Delirium Causes Risk Factors and Management

Nursing Management for Delirium Risk Factors

 Delirium etiology,pathophysiology,risk factors and assessment.Nursing interventions and management strategies.

Whats Is Delirium 

    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). 

Prevention 

    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).

Background And Statement Of Problem

    Delirium is a disturbance of consciousness with impaired attention and disorganized thinking that develops rapidly and with evidence of an underlying physiological or medical condition (American Psychiatric Association (APA), 2000).     

    Delirium is characterized by a reduced ability to focus, sustain, or shift attention: memory impairment: disorientation and/or illusions: visual or other hallucinations; or misperceptions of stimuli. 

    Delusional thinking may also occur. Unlike other chronic cognitive impairments, delirium develops over a short time and tends to fluctuate during the course of the day. 

    A patient may present with either hyperactive, hypoactive, or mixed motoric subtypes of delirium (Meagher, 2009). Nurses typically associate delirium with hyperactivity and distressing, time-consuming, and harmful patient behaviors. 

    However, the hypoactive subtype, with its lack of overt psychomotor activity, is also common (Meagher, 2009; Pandharipande, Cotton, et al., 2007) and has a higher risk of mortality, especially when superimposed on dementia (Yang et al. , 2009).

Etiology and Epidemiology 
Prevalence and Incidence

    Among medical inpatients, delirium is present on admission to the hospital in 10%-31% of older patients, and during hospitalization, 11% to 42% of older adults develop delirium (Siddiqi et al., 2006). 

    Among hip surgery patients, the incidence of delirium is 4%-53%. Those with hip fractures and cognitive impairment have the highest risk of delirium. (Bruce, Ritchie. Blizard , Lai, & Raven, 2007), Older adults admitted to medical intensive care units (ICUs) have both prevalent and incident delirium of 31% ( McNicoll et al., 2003). 

    In surgical (S) ICUs, the prevalence of delirium on admission is only 2.6%, but 28.3% develop delirium during their SICU stay (Balas et al., 2007). Up to 83% of mechanically ventilated patients in ICUs experience delirium (Ely. Inouye, et al., 2001), and more than half of older patients in medical ICUs still have delirium when transferred (Pisani, Murphy, Araujo, & Van Ness, 2010). 

    The incidence of delirium superimposed on dementia ranges from 22% to 89% (Fick, Agostini, & Inouye, 2002). Delirium may persist for months after discharge (Cole, Ciampi , Belzile , & Zhong, 2009).

Pathophysiology

    The pathogenesis of delirium is not well understood, but increasing evidence supports cholinergic deficiency and/or dopamine excess as well as cytokine activity as causes of delirium (Inouye, 2006). A genetic association between delirium and the apolipoprotein E epsilon 4 allele has also been identified (van Munster, Korevaar , Zwinderman , Leeflang , & de Rooji , 2009),

Risk Factors

    The strongest predisposing risk factors for delirium are age (70 years and older), severity of illness, and cognitive impairment (Michaud et al., 2007). 

    Other factors include depression, sensory impairment, fluid and electrolyte disturbances, and polypharmacy (especially psychotropics). 

    Precipitating factors for delirium occurring during hospitalization include central nervous system pathology (such as stroke), metabolic, electrolyte and/or endocrine disturbances, and infection and drug toxicity or with draw. 

    Pain, hypoperfusion/hypoxia, number of drugs (especially psychotropic and anticholinergic), and restraints have also been implicated. Finally, environmental factors such as ICU admission, multiple room changes, and an absence of a clock or glasses may also contribute to the development of delirium (Michaud et al., 2007). 

    In older patients admitted for hip surgery, early cognitive impairment, such as memory impairments, incoherence, disorientation, as well as an underlying physical illness and age, are especially strong predictors of delirium (de Jonghe et al., 2007; Kalisvaart et al . , 2006).

Outcomes of Hospitalized

    The outcomes of delirium are serious, especially in hospitalized older patients whose delirium persists post discharge. 

    Those with persistent delirium at 1, 3, and 6 months post-discharge consistently have increased mortality, nursing home placement, and decreased functional status and cognition than older adults who do not experience delirium (Cole, McCusker, Ciampi , &Belzile , 2008; Witlox et al., 2010). 

    Delirium also results in significant distress for the patient, their family members, and nurses ( Bruera et al., 2009; Cohen, Pace, Kaur, &Bruera , 2009). Clearly, delirium is a high-priority nursing challenge for all who care for hospitalized older adults.

Assessment Of The Problem

    The first critically important step in the assessment of delirium is identifying the risk factors for delirium (see discussed “Risk Factors”) because eliminating or reducing these risk factors may prevent delirium in many cases ( Milisen et al., 2005 ) . 

    Recognizing the features of delirium is important in order to further identify, eliminate, or reduce the precipitating factor(s) such as pain, infection, or other acute illnesses. 

    This can best be done by routinely assessing patients at risk for delirium with a standardized screening tool for delirium, although this is currently occurring only in 17% of hospitals (Neuman, Speck, Karlawish, Schwartz, &Shea , 2010).

     The Confusion Assessment Method (CAM) has high sensitivity and specificity in ICU, Emergency Department, acute and long-term care settings for detecting delirium (Wei, Fearing, Sternberg, & Inouye, 2008), and is the most widely used delirium screening instrument in hospitalized older adults. 

    A version of the CAM for patients in intensive care units (CAM-ICU: Ely, Margolin, et al., 2001) is recommended for use with critically ill older adults (Jacobi et al., 2002; Schuurmans. Deschamps, Markham, Shortridge -Baggett, &Duursma , 2003). 

    The CAM instrument identifies the key features of delirium acute onset, inattention, disorganized thinking, altered level of consciousness, disorientation, memory impairment, perceptual disturbances, psychomotor agitation or retardation, and altered sleep-wake cycles (Inouye et al., 1990) . 

    For a diagnosis of delirium, there must be the presence of Feature 1 (acute onset or fluctuating course). Feature 2 (inattention), and either Feature 3 (disorganized thinking) or Feature 4 (altered level of consciousness).

    It is important to remember that delirium may occur concurrently with dementia or depression. From 22% to 89% of older adults with dementia also have delirium superimposed on dementia (Fick et al., 2002). 

    As noted, patients with dementia are at increased risk for developing delirium and have worse outcomes when they do (Yang et al., 2009). Family and caregivers can be invaluable in helping to distinguish cognitive changes in those circumstances when the patient is not well known.

    Bedside nurses are in the best position to recognize delirium because they possess the skill and responsibility of ongoing patient assessment and are in key positions to recognize risk factors for delirium and the earliest cognitive changes heralding the onset of delirium. 

    Early identification of risk factors for and the earliest onset of delirium are critical to implement strategies to minimize the occurrence of this devastating pathology in hospitalized older adults.

Interventions And Care Strategies

    According to the most recent Cochrane Review (Siddiqi et al., 2007), there is no strong evidence from delirium prevention studies to guide clinical practice. 

    Only one of six randomized controlled trials (RCT) effectively prevented delirium with proactive geriatric consultation for older adults undergoing surgery for hip fracture (Marcantonio et al., 2001). 

    Prophylactically administered low-dose haloperidol reduced the severity and duration of delirium but not its incidence ( Kalisvaart et al., 2005). 

    However, given the prevalence and seriousness of delirium, its complex and varied etiology, and the challenges associated with conduction RCTs, we strongly recommend the use of clinical practice guidelines based on other strong intervention studies for both prevention and treatment of delirium.

    Once it has been determined that the patient is at risk for delirium, a standardized delirium protocol should be initiated immediately. Protocols tested in two multicomponent interventions effectively prevented delirium (Inouye et al., 1999; Marcantonio et al., 2001). 

    The protocols varied somewhat, but two principles emerged from the research: Minimize the risk for delirium by preventing or eliminating the etiologic agent or agents and providing a therapeutic environment and general supportive nursing care (see Section V. Nursing Care Strategies, in Protocol 11.1) . 

    Older adults on a specialized geriatric unit receiving inter professionally and protocol-guided care by a staff that had received specialized geriatric care education also developed significantly less delirium (Lundstrom et al., 2007).

    Patients who developed delirium after hip surgery, when treated with a multicomponent intervention program had fewer days of delirium, complications, total days of hospitalization (Lundstrom et al., 2007), and improved health-related quality of life without incurring increased costs ( Pitkala et al., 2008). 

    Although multicomponent delirium-reduction interventions have yet to be tested in critical care settings, sedation interruption and early occupational and physical therapy in patients who are mechanically ventilated resulted in shorter duration of delirium (Schweickert et al., 2009 ).

    Although nonpharmacologic interventions are preferred and should be used first (Michaud et al., 2007), antipsychotics (such as haloperidol) are used and are found to be efficacious in certain populations with agitated delirium (Breitbart et al., 1996; Devlin et al ., 2010). 

    Light propofol sedation my reduces severity and duration of delirium in hip surgery patients ( Sieber et al., 2010).

    Dexmedetomidine ( dex ; a y-aminobutyric acid receptor agonist), a promising alternative for sedation, resulted in decreased delirium when compared with other commonly used sedation in ICU settings. 

    When used for postoperative sedation after cardiac surgery, dex has been associated with lower rates of delirium and costs when compared with propofol and midazolam (Maldonado et al., 2009) and shorter duration of delirium when compared to morphine ( Shehabi et al., 2009 ). 

    In patients who are mechanically ventilated, dex is more efficacious than lorazepam in number of days at the targeted level of sedation and more days alive without coma or delirium (Pandharipande, Pun, et al., 2007). 

    When compared to midazolam in patients who are mechanically ventilated , patients treated with dex have less delirium (Riker et al., 2009). Alternative forms of pain management may also help reduce delirium. 

    Hip fracture patients at low risk for delirium who received a prophylactic fascia iliac block developed significantly less delirium than those receiving traditional pain management regimens ( Mouzopoulos et al., 2009).