Transitioning to Adult-Gerontology

APRN Education: Slide Library

APRN Assessment and Management of

Older Adults with Delirium

Authors: Lois Evans, PhD, RN, FAANPamela Z. Cacchione, PhD, APRN, GNP, BCUniversity of Pennsylvania School of Nursing

Adult-Gerontology APRN Slide Library

• The APRN Slide Library is a resource of

“Transitioning to Adult-Gerontology APRN

Education” a project of AACN and the Hartford

Institute for Geriatric Nursing 2010-2012

• The project is funded by the John A. Hartford

Foundation

Adult-Gerontology APRN Slide Library"All materials are jointly copyrighted by the American Association of Colleges of Nursing (AACN) and The Hartford Institute for Geriatric Nursing, College of Nursing, New York University or are used with permission from the original source. Permission is hereby granted to reproduce, post, download, and/or distribute, this material for not-for-profit educational purposes only, provided that the American Association of Colleges of Nursing (AACN) and The Hartford Institute for Geriatric Nursing, College of Nursing, New York University are cited as the source. They may not be used for ANY commercial or other purpose."

Available at www.hartfordign.org

E-mail notification of usage to: hartford.ign@nyu.edu

Further information about the APRN program can be found at

www.aacn.nche.edu/APRN Gerontology.htm

Purpose of the APRN Slide Library - Delirium

• To provide APRN faculty with an overview of delirium

in older adults*

• To introduce APRN faculty to print and web

resources on assessment, diagnosis & management

of delirium

• To provide APRN faculty with slides on delirium to

use in lectures & to share with APRN students

* These slides have been modified by faculty from the Geropsychiatric

Nursing Collaborative from slides prepared for the Geriatric Nursing

Education Consortium (GNEC) program (www.aacn.nche.edu).

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Endorsement and Support

The content for these slides is endorsed by:

National Gerontological Nursing Association (NGNA): http://www.ngna.org

American Academy of Nursing GeropsychiatricNursing Collaborative: http://www.aannet.org/i4a/pages/index.cfm?pageid=3833

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Web-resources

http: //www.ConsultGeriRN.org Try This ® and How to Try This General Assessment Series, e.g.

� Confusion Assessment Method (CAM)

� Beers Criteria for Potentially Inappropriate Medication Use in the Elderly

� Mental Status Assessement of Older Adults: the MiniCog

� The Geriatric Depression Scale (GDS)

http: //www.ConsultGeriRN.org Try This ® and How to Try This Dementia Assessment Series, e.g.

� Assessing and Managing Delirium in Persons wih Dementia

� Recognition of Dementia in Hospitalized Older Adults

Web-Resources

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Web-resources

� http: //www.ConsultGeriRN.org select Evidence-based Geriatric Topics, e.g. protocols on: � Delirium� Atypical Presentation of Illness� Depression� Sleep

� American Medical Directors Association (AMDA Clinical Practice Guidelines for long-term care: http://www.amda.com/; select Altered Mental Status

� www.elderlife.med.yale.edu/public/doclinks.php?pageid=01.02.03� www.medscape.com/viewarticle/503089_6� www.joannabriggs.edu.au/events/2009NAC/docs/Day

Web-Resources

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Source Books: GeriatricsAuerhahn, C., Capezuti, E., Flaherty, E., & Resnick, B. (eds.) (2007). Geriatric Nursing

Review Syllabus: A Core Curriculum in Advanced Practice Geriatric Nursing, 2nd Edition: New York: American Geriatrics Society. (3rd Edition, May, 2011)

• A concise & comprehensive text developed by the American Geriatrics Society (AGS) & the NYU Hartford Institute for Geriatric Nursing , adapted for APRNs from the AGS Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, 6th Edition

• Authored by > 100 interdisciplinary experts in care of older adults

• 59 chapters on prevailing management strategies, extensive reference, appendix with assessment instruments, 100 case-oriented, multiple choice questions and a self-assessment tool. (www.americangeriatrics.org/.../the_geriatric_nursing_review_syllabus_2nd_edition/

Auerhahn, C. & Kennedy-Malone, L. (2010). Integrating Gerontological Content into Advanced Practice Nursing Education. New York: Springer Publishing Co.

• Clear, user-friendly guidelines for integrating gerontological content into non-gerontological APRN programs

• Detailed lists of print resources and e-Learning materials

• Utilizes a competency-based framework

• “Success stories” written by APRN faculty who have integrated gerontological content into non-gerontological courses

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Delirium: Definition

A transient and nonspecific organic mental syndrome characterized by:

� Acute onset (hours to days), tending to fluctuate over the 24 hour period

� Reduced ability to focus, sustain or shift attention

� Disturbed level of consciousness, such as reduced clarity of awareness

� Change in cognition such as memory loss, disorientation and/or language disturbance

� Perceptual disturbance not better accounted for by a pre-existing, established or evolving dementia

10

Delirium: Incidence in Hospitalized

Older Adults

11%

Delirium occurrences in

hospitalized

patients

Older Patients > SusceptibilityRange 11-42%: Medical

and <50%: Surgical

50%

All patients High risk cases

11

Delirium: Incidence, Prevalence,

Outcomes

� Highly prevalent (11-24%) on ACH admission, with incident

delirium < 56% in hospitalized older adults

� Incidence is < 87% for OA in ICU

� Incidence is 60% for older adults in post acute care and

nursing homes

� Potentially life threatening, with 22-76% mortality rates

among older adults in ACH

� Typically evident within 48 hours of hospital admission

� Course is variable, depending on pre-existing condition

and cause(s ) of delirium

12

Delirium: Background

� Diagnosis of delirium is highly clinical and dependent upon clinician's level of expertise, systematic screening & careful clinical observations

� Progression to stupor and/or coma, seizures, and death is possible.

� Delirium is a cardinal sign of a geropsychiatric emergency and must be promptly identified and addressed with biopsychosocial and environmental interventions.

� Early recognition of delirium followed by rapid management of underlying medical and environmental factors decreases the severity and can lead to improved outcomes.

13

Delirium Outcomes

Higher levels of pre-morbid function = better outcomes

Increased risk for longer hospital LOS & post acute or NH placement

Loss of function, falls and other complications

Frequent misdiagnosis = high morbidity and mortality

Unwarranted use of physical and chemical restraints

Cost assessed at $6.9 billion a year

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Predisposing Factors for Delirium

� Advanced old age

� Brain injury, including Dementia

� Severe illness or surgery

� Anesthesia

� Hypoxia

� Medications/ poly-pharmacy (4+ medications per day)

� Co-morbid Illness

� Depression

� Sensory impairment

� Electrolyte imbalance and dehydration

� Infection

� Pain

� Previous episodes of delirium

� Alcohol Abuse

PZC1

Slide 14

PZC1 Voyer, P. Richard, S., Doucet, L., Cyr, N., Carmichael, P-H. (2010) Examination of the multifactorial model of delirium among Long-term care residensw with dementia. Geriatric Nursing, 31; 105-114.Inouye and Charpentier (1996) they already haveInouye, S. ( 2006). delirium in older persons. The New England Journal of Medicine, 354; 1157-1165.Pamela Z. Cacchione, 2/5/2011

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Delirium: Medication-Related

Precipitating Factors� Anticholinergics

� Opiates

� Benzodiazepines

� Corticosteriods

� Alcohol withdrawal

� Sedative-hypnotic drug withdrawal

� Any newly prescribed medication

� Over the counter (OTC) “home remedies,” especially those with

anticholinergic effects (NSAIDS, nasal sprays, cold and flu meds)

� Addition of 3 newly prescribed medications

PZC2PZC3

Slide 15

PZC2 Irving, K., Fick, D. & Foreman, M. (2006). Delirium: A new appraisal of an old problem. International Journal of Older People Nursing, 1 (106-112).Pamela Z. Cacchione, 2/5/2011

PZC3 Tune, L., Mulsane, B. & Gharabawi, G. (2003). Anticholinergic effec of atypical antipsychotics in elderly people. European Neuropsychopharmacology, 12,; 315-316.Pamela Z. Cacchione, 2/5/2011

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Delirium: Inouye and Charpentier

Risk ModelRelies on the interaction of the following 2 factors:

� Predisposing host baseline factors, e.g.,

� Vision impairment

� Severe illness

� Pre-existing cognitive impairment

� Dehydration

�Treatment-related precipitating factors, e.g.,

� Physical restraints

� Malnutrition

� Bladder catheter

� > Three medications

� Any iatrogenic event

PZC4

Slide 16

PZC4 Michaund, L., Bula, C., Berney, A., Camus, V., Voellinger, R., Stiefel, F., Burnand, B. et al., (2007). Delirium: guidelines for general hospitals. Journal of Psychosomatic Research, 62; 371-383.

Fick, D., Kolanowski, A., Beattie, E., McCrow, J. (2009), Delirium in Early-Stage ALzheimer's Disease. Journal of Gerontological Nursing. 35(3); 30-38.Pamela Z. Cacchione, 2/5/2011

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� Early identification & modification of predisposing factors

� Early recognition & treatment of cognitive impairment

� Rapid identification & treatment of acute illness

� Assessment & appropriate management of pain

� Maintenance of normal sleep-wake cycle

� Avoidance of deliriogenic medications & polypharmacy

� Assurance of adequate hydration & nutrition

Prevention of Delirium in Older

Adults

Prevention of Delirium in Older

Adults cont’d• Enhancement of sensory status by use of sensory aids

& appropriate levels of light

& sound

• Enhancement of cognitive

reserve

• Provision for family presence

• Avoidance of urinary catheterization

• Avoidance of physical

restraint use

• Assessment & management

of drug and alcohol

withdrawal

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Delirium: Clinical Presentation

Clinical subtype

MixedHypoactiveHyperactive

� Increased psychomotor

activity, such as rapid speech,

irritability, and

restlessness

� Lethargy

� Slowed speech

� Decreased

alertness

� Apathy

� Shift between hyperactive and

hypoactive states

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Delirium: History

� When did the change in mental status begin?

� Does the condition change over a 24-hour period?

� Is there a change in the person’s sleep patterns?

� What specific thought problems have been noticed?

� Is there a history of mental illness or similar thought disturbance?

� Has there been a sudden decline in physical function or a new onset of falls?

� Query family or collateral source from prior setting as to ‘what is normal’ for this patient.

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Delirium: Change in Mental Status

� An abnormal mental status exam that is a change from baseline for

the person is the hallmark of delirium

� Abnormalities may include inattention, fluctuations in level of

consciousness, new short term memory impairment, altered speech

patterns, disorganized speech and (possibly) delusions or

hallucinations

� Mental status screening tests are helpful in identifying cognitive

deficits and should be performed routinely in older patients: on

admission and at least daily during stay

CA3

Slide 21

CA3 This picture has nothing to do with the text on this slide - there must be another you can use?Carolyn Auerhahn, 12/31/2010

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Delirium Screening Instruments

� Instruments specific for detecting delirium based on

observation of behavior rather than formal testing:

� Confusion Assessment Method (CAM) diagnostic

algorithm

� NEECHAM Confusion Scale CA4

Slide 22

CA4 same comment as the previous slideCarolyn Auerhahn, 12/31/2010

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The CAM Diagnostic Algorithm

� Can be accurately administered by individuals without formal psychiatric training

� Based on the Diagnostic and Statistical Manual of Mental Disorders-TR criteria for delirium

� Captures cardinal elements of delirium & incorporates specific observations relevant to each

� Patients are identified as positive for delirium using the CAM if 3 out of 4 features are present: acute onset and fluctuating course* and inattention* with either disorganized thinking or altered level of consciousness

� *denotes required features

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The NEECHAM Confusion Scale

� Uses a structured database derived during routine nursing

assessments and interactions with patients

� Is sensitive to both the hyperactive and hypoactive forms of delirium

� Evaluates nine components of information processing, performance,

and vital function

� Can be repeated at frequent intervals to monitor change in mental

status over time

� Minimal response burden on the patient

� No learning effect from repetition of items

� Can detect delirium in its early stage

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Range of scores is 0-30

0-19: Moderate to Severe

20-24: Mild or Early Dev

25-26 None but High Risk

>26 No Delirium

NEECHAM Confusion Scale

The NEECHAM Confusion Scale

Rating Scales for Delirium

�Delirium Rating Scale

�Memorial Delirium Assessment Scale

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Delirium Assessment:

Vigilance A Test

� Helps to confirm suspected delirium

� After instructing the patient to raise his or her

hand only when the letter “A” is heard, the

examiner then begins saying letters from the

alphabet randomly.

� Delirious patients have inconsistent

responses.

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Delirium Assessment:

Direct Observation � Routine and periodic observation of the older

adult’s level of:

� Alertness (alert, hyper-alert or hypo-alert)

� General behavior

� Mood & affect

� Speech disturbance/verbalizations

� Motor behavior

29

General Cognitive Function:

Assessment Instruments

� MiniCog

� Mini-Mental Status Examination (MMSE) *

� MoCA

� Saint Louis University Mental Status

Examination (SLUMS)

� Short Portable Mental Status

Questionnaire� *copyrighted

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Delirium: Physical Exam

Examine for signs of: � Hypoxia� Volume depletion/overload� Cardiovascular injury� Metabolic encephalopathy � Alcohol withdrawal� Hypo- or hyperthermia� New onset incontinence� Urinary retention or fecal impaction

Check

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Delirium: Diagnostic Tests

Choice based on history and physical findings

Baseline laboratory studies:

� Urinalysis

� Basic or Comprehensive Metabolic Panel

� Blood work: CBC, Thyroid function test

Further diagnostic testing (based on exam):

� Head CT

� EKG

� Chest X-Ray

32

Delirium: Diagnostic Tests cont'd

� When difficult to differentiate delirium

from acute psychotic

state

� Electroencephalography

The electroencephalogram reveals:

Diffuse slowing in most cases of delirium

Fast activity in cases of delirium related to drug withdrawal

Normal patterns in patients with acute functional psychosis

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Delirium: Environmental

Predisposing Factors

� Transfers within the hospital or unit

� Absence of a clock or watch

� Absence of reading glasses, hearing aid

� Absence of family members

� Use of physical restraints

34

Differentiating Delirium from Dementia &

Depression

� Chronic cognitive impairment seen in dementia typically:

� Occurs gradually over time

� Persists greater than one month

� Is irreversible

� Most older adults with dementia are alert and able to maintain attention in the early stages of dementia

� Depression may also present acutely with deficits in ability to sustain attention.

� Depression may present similar to hypo- or hyper-active delirium; therefore, it is important to screen for depression in older adults who present with a mixed picture.

35

Delirium: Differential Diagnosis

� With recent change in cognition, an older person

should be presumed delirious until proven otherwise

� Sudden cognitive and/or functional deterioration in a

patient with dementia suggests delirium

superimposed on dementia

� Apathy, slowed speech and mood disturbance may

be indicative of hypoactive delirium rather than

depression

36

Delirium: Differential Diagnosis� Functional psychosis

� Acute functional psychosis can resemble delirium

� Onset at an earlier age

� Most older patients with functional psychosis have a history

of psychiatric illness

� Hallucinations tend to be auditory

� Delusions are more elaborate than those associated with

delirium

� Dementia with Lewy Bodies includes fluctuating cognition and

visual hallucinations

� Consultation with a psychiatrist or a neurologist may be

necessary in difficult cases

37

Delirium: General Management

� Multi-component interventions are most effective

� Prompt recognition & treatment of underlying cause

� Creation of a maximum supportive environment

� Immediate medical treatment as necessary

� Discontinuation or reduced doses of medications thought to be deliriogenic

� Use of environmental interventions such as a delirium room

Ensure

38

Delirium: General Management-

Nutrition & Hydration

� Accurate 24 hour I & O

� Avoidance of depletion-dehydration syndrome

� Enteral tube feeding or hyperalimentation as

necessary

� Address any excess output issues such as

polyuria or diarrhea

Ensure

39

Delirium: General Management

� Pulmonary care to ensure adequate oxygenation, avoid atelectasis and pneumonia

� Bowel and bladder protocols to prevent or treat constipation, diarrhea, and urinary incontinence

� Vigilence for fall risk and patient safety

� Use cognitive stimulation

� Avoid complications of immobility

� Minimize skin breakdown

40

Delirium: Managing the Environment

� Presence of family members

� Inclusion of familiar items from home

� Use of glasses & hearing aids

� Avoidance of physical restraints

� Delirium room for high risk patients

� Night-light and minimization of noise

� Interrupt sleep only when absolutely

necessary

41

Delirium: Maximizing Cognition

� Re-orientating strategies � Inclusion of orienting facts in

normal conversation� Discussion of current events� Discussion of specific interests� Structured reminiscence� Word games� Cognitive stimulation

42

Delirium: Medication Management

Use medications when:

� behaviors associated with psychotic thinking and perceptual

disturbances (e.g., hallucinations) pose a safety risk or are

distressing to the individual.

� delirium interferes with needed medical therapies and

behavioral interventions fail

Do Not use medications as a substitute for detection, correction, or elimination of underlying causes of delirium

Use low doses of medications over the shortest possible time

period

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Delirium: Medication Management

� First line therapy: Low doses high-potency neuroleptics (e.g. ,haloperidol)

� Associated with extrapyramidal symptoms (EPS)

� Newer antipsychotics (e.g., olanzapine and risperidon) have a lower incidence of EPS and may be better tolerated in older patients

� Neuroleptic Malignant Syndrome, a more serious side effect of antipsychotic therapy, can occur with high-potency as well as with novel anti-psychotics

� Benzodiazepines (e.g., lorazepam) are recommended with alcohol withdrawal or withdrawal from benzodiazepines.

� In non-alcohol withdrawal, benzodiazepines potentially worsen delirium and should be used with caution

44

Delirium Management: Aftercare

� Help the patient and family understand the bizarre and bewildering experience

� Psychiatric care to facilitate resolution through:

� Sensitive retrospective exploration of the experience

� Increasing patient’s understanding and acceptance

� Encouraging patients to report risk of delirium for subsequent hospitalizations

� Comprehensive discharge planning

� Home care referral

� Physical and occupational therapy

� Psychiatric nursing home care services

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Delirium: Conclusion

� Historically seen as: A benign and expected condition related to hospitalization

� Currently seen as: A serious health problem with significant negative consequences

� APRNs are frontline in early identification of patients most at risk for delirium and early detection of symptoms

� Routine and systematic assessment for confusion is key