral neck fracture: A randomized intervention study. Aging Clinical and Experimental Research, 19(3), 178-186. Evidence Level II.

20. Marcantonio, E. R., Flacker, J. M., Wright, R. J., & Resnick, N. M. (2001). Reducing delirium after hip fracture: A randomized trial. Journal of the American Geriatrics Society, 49(3) 516–679. Evidence Level II.

Last updated - July 2012

Journal Articles

Ely, E.W., Margolin, R., Francis, J., May, L., Truman, B., Dittus, R, Speroff, T., Gautam, S., Bernard, G., & Inouye, S. (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(7), 1370-1379. Evidence Level IV: Nonexperimental study.

Fick, D., Kolanowski, A., Waller, J., & Inouye, S.K. (2005). Delirium superimposed on dementia in a community-living managed care population: A three year retrospective study of prevalence, costs, and utilization.Journals of Gerontology: Medical Sciences, 60A(6), 748-753.

Inouye, S.K. (2006). Delirium in older persons. NEJM, 354, 1157-65. Evidence Level VI: Expert Opinion.

Inouye, S.K., Bogardus, S.T. Jr., Charpentier, P.A., Leo-Summers, L., Acampora, D., Holford, T.R., & Cooney, L.M., Jr. (1999). A multicomponent intervention to prevent delirium in hospitalized older patients. New England Journal of Medicine, 340, 669-676.  Evidence Level II: Single Experimental Study.

Inouye, S.K., Foreman, M.D., Mion, L.C., Katz, K.H., & Cooney, L.M. (2001). Nurses’ recognition of delirium and its symptoms: Comparison of nurse and researcher ratings. Archives of Internal Medicine, 161, 2467-2473. Evidence Level IV: Nonexperimental study.

Inouye, S., van Dyck, C., Alessi, C., Balkin, S., Siegal, A. & Horwitz, R. (1990). Clarifying confusion: The confusion assessment method. Annals of Internal Medicine, 113(12), 941-948. Evidence Level IV: Nonexperimental study.

Laurila, J.V., Pitkala, K.H., Strandberg, T.E., & Tilvis, R.S. (2002).  Confusion assessment method in the diagnostics of delirium among aged hospital patients: Would it serve better in screening than as a diagnostic instrument? International Journal of Geriatric Psychiatry, 17(12), 1112-1119. Evidence Level IV: Nonexperimental study.

Schuurmans, M.J., Deschamps, P.I., Markham, S.W., Shortridge-Baggett, L.M. & Duursma, S.A. (2003). The measurement of delirium: Review of scales.Research and Theory for Nursing Practice: An International Journal, 17(3), 207-224. Evidence Level V: Literature Review.

Segatore, M., & Adams, D. (2001). Managing delirium and agitation in elderly hospitalized orthopaedic patients: Part I-Theoretical aspects.  Orthopaedic Nursing, 20(1), 31-45.

Waszynski, C.M.  (2007). How to try this: Detecting delirium.  AJN, 107(12), 50-60. Available online at http://www.nursingcenter.com/prodev/ce_article.asp?tid=756744

Last updated - March 2008