Understanding Delirium in the Hospitalized Older Adult | Knowledge is Power

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by Kim Valentine Kim Valentine, BSN, RN

Specializes in Community Health, Care Coordination and Geriatrics. Has 40 years experience.

The percentage of adults over age 65 in the United States is now more than 16% of the population. Because this age group tends to have more comorbid and chronic conditions, they are twice as likely to be hospitalized as compared to people under the age of 65.  Delirium is a recognized complication of hospital admissions for the older adult and carries a high risk of morbidity, so identification and treatment are vital to better outcomes.  

Possible Signs Of Delirium

Understanding Delirium in the Hospitalized Older Adult | Knowledge is Power

Summary

The percentage of adults over age 65 in the United States is now more than 16% of the population. Because this age group tends to have more comorbid and chronic conditions, they are twice as likely to be hospitalized as compared to people under the age of 65.  Delirium is a recognized complication of hospital admissions for the older adult and carries a high risk of morbidity, so identification and treatment are vital to better outcomes.1

Delirium in older adults is a medical emergency and can be misdiagnosed in a busy acute care setting. Of all adults over age 65 admitted to the hospital, 30% will develop delirium or acute confusion2.  A delay in identification and treatment increases the likelihood of the patient developing severe complications, coma and possibly death.  Research shows that of all the patients in hospital with delirium, 35 to 40% will die within 1 year of complications associated with that episode of delirium.3 As nurses, we must be alert to the signs of delirium in our patients and advocate for prompt treatment of the cause.

What are the questions we need to ask ourselves as nurses to understand delirium?

Who is most at risk of developing delirium in the acute care setting?

  • Older adults over age 65
  • Patients with a pre-existing dementia or depression
  • Older adults with multiple comorbidities 
  • Patients with drug and or alcohol addictions

What are some of the possible causes of delirium?

  • Urinary tract infection
  • Respiratory infection
  • Constipation
  • Dehydration
  • Hyponatremia or other metabolic imbalances
  • Pain 
  • Malnutrition
  • Medical procedures (post-operative)
  • Alcohol or drug withdrawal
  • Sleep deprivation

Where in the acute care setting are patients at most risk?

  • Critical care units
  • Emergency Department
  • Recovery room
  • Any treatment area where there is a high level of sensory stimulation

How does delirium present?

  • Poor concentration
  • Disorientation to time and place
  • Difficulty speaking
  • Auditory or visual hallucinations
  • Slowed movements or sleepiness (psychomotor retardation) as in hypoactive delirium
  • Disturbed sleep habits and calling out
  • Reversed sleep-wake cycle 
  • Withdrawn and quiet
  • Behavioral changes 
  • Restlessness and agitation
  • Combative behavior

Delirium vs Dementia

When a patient presents as “confused” in the hospital setting, the clinician may conclude the patient has dementia, however, a new presentation of confusion may very well be delirium.  

Dementia is a progressive decline in cognition and function

Example: Mom has been slowly, over time having problems with her short-term memory. It seems now that she can’t seem to remember the steps to baking that apple pie she used to create with ease.

Delirium has an acute onset and a fluctuating course; sometimes described as a “waxing and waning"

Example: Mom seemed fine in the morning but by the afternoon she was talking to her deceased husband.  Then in the evening, Mom is back to her baseline.  Mom may be fine one day and confused the next.  

A fluctuating course is a primary feature of delirium. Therefore, a screening tool such as the Confusion Assessment Method or “CAM”4 should be conducted at least every shift. A CAM will properly identify this variable course so an underlying source may be investigated. Once identified, an appropriate treatment can be introduced.  Even when treatment is completed, delirium may not be cleared immediately.  There have been cases where delirium takes weeks (and even months) to clear.

Important points to consider include

  • A severe case of delirium may worsen an already existing dementia.  
  • Multiple episodes of delirium will be detrimental to cognition as a repeated assault on the brain. 
  • A screening assessment for dementia such as a Montreal Cognitive Assessment should never be conducted during an episode of delirium.

As nurses, we are primary caregivers for our patients while they are in the hospital, so advocacy for appropriate treatment is especially vital.  The older adult patient presenting with symptoms of delirium may have a reversible condition, so prompt management may be the difference between life and debilitating complications or even death. Knowledge is power!


References/Resources

1Persons with hospital stays in the past year, by selected characteristics: United States, selected years 1997–2018

2Abrupt change in mental status

3Delirium

4Assessing and Managing Delirium in Older Adults with Dementia

Older Americans: Key Indicators of Well-Being

Delirium: Overview

Delirium

 

Kim Valentine BSN RN is a registered nurse with extensive experience in hospital and community health. Her current position is working as a Care Coordinator is a small rural hospital with a passion for improving the health literacy in our communities.

2 Articles   19 Posts

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18 Comment(s)

Susie2310

Susie2310

2,073 Posts

Thank you for bringing our attention to this very important topic.  

I remember reading a study that showed delirium is under-recognized by nurses in the ER setting, due, if I recall correctly, to lack of knowledge of the symptoms, which without a proper assessment strategy can be difficult to discern as the presentation of delirium can be subtle and symptoms can be missed, deemed to be due to other causes, or deemed to be unimportant.  

The CAM is a validated tool that I understand has high specificity and sensitivity.

I once brought new symptoms of delirium a hospitalized friend was experiencing to the attention of their nurse.  The nurse's response was that this (delirium) is common in older people and that the staff see this a lot.  I was surprised when the nurse didn't assess the patient and inform the physician of the situation.  I concluded that a new onset of symptoms of delirium in an older person was not considered by staff to be especially important or worthy of expending time and resources in assessing and treating, which surprised me given the devastating consequences this problem can cause for the patient and their family members.  I stayed with the patient and continued to observe them and re-orient them as needed.  Fortunately, in this person's case, the symptoms were transitory and the patient was able to be discharged safely without any further problems.

I believe it is well worth taking the time to become familiar with the CAM tool and learning how to use it, and also learning about the presentation of delirium and the differences in presentation between delirium and dementia.

 

 

Edited by Susie2310

JBMmom, MSN, NP

Specializes in New NP Hospitalist, Critical care, Med-surg, LTC. Has 10 years experience. 4 Articles; 2,132 Posts

I think that delirium is one the hardest conditions I am dealing with as a night hospitalist. The older patients, especially those that have a condition that keeps them bed bound (either because they are truly non weight-bearing or staff doesn't have the time to get them up as frequently as anyone would like), are at such risk. Taking them out of their familiar home environment, away from their routine and familiar faces, does take such a toll. And then we are faced with how to effectively treat. Medications? Sitter? Restraints? Trying to maintain sleep wake cycle, encouraging family presence, ambulating as much as possible, there are so many things that could potentially help but once we're on the path it becomes so hard to treat. It's really sad to see people that decline rapidly due to hospitalization and ultimately die, maybe even not of what originally brought them to be hospitalized. Thank you for your article. 

Susie2310

Susie2310

2,073 Posts

16 minutes ago, JBMmom said:

I think that delirium is one the hardest conditions I am dealing with as a night hospitalist. The older patients, especially those that have a condition that keeps them bed bound (either because they are truly non weight-bearing or staff doesn't have the time to get them up as frequently as anyone would like), are at such risk. Taking them out of their familiar home environment, away from their routine and familiar faces, does take such a toll. And then we are faced with how to effectively treat. Medications? Sitter? Restraints? Trying to maintain sleep wake cycle, encouraging family presence, ambulating as much as possible, there are so many things that could potentially help but once we're on the path it becomes so hard to treat. It's really sad to see people that decline rapidly due to hospitalization and ultimately die, maybe even not of what originally brought them to be hospitalized. Thank you for your article. 

I think the family presence is a hugely important aspect of both preventing and recognizing early symptoms of delirium and of counteracting the symptoms where possible through re-orienting the patient, interacting with the patient, and providing as much of their normal routine as possible.  Unfortunately, Covid visitor restrictions have made family presence harder to achieve.

I believe it's very important for nurses to be aware of conditions/factors that can contribute to the onset of delirium as these are many and varied.

Edited by Susie2310

MunoRN, RN

Specializes in Critical Care. Has 10 years experience. 8,028 Posts

On 6/22/2022 at 4:34 PM, Susie2310 said:

Thank you for bringing our attention to this very important topic.  

I remember reading a study that showed delirium is under-recognized by nurses in the ER setting, due, if I recall correctly, to lack of knowledge of the symptoms, which without a proper assessment strategy can be difficult to discern as the presentation of delirium can be subtle and symptoms can be missed, deemed to be due to other causes, or deemed to be unimportant.  

The CAM is a validated tool that I understand has high specificity and sensitivity.

I once brought new symptoms of delirium a hospitalized friend was experiencing to the attention of their nurse.  Their response was that this (delirium) is common in older people and that the staff see this a lot.  I was surprised when the nurse didn't assess the patient and inform the physician of the situation.  I concluded that a new onset of symptoms of delirium was not considered by staff to be especially important or worthy of expending time and resources in assessing and treating, which surprised me given the devastating consequences this problem can cause for the patient and their family members.  I stayed with the patient and continued to observe them and re-orient them as needed.  Fortunately, in this person's case, the symptoms were transitory and the patient was able to be discharged safely without any further problems.

I believe it is well worth taking the time to become familiar with the CAM tool and learning how to use it, and also learning about the presentation of delirium and the differences in presentation between delirium and dementia.

The CAM assessments are a standard part of our assessments in the ICU, but they don't actually play any meaningful role in preventing or treating delirium.

The evidence-based interventions used to prevent delirium are the same as those used to treat delirium, so a positive CAM doesn't really affect clinical decision making.

Ideally, interventions to prevent delirium are applied to all hospitalized patients, but in cases where interventions need to be prioritized then a delirium-risk assessment is far more useful.  These do exist but they basically consist of: "is the patient in the hospital?" if yes then they are at risk for delirium.  And "is the patient critically ill?" if yes then they are at even higher risk for delirium.  

RNperdiem

RNperdiem, RN

Has 14 years experience. 4,520 Posts

What are the treatments available for delirium except leaving the hospital for a more familiar routine and activity?

I know prevention is the key, but in my windowless (small windows look out onto brick walls) ICU, where sleep is interrupted by Q2 hr turns, meds, assessments, require pain meds,  and patients are usually bed bound, what else can I do? I verbally orient my patients, use the least sedation needed, and hopefully transfer people out, but in our world, delirium is quite common.

JBMmom, MSN, NP

Specializes in New NP Hospitalist, Critical care, Med-surg, LTC. Has 10 years experience. 4 Articles; 2,132 Posts

1 hour ago, RNperdiem said:

but in our world, delirium is quite common.

In my ICU we face the same problem. I have coworkers that leave lights on 24/7, enter the room speaking loudly at all times of night, think nothing of leaving the full body bath until 3am, etc. I think that in some ways an ICU admission is always going to induce a certain amount of delirium, but we need to create a culture where everyone is aware of the small things that could make a difference, and do our best to encourage the least invasive care and routines. 

For those that are not in the ICU, elderly patients are at most risk. Young people might be grumpy and sleep deprived but not delirious. Elderly people need minimal interventions at night when possible. I think that lighting is one of the key aspects that people often overlook. Everyone wants to be able to look in the room and easily see their patient, but if bright lighting is on 24/7, they're not going to get restful sleep and that's a big problem. 

Kim Valentine, BSN, RN

Specializes in Community Health, Care Coordination and Geriatrics. Has 40 years experience. 2 Articles; 19 Posts

13 hours ago, RNperdiem said:

What are the treatments available for delirium except leaving the hospital for a more familiar routine and activity?

I know prevention is the key, but in my windowless (small windows look out onto brick walls) ICU, where sleep is interrupted by Q2 hr turns, meds, assessments, require pain meds,  and patients are usually bed bound, what else can I do? I verbally orient my patients, use the least sedation needed, and hopefully transfer people out, but in our world, delirium is quite common.

I think the first key is to identify if there is a reversible source, like an infection or electrolyte imbalance, etc. I see it more than I'd like to, that older adults in a delirium are deemed  as having "dementia"  and little is done for them except adding more sedation.  

Kim Valentine, BSN, RN

Specializes in Community Health, Care Coordination and Geriatrics. Has 40 years experience. 2 Articles; 19 Posts

13 hours ago, RNperdiem said:

What are the treatments available for delirium except leaving the hospital for a more familiar routine and activity?

I know prevention is the key, but in my windowless (small windows look out onto brick walls) ICU, where sleep is interrupted by Q2 hr turns, meds, assessments, require pain meds,  and patients are usually bed bound, what else can I do? I verbally orient my patients, use the least sedation needed, and hopefully transfer people out, but in our world, delirium is quite common.

The first set to treatment is identifying the cause such as an infection, pain, constipation or abnormal lab values.  Sometimes the solution is right in front of us.  I know in critical care it is a challenge to alter the environment.

In the hospital I'm at there are so many overflow in-patients in the ED.  There are elderly patients admitted with the diagnosis of "delirium" lying on a narrow stretcher in a busy ED.  Nothing "low stimulation" about that! 

Kim Valentine, BSN, RN

Specializes in Community Health, Care Coordination and Geriatrics. Has 40 years experience. 2 Articles; 19 Posts

On 6/22/2022 at 5:06 PM, MunoRN said:

The CAM assessments are a standard part of our assessments in the ICU, but they don't actually play any meaningful role in preventing or treating delirium.

The evidence-based interventions used to prevent delirium are the same as those used to treat delirium, so a positive CAM doesn't really affect clinical decision making.

Ideally, interventions to prevent delirium are applied to all hospitalized patients, but in cases where interventions need to be prioritized then a delirium-risk assessment is far more useful.  These do exist but they basically consist of: "is the patient in the hospital?" if yes then they are at risk for delirium.  And "is the patient critically ill?" if yes then they are at even higher risk for delirium.  

I think the CAM is useful to draw attention to the clinician that there is a delirium going on  and not just assuming the patient has dementia thereby delaying treatment.  But it is a screening tool and not diagnostic. 

Edited by Kim Valentine

Kim Valentine, BSN, RN

Specializes in Community Health, Care Coordination and Geriatrics. Has 40 years experience. 2 Articles; 19 Posts

12 hours ago, JBMmom said:

In my ICU we face the same problem. I have coworkers that leave lights on 24/7, enter the room speaking loudly at all times of night, think nothing of leaving the full body bath until 3am, etc. I think that in some ways an ICU admission is always going to induce a certain amount of delirium, but we need to create a culture where everyone is aware of the small things that could make a difference, and do our best to encourage the least invasive care and routines. 

For those that are not in the ICU, elderly patients are at most risk. Young people might be grumpy and sleep deprived but not delirious. Elderly people need minimal interventions at night when possible. I think that lighting is one of the key aspects that people often overlook. Everyone wants to be able to look in the room and easily see their patient, but if bright lighting is on 24/7, they're not going to get restful sleep and that's a big problem. 

Good point!  I also realize critical care areas are some of the most challenging environments. 

Kim Valentine, BSN, RN

Specializes in Community Health, Care Coordination and Geriatrics. Has 40 years experience. 2 Articles; 19 Posts

On 6/22/2022 at 4:34 PM, Susie2310 said:

Thank you for bringing our attention to this very important topic.  

I remember reading a study that showed delirium is under-recognized by nurses in the ER setting, due, if I recall correctly, to lack of knowledge of the symptoms, which without a proper assessment strategy can be difficult to discern as the presentation of delirium can be subtle and symptoms can be missed, deemed to be due to other causes, or deemed to be unimportant.  

The CAM is a validated tool that I understand has high specificity and sensitivity.

I once brought new symptoms of delirium a hospitalized friend was experiencing to the attention of their nurse.  The nurse's response was that this (delirium) is common in older people and that the staff see this a lot.  I was surprised when the nurse didn't assess the patient and inform the physician of the situation.  I concluded that a new onset of symptoms of delirium in an older person was not considered by staff to be especially important or worthy of expending time and resources in assessing and treating, which surprised me given the devastating consequences this problem can cause for the patient and their family members.  I stayed with the patient and continued to observe them and re-orient them as needed.  Fortunately, in this person's case, the symptoms were transitory and the patient was able to be discharged safely without any further problems.

I believe it is well worth taking the time to become familiar with the CAM tool and learning how to use it, and also learning about the presentation of delirium and the differences in presentation between delirium and dementia.

Thank you for your comment. That must have been such a challenging situation for you to be in! I also wonder sometimes if "ageism" plays a role?

I agree validated screening tools such as the CAM are so important to be familiar with and utilize in everyday practice.