Preventing Inpatient Delirium

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Introduction   

Delirium is a common disorder associated with multiple short—and long-term complications and characterized by acute brain dysfunction. According to DSM-5 criteria, it is an impairment in attention and awareness that develops over a relatively short time interval, fluctuates throughout the day, and is associated with additional cognitive deficits such as memory deficits, disorientation, or perceptual disturbances (1). Delirium can also be known as acute confusional state, toxic or metabolic encephalopathy, or acute brain failure (1). Delirium, which is acquired because of an inpatient stay, is often a common complication for older adult clients. Delirium is often under-reported, missed, or mistaken for other conditions (4). It is associated with a higher mortality risk, length of stay, and institutionalization rate (4). Due to the high occurrence rate among inpatient clients and its consequences, it has become a serious health concern (5).  

Delirium is commonly not recognized and poorly managed, which can be due to different clinical presentations, fluctuating symptoms, those who have preexisting dementia, and a lack of routine cognitive assessments (6). Delirium can occur at any age, but its prevalence increases with age and medical complexity. Therefore, prevention is an essential part of its management and the prevention of complications. Delirium is a costly and potentially damaging illness in clients who are staying in hospitals and long-term care facilities. Healthcare professionals need to be aware that people in a hospital, long-term care facility, or nursing home may be at an increased risk of delirium. Delirium can have serious consequences, such as an increased risk of dementia and death. For those in the hospital, it may increase their length of stay and risk of long-term care admission (3). 

The primary purpose of this course is to provide healthcare providers with evidence-based guidance on identifying those at an increased risk for delirium. This course will provide necessary information on preventing delirium in inpatient clients, whether in hospitals, long-term care facilities, or nursing homes. It will cover how to identify clients at risk and to avoid onset. It aims to improve healthcare providers’ knowledge to reduce hospital stays and complications. 

Delirium 

As previously mentioned, inpatients are at an increased risk of developing delirium. This can be due to sepsis or disturbances in inflammation and coagulation pathways leading to microvascular thrombosis (5). Illness often disrupts circadian rhythms and sleep patterns, and the use of sedatives and benzodiazepines can impair immunity and, therefore, contribute to delirium (5). 

Delirium can occur in the community and ranges from 1 to 2% but increases to 10% to 30% in elderly clients who present to the emergency department (1). In medical-surgical units, the incidence increases to approximately 14 to 24% and continues to rise to 70 to 87% when clients are in the intensive care unit (1). Post-operative clients have a 15 to 53% chance of being diagnosed with delirium, especially if they are over the age of 70 (1). It is estimated that delirium can occur in 17-44% of older adults 50 years and older who are residing inpatient (4). Evidence suggests that delirium can be prevented for up to 40% of those aged 65 and older (4). Delirium occurs in about 30% of all ICU clients regardless of age and increases in occurrence up to 80% of those on mechanical ventilation (5).  

Pathophysiology 

First, healthcare providers must understand the pathophysiology of delirium to understand better its effects on the brain and how to prevent it in an inpatient setting. No single method or hypothesis can explain delirium’s etiology because it is a complex and multifactorial process. Several hypotheses describe different aspects of the pathophysiology of delirium, and multiple processes are likely to co-occur to create delirium syndrome in clients.  

• Increased Age 
  • Can lead to diminished physiologic reserve 
  • Increases vulnerability to physical stress and illness 
  • Changes associated with age include  
    • Decreased brain blood perfusion 
    • Increased neuron loss 
    • Changes in the proportion of stress-regulating neurotransmitters.  
• Neuroinflammation 
  • Peripheral inflammation damages endothelial cell-cell adhesions at the blood-brain barrier 
  • Increased endothelial permeability promotes inflammation in the central nervous system, causing further damage, ischemia, and neuronal death 
• Reactive Oxidation Species 
  • Along with reactive nitrogen species, they are mediators of cellular damage.  
  • The central nervous system is particularly vulnerable due to its high lipid content and low antioxidant capacity 
• Circadian Rhythm Dysregulation 
  • Disruption in sleep duration and quality and melatonin secretion leads to dysfunction of many systems.  
    • Melatonin affects many functions in the central nervous system, including: 
      • Regulation of sleep-wake cycles 
      • Glucose regulation 
      • Core body temperature 
      • Antioxidant defenses 
      • Immune system response. 
• Neurotransmitter Imbalance 
  • Decreased acetylcholine and increased dopamine activity.  
    • The brain’s dopaminergic and cholinergic pathways overlap; their balance is vital to brain function 
• Neuroendocrine 
  • Increased glucocorticoid released in response to physiologic stress  
  • Increase in the vulnerability of neurons to subsequent damage  
  • Impacted regulation of gene transcription, cellular signaling, and glial cell behavior 

Etiology 

Delirium is a manifestation of stress on the function of the central nervous system in a vulnerable client (7). As previously stated, it is a clinical syndrome characterized by altered attention, consciousness, and cognition with a reduced ability to focus, maintain, or shift attention (7). Pathophysiology is not fully understood, and there is no single etiology, as an underlying medical condition often causes it (7). Multiple theories describe the potential pathophysiological causes of delirium, and usually, each case of delirium includes one or more of these theories, which were previously discussed under pathophysiology (7). Most models describe delirium as an interaction of a vulnerable client with predisposing factors who also display certain precipitating factors, all of which will be discussed later in the course (7). 

Before discussing the causes of delirium, the three subtypes of delirium, which are categorized according to the client’s psychomotor behavior, must be examined (1). 

• Hyperactive delirium 
  • 23% of cases  
  • Mostly seen outside the ICU  
  • Characterized by: 
    • Agitation 
    • Restlessness 
    • Emotional lability 
    • Positive psychotic features  
      • Hallucinations and delusions  
• Hypoactive delirium 
  • 24.5-43.5% 
  • Observed more in an ICU setting 
  • Often underrate and is associated with worse prognosis  
  • Characterized by: 
    • Confusion 
    • Sedation 
    • Apathy 
    • Decreased responsiveness 
    • Slowed motor function 
    • Withdrawn attitude 
    • Lethargy  
    • drowsiness 
• Mixed delirium  
  • 52.5% 
  • Observed more in an ICU setting 
  • Most frequent type  
  • Fluctuation between hypoactive and hyperactive features 

Causes of Delirium 

The specific leading causes of delirium include, but are not limited to: (1) 

• Infections 
• Alcohol/substance abuse  
• Wernicke’s disease  
• Metabolic  
• Hypoglycemia  
• Medications 
• Trauma 
• Neurocognitive  
• Seizures 
• Vascular  
• Hypoxia  
• Vitamin deficiencies 
• Endocrinopathies 
• Toxin or health metal ingestion 

Risk Factors for Delirium 

A wide range of factors affect clients who are at risk for developing delirium in the inpatient at a facility. Some factors are predisposing, and some are precipitating. Delirium involves an interaction between the client’s predisposing vulnerabilities, putting them at greater risk when encountering precipitating factors.  

Predisposing factors (related to the person): (2) 

• Dementia or cognitive impairment  
• Older age (>75 years old) 
• Functional impairment (mobility and decreased activities of daily living) 
• Visual or hearing impairment  
• Comorbidity  
• Severe or terminal illness 
• History or previous episode of delirium  
• Depression 
• Respiratory disorder  
• History of transient ischemia or stroke  
• Alcohol misuse 
• Renal impairment  
• Malnutrition or dehydration 
• Frailty  

Precipitating factors (related to the illness or environment): (2) 

• Medications  
  • Polypharmacy 
  • Psychoactive drugs 
  • Sedatives  
  • Hypnotics (high risk) 
• Use of an indwelling catheter 
• Physiological  
  • Increased serum urea or BUN 
  • Creatinine ratio 
  • Abnormal serum albumin, sodium, glucose, or potassium  
  • Metabolic acidosis  
• Infection (chest and urinary)  
• Use of physical restraint or immobility  
• Hospitalization/length of stay 
• Lack of visitors 
• Absence of visible sunlight 
• Any harmful disease or medical complication  
• Surgery  
  • Aortic aneurysm 
  • Non-cardiac thoracic 
  • Neurosurgery 
  • Hip surgery  
  • Complex abdominal 
• Trauma or urgent admission 
• Malnutrition or dehydration 
• Constipation 
• Hypoxia 
• Alcohol withdrawal 
• Uncontrolled pain 
• Neurological insults 
• Sleep deprivation 
• Organ failure 
• Coma 

Signs and Symptoms 

Delirium signs and symptoms can develop quickly, either over hours or days, and can fluctuate throughout the day and are often worse at night.  

Signs and symptoms include: (2) 

• Difficulty directing, focusing, sustaining, or shifting attention  
• Confusion  
• Fluctuating or reduced consciousness  
• Disorientation to time and place  
• Disturbances of sleep-wake cycle  
  • Agitation or restlessness at night  
  • Drowsy during the day  
• Impaired recent memory  
• Speech or language disturbances (rambling speech) 
• Increased or decreased psychomotor activity 
• Emotional disturbances  
  • Fearfulness 
  • Irritability  
    • Anger 
• Sadness 
• Hallucinations and delusions 
• Lethargy and fatigue 

Treatment and Management of Delirium 

Delirium Assessments 

The two assessments mentioned are highly proven and used for diagnosing and evaluating delirium over time. These assessments look at attention, orientation, and memory and can be used on non-verbal clients. In addition to the assessments, electroencephalogram (EEG) has also been used to diagnose delirium; however, due to its low specificity and issues with clinical applicability, it is not often used as a practical test. (1) 

• Confusion Assessment Method-ICU (CAM-ICU). 
  • Based on a series of questions and commands that are designed to detect the features of delirium  
  • Quick to perform  
  • Requires minimal training 
  • Can be used on non-verbal clients, in the emergency room, and in nursing homes 
  • Diagnosis is based on the presence of two primary criteria (acute or fluctuating onset plus lack of attention) and at least one minor criteria (disorganized thinking or altered level consciousness level)  
• Intensive Care Delirium Screening Checklist (ICDSC) (9) [See Table 1 below]. 
  • Evaluates the level of consciousness with eight items  
    • Scored 1 (present) 
    • Scored 0 (absent) 
    • A total of 8 points, four or greater, is positive for delirium 
  • Symptoms evaluated over 8-24 hours 
  • Administration complex in non-verbal clients  
  • Requires training to interpret results  

Table 1. The Intensive Care Delirium Checklist (9) 

Other instruments for the diagnosis of delirium include: (8) 

• Delirium Detection Score (DDS) 
  • Based on an instrument designed to evaluate delirium associated with alcoholic deprivation 
• Cognitive Test of Delirium (CTD) 
  • Tool that requires a considerable amount of time for its administration 
• Memorial Delirium Assessment Scale (MDAS) 
  • Originally designed for clients with advanced cancer 
  • Later adapted for use in critically ill clients 
• Neelon and Champagne Confusion Scale (NEECHAM) and Delirium Rating Scale‐Revised 98 (DRS‐R‐98) 
  • They are helpful but less widely used 

Pharmacological and Non-pharmacological Management Strategies 

Currently, no identified therapies (medications or interventions) are proven to decrease delirium’s duration. Therefore, treating the underlying physiological cause is the most important. Also, other interventions should be considered for delirium management such as: (1) 

• Treatment of the underlying cause 
• Correction of potential electrolyte disturbances 
• Removal of offending pharmacological agents 
• Maintain proper sleep/wake cycles 
• Manage pain 
• Address sensory impairments (hearing, vision) 
• Encourage family visits and frequent reorientation. 
• Early mobilization 

Medications to treat delirium include: (1) 

• Antipsychotics  
  • Includes haloperidol and atypical antipsychotics  
• Dexmedetomidine  
• Short-acting benzodiazepines  
  • Midazolam and lorazepam  
• Rivastigmine, donepezil, and physostigmine  
  • Evidence of effectiveness is inadequate 

Non-pharmacological interventions for delirium include: (1) 

• Behavioral strategies  
• Mobilization  
• Use of restraints (considered last resort) 

Preventing and Managing Delirium 

No evidence supports the idea that pharmacological interventions can prevent delirium. However, several non-pharmacological interventions are effective. Therefore, preventing delirium is the most effective strategy to reduce its frequency and associated complications. Preventing delirium means using methods to effectively decrease the risk of delirium incidents, thereby improving clinical outcomes for clients with certain risk factors (5). Delirium prevention methods work best when they are implemented consistently and deliberately. Typically, 30-40% of delirium episodes are preventable with the proper measures (5).  

Prevention and management strategies include: (3) 

• Ensure clients at risk are cared for by a team of healthcare professionals who are familiar with them. Avoid moving people within and between floors, departments, or rooms unless necessary 
• Give a personalized multicomponent intervention package: 
  • Within 24 hours of admission, assess clients at risk for any clinical factors 
  • Based on the results of this assessment, provide a multicomponent intervention personalized to the client’s individual needs and care setting as outlined in the recommendations 
• The personalized multicomponent intervention package should be shared with the multidisciplinary team 
• Address any cognitive impairment and disorientation: 
  • Provide appropriate lighting and clear signage 
    • 24-hour clock 
    • Visible calendar 
  • Frequent reorientation (person, place, time) 
  • Introducing cognitively stimulating activities (reminiscence) 
  • Coordinate regular visits from family and friends 
• Address dehydration and constipation: 
  • Ensure adequate fluid intake  
• Assess for hypoxia 
• Address infection: 
  • Assess and treat infection 
  • Avoid any unnecessary invasive procedures 
  • Implement infection control protocols with procedures 
• Address immobility or limited mobility: 
  • Encourage clients to: 
    • Mobilize soon after surgery 
    • Walk 
  • Encourage all clients to participate in active range-of-motion exercises 
• Address pain: 
  • Assess for pain 
  • Assess for non-verbal signs of pain 
  • Review appropriate pain management strategies  
• Medication review for polypharmacy 
• Address poor nutrition: 
  • Consult nutrition support 
  • Ensure dentures fit properly 
• Address sensory impairment: 
  • Resolve any changeable causes of the impairment 
• Ensure that hearing and visual aids are available and used by clients   
• Promote good sleep patterns and sleep hygiene: 
  • Avoid nursing or medical procedures during sleeping hours, if possible 
  • Schedule medication rounds to avoid disturbing sleep 
  • Reduce noise to a minimum during sleep periods 

Client Education 

In addition to all the other prevention methods listed and management strategies. Educating clients and families on reducing the risk of delirium is essential (7). 

• Promote sleep hygiene 
• Mobilize clients early 
• Make sure the client has a hearing aid and glasses 
• Manage pain adequately 
• Maintain good hydration and nutrition 
• Monitor bowel and bladder function 
• Try to detect delirium early 
• Optimize the environment 
• Avoid any stress 
• Communicate with the client 
• Refer to a specialist ASAP 

Conclusion

Delirium is a common, costly, and potentially damaging disorder seen in clients who are hospitalized or staying in long-term care facilities. Delirium is associated with an increase in morbidity and mortality. The diagnosis and management of delirium are complicated and are often best done with an interdisciplinary healthcare team consisting of a geriatrician, neurologist, psychiatrist, internist, intensivist, nurses, and physical and occupational therapists. Therefore, delirium prevention could be one of the most effective methods for preventing complications. Nurses and family members are often the first to identify the presence of delirium. These findings should be communicated to the healthcare team for the best results. Maintaining a quiet environment for the client, maximizing sleep at night, encouraging mobility and nutrition, ensuring client safety, and communicating with the client and family are the most important when it comes to prevention strategies. (7) 

The primary treatment for delirium is based on prevention and non-pharmacologic interventions. Prevention has been shown to reduce the incidence of delirium in elderly clients, falls, and overall healthcare costs. These prevention interventions include identifying at-risk clients, decreasing environmental disturbances, increasing re-orientation interventions, and maximizing mobility. Pharmacological agents are typically only used in episodes of substance withdrawal-associated delirium, delirium at the end of life, and episodes of hyperactive delirium where the client’s behavior is a threat to themselves or others. There should be open communication between the interdisciplinary team members to ensure that the client receives goal-directed treatment and care. (7) 

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