Transcript Slide 1

Transitioning to Adult-Gerontology
APRN Education: Slide Library
APRN Assessment and Management of
Older Adults with Delirium
Authors: Lois Evans, PhD, RN, FAAN
Pamela Z. Cacchione, PhD, APRN, GNP, BC
University of Pennsylvania School of Nursing
Adult-Gerontology APRN Slide Library
• The APRN Slide Library is a resource of
“Transitioning to Adult-Gerontology APRN
Education” a project of AACN and the Hartford
Institute for Geriatric Nursing 2010-2012
• The project is funded by the John A. Hartford
Foundation
Adult-Gerontology APRN Slide Library
"All materials are jointly copyrighted by the American
Association of Colleges of Nursing (AACN) and The Hartford
Institute for Geriatric Nursing, College of Nursing, New York
University or are used with permission from the original source.
Permission is hereby granted to reproduce, post, download,
and/or distribute, this material for not-for-profit educational
purposes only, provided that the American Association of
Colleges of Nursing (AACN) and The Hartford Institute for
Geriatric Nursing, College of Nursing, New York University are
cited as the source. They may not be used for ANY commercial
or other purpose."
Available at www.hartfordign.org
E-mail notification of usage to: [email protected]
Further information about the APRN program can be found at
www.aacn.nche.edu/APRN Gerontology.htm
Purpose of the APRN Slide Library - Delirium
• To provide APRN faculty with an overview of delirium
in older adults*
• To introduce APRN faculty to print and web
resources on assessment, diagnosis & management
of delirium
• To provide APRN faculty with slides on delirium to
use in lectures & to share with APRN students
* These slides have been modified by faculty from the Geropsychiatric
Nursing Collaborative from slides prepared for the Geriatric Nursing
Education Consortium (GNEC) program (www.aacn.nche.edu).
Endorsement and Support
The content for these slides is endorsed by:
National Gerontological Nursing Association (NGNA):
http://www.ngna.org
American Academy of Nursing Geropsychiatric
Nursing Collaborative:
http://www.aannet.org/i4a/pages/index.cfm?pageid=3833
Web-resources
Web-Resources
http: //www.ConsultGeriRN.org Try This ® and How to Try This General
Assessment Series, e.g.
 Confusion Assessment Method (CAM)
 Beers Criteria for Potentially Inappropriate Medication Use in the
Elderly
 Mental Status Assessement of Older Adults: the MiniCog
 The Geriatric Depression Scale (GDS)
http: //www.ConsultGeriRN.org Try This ® and How to Try This Dementia
Assessment Series, e.g.
 Assessing and Managing Delirium in Persons wih Dementia
 Recognition of Dementia in Hospitalized Older Adults
Web-resources
Web-Resources


http: //www.ConsultGeriRN.org select Evidence-based Geriatric Topics,
e.g. protocols on:
 Delirium
 Atypical Presentation of Illness
 Depression
 Sleep
American Medical Directors Association (AMDA Clinical Practice
Guidelines for long-term care: http://www.amda.com/; select Altered
Mental Status
 www.elderlife.med.yale.edu/public/doclinks.php?pageid=01.02.03
 www.medscape.com/viewarticle/503089_6
 www.joannabriggs.edu.au/events/2009NAC/docs/Day
Source Books: Geriatrics
Auerhahn, C., Capezuti, E., Flaherty, E., & Resnick, B. (eds.) (2007). Geriatric Nursing
Review Syllabus: A Core Curriculum in Advanced Practice Geriatric Nursing, 2nd
Edition: New York: American Geriatrics Society. (3rd Edition, May, 2011)
•
•
•
A concise & comprehensive text developed by the American Geriatrics Society (AGS) & the
NYU Hartford Institute for Geriatric Nursing , adapted for APRNs from the AGS Geriatrics
Review Syllabus: A Core Curriculum in Geriatric Medicine, 6th Edition
Authored by > 100 interdisciplinary experts in care of older adults
59 chapters on prevailing management strategies, extensive reference, appendix with
assessment instruments, 100 case-oriented, multiple choice questions and a selfassessment tool.
(www.americangeriatrics.org/.../the_geriatric_nursing_review_syllabus_2nd_edition/
Auerhahn, C. & Kennedy-Malone, L. (2010). Integrating Gerontological Content into
Advanced Practice Nursing Education. New York: Springer Publishing Co.
•
•
•
•
Clear, user-friendly guidelines for integrating gerontological content into non-gerontological
APRN programs
Detailed lists of print resources and e-Learning materials
Utilizes a competency-based framework
“Success stories” written by APRN faculty who have integrated gerontological content into
non-gerontological courses
Delirium: Definition
A transient and nonspecific organic mental syndrome
characterized by:
 Acute onset (hours to days), tending to fluctuate over the
24 hour period
 Reduced ability to focus, sustain or shift attention
 Disturbed level of consciousness, such as reduced clarity
of awareness
 Change in cognition such as memory loss, disorientation
and/or language disturbance
 Perceptual disturbance not better accounted for by a preexisting, established or evolving dementia
Delirium: Incidence in Hospitalized
Older Adults
11%
All patients
Delirium
occurrences in
hospitalized
patients
Older Patients > Susceptibility
Range 11-42%: Medical
and
<50%: Surgical
50%
High risk cases
Delirium: Incidence, Prevalence,
Outcomes
 Highly prevalent (11-24%) on ACH admission, with incident
delirium < 56% in hospitalized older adults
 Incidence is < 87% for OA in ICU
 Incidence is 60% for older adults in post acute care and
nursing homes
 Potentially life threatening, with 22-76% mortality rates
among older adults in ACH
 Typically evident within 48 hours of hospital admission
 Course is variable, depending on pre-existing condition
and cause(s ) of delirium
Delirium: Background
 Diagnosis of delirium is highly clinical and dependent upon
clinician's level of expertise, systematic screening & careful
clinical observations
 Progression to stupor and/or coma, seizures, and death is
possible.
 Delirium is a cardinal sign of a geropsychiatric emergency
and must be promptly identified and addressed with
biopsychosocial and environmental interventions.
 Early recognition of delirium followed by rapid management
of underlying medical and environmental factors decreases
the severity and can lead to improved outcomes.
Delirium Outcomes
Loss of function,
falls and other
complications
Increased risk for
longer hospital LOS
& post acute or NH
placement
Higher levels of premorbid function =
better outcomes
Cost assessed at
$6.9 billion a year
Unwarranted use of
physical and
chemical restraints
Frequent
misdiagnosis = high
morbidity and
mortality
Predisposing Factors for Delirium






Advanced old age
Brain injury, including
Dementia
Severe illness or surgery
Anesthesia
Hypoxia
Medications/ polypharmacy (4+
medications per day)








Co-morbid Illness
Depression
Sensory impairment
Electrolyte imbalance and
dehydration
Infection
Pain
Previous episodes of delirium
Alcohol Abuse
Delirium: Medication-Related
Precipitating Factors
Anticholinergics
Opiates
Benzodiazepines
Corticosteriods
Alcohol withdrawal
Sedative-hypnotic drug withdrawal
Any newly prescribed medication
Over the counter (OTC) “home remedies,” especially those with
anticholinergic effects (NSAIDS, nasal sprays, cold and flu meds)
 Addition of 3 newly prescribed medications








Delirium: Inouye and Charpentier
Risk Model
Relies on the interaction of the following 2 factors:
 Predisposing host baseline factors, e.g.,




Vision impairment
Severe illness
Pre-existing cognitive impairment
Dehydration
Treatment-related precipitating factors, e.g.,





Physical restraints
Malnutrition
Bladder catheter
> Three medications
Any iatrogenic event
Prevention of Delirium in Older
Adults



Early identification &
modification of
predisposing factors
Early recognition &
treatment of cognitive
impairment
Rapid identification &
treatment of acute illness




Assessment & appropriate
management of pain
Maintenance of normal sleepwake cycle
Avoidance of deliriogenic
medications & polypharmacy
Assurance of adequate
hydration & nutrition
Prevention of Delirium in Older
Adults cont’d
• Enhancement of sensory
status by use of sensory aids
& appropriate levels of light
& sound
• Enhancement of cognitive
reserve
• Provision for family presence
• Avoidance of urinary
catheterization
• Avoidance of physical
restraint use
• Assessment & management
of drug and alcohol
withdrawal
Delirium: Clinical Presentation
Clinical subtype
Hyperactive
 Increased
psychomotor
activity, such as
rapid speech,
irritability, and
restlessness
Hypoactive
 Lethargy
 Slowed speech
 Decreased
alertness
 Apathy
Mixed
 Shift between
hyperactive and
hypoactive
states
Delirium: History







When did the change in mental status begin?
Does the condition change over a 24-hour period?
Is there a change in the person’s sleep patterns?
What specific thought problems have been noticed?
Is there a history of mental illness or similar thought
disturbance?
Has there been a sudden decline in physical function
or a new onset of falls?
Query family or collateral source from prior setting as
to ‘what is normal’ for this patient.
Delirium: Change in Mental Status
 An abnormal mental status exam that is a change from baseline for
the person is the hallmark of delirium
 Abnormalities may include inattention, fluctuations in level of
consciousness, new short term memory impairment, altered speech
patterns, disorganized speech and (possibly) delusions or
hallucinations
 Mental status screening tests are helpful in identifying cognitive
deficits and should be performed routinely in older patients: on
admission and at least daily during stay
Delirium Screening Instruments
 Instruments specific for detecting delirium based on
observation of behavior rather than formal testing:
 Confusion Assessment Method (CAM) diagnostic
algorithm
 NEECHAM Confusion Scale
The CAM Diagnostic Algorithm
 Can be accurately administered by individuals
without formal psychiatric training
 Based on the Diagnostic and Statistical Manual of
Mental Disorders-TR criteria for delirium
 Captures cardinal elements of delirium &
incorporates specific observations relevant to each
 Patients are identified as positive for delirium using
the CAM if 3 out of 4 features are present: acute
onset and fluctuating course* and inattention* with
either disorganized thinking or altered level of
consciousness

*denotes required features
The NEECHAM Confusion Scale





Uses a structured database derived during routine nursing
assessments and interactions with patients
Is sensitive to both the hyperactive and hypoactive forms of delirium
Evaluates nine components of information processing, performance,
and vital function
Can be repeated at frequent intervals to monitor change in mental
status over time
 Minimal response burden on the patient
 No learning effect from repetition of items
Can detect delirium in its early stage
The NEECHAM Confusion Scale
NEECHAM Confusion Scale
0-19: Moderate to Severe
20-24: Mild or Early Dev
25-26 None but High Risk
>26 No Delirium
Range of scores
is 0-30
Rating Scales for Delirium
Delirium Rating Scale
Memorial Delirium Assessment Scale
Delirium Assessment:
Vigilance A Test
 Helps to confirm suspected delirium
 After instructing the patient to raise his or her
hand only when the letter “A” is heard, the
examiner then begins saying letters from the
alphabet randomly.
 Delirious patients have inconsistent
responses.
Delirium Assessment:
Direct Observation
 Routine and periodic observation of the older
adult’s level of:
 Alertness (alert, hyper-alert or hypo-alert)
 General behavior
 Mood & affect
 Speech disturbance/verbalizations
 Motor behavior






General Cognitive Function:
Assessment Instruments
MiniCog
Mini-Mental Status Examination (MMSE) *
MoCA
Saint Louis University Mental Status
Examination (SLUMS)
Short Portable Mental Status
Questionnaire
*copyrighted
Delirium: Physical Exam
Examine for signs of:
 Hypoxia
 Volume depletion/overload
 Cardiovascular injury
 Metabolic encephalopathy
 Alcohol withdrawal
 Hypo- or hyperthermia
 New onset incontinence
 Urinary retention or fecal impaction
Check
Delirium: Diagnostic Tests
Choice based on history and physical findings
Baseline laboratory studies:
 Urinalysis
 Basic or Comprehensive Metabolic Panel
 Blood work: CBC, Thyroid function test
Further diagnostic testing (based on exam):
 Head CT
 EKG
 Chest X-Ray
Delirium: Diagnostic Tests cont'd

When difficult to
differentiate delirium
from acute psychotic
state
 Electroencephalography
The electroencephalogram reveals:
Diffuse slowing in most cases of delirium
Fast activity in cases of delirium related to drug withdrawal
Normal patterns in patients with acute functional psychosis
Delirium: Environmental
Predisposing Factors





Transfers within the hospital or unit
Absence of a clock or watch
Absence of reading glasses, hearing aid
Absence of family members
Use of physical restraints
Differentiating Delirium from Dementia &
Depression




Chronic cognitive impairment seen in dementia typically:
 Occurs gradually over time
 Persists greater than one month
 Is irreversible
Most older adults with dementia are alert and able to maintain
attention in the early stages of dementia
Depression may also present acutely with deficits in ability to
sustain attention.
Depression may present similar to hypo- or hyper-active
delirium; therefore, it is important to screen for depression in
older adults who present with a mixed picture.
Delirium: Differential Diagnosis



With recent change in cognition, an older person
should be presumed delirious until proven otherwise
Sudden cognitive and/or functional deterioration in a
patient with dementia suggests delirium
superimposed on dementia
Apathy, slowed speech and mood disturbance may
be indicative of hypoactive delirium rather than
depression
Delirium: Differential Diagnosis



Functional psychosis
 Acute functional psychosis can resemble delirium
 Onset at an earlier age
 Most older patients with functional psychosis have a history
of psychiatric illness
 Hallucinations tend to be auditory
 Delusions are more elaborate than those associated with
delirium
Dementia with Lewy Bodies includes fluctuating cognition and
visual hallucinations
Consultation with a psychiatrist or a neurologist may be
necessary in difficult cases
Delirium: General Management






Multi-component interventions are most effective
Prompt recognition & treatment of underlying cause
Creation of a maximum supportive environment
Immediate medical treatment as necessary
Discontinuation or reduced doses of medications thought
to be deliriogenic
Use of environmental interventions such as a delirium
room
Ensure
Delirium: General ManagementNutrition & Hydration Ensure
 Accurate 24 hour I & O
 Avoidance of depletion-dehydration syndrome
 Enteral tube feeding or hyperalimentation as
necessary
 Address any excess output issues such as
polyuria or diarrhea
Delirium: General Management
 Pulmonary care to ensure adequate oxygenation,
avoid atelectasis and pneumonia
 Bowel and bladder protocols to prevent or treat
constipation, diarrhea, and urinary incontinence
 Vigilence for fall risk and patient safety
 Use cognitive stimulation
 Avoid complications of immobility
 Minimize skin breakdown
Delirium: Managing the Environment






Presence of family members
Inclusion of familiar items from home
Use of glasses & hearing aids
Avoidance of physical restraints
Delirium room for high risk patients
Night-light and minimization of noise
 Interrupt sleep only when absolutely
necessary
Delirium: Maximizing Cognition
 Re-orientating strategies
 Inclusion of orienting facts in
normal conversation
 Discussion of current events
 Discussion of specific interests
 Structured reminiscence
 Word games
 Cognitive stimulation
Delirium: Medication Management
Use medications when:
 behaviors associated with psychotic thinking and perceptual
disturbances (e.g., hallucinations) pose a safety risk or are
distressing to the individual.
 delirium interferes with needed medical therapies and
behavioral interventions fail
Do Not use medications as a substitute for detection, correction, or
elimination of underlying causes of delirium
Use low doses of medications over the shortest possible time
period
Delirium: Medication Management

First line therapy: Low doses high-potency neuroleptics (e.g.
,haloperidol)
 Associated with extrapyramidal symptoms (EPS)
 Newer antipsychotics (e.g., olanzapine and risperidon) have a
lower incidence of EPS and may be better tolerated in older
patients
 Neuroleptic Malignant Syndrome, a more serious side effect of
antipsychotic therapy, can occur with high-potency as well as
with novel anti-psychotics
 Benzodiazepines (e.g., lorazepam) are recommended with
alcohol withdrawal or withdrawal from benzodiazepines.
 In non-alcohol withdrawal, benzodiazepines potentially
worsen delirium and should be used with caution
Delirium Management: Aftercare



Help the patient and family understand the bizarre and
bewildering experience
Psychiatric care to facilitate resolution through:
 Sensitive retrospective exploration of the experience
 Increasing patient’s understanding and acceptance
 Encouraging patients to report risk of delirium for
subsequent hospitalizations
Comprehensive discharge planning
 Home care referral
 Physical and occupational therapy
 Psychiatric nursing home care services
Delirium: Conclusion
 Historically seen as: A benign and expected condition
related to hospitalization
 Currently seen as: A serious health problem with
significant negative consequences
 APRNs are frontline in early identification of patients
most at risk for delirium and early detection of
symptoms
 Routine and systematic assessment for confusion is
key