Dementia and delirium

6 Dementia and delirium



Davina Porock, Wendy L. Walker



CHAPTER AIMS




• To identify the difference between dementia and delirium


• To recognise the signs of delirium and dementia and possible causes


• To understand the management and delivery of care for people with delirium and dementia as part of high-quality nursing practice and care delivery



Introduction


In the region of 60% of hospital patients will have pre-existing mental health problems or will develop one during their hospital stay; 80% of these individuals will have delirium, dementia or depression (Nursing and Midwifery Council (NMC) 2010). Delirium and dementia are two significant cognitive disorders that have overlapping characteristics which can make a definitive diagnosis difficult in the acute hospital setting.


As the population of older people with dementia is estimated to rise from 600 000 to 840 000 by 2026, and reach 1.2 million by 2050 (Alzheimer’s Society 1998), the need to improve diagnosis and implement prompt appropriate interventions is essential, as these patients are known to have higher mortality rates than patients with no cognitive disorder.


In this chapter we consider some of the issues related to these important health and wellbeing problems. Some of the more common terms you may come across in your clinical placements, including surgical, medical and mental health, are explored initially.



Confusion


In clinical practice you will come across many people who are confused, and you must remember that confusion is a symptom of an underlying condition rather than a condition in itself. Confusion can be acute or chronic. Acute confusion arises as a symptom of delirium that is considered temporary if treated appropriately. Chronic confusion is a feature of dementia and is progressive and irreversible.



Delirium


Delirium is an acute disorder of the mental processes. It is not a disease, but a set of symptoms that are the result of an underlying health problem. Delirium can appear in varying degrees of intensity, and it occurs when brain activity is affected. Patients can suffer from hyperactive delirium and become agitated, restless and may be aggressive. Hypoactive delirium is when they are quiet and withdrawn, and mixed delirium is when patients display both behaviours. However, people with hypoactive delirium may not be recognised by staff (Flick et al 2007).


Delirium is a common problem in acutely ill older adults. In the region of 20–30% of people on medical wards and 10–50% of people having surgery develop delirium (National Institute for Health and Clinical Excellence (NICE) 2010). If your placement is classed as one of these types of learning environment, you may well meet a patient who has this problem.


The particular recognisable characteristic of delirium is impaired cognitive function and reduced ability to focus, sustain or shift attention which has developed over a short period of time (usually over hours or days), and generally fluctuates during the course of the day. It is associated with a disturbance in the sleep–wake cycle and an increase or decrease in psychomotor activity. Although delirium usually only lasts for a few days, it may persist for weeks or even months.


Delirium is formally defined as a diagnosis in the Diagnosis and Statistical Manual of Mental Health Disorders, version 4 (DSM-IV 2000). As you will see, it is a complex condition to diagnose with a lot of conditional attributes, thus the diagnosis includes guidance on detection rather than just a definition and characteristics (see Box 6.1).



Box 6.1 Delirium: definition and examples




A. Disturbance of consciousness (i.e. reduced clarity of awareness of the environment) with reduced ability to focus, sustain or shift attention


B. A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a pre-existing, established or evolving dementia


C. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day


D. There is evidence from the history, physical examination or laboratory findings of the following:


image the disturbance is caused by the direct physiological consequences of a general medical condition or

image the symptoms of criteria A and B developed during substance intoxication or medication use is aetiologically related to the disturbance or

image the symptoms of criteria A and B developed during, or shortly after, a withdrawal syndrome or

image the delirium has more than one aetiology (e.g. more that one aetiological general medical condition, a general medical condition plus medication side effect) or

image a clinical presentation of delirium that is suspected to be due to a general medical condition or substance use but for which there is insufficient evidence to establish a specific aetiology or

image delirium due to causes not listed in this section (e.g. sensory deprivation)

(Waite et al 2008)


The signs and symptoms of delirium, summarised in Box 6.2, are important to recognise because, if untreated, delirium can trigger the onset of chronic confusion (dementia) and result in nursing home placement. The important point to make is that these signs and symptoms have had a rapid onset so listening to family members is really important in ascertaining if the symptoms are new or related to existing dementia.



Box 6.2 Delirium: signs and symptoms


Symptoms of delirium generally fluctuate throughout the day and include the following:



image Difficulty focusing, sustaining or shifting attention


image Memory impairment, particularly recent memory


image Disturbance of the sleep–wake cycle, for example drowsy during the day and agitated or restless at night


image Speech or language disturbances, e.g. rambling speech


image Disorientation to place or time


image Disturbance in psychomotor behaviour


image Agitation with increased psychomotor behaviour


image Sluggishness with decreased psychomotor behaviour


image Emotional disturbances – mood swings over the course of a day


image Misinterpretations, illusions or hallucinations


(Waite et al 2008)


There are a number of potential causes of delirium, for example physical illness, pain, fever, toxic drug reactions, poisons, brain injury, traumatic shock, lack of food and/or water, sleep, substance misuse, cancer, postoperative delirium, urinary tract infections, pneumonia, chest infection, metabolic and endocrine disorders.


Patients with delirium will exhibit a poor attention span and personality changes. They may also have language disturbance and chatter meaninglessly. Other symptoms include increased anxiety, restlessness, sudden mood swings, fear, hallucinations, shouting and sometimes patients are violent. The disturbed consciousness, cognitive function and perceptual difficulties have an acute onset and fluctuating course. Frequently the symptoms are worse at night, causing stress and sleep deprivation for other patients.



Assessment of delirium


Without careful assessment, delirium can be confused with conditions such as dementia, depression and psychosis. Therefore, a thorough assessment is required, which should include a comprehensive history and in-depth assessment to confirm diagnosis (NICE 2010). A physical examination should also be undertaken to identify the cause: a range of blood tests (liver and renal function, electrolytes, blood count, serum calcium and glucose), urinalysis, chest X-ray, oxygen saturation and electrocardiogram will be required to determine the underlying cause. Medication should be assessed and, as required, amendments to prescriptions to minimise the effects of drug toxicity. Symptoms will subside as the underlying cause is addressed.


Some patients are more susceptible to delirium. Older people over 70 years of age, those with hearing and vision impairment and some cognitive impairment are at greatest risk. For these people, the onset of a severe medical illness, sleep deprivation for any reason, increased immobility and falls, dehydration and incontinence increase the risk of delirium. In fact, when an older person exhibits symptoms of delirium then immediate assessment for one or more of these treatable conditions should be carried out. A simple mnemonic to remember the key risk factors ofdelirium is PINCHME as shown in Box 6.3 (European Delirium Association 2010).



Box 6.3 Mnemonic for delirium




P = Pain


IN = Infection


C = Constipation


H = Hydration


M = Medications


E = Environment


(European Delirium Association 2010)



Nursing actions


Nursing interventions should be provided with consideration for privacy, dignity and respect. These interventions should include managing a safe environment, orientating the person to time and place, ensuring they get adequate oxygen, hydration, nutrition, monitoring and managing constipation and pain.


Involve the family in the planning and provision of aspects of personal care, assisting with meals and giving drinks. Control the environment by reducing noise and bright lights and use large print and picture signage. Avoid moving the patient between wards and rooms (NICE 2010) and provide consistent care given by a limited number of people. Boxes 6.4 and 6.5 identify some key environmental and clinical strategies for managing delirium in hospital summarised from the European Delirium Association Website.



Box 6.4 Environmental strategies for delirium prevention and management




image Lighting appropriate to time of day


image Provision of single room


image Quiet environment especially at rest times – noise reduction strategies (e.g. use of vibrating pagers rather than call bells)


image Clock and calendar that clients can see


image Encourage family and carer involvement/visits


image Encourage family/carer to bring in client’s personal and familiar objects


image Avoid room changes



Box 6.5 Clinical strategies for delirium prevention and management




image Ensure adequate intake of food and fluids


image Hearing and visual aids available and used


image Avoid constipation


image Encourage and assist with mobilisation


image Encourage independence in basic activities of daily living


image Medication review


image Promote relaxation and sufficient sleep


image Manage discomfort or pain


image Provide orienting information including name and role of staff members


image Minimise use of indwelling catheters


image Avoid physical restraints


image Avoid psychoactive drugs


image Use interpreters and other communication aids

Related posts:

  1. The concept of independence in old age
  2. Reflection and future learning
  3. Policy related to working with older people in nursing practice
  4. Caregiving in later life

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Mar 1, 2017 | Posted by in NURSING | Comments Off on Dementia and delirium

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