content
ON
DELIRIUM
INTRODUCTION
Neurocognitive disorders (NCDs) include those in which a clinically significant deficit in
cognition or memory exists, representing a significant change from a previous level of
functioning. These disorders were previously identified in the Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition, Text Revision (American Psychiatric Association 2000) as
"Dementia, Delirium, Amnestic, and Other Cognitive Disorders." In the DSM-5, NCDs include
delirium and the syndromes called major NCD or minor NCD which are then or specified
according to the underlying cause (such as Alzheimer's disease, Parkinson's disease others).
DEFINITION OF DELIRIUM
Delirium is a syndrome, not a disease, and it has many causes.
Delirium is a mental state characterized by an acute disturbance of cognition, manifested by
short-term confusion, excitement, disorientation, and clouded consciousness. Hallucinations and
illusions are common.
Delirium is characterized by a disturbance in attention and awareness and a change in cognition
that develop rapidly over a short period (APA, 2013).
In DSM-IV-TR, delirium is characterized by a disturbance of consciousness and a change in
cognition that develop over a short...time'.
EPIDEMIOLOGY
Delirium is a common disorder. About 10 to 15 percent of patients on general surgical wards and
15 to 25 percent of patients on general medical wards experience delirium during their hospital
stays. About 30% of patients in surgical intensive care units and cardiac intensive care units and
40 to 50% of patients who recovering from surgery for hip fractures have an episode of delirium.
Advanced age is a major risk factor for the development of delirium. About 30 to 40 percent of
hospitalized patients more than 65 years old have an episode of delirium.
PREDISPOSING FACTORS DELIRIUM
Individuals most predisposed to delirium include those with serious medical, surgical, or
neurological conditions. People older than age 65 are considered a high-risk group, and geriatric
syndromes such as dementia, depression, falls, and elder abuse are often precipitating factors
(Kalish, Gillham, & Unwin, 2014). Some examples of conditions known to precipitate delirium
include the following (Black & Andreasen, 2014; Sadock et al., 2015):
Systemic infections
Febrile illness
Metabolic disorders, such as electrolyte imbalances, hypercarbia, or hypoglycemia
Hypoxia and chronic obstructive pulmonary disease Hepatic failure or renal failure
Head trauma Seizures
Migraine headaches
Brain abscess or brain neoplasms
Stroke
Nutritional deficiency-thiamine, B12 or folic acid
Uncontrolled pain
Burns
Heat stroke
Orthopedic and cardiac surgeries
Social isolation
Other Etiological Implications
Substance Intoxication Delirium
In this subtype, the symptoms of delirium are attributed to intoxication from certain substances,
such as alcohol, amphetamines, cannabis, cocaine, hallucinogens, inhalants, opioids,
phencyclidine, sedative, hypnotic, and anxiolytics, or other or unknown substances (APA, 2013).
Substance Withdrawal Delirium
Withdrawal from certain substances can precipitate symptoms of delirium that are sufficiently
severe to warrant clinical attention. These substances include alcohol; opioids; sedatives,
hypnotics, or anxiolytics; and others.
Medication Induced Delirium
Medications that have been known to precipitate delirium include anticholinergics,
antihypertensives, corticosteroids, anticonvulsants, cardiac glycosides, analgesics, anesthetics,
antineoplastic agents, antiparkinsonian drug and others (Puri & Treasaden, 2012; Sadock et al.,
2015).
Delirium Due to Another Medical Condition or to Multiple Etiologies
There may be evidence from the history, physical examination, or laboratory findings that
symptoms of delirium are associated with another medical condition or can be attributable to
more than one cause. The current evidence supports that delirium is usually the result of many
factors rather than one (Kalish et al., 2014).
SYMPTOMS OF DELIRIUM
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
Behaviour changes
These may include:
Seeing things that don't exist (hallucinations)
Restlessness, agitation
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
Delirium is categorized by its cause, severity, and characteristics:
Hyperactive delirium. Probably the most easily recognized type, this may include
restlessness, 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.
PHYSICAL AND LABORATORY TESTS
The following tests can help them check for imbalances in a person’s brain chemistry or
electrolyte levels and confirm the presence of any other medical conditions:
blood chemistry test
head scans
urine tests
drug and alcohol tests
electrocardiography
chest X-ray
CT scan
liver function test
lumbar puncture
thyroid test
COURSE AND PROGNOSIS
Although the onset of delirium is usually sudden, prodromal symptoms (for .e.g. restlessness and
fearfulness) may occur in the days preceding the onset of florid symptoms The symptoms of
delirium usually last as long as the casually relevant factors are present, although delirium
generally lasts less than a week.
TREATEMENT
Depending on the cause of the delirium, treatment may include taking or stopping certain
medications.
In older adults, an accurate diagnosis is important for treatment, as delirium symptoms are
similar to dementia, but the treatments are very different.
Medications
Doctor will prescribe medications to treat the underlying cause of delirium. For example, if
delirium is caused by a severe asthma attack, you might need an inhaler or breathing machine to
restore breathing.
If a bacterial infection is causing the delirium symptoms, antibiotics may be prescribed.
In some cases, doctor may recommend that stop drinking alcohol or stop taking certain
medications (such as codeine or other drugs that depress).
If agitated or depressed, may be given small doses of one of the following medications:
antidepressants to relieve depression
sedatives to ease alcohol withdrawal
dopamine blockers to help with drug poisoning
thiamine to help prevent confusion
Counseling
If feeling disoriented, counseling may help to anchor thoughts. Counseling is also used as a
treatment for people whose delirium was brought on by drug or alcohol use. In these cases, the
treatment can help abstain from using the substances that brought on the delirium.
In all cases, counseling is intended to make feel comfortable and give a safe place to discuss
thoughts and feelings.
NURSING MANAGEMENT
Assessment
Nursing assessment of the client with delirium is based on knowledge of the
symptomatology associated with the various disorders. Subjective and objective data are
gathered by various members of the health-care team. Clinicians report use of a variety of
methods for obtaining assessment information.
The client history: Nurses play a significant role in acquiringthe client history, including
the specific mental and physical changes that have occurred and the age at which changes
began.
From the client history, nurses should assess the following areas of concern: (1) type,
frequency, and severity of mood swings, personality and behavioral changes, and
catastrophic emotional reactions. (2) Cognitive changes. such as problems with attention
span, thinking process. problem-solving, and memory. (3) Language difficulties. (4)
Orientation to person, place, time, and situation. (5) Appropriates of social behavior.
Physical examination
Signs of damage to the nervous system
Evidence of diseases of other organs that could affect mental function.
Nursing Diagnosis
1. Risk for trauma related to impairments in cognitive and psychomotor functioning.
2. Disturbed thought processes related to cerebral degeneration evidence by disorientation,
confusion, memory deficits, and inaccurate interpretation of environment.
3. Self care deficit related to disorientation, confusion, memory deficits evidenced by
inability to fulfill activities of daily living.
1. Risk for trauma related to impairments in cognitive and psychomotor
functioning.
Nursing interventions
The following measures may be instituted:
a. Arrange furniture and other items in the room to accommodate client's disabilities.
b. Store frequently used items within easy access.
c. Keep the bed in the lowest position from the floor when the client is not being
immediately attended to. Pad side rails and headboard if client has history of seizures.
Keep bedrails up when client is in bed.
d. Assign room near nurses' station; observe frequently.
e. Assist client with ambulation.
f. Keep a dim light on at night.
g. If client is a smoker, cigarettes and lighter or matches should be kept at the nurses'
station and dispensed only when someone is available to stay with client while he or she
is smoking.
h. Frequently orient client to place, time, and situation.
i. If client is prone to wander, provide an area within which wandering can be carried out
safely.
j. Soft restraints may be required if client is very disoriented and hyperactive.
2. Disturbed thought processes related to cerebral degeneration evidence by
disorientation, confusion, memory deficits, and inaccurate interpretation of
environment
Interventions
For the Client Who Is Disoriented
Try to keep the client as oriented to reality as possible.
Use clocks and calendars with large numbers that are easy to read.
Place large, colorful signs on the doors to identify clients' rooms, bathrooms,
activity rooms, dining rooms, and chapel.
Allow the client to have as many of his or her personal items as possible. Even an
old familiar chair in the room can provide a degree of comfort.
If at all possible, encourage family and close friends to be a part of the client's
care, to promote feelings of security and orientation.
Provide the client with radio, television, and music if they are diversions the client
enjoys; these may add a feeling of familiarity to the environment.
Ensure that noise level is controlled to prevent excess stimulation. One study
found that use of earplugs at night decreased risk for delirium by 53 percent and
patients reported improved sleep (Van Rompaey et al., 2012)
Allow the client to view old photograph albums and utilize reminiscence therapy.
These are excellent ways to provide orientation to reality.
Maintain consistency of staff and caregivers to the best extent possible.
Familiarity promotes comfort and feelings of security.
3. Self care deficit related to disorientation, confusion, memory deficits evidenced
by inability to fulfill activities of daily living.
Interventions
Provide a simple, structured environment for the client, identify self-care deficits,
and offer assistance as required.
Allow plenty of time for the client to complete tasks.
Provide guidance and support for independent actions by talking the client
through the task one step at a time.
Provide a structured schedule of activities that does not change from day to day.
Ensure that ADLs follow the client's usual routine as closely as possible.
Minimize confusion by providing for consistency in assignment of daily
caregivers.
Perform an ongoing assessment of the client's ability to fulfill his or her
nutritional needs, ensure personal safety, follow the medication regimen, and
communicate the need for assistance with activities that he or she cannot
accomplish independently. Anticipate needs that are not verbally communicated.
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.
CONCLUSION
REFFERANCE
1. Ahuja, N (2011). A short Textbook of Psychiatry (7th ed.). Jaypee Brothers Medical
Publishers (P) LTD.
2. Kapoor, B. (1994). A Textbook of Psychiatric Nursing (1 st ed.). Delhi: Kumar Publishing
House.
3. Sreevani, R (2016). A guide to Mental Health and Psychiatric Nursing (4 th ed.). Jaypee
Brothers Medical Publishers (P) Ltd.
4. Stuart, GW (2009). Principles and Practice of Psychiatric Nursing (9 th ed.).Noida: Reed
Elsevier India Pvt Ltd.
5. Townsend, M C. Psychiatric Mental Health Nursing: Concepts of Care In Evidence-Based
Practice (8th ed.) New Delhi: Jaypee Brothers Medical Publishers (P) LTD.
