Introduction:
Delirium is
characterized by an acute
decline in both the level of consciousness
and cognition with particular impairment in attention. The person is
extremely distractible and must be
repeatedly reminded to focus attention.
Definition:
The term Delirium
originates from the Latin verb deliro- to be crazy, which is taken from de+
lira, a furrow (i.e; to go out of the furrow).
"Delirium is
characterized by a disturbance in attention and awareness and a change in
cognition that develop rapidly over a short period". -APA, 2013
Epidemiology:
According to a
study, Incidence, prevalence and risk factors for delirium in elderly admitted
to a coronary care unit by Sandeep Grover etal in 2014, states that: among
the 152 patients evaluated, 37(24.34%)
had delirium at the first assessment (i.e. within 24 hours of admission in CCU)
and were classified as 'prevalence cases' of delirium. Fifteen cases ( 13.04%)
developed delirium after 24 hours of CCU stay and were considered as 'incidence
cases' of delirium.
Etiology:
The etiology of
delirium is complex and multifaceted. Because delirium is a fluctuating
process, it is difficult to establish its onset or termination- Delirium in
older adult is associated with
medications, infections, fluid and imbalance, metabolic disturbances or hypoxia
or ischemia. The probability of the syndrome developing increases if certain
predisposing factors, are also present.
Predisposing
factors:
·
Systemic infections
·
Febrile illness
·
Metabolic disorders, such as
hypoxia, hypercarbia, or hypoglycaemia
·
Hepatic encephalopathy
·
Head trauma
·
Seizures
·
Migraine headaches
·
Brain abscess
·
Postoperative states
·
Electrolyte imbalance
·
Drugs and poisons
·
Nutritional problems
Clinical Features:
The onset of
delirium is rapid- over a few hours or days- and the symptoms can be highly
variable and intermittent. The features develop rapidly and tend to fluctuate
over time.
Symptoms includes:
1.
Impairment of consciousness: clouding
of consciousness ranging from drowsiness to stupor and coma.
2.
Impairment of attention:
difficulty in shifting, focusing and sustaining attention and hallucinations,
most often visual.
3.
Impairment of abstract thinking
and comprehension, impairment of immediate and recent memory, increased reaction
time.
4.
Psychomotor disturbance: hypo
or hyper activity, aimless grouping or picking at the bed clothes
(flocculation), enhanced startle reaction.
5.
Disturbance of the sleep-wake
cycle: insomnia or in severe cases total sleep loss or reversal of sleep-wake
cycle, daytime drowsiness, nocturnal worsening of symptoms, disturbing dreams
or nightmares, which may continue as hallucinations after awakening.
6.
Emotional disturbances:
depression, anxiety, fear, irritability, euphoria, apathy.
Types:
Substance
intoxication delirium:
In this type, the
symptoms of delirium are attributed to intoxication from certain substances,
such as alcohol; amphetamines; cannabis; cocaine; hallucinogens; inhalants;
opioids; phencyclidine; sedative, hypnotics, and anxiolytics, or others (or unknown)
substance (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; sedative, hypnotics, and anxiolytics; and others.
Medication-Induced Delirium:
Medications that
have been known to precipitate delirium include anticholinergics, antihypertensives,
corticosteroids, anticonvulsants, cardiac glycosides, analgesics, anaesthetics,
antineoplastic agents, antiparkinson drugs, H2- receptor (e.g., cimetidine), and others.
Delirium due to
Another Medical Condition or to Multiple Etiologies:
There may be evidence from the history,
physical examination, or laboratory findings that the symptoms of delirium are
associated with another medical condition or can be attributable to more than
one cause.
Diagnostic
Tests:
Diagnose delirium
based on medical history, tests to assess mental status and the identification
of possible contributing factors. An examination may include:
Mental
status assessment start by assessing
awareness, attention and thinking. This may be done informally through
conversation, or with tests or screenings that assess mental state, confusion,
perception and memory.
Physical
and neurological exams. Perform a physical exam, checking for signs of
health problems or underlying disease. A neurological exam — checking vision,
balance, coordination and reflexes — can help determine if a stroke or another
neurological disease is causing the delirium.
Other
: Brain-imaging tests may be used when a diagnosis can't be made with other
available information.
Blood test:
·
Complete blood cell count with
differential Helpful to diaglose infection and anemia
·
Electrolytes - To diagnose low
or high levels
·
Glucose - To diagnose hypoglycaemia,
diabetic ketoacidosis
·
Renal and liver function tests
- To diagnose liver and renal failure
·
Thyroid function studies - To
diagnose hypothyroidism
·
Urine analysis - Used to diagnose
urinary tract infection
·
Urine and blood drug screen -
Used to diagnose toxicological causes
·
Thiamine and vitamin B-12
levels Used to detect deficiency states of these vitamins
·
Tests for bacteriological and
viral etiologies
Diagnostic
criteria: ICD 10 criteria
·
F00-F09: Organic, including
symptomatic, mental disorders.
·
F05: Delirium, not induced by
alcohol and other psychoactive substances
o
F05.0. Delirium, not
superimposed on dementia, so described
o
F05.l. Delirium, superimposed
on dementia
o
F05.8. Other delirium
o
F05.9: Delirium, unspecified
Medical
Management:
determination and
correction of the underlying causes
fluid and
electrolyte balance, hypoxia, anoxia, and diabetic problems.
The agitation and aggression
demonstrated by the client with delirium may require chemical and / or
mechanical for his or her personal
safety.
Antipsychotic
agents :Haloperidol is the preferred drug because it is potent and has fewer
anticholinergic and hypotensive side effects. It is administered orally and IM.
Risperidone (Risperdal), olanzapine (Zyprexa), and quetiapine (Seroquel) at low
doses can be effective in controlling the aggression associated with delirium.
Electroconvulsive
therapy:
ECT is also a for
delirium when other approaches have failed.
Sleep-Wake
cycle:
Delirium is
frequently complicated by changes in the sleep-wake cycle. Brief, judicious of
sedating agents, such as zolpedem (Ambien) or trazodone (Desyfrel), to reset
the sleep-wake cycle may be appropriate. Care should be taken to avoid excess
sedation because of falls, aspiration, and inability to perform or assist with
activities of daily living.
Nursing
Management:
Nursing
diagnosis:
1.
Acute confusion
Interventions:
·
Do not allow the client to
assume responsibility for decisions or actions if he or she is unsafe.
·
If limits on the client's
actions are necessary, explain limits and reasons clearly, within the client's
ability to understand.
·
Involve the client in making
plans or decisions as much as he or she is able to participate.
·
Assess the client daily or more
often if needed for his or her level of
·
Assist the client to establish
a daily routine, including hygiene, activities, and forth.
·
Teach the client about
underlying cause(s) of confusion and delirium.
2.
Impaired social interaction
Intervention:
·
Encourage the client to
feelings, especially feelings of anger,
and so forth.
·
Give the client positive
feedback when he or she is able to identify areas that are difficult for him or
her.
·
Ask the client to clarify any
feelings that he or she expresses vaguely.
Encourage the client to be specific.
·
Encourage the client to
interact with staff or other clients on topics of interest.
·
Give the client positive
feedback for engaging in social interactions and leisure activities.
3.
Risk for injury
Interventions:
·
Restrict environmental stimuli,
keep unit calm and well- illuminated.
·
There should always be somebody
at the patient's bedside reassuring and supporting
·
As the patient is responding to
a terrifying unrealistic world of hallucinatory
and delusions, special precautions are needed to protect him from protect others.
Geriatric
consideration:
A. Obtain geriatric
consultation.
B. Eliminate or
minimize risk factors
1.. Administer
medicaüons judiciously; avoid high-risk medicaüons.
2.Prevent/promptly
and appropriately treat infections.
3.Prevent/promptly
treat dehydration and electrolyte disturbances.
4.Provide adequate
pain control
5.Maximize oxygen
delivery (supplemental oxygen, blood, and BP support needed).
6.Use sensory aids
as appropriate.
7. Regulate
bowel/bladder function.
8. Provide adequate
nutrition
C. Provide a therapeutic
environment.
1. Foster
orientation: frequently reassure and reorient patient (unless patient becomes
agitated); use easily visible calendars, clocks, caregiver identification;
carefully explain all activities; communicate clearly
2.Provide
appropriate sensory stimulation: quiet room; adequate light; one task at a
time; noise-reduction strategies
3.Facilitate sleep:
back massage, warm milk or herbal tea at bedtime; relaxation music/tapes;
noise-reduction measures; avoid awakening patient
4.Foster
familiarity: encourage family/friends to at
bedside; bring familiar objects from home; maintain consistency of caregivers;
minimize relocations
5.Maximize
mobility: avoid and urinary catheters; ambulate or active ROM times daily
6.Communicate
clearly, provide explanations
7.Reassaure and
educate family
8.Minimize invasive
interventions
9.Consider
psychotropic medication as a last resort for agitation
Conclusion:
Delirium is a
change in and develops over a short time. It is usually reversible if the
underlying cause is idenffied and treated quickly. It is a serious disorder and
should always be as an emergency
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