Assessment and Management of Delirium - Essay Example

Assessment and Management of Delirium Introduction: Delirium, according to Palmer, 2006, is an acute disorder of “attention and global cognitive function”. In essence what this means is that delirium is an altered mental state of the patient, with relation to their perceptions of their environment, attention span, alertness, speech, memory and other functions related to the brain. There is evidence to suggest that the clinical picture of delirium in elderly and younger patients are similar, with the likelihood of a more chronic course in the elderly, and more elderly patients in different medical and surgical care situations tend to be affected by delirium (Leentjens, & van der Mast, 2005). Patients developing delirium face the risk of future functional decline, which is the possible loss of capacity to perform daily activities by themselves. In addition they face the risk cognitive risk and increased chances of mortality. In the elderly delirium is often found to cause extended hospitalization, increased risk for placement in nursing homes, persistent functional decline and debilitating complications like falls, injury and immobility (Palmer, 2006). The risk that delirium poses can be avoided through prevention and early detection. Ski & O’Connell, 2006, report that the complications resulting from delirium are experienced more often as a result of under diagnosis and improper management, and that this may have resulted from the insufficient research that has been undertaken on delirium, leading to insufficient evidence and understanding of delirium Risk Factors for Delirium: Proper assessment of elderly patients with medical care requirements reduces the risk of under diagnosis of delirium. This requires the nursing professionals to have an adequate knowledge of the risk factors of delirium, so that such patients are monitored more aggressively. The elderly are more prone to delirium with up to sixty percent of elderly patients experiencing delirium prior or during hospitalization, and the surprising issue is that in nearly seventy percent of these cases, early diagnosis is missed (Waszynski, 2004). Elderly patients are hospitalized because of medical care requirements, or as a result of surgical procedure requirements. Either of these stressful events can trigger delirium in the elderly. In elderly patients hospitalized because of medical illness, the most common causes of delirium are acute infections like pneumonia and urosepsis; hypoxemia, hypotension, and the treatment involving psychoactive medications. These psychoactive medications can range from antiarrythmic agents, tricyclic antidepressants, and neuroleptics to the more commonly used gastro-intestinal medications like H2 receptor antagonists and antihistamines. The risk is enhanced when these drugs are used either in large doses, or in combination at lower dosages. Even antibiotics like ciprofloxacin, analgesics like non-steroidal anti-inflammatory drugs (NSAIDs), and opiates have the potential for causing delirium. Alcohol and drug intoxication and withdrawal, and neurological illnesses like stroke, tumor or infection are also associated with delirium (Palmer, 2006). The risk of delirium in post operative elderly patients varies with the type of surgical procedure involved. It varies from ten to fifteen percent in general surgery patients to thirty to sixty percent in elderly patients where repair of hip fractures or knee arthroplasty is involved. There is still no clarity on the specific risk factors that contribute to post-surgical delirium, though it is assumed that both anesthesia and surgery do contribute. Some of the factors that are considered as possible candidates for postoperative delirium include polypharmacy, preoperative anticholinergic drugs, cognitive impairment, enhanced age, intraoperative hypoxemia, perioperative hypotension and the presence of postoperative complications. The knowledge of these risk factors and their potential for causing delirium, help in reducing the possibility of for delirium in the elderly patients, through proper monitoring of the high risk patients ((Palmer, 2006). This medical risk factor model provides a means for assessing the risk for delirium in an elderly patient hospitalized, as a result of either a medical or a surgical event. The reason for this is that it offers a means for easier assessment, at the time of clinical examination and can be quantified and monitored by specially trained nursing professionals. Another advantage is that the risk for delirium can be adjusted, as changes are observed in the condition of the patient during the period of hospitalization (Kalisvaart, Vreeswijk, deJonghe, van der Ploeg, van Gool & Eikenbloom, 2006). Assessment of Delirium: The risk factors are only a guide to the probability of an elderly patient going in for delirium. However, it is only through proper assessment of the patient that the presence of delirium can be ascertained. Accurate assessment of delirium is the primary challenge for medical professionals in elderly patients with a high risk for delirium. There are several assessment modules to assist in the assessment of delirium. The Diagnostic and Statistics Manual for Mental Disorders (DSM – IV) provides the diagnostic definition for delirium. Barthel Index, which assess the baseline activities, Geriatric Depression Scale score for assessing mood disorders, standardized Snellen test to ascertain visual impairment, Acute Physiology Age and Chronicle Examination (APACHE II) for measuring severe illness, Mini-Mental State Examination (MMSE) for indication of cognitive impairment, the blood urea nitrogen (BUN) to creatinine ratio to verify dehydration, and the Visual Analog Scale for Confusion are the commonly used assessment tools for delirium (Kalisvaart, et al, 2006). According to Nave, 1992, systematic assessment of the cognitive capacity, moods and functional capacity of the patient through simple psychological tests provides vital input for the diagnosis and management of delirium. The currently accepted ‘gold standard’ for the assessment of delirium is the Confusion Assessment Method (CAM). CAM offers two distinct advantages. It was formulated on the basis of the diagnostic criteria set by the Diagnostic and Statistics Manual for Mental Disorders DSM – IV. In addition it is simple enough to be used by professionals who are not psychiatrists. (Ski & O’Connell, 2006). Confusion Assessment Method (CAM): CAM consists of two parts. The first part is an assessment instruments that checks for overall cognitive impairment. The second part has only those four features that have been associated with the greatest capability of distinguishing delirium or reversible confusion from other kinds of cognitive impairment. Concurrent validation and psychiatric diagnosis have demonstrated that CAM has a sensitivity of 94-100% and a specificity of 90-95%. Another advantage is that CAM significantly correlates with other mental status measurements like Mini-Mental Status Examination, the Visual Analog Scale for Confusion, and the digit span test. The other advantages of CAM are that it closely correlates with DSM-IV criteria for delirium, and it can be administered within a short duration of five minutes (Waszynski, 2004). There are however certain limitations with CAM. It has a false positive rate of ten percent, and can only identify the presence or absence of delirium, but not the severity of delirium, if its presence is indicated. From a nursing perspective, sufficient research is yet to be undertaken to provide evidence of its effective use by nursing professionals to assess the presence or absence of delirium. (Leentjens, & van der Mast, 2005). Despite the lack of evidence of effective use of CAM by nursing professionals, its simplicity makes it an extremely potential assessment tool for nursing professionals and this can be seen from the CAM diagnostic algorithm. The first feature looked for is the whether there has been an acute change in the mental status of the patient, and whether this change has a fluctuating nature. This information can be got from the family members of the patient by the nursing professional, or in case the onset has occurred during hospitalization by the observations of the patient. The second feature is the presence of inattentiveness in the patient, which a nursing professional can ascertain through communication with the patient. The third feature is the presence of disorganized or incoherent thought processes in the patient, which is demonstrated by rambling and irrelevant conversation, which can be ascertained by a nursing professional. The final feature is the altered level of consciousness of the patient, which is verifiable by observing whether the patient is alert or normal; vigilant or hyper-alert; lethargic or drowsy or easily aroused, in stupor and cannot be easily aroused; or in coma and cannot be aroused. The presence of first and second features along with either the third or fourth features, confirms the assessment of the presence of delirium, which calls for immediate intervention to identify and treat underlying causes, and give the appropriate supportive care (Waszynski, 2004). The major concern that should be present in the assessment for delirium is the possibility of misdiagnosis of delirium as dementia, depression, or functional psychosis, with particular emphasis on dementia. This is because the clinical presentation of delirium and dementia tend to overlap. However, there are characteristics of delirium and dementia that assist in making a differential diagnosis between delirium and dementia (Palmer, 2006). The characteristics of delirium are an acute onset with a fluctuating course and the duration of which can be measured in hours or weeks. A patient in delirium demonstrates fluctuating attention, hallucinations, and the sleep wake pattern is disrupted. In the case of dementia, the onset is insidious with a stable course. The characteristics demonstrated by the patient include normal attentiveness, with usually normal perception and fragmented sleep wake pattern. These characteristics can be observed by nursing professionals to differentiate between delirium and dementia (Wheeler, 2005). Management of Delirium: Managing behavioral disorders like delirium pose a severe challenge to medical professionals, particularly the nursing professionals, as two levels of management are required, which is managing the acute medical or surgical event of the patient and the delirium. A simple example of this is that the acute condition may require addition of drugs, which may be a contributory factor to delirium, and so maintaining a balance between the management of both is the challenge posed (Segatore & Adams, 2001). Palmer, 2006, points out that the first step in management of delirium is in its prevention. For this patients with a high risk for delirium need to be identified immediately on admission or shortly after. Depending on the presence of risk factors establishing protocols in the prevention and management of delirium should it develop need to be established. These protocols should target the various risk factors and help in optimizing cognitive functioning through re-orientation and therapeutic activities; prevent sleep deprivation through relaxation and noise reduction; reduce immobility through ambulation and exercise; improve vision though the use of visual aids and illumination; improve hearing with hearing aids; and compensate for dehydration with volume repletion (Palmer, 2006). Management of delirium requires the underlying causes to be identified and treated along with supportive measures for the patient. Significant aspects of management also include providing optimum levels of stimulation, reorienting patients, education and support to the families involved in understanding the nature of delirium. Pharmacological intervention in the management of delirium is a limited option, and needs to be considered only when there are specific symptoms demonstrated by the patient like aggression, severe agitation or psychosis (Conn & Lieff, 2001). Pharmacological interventions may become necessary for some patients with delirium. However it must be realized that no pharmacological agents have been approve by the Food and Drug Administration (FDA) specific to the treatment of delirium (Palmer, 2006). Current beliefs in the use of pharmacological agents are based on the finding of some studies. The neuoroleptic haloperidol is considered the drug of choice in the treatment of bothersome symptoms of delirium. When loss of sleep or anxiety is involved, or in the case of withdrawal from alcohol or benzodiazepines need to be treated, lorezapam is considered to be the useful pharmacological agent (Conn & Lieff, 2001). The nature of delirium makes nursing care an important element in all aspects of assessment and management of delirium important. Studies have shown the significant role that can be played by nursing professionals in the prevention, assessment and management of delirium (Finotto, Artioli, Davoli & Boni, 2006). Delirium is an issue of concern in post acute care settings too. In post acute care settings nurse-led, unit based delirium intervention strategies are proving to be effective in the prevention and management of delirium. The features of these nurse-led, unit-based intervention strategies include assessment and treatment of possible causes and contributory factors to delirium, prevention and management of common delirium complications, and rejuvenating cognitive and self-care functions of the patient. The importance of the nursing professional in the prevention, assessment and management of delirium stems from the care that they provide the patients, and hence are in a position to effectively monitor the status of the patient. .Adequate knowledge and training provides them with the armory to handle the other aspects of the assessment and management of delirium (Bergmann, Murphy, Kiely, Jones & Marcantonio. 2005). Recognizing the importance of the nursing role in the assessment and management of delirium, Palmer, 2006, suggests the placing of patients with delirium or a high risk for delirium in a room close to the nurses’ station to enable more effective monitoring and socialization of the patient by the nursing professionals. Conclusion Delirium is a frequent occurrence in acute, as well as post-acute environments of the hospital. It often is under diagnosed. Prevention, assessment, and management of delirium involve a proper understanding of the risk factors involved in delirium. Pharmacological agents have a minimal role to play in the treatment of delirium, and hence management of delirium is based on assessment and treatment of possible causes and contributory factors to delirium, prevention and management of common delirium complications, and rejuvenating cognitive and self-care functions of the patient. This makes for nursing professionals having a significant role in the prevention, assessment, and management of delirium. . . Literary References Bergmann, M.A. Murphy, K.M., Kiely, D K., Jones, R.N., & Marcantonio, E.R. (2005). A model for management of delirious post acute care patients. Journal of the American Geriatrics Society, 53(10), 1817-1825. Conn, D. K. & Lieff, S. (2001). Diagnosing and managing delirium in the elderly. Canadian family physician. Medecin de famille canadien, 47, 101-108. Finotto, S. Artioli, G. Davoli, L. & Boni, B. (2006). Nursing interventions for the prevention of the delirium in intensive care unite (ICU): a randomized study. Professioni infermieristiche, 59(4), 228-232. Kalisvaart, K.J., Vreeswijk, R., deJonghe, J.F.M., van der Ploeg, T., van Gool, W. & Eikenbloom, P. (2006). Risk Factors and Prediction of Postoperative Delirium in Elderly Hip-Surgery Patients: Implementation and Validation of a Medical Risk Factor Model. Journal of the American Geriatrics Society, 545), 817-822. Leentjens, A.F.G. & van der Mast, R.C. (2005). Delirium in Elderly People: An Update. Current Opinion in Psychiatry, 18(3), 325-330. Nave, D.W. (1992). Assessment of cognition, mood, and function: vital clinical data in geriatric psychiatry. The Journal of the Louisiana State Medical Society, 144(10), 451-458. Palmer, R.M. (2006). Management of Common Clinical Disorders in Geriatric Patients: Delirium. ACP Medicine Online, Retrieved March 5, 2007, from, Medscape Today. Web site: http://www.medscape.com/viewarticle/534766 Ski, C. & O’Connell, B. (2006). Mismanagement of delirium places patients at risk. The Australian journal of advanced nursing, 23(3), 42-46. Segatore, M. & Adams, D. (2001). Managing delirium and agitation in elderly hospitalized orthopaedic patients: Part I--Theoretical aspects. Orthopaedic Nursing, 20(1), 31-43. Waszynski, C.M. (2004). Confusion Assessment Method (CAM). Dermatology Nursing, 16(3), 309-310. Wheeler, M.S. (2005). Delirium and Dementia at the End of Life. Disclosures, Retrieved March 5, 2007, from, Medscape Today. Web site: http://www.medscape.com/viewarticle/499458 Read More