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186
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able to:
1. describe hospitalized older adults at risk for delirium
2. list four outcomes associated with delirium
3. discuss the importance of early recognition of delirium
4. develop a plan to prevent or treat delirium
OVERVIEW
Delirium is a common syndrome in hospitalized older adults and is one of the major
contributors to poor outcomes of health care and institutionalization for older patients
(Siddiqi, House, & Holmes, 2006). Delirium has been shown to be preventable by
identifying modi�able risk factors and using a standardized nursing practice proto-
col (Milisen, Lemiengre, Braes, & Foreman, 2005) and involving a geriatric special-
ist (Siddiqi, Stockdale, Britton, & Holmes, 2007). If delirium does develop, early
recognition is of paramount importance in order to treat the underlying pathology
and minimize delirium’s sequelae. Nurses play a key role in both the prevention and
early recognition of this potentially devastating condition in older hospitalized adults
(Milisen et al., 2005).
BACKGROUND AND STATEMENT OF PROBLEM
Definition
Delirium is a disturbance of consciousness with impaired attention and disorganized
thinking that develops rapidly and with evidence of an underlying physiologic or medi-
cal condition (American Psychiatric Association [APA], 2000). Delirium is character-
ized by a reduced ability to focus, sustain, or shift attention; memory impairment;
Dorothy F. Tullmann, Kathleen Fletcher, and
Marquis D. Foreman
Delirium
11
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
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Delirium 187
disorientation and/or illusions; visual or other hallucinations; or misperceptions of stim-
uli. Delusional thinking may also occur. Unlike other chronic cognitive impairments,
delirium develops over a short time and tends to �uctuate during the course of the day.
A patient may present with either hyperactive, hypoactive, or mixed motoric subtypes
of delirium (Meagher, 2009). Nurses typically associate delirium with hyperactivity and
distressing, time-consuming, and harmful patient behaviors. However, the hypoactive
subtype, with its lack of overt psychomotor activity, is also common (Meagher, 2009;
Pandharipande, Cotton, et al., 2007) and has a higher risk of mortality, especially when
superimposed on dementia (Yang et al., 2009).
Etiology and Epidemiology
Prevalence and Incidence
Among medical inpatients, delirium is present on admission to the hospital in 10%–31%
of older patients, and during hospitalization, 11% to 42% of older adults develop
delirium (Siddiqi et al., 2006). Among hip surgery patients, the incidence of delirium
is 4%–53%. �ose with hip fractures and cognitive impairment have the highest risk
of delirium. (Bruce, Ritchie, Blizard, Lai, & Raven, 2007). Older adults admitted to
medical intensive care units (ICUs) have both prevalent and incident delirium of 31%
(McNicoll et al., 2003). In surgical (S) ICUs, the prevalence of delirium on admis-
sion is only 2.6%, but 28.3% develop delirium during their SICU stay (Balas et al.,
2007). Up to 83% of mechanically ventilated patients in ICUs experience delirium (Ely,
Inouye, et al., 2001), and more than half of older patients in medical ICUs still have
delirium when transferred (Pisani, Murphy, Araujo, & Van Ness, 2010). �e incidence
of delirium superimposed on dementia ranges from 22% to 89% (Fick, Agostini, &
Inouye, 2002). Delirium may persist for months after discharge (Cole, Ciampi, Belzile,
& Zhong, 2009).
Pathophysiology
�e pathogenesis of delirium is not well understood, but increasing evidence supports
cholinergic de�ciency and/or dopamine excess as well as cytokine activity as causes of
delirium (Inouye, 2006). A genetic association between delirium and the apolipopro-
tein E epsilon 4 allele has also been identi�ed (van Munster, Korevaar, Zwinderman,
Lee�ang, & de Rooji, 2009).
Risk Factors
�e strongest predisposing risk factors for delirium are age (70 years and older), sever-
ity of illness, and cognitive impairment (Michaud et al., 2007). Other factors include
depression, sensory impairment, �uid and electrolyte disturbances, and polyphar-
macy (especially psychotropics). Precipitating factors for delirium occurring during
hospitalization include central nervous system pathology (such as stroke), metabolic,
electrolyte and/or endocrine disturbances, and infection and drug toxicity or with-
drawal. Pain, hypoperfusion/hypoxia, number of drugs (especially psychotropic and
anticholinergic), and restraints have also been implicated. Finally, environmental fac-
tors such as ICU admission, multiple room changes, and an absence of a clock or
glasses may also contribute to the development of delirium (Michaud et al., 2007). In
older patients admitted for hip surgery, early cognitive impairment, such as memory
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188 Evidence-Based Geriatric Nursing Protocols for Best Practice
impairments, incoherence, disorientation, as well as an underlying physical illness
and age, are especially strong predictors of delirium (de Jonghe et al., 2007; Kalisvaart
et al., 2006).
Outcomes
�e outcomes of delirium are grave, especially in hospitalized older patients whose delir-
ium persists postdischarge. �ose with persistent delirium at 1, 3, and 6 months post-
discharge consistently have increased mortality, nursing home placement, and decreased
functional status and cognition than older adults who do not experience delirium (Cole,
McCusker, Ciampi, & Belzile, 2008; Witlox et al., 2010).
Delirium also results in signi�cant distress for the patient, their family members,
and nurses (Bruera et al., 2009; Cohen, Pace, Kaur, & Bruera, 2009). Clearly, delirium
is a high-priority nursing challenge for all who care for hospitalized older adults.
ASSESSMENT OF THE PROBLEM
�e �rst critically important step in the assessment of delirium is identifying the risk
factors for delirium (see discussed “Risk Factors”) because eliminating or reducing these
risk factors may prevent delirium in many cases (Milisen et al., 2005). Recognizing the
features of delirium is important in order to further identify, eliminate, or reduce the
precipitating factor(s) such as pain, infection, or other acute illnesses. �is can best be
done by routinely assessing patients at risk for delirium with a standardized screening
tool for delirium (see “Resources” section), although this is currently occurring only in
17% of hospitals (Neuman, Speck, Karlawish, Schwartz, & Shea, 2010).
�e Confusion Assessment Method (CAM) has high sensitivity and speci�city in
ICU, Emergency Department, acute and long-term care settings for detecting delir-
ium (Wei, Fearing, Sternberg, & Inouye, 2008), and is the most widely used delirium
screening instrument in hospitalized older adults. A version of the CAM for patients in
intensive care units (CAM-ICU; Ely, Margolin, et al., 2001) is recommended for use
with critically ill older adults (Jacobi et al., 2002; Schuurmans, Deschamps, Markham,
Shortridge-Baggett, & Duursma, 2003). �e CAM instrument identi�es the key fea-
tures of delirium—acute onset, inattention, disorganized thinking, altered level of con-
sciousness, disorientation, memory impairment, perceptual disturbances, psychomotor
agitation or retardation, and altered sleep–wake cycles (Inouye et al., 1990). For a diag-
nosis of delirium, there must be the presence of Feature 1 (acute onset or �uctuat-
ing course), Feature 2 (inattention), and either Feature 3 (disorganized thinking) or
Feature 4 (altered level of consciousness).
It is important to remember that delirium may occur concurrently with dementia
or depression. From 22% to 89% of older adults with dementia also have delirium
superimposed on the dementia (Fick et al., 2002). As noted, patients with dementia are
at increased risk for developing delirium and have worse outcomes when they do (Yang
et al., 2009). Family and caregivers can be invaluable in helping to distinguish cogni-
tive changes in those circumstances when the patient is not well known (see Chapter 8,
Assessing Cognitive Function).
Bedside nurses are in the best position to recognize delirium because they possess
the skill and responsibility of ongoing patient assessment and are in key positions to
recognize risk factors for delirium and the earliest cognitive changes heralding the onset
of delirium. Early identi�cation of risk factors for and the earliest onset of delirium are
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Delirium 189
critical to implement strategies to minimize the occurrence of this devastating pathology
in hospitalized older adults.
INTERVENTIONS AND CARE STRATEGIES
According to the most recent Cochrane Review (Siddiqi et al., 2007), there is no strong
evidence from delirium prevention studies to guide clinical practice. Only one of six
randomized controlled trials (RCT) e�ectively prevented delirium with proactive geri-
atric consultation for older adults undergoing surgery for hip fracture (Marcantonio
et al., 2001). Prophylactically administered low-dose haloperidol reduced the severity
and duration of delirium but not its incidence (Kalisvaart et al., 2005). However, given
the prevalence and seriousness of delirium, its complex and varied etiology, and the
challenges associated with conduction RCTs, we strongly recommend the use of clinical
practice guidelines based on other strong intervention studies for both prevention and
treatment of delirium.
Once it has been determined that the patient is at risk for delirium, a standardized
delirium protocol should be initiated immediately. Protocols tested in two multicom-
ponent interventions e�ectively prevented delirium (Inouye et al., 1999; Marcantonio
et al., 2001). �e protocols varied somewhat, but two principles emerged from the
research: Minimize the risk for delirium by preventing or eliminating the etiologic agent
or agents and provide a therapeutic environment and general supportive nursing care
(see Section V, Nursing Care Strategies, in Protocol 11.1). Older adults on a specialized
geriatric unit receiving interprofessionally and protocol-guided care by a sta� that had
received specialized geriatric care education also developed signi�cantly less delirium
(Lundstrom et al., 2007).
Patients who developed delirium after hip surgery, when treated with a mul-
ticomponent intervention program had fewer days of delirium, complications,
total days of hospitalization (Lundstrom et al., 2007), and improved health-related
quality of life without incurring increased costs (Pitkala et al., 2008). Although
multicomponent delirium-reduction interventions have yet to be tested in critical
care settings, sedation interruption and early occupational and physical therapy in
patients who are mechanically ventilated resulted in shorter duration of delirium
(Schweickert et al., 2009).
Although nonpharmacologic interventions are preferred and should be used �rst
(Michaud et al., 2007), antipsychotics (such as haloperidol) are used and are found to be
e�cacious in certain populations with agitated delirium (Breitbart et al., 1996; Devlin
et al., 2010). Light propofol sedation my reduce severity and duration of delirium in hip
surgery patients (Sieber et al., 2010).
Dexmedetomidine (dex; a g-aminobutyric acid receptor agonist), a promising alter-
native for sedation, resulted in decreased delirium when compared with other commonly
used sedation in ICU settings. When used for postoperative sedation after cardiac sur-
gery, dex has been associated with lower rates of delirium and costs when compared with
propofol and midazolam (Maldonado et al., 2009) and shorter duration of delirium
when compared to morphine (Shehabi et al., 2009). In patients who are mechanically
ventilated, dex is more e�cacious than lorazepam in number of days at the targeted
level of sedation and more days alive without coma or delirium (Pandharipande, Pun,
et al., 2007). When compared to midazolam in patients who are mechanically venti-
lated, patients treated with dex have less delirium (Riker et al., 2009).
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190 Evidence-Based Geriatric Nursing Protocols for Best Practice
Alternative forms of pain management may also help reduce delirium. Hip fracture
patients at low risk for delirium who received a prophylactic fascia iliac block developed
signi�cantly less delirium than those receiving traditional pain management regimens
(Mouzopoulos et al., 2009).
Mr. Z is an 82-year-old patient admitted to your unit for prostate surgery. He is a retired
accountant, lives with his wife, and is very active. He drives a car, plays golf, and regu-
larly participates in activities at the senior center. His Type II diabetes is well controlled
on Actoplus Met (pioglitazone hydrochloride and metformin hydrochloride). Mr. Z
reports that he has decreased his �uid intake so he can avoid waking several times dur-
ing the night to urinate. He also has a history of hypertension, moderate hearing loss
(hearing aids bilaterally), and previous surgery for inguinal hernia repair. He wears bifo-
cal glasses for distance and reading. He is alert, oriented, and expresses a good under-
standing of his upcoming surgery. His preoperative laboratory values are within normal
limits except for a low hematocrit and a blood urea nitrogen/creatinine (BUN/Cr) ratio
slightly elevated. His medications include Actoplus Met (pioglitazone hydrochloride and
metformin hydrochloride) for his diabetes and Calan (verapamil) for hypertension.
What Factors Present on Admission to the Hospital Put Mr. Z at Risk for Developing Delirium?
N Age. Older adults are at greater risk for delirium, particularly if they have
underlying dementia or depression. Physiologic changes that occur with aging
can a�ect the ability of older adults to respond to physical and physiologic
stress and to maintain homeostasis.
N Dehydration. An elevated BUN/Cr ratio indicates dehydration (from decreased
�uid intake), a frequent contributing factor (along with electrolyte imbalance)
to delirium of hospitalized older adults.
N Anemia. Because of a low hematocrit, the body has diminished ability to
deliver adequate oxygen to the brain, making delirium more likely.
N Sensory de�cits. �ose with vision and hearing loss are more likely to misinter-
pret sensory input, which places them at increased risk for delirium.
It is important to understand that it might not be one particular factor but the
interplay of patient vulnerability (predisposing factors) and precipitating factors—
common during hospitalization—which place the older adult at risk for delirium.
What Can You Do to Help Prevent Delirium in Mr. Z?
N If possible, consult with a geriatric specialist (geriatrician or geriatric nurse
practitioner) for a thorough geriatric assessment of Mr. Z.
N Make sure his glasses and hearing aids are on and functioning.
N Explore reasons for the low hematocrit.
CASE STUDY
(continued)
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Delirium 191
You provide care for Mr. Z again 2 days after surgery. He is confused and picking at the
air and oriented to self only. An indwelling urinary catheter and peripheral intravenous line
are in place. In his report, the day-shift nurse mentioned considering a physical restraint
because Mr. Z was increasingly restless and was CAM positive, indicating he has delirium.
What Are the Clinical Features of Delirium?
N Disturbance of consciousness characterized by reduced clarity and awareness of
the environment: reduced ability to focus, sustain, and shift attention. Patients
have trouble following instructions or making sense of their environment, even
with cues. �ey may also get “stuck” on a particular concern or thought.
N Cognitive changes: memory de�cit, disorientation, language disturbance, and/
or perceptual disturbance.
N Perceptual disturbances: Hallucinations and delusions are common. Patients
can be hyperactive and agitated or lethargic (hypoactive) and less active. �e
latter presentation is of particular concern because it is often not recognized
by health care providers as delirium. �e presentation may also be mixed, with
the patient �uctuating from one to the other behavioral state.
N Delirium can be characterized by disturbances in the sleep–wake cycle and rap-
idly shifting emotional disturbances, with escalation of the disturbed behavior
at night (sundowning).
N �e cardinal sign of delirium is that the cited changes occur rapidly over several
hours or days.
It is also important to consider that delirium may occur concurrently with demen-
tia or depression. In fact, these patients are at increased risk for developing delirium.
Family and caregivers can be invaluable in helping to identify or distinguish cognitive
changes in circumstances when the patient is not well known to you.
What Additional Factors May Now Be Contributing to Mr. Z’s Delirium?
N Anesthesia and other medications. It takes several hours for the body to clear the
e�ects of anesthesia. Inasmuch as older adults have a larger percentage of body fat
than younger persons do, and many drugs are fat-soluble, drug e�ects will last lon-
ger. Also, older adults tend to have less cellular water; hence, water- soluble drugs
will be more concentrated and have a more pronounced e�ect. Nurses need to ask
the patient or family if any new drugs other than pain medication have been added.
What is the dose and frequency of the pain medications? Is the dose appropriate?
N Pain. What is Mr. Z’s pain control regimen and status? Poor pain control con-
tributes to restlessness and is associated with delirium. Is the current drug the
best for good pain relief in this patient?
N Hypoxemia. Mr. Z is at risk because of limited mobility and possible atelectasis
after surgery. What is his oxygen saturation (SpO
2
)? Does he have crackles or
diminished breath sounds?
(continued)
CASE STUDY (continued)
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192 Evidence-Based Geriatric Nursing Protocols for Best Practice
N Infection, in�ammation, or other medical illness. Postoperative infections, intra-
operative myocardial infarctions (MIs), or strokes are possible causes of delir-
ium in this case. Could Mr. Z have a urinary tract infection (UTI) since his
postprostate surgery and particularly since he has a Foley catheter? An in�am-
matory response to a new medical problem may be the cause of the delirium.
N Unfamiliar surroundings. Particularly for those with sensory de�cits, unfamil-
iar environments can lead to misinterpretations of information, which may
contribute to delirium.
What Steps Should Be Taken Now?
N Avoid the use of restraints, which could worsen Mr. Z’s agitation.
N Call the physician or nurse practitioner immediately and report your �ndings;
request that the patient be evaluated to determine the underlying cause of the
delirium. If Mr. Z’s delirium worsens, he may also need medication (e.g., low
dose haloperidol) to control his symptoms.
N Frequent reality orientation. Frequent orientation, reassurance, and helping
Mr. Z interpret his environment and what is happening to him should be
helpful. (Monitor the patient’s reaction. If the patient becomes upset or angry,
you will need to modify your approach to that of more reassurance and vali-
dating the patient’s experience rather than reorienting).
N Are Mr. Z’s hearing aids and glasses in place, and clean and functioning? Impaired
sensory input contributes signi�cantly to delirium. Also, he may seem more
confused than he really is if he is not able to hear what you are saying.
N Invite family/signi�cant others to stay as much as they are able to assist with his
orientation, reassurance, and sense of well-being. Monitor the e�ect of family
visitation. If the patient has increased agitation or anxiety, then limit the visita-
tion of the individual who seems to be triggering Mr. Z’s upset.
N Mobilize the patient. Mobility assists with orientation and helps prevent problems
associated with immobility, such as atelectasis and deep venous thrombosis.
N Judicious use of medications for pain, sleep, or anxiety. Drugs used to address
these issues can exacerbate the delirium. Try nonpharmacologic approaches for
sleep and anxiety �rst. If Mr. Z is having pain, are the drug and dose appropri-
ate for him? A regular schedule of a smaller dose or non-narcotic pain medica-
tion almost always is better than prn dosing.
N Try to provide for adequate sleep: noise reduction at night; soft, relaxing
music; warm milk; herbal tea; massage; and rescheduling care in order not
to interrupt sleep.
N Make sure the patient is well hydrated.
N Talk to the doctor or NP about removing the indwelling urinary catheter. Because
of his surgery, Mr. Z may need it immediately post-op, but it should be removed
as soon as possible. Additionally, recommend a urinalysis to rule out UTI.
N Address safety concerns (e.g., increase surveillance). Mr. Z is now also at risk for
falls and/or pressure ulcers.
CASE STUDY (continued)
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Delirium 193
Protocol 11.1: Delirium
I. GOAL: To reduce the incidence of delirium in hospitalized older adults.
II. OVERVIEW:
A. Delirium is a common syndrome in hospitalized older adults and is associated
with increased mortality, hospital costs, and long-term cognitive and functional
impairment (Siddiqi et al., 2006).
B. Delirium can sometimes be prevented with the recognition of high-risk patients,
implementation of a standardized delirium-reduction protocol, and proactive
geriatric consultation (Bruera et al., 2009).
C. Recognition of risk factors and routine screening for delirium should be part of
comprehensive nursing care of older adults (Milisen et al., 2005).
III. BACKGROUND AND STATEMENT OF PROBLEM:
A. De�nition: Delirium is a disturbance of consciousness with impaired attention
and disorganized thinking or perceptual disturbance that develops acutely, has
a �uctuating course, and with evidence that there is an underlying physiologic
or medical condition causing the disorder (APA, 2000).
B. Etiology and Epidemiology
1. Prevalence and incidence: Medical inpatients, prevalence is 10% to 31%; inci-
dence is 3% to 29% (Siddiqi et al., 2006). Hip surgery patients, incidence of
delirium is 4% to 53% with hip fractures and cognitive causing higher risk of
delirium (Bruce et al., 2007). Medical ICUs, prevalence and incidence both
31% (McNicoll et al., 2003). Surgical ICUs, prevalence 2.6%, incidence 28.3%
(Balas et al., 2007). Mechanically ventilated patients in ICU, up to 83% during
ICU stay (Ely et al., 2001), more than 50% of medical ICU patients still have
delirium when transferred (Pisani et al., 2010). Incidence of delirium superim-
posed on dementia, 22% to 89% (Fick et al., 2002).
2. Pathophysiology: Unclear, may be cholinergic de�ciency, dopamine excess, or
cytokine activity (Inouye, 2006). A genetic association with apolipoprotein E
epsilon 4 allele identi�ed (van Munster et al., 2009).
NURSING STANDARD OF PRACTICE
(continued)
SUMMARY
Delirium is a common occurrence in hospitalized older adults and contributes to poor
outcomes. �us, it is important to promptly identify those patients at risk for delir-
ium and implement preventive measures as well as promptly recognize delirium when
it appears. Nursing assessments using validated delirium screening instruments must
become routine. A standard of practice protocol provides concise information to guide
nursing care of individuals at risk for or experiencing delirium.
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194 Evidence-Based Geriatric Nursing Protocols for Best Practice
3. Risk factors: Predisposing, age (70 years and older), severity of illness and cog-
nitive impairment; also depression, sensory impairment, �uid and electrolyte
disturbances and polypharmacy (especially psychotropics). Precipitating, cen-
tral nervous system pathology (such as stroke), metabolic, electrolyte and/or
endocrine disturbances, infection and drug toxicity or withdrawal; also pain,
hypoperfusion/hypoxia, number of drugs, (especially psychotropic and anti-
cholinergic) and restraints. Environmental factors, ICU admission, multiple
room changes, and an absence of a clock or glasses (Michaud et al., 2007).
4. Outcomes: Increased mortality, nursing home placement, and decreased
functional status and cognition (Cole et al., 2008; Witlox et al., 2010).
Distress for the patient, their family members, and nurses (Cohen et al.,
2009; Bruera et al., 2009).
IV. PARAMETERS OF ASSESSMENT
A. Assess for risk factors (Michaud et al., 2007)
1. Baseline or pre-morbid cognitive impairment (see Chapter 8, Assessing
Cognitive Function)
2. Medications review (see Chapter 17, Reducing Adverse Drug Events)
3. Pain (see Chapter 14, Pain Management)
4. Metabolic disturbances (hypoglycemia, hypercalcemia, hyponatremia,
hypokalemia)
5. Hypoperfusion/hypoxemia (BP, capillary re�ll, SpO2)
6. Dehydration (physical signs/symptoms, intake/output, Na1, BUN/Cr)
7. Infection (fever, WBCs with di�erential, cultures)
8. Environment (sensory overload or deprivation, restraints)
9. Impaired mobility
10. Sensory impairment (vision, hearing)
B. Features of delirium (APA, 2000; Inouye et al., 1990)—assess every shift (see
“Resources” for validated instruments)
1. Acute onset; evidence of underlying medical condition
2. Alertness: Fluctuates from stuporous to hypervigilant
3. Attention: Inattentive, easily distractible, and may have di�culty shifting
attention from one focus to another; has di�culty keeping track of what
is being said
4. Orientation: Disoriented to time and place; should not be disoriented to
person
5. Memory: Inability to recall events of hospitalization and current illness;
unable to remember instructions; forgetful of names, events, activities,
current news, and so forth
6. �inking: Disorganized thinking; rambling, irrelevant, incoherent con-
versation; unclear or illogical �ow of ideas; or unpredictable switching
from topic to topic; di�culty in expressing needs and concerns; speech
may be garbled
7. Perception: Perceptual disturbances such as illusions and visual or audi-
tory hallucinations; and misperceptions such as calling a stranger by a
relative’s name.
Protocol 11.1: Delirium (cont.)
(continued)
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Delirium 195
8. Psychomotor activity: May �uctuate between hypoactive, hyperactive,
and mixed subtypes
V. NURSING CARE STRATEGIES (based on protocols in multicomponent delirium
prevention studies [Inouye et al., 1999; Lundstrom et al., 2007; Marcantonio, Flacker,
Wright, & Resnick, 2001])
A. Obtain geriatric consultation.
B. Eliminate or minimize risk factors.
1. Administer medications judiciously; avoid high-risk medications (see Chap-
ter 17, Reducing Adverse Drug Events).
2. Prevent/promptly and appropriately treat infections.
3. Prevent/promptly treat dehydration and electrolyte disturbances.
4. Provide adequate pain control (see Chapter 14, Pain Management).
5. Maximize oxygen delivery (supplemental oxygen, blood, and BP support as
needed).
6. Use sensory aids as appropriate.
7. Regulate bowel/bladder function.
8. Provide adequate nutrition (see Chapter 22, Nutrition).
C. Provide a therapeutic environment.
1. Foster orientation: frequently reassure and reorient patient (unless patient
becomes agitated); use easily visible calendars, clocks, caregiver identi�cation;
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; relax-
ation music/tapes; noise reduction measures; avoid awaking patient.
4. Foster familiarity: encourage family/friends to stay at bedside; bring familiar
objects from home; maintain consistency of caregivers; minimize relocations.
5. Maximize mobility: avoid restraints (see Chapter 13, Physical Restraints
and Side Rails in Acute and Critical Care Settings) and urinary catheters;
ambulate or active ROM three times daily.
6. Communicate clearly, provide explanations.
7. Reassure and educate family (see Chapter 24, Family Caregiving).
8. Minimize invasive interventions.
9. Consider psychotropic medication as a last resort for agitation.
VI. EVALUATION/EXPECTED OUTCOMES
A. Patient
1. Absence of delirium or
2. Cognitive status returned to baseline (prior to delirium)
3. Functional status returned to baseline (prior to delirium)
4. Discharged to same destination as prehospitalization
B. Health care provider
1. Regular use of delirium screening tool
2. Increased detection of delirium
3. Implementation of appropriate interventions to prevent/treat delirium
from standardized protocol
Protocol 11.1: Delirium (cont.)
(continued)
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196 Evidence-Based Geriatric Nursing Protocols for Best Practice
RESOURCES
Recommended Delirium Screening Instruments
Confusion Assessment Method (CAM; Inouye et al., 1990; Wei et al., 2008)
Confusion Assessment Method for the Intensive Care Unit (CAM-ICU; Ely et al., 2001).
Other Delirium Screening Instruments
Delirium-O-Meter (de Jonghe, Kalisvaart, Timmers, Kat, & Jackson, 2005)
May be used for monitoring the di�erent characteristics and the severity of delirium in geriatric
patients.
Delirium Rating Scale (DRS)-98 (Trzepacz et al., 2001)
May be used to assess delirium severity.
Mini-Mental State Examination (MMSE; Folstein, Folstein, & McHugh, 1975; O’Kee�e, Mulkerrin,
Nayeem, Varughese, & Pillay, 2005)
May be used to monitor course of delirium in hospitalized patients.
Additional Information About Delirium
Consult GeriRN
An online resources containing information regarding assessing and caring for older adults sponsored
by the Hartford Institute for Geriatric Nursing at New York University College of Nursing.
http://consultgerirn.org/resources
4. Decreased use of physical restraints
5. Decreased use of antipsychotic medications
6. Increased satisfaction in care of hospitalized older adults
C. Institution
1. Sta� education and interprofessional care planning
2. Implementation of standardized delirium screening protocol
3. Decreased overall cost
4. Decreased length of stays
5. Decreased morbidity and mortality
6. Increased referrals and consultation to above-speci�ed specialists
7. Improved satisfaction of patients, families, and nursing sta�
VII. FOLLOW-UP MONITORING OF CONDITION
A. Decreased delirium to become a measure of quality care
B. Incidence of delirium to decrease
C. Patient days with delirium to decrease
D. Sta� competence in recognition and treatment of acute confusion/delirium
E. Documentation of a variety of interventions for acute confusion/delirium
Na
1
5 sodium; BUN/Cr 5 blood urea nitrogen/creatinine ratio; BP 5 blood pressure; Hgb/Hct 5
hemoglobin and hematocrit; SpO
2
5 pulse oxygen saturation; WBCs 5 white blood cells;
URI 5 upper respiratory infection; UTI 5 urinary tract infection; ROM 5 range of motion
Protocol 11.1: Delirium (cont.)
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Delirium 197
ICU Delirium and Cognitive Impairment Study Group
http://www.icudelirium.org/delirium/
Hospital Elderlife Program
http://elderlife.med.yale.edu/public/pubs.php?pageid=01.03.07
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