Transcript Delirium & Dementia

Delirium & Dementia:
Double Trouble
By Denise L. Lyons, GCNS-BC, MSN; Shannon
M. Grimley, GCP, PharmD; and Linda Sydnor,
GCNS-BC, MSN
LPN2009, March/April 2009
2.3 ANCC contact hours
Online: www.lpnjournal.com
© 2009 by Lippincott Williams & Wilkins. All world rights reserved
Delirium’s long-lasting
complications
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Decline in cognitive and physical function
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Increased length of hospital stay
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Greater need for nursing care
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Delayed rehabilitation
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Nursing home placement
Prevalence of delirium
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In patients with dementia age 65 and older –
22% to 89%
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May be underreported when patient also has
dementia
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Often diagnosed as worsening dementia
Prevalence of delirium
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25% of older adults are hospitalized with
delirium
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56% develop delirium while hospitalized
What’s the difference?
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Dementia is chronic, develops slowly, and isn’t
reversible
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Delirium is an acute change in mental status due
to a reversible medical condition
What’s the difference?
Onset
 Delirium: Acute
 Dementia: Insidious
Course
 Delirium: Fluctuating, with lucid intervals; worse
at night
 Dementia: Slowly progressive
What’s the difference?
Duration
 Delirium: Hours to weeks
 Dementia: Months to years
Sleep/wake cycle
 Delirium: Always disrupted
 Dementia: Sleep fragmented
What’s the difference?
Illness or drug toxicity
 Delirium: Either or both present
 Dementia: Often absent, especially in Alzheimer’s
Level of consciousness
 Delirium: Disturbed. Patient is less clearly aware
of the environment and less able to focus,
sustain, or shift attention
 Dementia: Usually normal until late in illness
What’s the difference?
Behavior
 Delirium: Activity often abnormally decreased
(somnolence) or increased (agitation)
 Dementia: Normal to slow; behavior may be
inappropriate
Speech
 Delirium: Hesitant, slow, or rapid; incoherent
 Dementia: Difficulty finding words; aphasia
What’s the difference?
Mood
 Delirium: Fluctuating, labile, from fearful or
irritable to normal or depressed
 Dementia: Often flat, depressed
Thought processes
 Delirium: Disorganized; may be incoherent
 Dementia: Impoverished; speech gives little info
What’s the difference?
Thought content
 Delirium: Delusions common; often transient
 Dementia: Delusions may occur
Perceptions
 Delirium: Illusions, hallucinations (usually visual)
 Dementia: Hallucinations may occur
What’s the difference?
Judgment
 Delirium: Impaired, often to a varying degree
 Dementia: Increasingly impaired over illness
Orientation
 Delirium: Usually disoriented, especially for time.
A known place may seen unfamiliar
 Dementia: Fairly well maintained, but becomes
impaired in later stages of illness
What’s the difference?
Attention
 Delirium: Fluctuates. Patient is easily distracted
and unable to concentrate on tasks
 Dementia: Usually unaffected until late in illness
Memory
 Delirium: Immediate and recent memory impaired
 Dementia: Recent memory and new learning
especially impaired
Who’s at risk?
Predictable risk factors for developing delirium:
 Age older than 70
 History of dementia
 Sleep deprivation
 Hearing or visual impairment
 Dehydration
 Severe illness or fractures
 Hospitalization
Who’s at risk?
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Recent surgery
Immobility
Previous episodes of delirium
Polypharmacy
Alcoholism
Multiple comorbidities
Common causes of delirium
Drugs
 prescribed, over-the-counter, and recreational
 alcohol withdrawal or intoxication
 polypharmacy (more than four medications)
 effects of anticholinergic drugs, psychoactive
drugs (anxiolytics, sedatives, hypnotics,
antipsychotics, antidepressants), opioids,
steroids
 drug toxicity, drug withdrawal
Common causes of delirium
Elimination
 urinary retention
 fecal impaction or diarrhea
Liver and other organs
 liver failure, hepatitis, cirrhosis
 heart failure, MI, hypotension, dysrhythmia
 kidney dialysis, renal insufficiency
Common causes of delirium
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GI bleeding, inflammation, infarction, infection
stroke, cerebral edema, subdural hematoma,
head injury, hydrocephalus, encephalopathy,
meningitis
bone marrow disease (anemia)
Infection
 urinary tract or respiratory infection
 sepsis
Common causes of delirium
Respiratory
 hypoxia, pneumonia, pulmonary embolism,
chronic obstructive pulmonary disease, asthma
 abnormal arterial blood gases, carbon dioxide,
retention, hyperventilation
Injury
 trauma, pain, stress
Common causes of delirium
Unfamiliar environment
 restraint use, underlying dementia
 hospitalization or change in residence
Metabolic
 fluid/electrolyte disturbance
 dehydration/volume depletion
 abnormal blood glucose level
Common causes of delirium
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elevated blood urea nitrogen or creatinine level
vitamin B12/folate deficiency
hypothyroidism, hyperthyroidism
fever, hypothermia
Promoting prevention
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Frequent bedside assessments of mental status
noting any changes in inattention or unorganized
thoughts
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Manage patient’s environment: minimize noise,
staff, room changes
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Respond immediately to suspected physiologic
causes of delirium: infection, medications etc.
Finding the cause
Observe the following:
 vital signs
 intake and output
 SpO2 level
 last bowel movement
 lung sound
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medical device use
pain level
new medications
blood glucose
urinalysis
Medications that can cause
problems
Many drugs can cause or exacerbate delirium:
 Alzheimer’s medications
 opioid analgesics
 nonopioid analgesics
 all anesthetics
 antianxiety/hypnotic agents, sedatives
 antiseizure drugs
 antidepressants
Medications that can cause
problems
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antihistamines
antihypertensives
antimicrobials
anti-Parkinson’s medications
antispasmodics (urinary)
cardiac medications
glucocorticoids
muscle relaxants
Diagnosing delirium
Two assessment tools may be helpful:
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Confusion Assessment Method (CAM)
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Neelon and Champagne Confusion Scale
Confusion Assessment Method
(CAM)
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Available in long and short forms
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Has 94% to 100% sensitivity rating
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Key features include: acute onset, fluctuating
course, inattention, disorganized thinking
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Diagnosis by CAM requires first two features
plus at least one of last two
Neelon and Champagne
Confusion Scale
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Based on routine nursing assessments
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Evaluates ten items divided into three levels:
processing, behavior, physiologic functioning
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Detects delirium in early stages
Medication management
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National guidelines support using antipsychotic
medications in patients with severe agitation or
psychosis
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Haloperidol (Haldol) is drug of choice; approved
for oral and I.M. administration; has few
anticholinergic effects; beware of QT changes
when giving I.V.
Other drugs
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Atypical antipsychotics may be given:
- risperidone (Risperdal)
- quetiapine (Seroquel)
- olanzapine (Zyprexa)
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Effectiveness is uncertain; fewer adverse reactions
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Benzodiazepines should only be used in alcohol
withdrawal or as sedative-hypnotic
Supportive care
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Maintain patient’s routine and have same care
staff as much as possible
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Create familiar environment with items from home
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Eliminate stressors (bright lights, loud telephone)
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Avoid invasive devices; remove as quickly as able
Supportive care
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Offer appropriate diversion activities
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Communicate in a low, clear, calm voice
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Be mindful of safety (bed in lowest position, area
free from clutter)
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Offer assistance to ambulate frequently
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Use assistive devices (glasses hearing aids)
Dealing with agitation
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Restraints are last resort
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Be creative and remain calm
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Modify environment so patient can move safely
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Use of family member or staff as one-on-one if
needed