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.
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
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.
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.

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
·         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
·         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
·         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 medica√ľons judiciously; avoid high-risk medica√ľons.
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

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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