A situation you’ll need to be able to differentiate (in both clinical and on exams) is delirium vs dementia. This table summarizes the key differences between these two common conditions.
|Acute onset, symptoms can improve and worsen over the course of the day
|Slow progression of cognitive decline that develops over time
|Often caused by medication and illness; causes can be multifactoral
|Caused by physiologic changes to the brain
|Affects attention; effect on memory varies
|TIME OF DAY
|Worsens at night
|Worsens at night
|ORIENTATION TO TIME/PLACE
In this lesson we’ll be focusing in delirium. What it is, who is at risk, how to recognize it and what we do about it. So, let’s get started!
What is delirium?
Delirium is abrupt onset confusion characterized by fluctuating alterations in attention, cognition and perception.
The first step in recognizing delirium is knowing which patients are at risk. Patients at risk for delirium are the elderly (especially those with dementia), polypharmacy (more than three medications), those taking certain medications such as benzodiazepines, patients in critical care environments where day/night are difficult to distinguish, patients with infection, anyone with electrolyte imbalances, patients with a history of depression or prior delirium, patients with a urinary catheter, malnourished patients, patients with liver or renal disease, patients on bedrest, immobile patients, restrained patients, dehydrated patients, patients who are in pain, anyone with visual or auditory impairment, patients withdrawing from drugs or alcohol, and those lacking in sensory input. Whew! That’s a lot!
Typically the first signs are confusion about time/place. The patient may not realize they are in the hospital at all. I’ve taken care of patients who thought they were on a cruise ship, eating pizza at their aunt’s house, and others who simply did not know where they were…they just knew it wasn’t home.
Other signs of delirium include being especially quiet (common in hypoactive delirium), being agitated or restless, inability to follow directions or pay attention, picking at the bedding or gown, and using inappropriate words. As delirium progresses the patient can hallucinate and even become aggressive.
Aside from the psychological stress delirium has on the patient and family, it is associated with significant complications: increased falls, increased length of stay, extended duration of long-term care after discharge, higher mortality, and even long-term cognitive decline. Many patients report PTSD and depression after suffering from hospital-associated delirium. So, the name of the game is to recognize who is at risk, do our best to prevent it, notice it early and intervene appropriately.
Interventions for delirium
The first thing to do when managing delirium is to mitigate predisposing factors as much as you can. The MD will look at medications, can you avoid restraints? Is the patient hydrated with electrolytes in balance? Can you optimize nutrition, treat infection, etc?
Other interventions include
- Normalize the sleep/wake cycle. As much as patients may want to lie in their rooms all day with the blinds drawn, it’s best if they have exposure to sunlight during the day. Open the blinds, turn on the lights. You also want to promote healthy sleep at night. Designate quiet times and cluster care to minimize disruptions are key interventions that can make a huge impact.
- Reorient the patient. While it may seem “easier” to just go along with the patient who thinks they are on a cruise ship, it only promotes further confusion. Reorient the patient to time, place and situation as needed.
- Ensure patients have glasses, hearing aids, dentures so they can see, hear, speak and eat optimally.
- Increase physical activity as much as the patient is able. Getting the patient moving is one of the most consistently reliable methods I’ve utilized at the bedside to improve delirium. Even just sitting up in the chair is incredibly helpful.
- Manage pain appropriately.
- Teach family members to speak calmly to the patient, using simple phrases and words. They can help reorient the patient by talking about other family members or friends (people the patient knows well). Another great patient-centered intervention is bringing the patient’s favorite music, playing their favorite TV shows, or bringing familiar items from home such as a blanket or pillow.
Caring for patients with delirium can be challenging for the nurse and frightening for family members. I hope you feel like you have some tools to utilize in the recognition, prevention and treatment of this common but serious condition.
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Agency for Clinical Innovation. (2015, October 14). Delirium risk factors. Agency for Clinical Innovation. https://aci.health.nsw.gov.au/chops/chops-key-principles/delirium-risk-identification-and-preventive-measures/delirium-risk-factors
Ahmed, S., Leurent, B., & Sampson, E. L. (2014). Risk factors for incident delirium among older people in acute hospital medical units: A systematic review and meta-analysis. Age and Ageing, 43(3), 326–333. https://doi.org/10.1093/ageing/afu022
Huang, MD, PhD, J. (2021, March). Overview of delirium and dementia. Merck Manual Professional Edition. https://www.merckmanuals.com/professional/neurologic-disorders/delirium-and-dementia/overview-of-delirium-and-dementia