Epidemiology

Delirium is the most common complication of hospitalization in older patients (Rice et al., 2011). The reported incidence of delirium in hospitalized patients ranges from 3% to 56% (Michaud et al., 2007), from 11% to 42% in medically ill older patients (Cerejeira & Mukactova-Ludinska, 2011), and from 4% to 65% in postoperative patients, depending on the type of surgery (Rudolph & Marcantonio, 2011). The high degree of variability in the reported incidence of delirium is most likely due to its underrecognition by both nurses and doctors who work in acute-care settings/hospitals.

Comorbidity and etiology

Delirium is always due to underlying physiological causes that are usually multifactorial in nature. There are underlying factors that predispose a patient to developing delirium, and there are immediate factors that precipitate the syndrome.

Predisposing factors for delirium include age, lower education level, sensory impairment, decreased functional status, comorbid medical conditions, malnutrition, and depression (Flagg et al., 2010). Postoperative conditions, systemic disorders, withdrawal of drugs and substances such as alcohol and sedatives, toxicity secondary to drugs or other substances, and impaired respiratory functioning (Tasman & Mohr, 2011).

While the key to offsetting the consequences of delirium is prompt recognition and investigations into possible causes, there is research evidence that the syndrome is poorly recognized and understood by both nurses and doctors (Rice et al., 2011; Flagg et al., 2010). Early recognition and diagnosis is challenging for clinicians due to lack of knowledge about cognitive impairment and its clinical assessment, failure to interpret the signs and symptoms, and nurses’ overreliance on disorientation as the only sign of cognitive impairment (Flagg et al., 2010).

At present the best evidence for the prevention and management of delirium in hospitalized patients is having clinical protocols for minimizing the risk factors and for the early detection of delirium (Cerejeira & Mukactova-Ludinska, 2011). The best approach is collaboration between health care providers, with nurses being in the most likely position to first observe the signs and symptoms of delirium (Milisen et al., 2005). In addition, proactive consultation with geriatric specialists has been shown to reduce delirium in hospitalized patients (Siddiqi et al., 2007).

Overall assessment

According to Wei and colleagues (2008), there are four cardinal features of delirium:

Suspect the presence of delirium when a patient abruptly develops a disturbance in consciousness that manifests as reduced clarity of awareness of the environment. The ability to focus, sustain, or shift attention is impaired. Questions must be repeated because the individual’s attention wanders, and the person might easily get off track and need to be refocused. Conversation is made more difficult because the person may be easily distracted by irrelevant stimuli. The person may have difficulty with orientation—first to time, then to place, and last to person. For example, a man with delirium may think that the year is 1972, that the hospital is home, and that the nurse is his wife. Orientation to person is usually intact to the extent that the person is aware of the self’s identity.

Fluctuating levels of consciousness are unpredictable. Disorientation and confusion are usually markedly worse at night and during the early morning. In fact, some patients may be confused or delirious only at night and may remain lucid during the day.

As nurses, our frequent interaction with hospitalized patients places us in a prime position to detect delirium. Nursing assessment includes observation of (1) cognitive and perceptual disturbances, (2) physical needs, and (3) moods and physical behaviors.

Self-assessment

Because the behaviors exhibited by the patient with delirium can be directly attributed to temporary medical conditions, intense personal reactions in staff are less likely to arise. In fact, intense, conflicting emotions are less likely to occur in nurses working with a patient with delirium than in nurses working with a patient with dementia, which is discussed later in this chapter. Nonetheless, it can be frustrating to interact with these patients, especially given the fluctuating nature of the clinical picture.

Diagnosis

Safety needs to play a substantial role in nursing care. Patients with delirium often perceive the environment in a distorted way, and objects are often misperceived (illusions and/or hallucinations). People and objects may be misinterpreted as threatening or harmful, and patients often act on these misinterpretations. For example, if feeling threatened or thinking that common medical equipment is harmful, the patient may pull off an oxygen mask, pull out an intravenous or nasogastric tube, or try to flee. In such a case, the person demonstrates a Risk for injury as evidenced by sensory deficits or perceptual deficits.

Hallucinations, distractibility, illusions, disorientation, agitation, restlessness, and/or misperception are major aspects of the clinical picture. When some of these symptoms are present, Acute confusion related to delirium is an appropriate nursing diagnosis.

If fever and dehydration are present, fluid and electrolyte balance will need to be managed. If the underlying cause of the patient’s delirium results in fever, decreased skin turgor, decreased urinary output or fluid intake, and dry skin or mucous membranes, then the nursing diagnosis of Risk for deficient fluid volume is appropriate. Fluid volume deficit may be related to fever, electrolyte imbalance, reduced intake, or infection.

Because disruption in the sleep/wake cycle may be present, the patient may be less responsive during the day and may become disruptively wakeful during the night. Restful sleep is not achieved, day or night; therefore, Disturbed sleep pattern or Sleep deprivation related to impaired cerebral oxygenation or disruption in consciousness is a likely nursing diagnosis.

Sustaining communication with a delirious patient is difficult. Impaired verbal communication related to cerebral hypoxia or decreased cerebral blood flow, as evidenced by confusion or clouding of consciousness, may be diagnosed.

Fear is one of the most common of all nursing diagnoses and may be related to illusions, delusions, or hallucinations, as evidenced by verbal and nonverbal expressions of fearfulness. Other nursing concerns include Self-care deficits and Impaired social interaction.

Outcomes identification

The overall outcome is that the delirious patient will return to the premorbid level of functioning. Although the patient can demonstrate a wide variety of needs, Risk for injury is always present. Appropriate outcomes include the following:

Implementation

The priorities of treatment are to keep the patient safe while attempting to identify the cause. If the underlying disorder is corrected, complete recovery is possible. If, however, the underlying disorder is not corrected and persists, irreversible neuronal damage can occur. Nursing concerns therefore center on the following:

The Nursing Interventions Classification (NIC) (Bulechek et al., 2013) can be used as a guide to develop interventions for a patient with delirium (Box 23-1). Medical management of delirium involves treating the underlying organic causes. If the underlying cause of delirium is not treated, permanent brain damage may ensue. Judicious use of antipsychotic or antianxiety agents may also be useful in controlling behavioral symptoms.

A patient in acute delirium should never be left alone. Because most hospitals and health facilities are unable to provide one-to-one supervision of the patient, family members can be encouraged to stay with the patient.

Evaluation

Long-term outcome criteria for a person experiencing delirium include the following:

Clinical picture

Dementia is the general term used to describe a variety of progressive conditions that develop when brain cells die or no longer function; Alzheimer’s disease (AD) is the most common type of dementia, accounting for 60% to 80% of all dementias (Alzheimer’s Association, 2012). It is a devastating disease that not only affects the person who has it but also places an enormous burden on the families and caregivers of those affected. Nurses practicing in most any setting will care for patients with AD and must be prepared to respond.

It is important to distinguish between normal forgetfulness and the memory deficit of AD and other dementias. Severe memory loss is not a normal part of growing older. Slight forgetfulness is a common phenomenon of the aging process (age-associated memory loss) but not memory loss that interferes with one’s activities of daily living. Table 23-1 outlines memory changes in normal aging and memory changes seen in dementia.

Many people who live to a very old age never experience significant memory loss or any other symptom of dementia. Most of us know of people in their 80s and 90s who lead active lives with the intellect intact. The slow, mild cognitive changes associated with aging should not impede social or occupational functioning.

Although dementia often begins with a worsening of ability to remember new information, it is marked by progressive deterioration in cognitive functioning and the ability to solve problems and learn new skills and by a decline in the ability to perform activities of daily living. A person’s declining intellect often leads to emotional changes such as anxiety, mood lability, and depression, as well as neurological changes that produce hallucinations and delusions.

There are several types of dementia. Dementia is associated with AD, frontotemporal lobar degeneration, Lewy bodies, vascular issues, traumatic brain injury, substances, HIV infection, Prion disease, Parkinson’s disease, and Huntington’s disease (APA, 2013). Regardless of the cause, dementia is classified as either a mild or a major neurocognitive disorder. Minor neurocognitive disorders are characterized by symptoms that place individuals in a zone between normal cognition and noticeably significant cognitive deterioration. The rationale for the introduction of a mild category is that identifying early-presenting symptoms may aid in earlier interventions at a stage when some disease-modifying therapies may be most neuroprotective (Sperling et al., 2011). Major neurocognitive disorders are characterized by substantial cognitive decline that results in curtailed independence and functioning among affected individuals.

Epidemiology

AD, the most common type of dementia, attacks indiscriminately, striking men and women, people of various ethnicities, rich and poor, and individuals with varying degrees of intelligence. Although the disease can occur at a younger age (early onset), most of those with the disease are 65 years of age or older (late onset). It is estimated that 5.4 million Americans have AD (Alzheimer’s Association, 2012). Globally, it is estimated that 24.3 million people have dementia, and the number of people will double every 20 years to 81.1 million by 2040 (Ferri et al., 2005).

It is estimated that one in eight people aged ≥ 65 years has AD and that 45% of the people ≥ 85 years has AD. Of the people with AD:

Etiology

Although the cause of AD is unknown, most experts agree that, like other chronic and progressive conditions, it is a result of multiple factors that include genetics, lifestyle, and environmental. While many causes are hypothesized, the greatest risk factor is advanced age (Alzheimer’s Association, 2012; Lehne, 2013).

Diagnostic tests

A wide range of problems may be mistaken for dementia or AD. Depression in the older adult is the disorder frequently confused with dementia. In fact, many persons diagnosed with Alzheimer’s dementia also meet the diagnostic criteria for a depressive disorder. In addition, dementia and depression or dementia and delirium can coexist. It is important that nurses and other health care professionals be able to assess some of the important differences among depression, dementia, and delirium. Table 23-2 outlines important differences among these three phenomena.

When symptoms of dementia are present, a comprehensive assessment must be completed in order to rule out conditions that mimic dementia but are treatable. Making a diagnosis of Alzheimer’s disease includes ruling out all other pathophysiological conditions through the history and through physical and laboratory tests, many of which are identified in Box 23-2.

Brain imaging with CT, positron emission tomography (PET), and other developing scanning technologies have diagnostic capabilities because they reveal brain atrophy and rule out other conditions such as neoplasms. The use of mental status questionnaires, such as the Mini-Mental State Examination and various other tests to identify deterioration in mental status and brain damage, is an important part of the assessment.

In addition to performing a complete physical and neurological examination, it is important to obtain a complete medical and psychiatric history, description of recent symptoms, review of medications used, and nutritional evaluation. The observations and history provided by family members are invaluable to the assessment process.