Community Care Resources - Delirium

Delirium is a disturbance of consciousness with reduced ability to focus, sustain, or shift attention. It is a change in cognition that occurs over a short period of time and tends to fluctuate over the course of the day. Symptoms include problems with attention, thinking, memory, psychomotor changes and disruption of the sleep-wake cycle. Delirium is usually triggered by acute medical or surgical illness, or by certain medications. Clinicians must be knowledgeable about the risk factors for the disorder, know how to recognize, diagnose, prevent, and treat it. (1)

 Why is it important?

  • 50% of affected individuals have delirium on discharge from hospital, or transfer to LTC
  • Increased mortality due to post-operative complications and functional decline
  • Delirium is a marker of an increased risk of the development of a dementia, even in older people without previous cognitive or functional impairment
  • Those already experiencing dementia, can develop a hypoactive (apathetic) subtype of delirium

Common Causes

  • Predisposing factors include: previous cognitive problems, sensory deficits, frailty, depression, dehydration and polypharmacy
  • There are many precipitating causes especially infections, drugs, cardio-respiratory disease, metabolic disturbances and pain

Key Considerations

  • Important to consider the possibility that delirium might occur with infections, medication change, recent surgery or pain
  • Provide information to family regarding delirium: stress importance of monitoring nutrition and hydration, correct hearing and vision problems, monitoring medications and looking for evidence of common aggravating factors (pain, infection, constipation, etc.)
  • Monitoring is crucial (e.g. use of CAM, DOS),routinely screen for delirium/changes in cognition
  • Recovery may takes weeks to months
  • Obtain medication history, reconcile, review, and optimize medications
  • Pharmacological treatments should be used only for marked agitation/restlessness while avoiding psychoactive drugs when possible

References

1.  American Medical Directors Association (2008). Delirium and acute problematic behavior in the long-term care
     setting. Columbia (MD): American Medical Directors Association (AMDA); 2008. 36 p. Retrieved Feb. 2014 from:
     http://www.guideline.gov/content.aspx?id=12379%20

2.  Chan, P. (2011). Clarifying the confusion about confusion: Current practices in managing geriatric delirium.
     BCMJ, Vol. 53, No. 8, October 2011, page(s) 409-415 Articles. Retrieved Feb. 2014 from:
     http://www.bcmj.org/articles/clarifying-confusion-about-confusion-current-practices-managing-geriatric-
     delirium%20

3.  Delirium – Preventing and Managing (2012). Retrieved Feb 14. 2014 from:
     http://seniorfriendlyhospitals.ca/toolkit/processes-care/delirium/preventing-and-managing 

Recommended Readings / Guidelines

1.  Canadian Coalition for Seniors’ Mental Health.  (2006).  National Guidelines for Seniors' Mental Health:
     The Assessment and Treatment of Delirium
.  Retrieved March 2014 from:
     http://ccsmh.ca/wp-content/uploads/2016/03/NatlGuideline_Delirium.pdf

2.  National Institute for Health and Clinical Excellence.  (2010).  Delirium, diagnosis, prevention and management
     Retrieved March 2014 from: 
     http://www.nice.org.uk/nicemedia/live/13060/49909/49909.pdf

3.  Registered Nurses’ Association of Ontario.  (2003).  Screening for Delirium, Dementia and Depression in the
     Older Adult
.  Retrieved March 2014 from:
     http://rnao.ca/bpg/guidelines/screening-delirium-dementia-and-depression-older-adult

4.  Registered Nurses’ Association of Ontario.  (2004). Caregiving Strategies for Older Adults with Delirium, Dementia
     and Depression
.  Retrieved March 2014 from: 
     http://rnao.ca/bpg/guidelines/caregiving-strategies-older-adults-delirium-dementia-and-depression