Question

Scenario

You are the nurse working triage in the emergency department (ED). This afternoon a woman brings in her father, ALI, a 72-year-old who is a retired doctor. The daughter reports that over the past several months she has noticed her father has progressively had problems with his mental capacity. These changes have developed gradually but seem to be getting worse. At times he is alert, and at other times he seems disoriented, depressed, and tearful. He is forgetting things and doing things out of the ordinary, such as placing the milk in the cupboard and sugar in the refrigerator. He had difficulty finding objects in the kitchen and at times forgets where his room is.

This morning he thought it was nighttime and wondered what his daughter was doing at his house. He could not pour his coffee, and he seems to be getting more agitated. ALI reports that he has been having memory problems for the past year and at times has difficulty remembering the names of family members and friends.

A review of his past medical history (PMH) is significant for hypercholesterolemia and coronary artery disease (CAD). He had a myocardial infarction (MI) 5 years ago. ALI’s vital signs (VS) today are all within normal limits (WNL).

Q: What patients’ behavior would you associate with delirium? Discuss three.

Answer 1

ANS:-

Introduction:

Delirium is a serious disturbance in mental abilities that results in confused thinking and reduced awareness of the environment. The start of delirium is usually rapid — within hours or a few days.

Delirium can often be traced to one or more contributing factors, such as a severe or chronic illness, changes in metabolic balance (such as low sodium), medication, infection, surgery, or alcohol or drug intoxication or withdrawal.

Because symptoms of delirium and dementia can be similar, input from a family member or caregiver may be important for a doctor to make an accurate diagnosis.

Symptoms

Signs and symptoms of delirium usually begin over a few hours or a few days. They often fluctuate throughout the day, and there may be periods of no symptoms. Symptoms tend to be worse during the night when it's dark and things look less familiar. Primary signs and symptoms include those below.

Reduced awareness of the environment

This may result in:

• An inability to stay focused on a topic or to switch topics
• Getting stuck on an idea rather than responding to questions or conversation
• Being easily distracted by unimportant things
• Being withdrawn, with little or no activity or little response to the environment

Poor thinking skills (cognitive impairment)

This may appear as:

• Poor memory, particularly of recent events
• Disorientation — for example, not knowing where you are or who you are
• Difficulty speaking or recalling words
• Rambling or nonsense speech
• Trouble understanding speech
• Difficulty reading or writing

Behavior changes

These may include:

• Seeing things that don't exist (hallucinations)
• Restlessness, agitation or combative behavior
• Calling out, moaning or making other sounds
• Being quiet and withdrawn — especially in older adults
• Slowed movement or lethargy
• Disturbed sleep habits
• Reversal of night-day sleep-wake cycle

Emotional disturbances

These may appear as:

• Anxiety, fear or paranoia
• Depression
• Irritability or anger
• A sense of feeling elated (euphoria)
• Apathy
• Rapid and unpredictable mood shifts
• Personality changes

Types of delirium

Experts have identified three types of delirium:

• Hyperactive delirium. Probably the most easily recognized type, this may include restlessness (for example, pacing), agitation, rapid mood changes or hallucinations, and refusal to cooperate with care.
• Hypoactive delirium. This may include inactivity or reduced motor activity, sluggishness, abnormal drowsiness, or seeming to be in a daze.
• Mixed delirium. This includes both hyperactive and hypoactive signs and symptoms. The person may quickly switch back and forth from hyperactive to hypoactive states.

Delirium and dementia

Dementia and delirium may be particularly difficult to distinguish, and a person may have both. In fact, delirium frequently occurs in people with dementia. But having episodes of delirium does not always mean a person has dementia. So a dementia assessment should not be done during a delirium episode because the results could be misleading.

Dementia is the progressive decline of memory and other thinking skills due to the gradual dysfunction and loss of brain cells. The most common cause of dementia is Alzheimer's disease.

Some differences between the symptoms of delirium and dementia include:

• Onset. The onset of delirium occurs within a short time, while dementia usually begins with relatively minor symptoms that gradually worsen over time.
• Attention. The ability to stay focused or maintain attention is significantly impaired with delirium. A person in the early stages of dementia remains generally alert.
• Fluctuation. The appearance of delirium symptoms can fluctuate significantly and frequently throughout the day. While people with dementia have better and worse times of day, their memory and thinking skills stay at a fairly constant level during the course of a day.

When to see a doctor

If a relative, friend or someone in your care shows any signs or symptoms of delirium, see a doctor. Your input about the person's symptoms, typical thinking and everyday abilities will be important for a proper diagnosis and for finding the underlying cause.

If you notice signs and symptoms of delirium in a person in a hospital or nursing home, report your concerns to the nursing staff or doctor rather than assuming that those problems have been observed. Older people recovering in the hospital or living in a long-term care facility are particularly at risk of delirium.

Causes

Delirium occurs when the normal sending and receiving of signals in the brain become impaired. This impairment is most likely caused by a combination of factors that make the brain vulnerable and trigger a malfunction in brain activity.

Delirium may have a single cause or more than one cause, such as a combination of a medical condition and drug toxicity. Sometimes no cause can be identified. Possible causes include:

• Certain medications or drug toxicity
• Alcohol or drug intoxication or withdrawal
• A medical condition, such as a stroke, heart attack, worsening lung or liver disease, or an injury from a fall
• Metabolic imbalances, such as low sodium or low calcium
• Severe, chronic or terminal illness
• Fever and acute infection, particularly in children
• Urinary tract infection, pneumonia or the flu, especially in older adults
• Exposure to a toxin, such as carbon monoxide, cyanide or other poisons
• Malnutrition or dehydration
• Sleep deprivation or severe emotional distress
• Pain
• Surgery or other medical procedures that include anesthesia

Several medications or combinations of drugs can trigger delirium, including some types of:

• Pain drugs
• Sleep medications
• Medications for mood disorders, such as anxiety and depression
• Allergy medications (antihistamines)
• Asthma medications
• Steroid medicines called corticosteroids
• Parkinson's disease drugs
• Drugs for treating spasms or convulsions

Risk factors

Any condition that results in a hospital stay, especially in intensive care or after surgery, increases the risk of delirium, as does being a resident in a nursing home. Delirium is more common in older adults.

Examples of other conditions that increase the risk of delirium include:

• Brain disorders such as dementia, stroke or Parkinson's disease
• Previous delirium episodes
• Visual or hearing impairment
• The presence of multiple medical problems

Complications

Delirium may last only a few hours or as long as several weeks or months. If issues contributing to delirium are addressed, the recovery time is often shorter.

The degree of recovery depends to some extent on the health and mental status before the onset of delirium. People with dementia, for example, may experience a significant overall decline in memory and thinking skills. People in better health are more likely to fully recover.

People with other serious, chronic or terminal illnesses may not regain the levels of thinking skills or functioning that they had before the onset of delirium. Delirium in seriously ill people is also more likely to lead to:

• General decline in health
• Poor recovery from surgery
• Need for institutional care
• Increased risk of death

Prevention

The most successful approach to preventing delirium is to target risk factors that might trigger an episode. Hospital environments present a special challenge — frequent room changes, invasive procedures, loud noises, poor lighting, and lack of natural light and sleep can worsen confusion.

Evidence indicates that certain strategies promoting good sleep habits, helping the person remain calm and well-oriented, and helping prevent medical problems or other complications can help prevent or reduce the severity of delirium.

History

The diagnosis of delirium is clinical. No laboratory test can diagnose delirium. Obtaining a thorough history is essential.

Because delirious patients often are confused and unable to provide accurate information, getting a detailed history from family, caregivers, and nursing staff is particularly important. Nursing notes can be very helpful for documentation of episodes of disorientation, abnormal behavior, and hallucinations

How long can you live with delirium?

Delirium can last for a few days, weeks or even months but it may take longer for people with dementia to recover. In hospitals, approximately 20-30% of older people on medical wards will have delirium and up to 50% of people with dementia. Between 10-50% of people having surgery can develop delirium.

How to Help a Person with Delirium-

1. Encouraging them to rest and sleep.

2. Keeping their room quiet and calm.

3. making sure they're comfortable.

4. Encouraging them to get up and sit in a chair during the day.

5. Encouraging them to work with a physical or occupational therapist.

6. Helping them eat and drink.

Objectives

Aggressive behaviors by patients with dementia present risk to healthcare workers and patients alike. An information processing model of aggressive behavior, developed to study aggressive behaviors among children, was applied to the study of aggression among older hospital patients with dementia. Hypotheses were that delirium and mental health history or depression history, respectively, would relate to increased risk of aggressive behaviors toward hospital staff.

Method

Electronic medical records were sampled for one year (N=5,008) and screened using the EMERSE search engine and hand review for dementia (n=505) and aggressive behavior in individuals with dementia (n=121). Records were reviewed for presence of a mental health history other than dementia and presence of delirium at the time of aggression.

Results

Results of stepwise logistic regression analyses were that interaction effects representing delirium and either mental health or depression history were associated with greater risk of aggressive behavior. Significant main effects were found for both dementia and mental health or depression history, respectively. Of the lowest risk group, 12% of patients exhibited aggression by comparison to 24%–35% of those with delirium, mental health or depression history, or the combination of these risk factors.