Delirium

INTRODUCTION:
• Cognition includes a number of specific
functions, such as the acquisition and use of
language, the ability to be oriented in time
and space, and the ability to learn and solve
problems.
• It includes judgment, reasoning, attention,
comprehension, concept formation, planning,
and the use of symbols, such as numbers and
letters used in mathematics and writing.

• Memory, a facet of cognition, refers
to the ability to recall or reproduce
what has been learned or
experienced. It is more than simple
storage and retrieval; it is a complex
cognitive mental function.

Definition:
“Delirium is an acute organic mental
disorder characterized by impairment
of consciousness disorientation and
disturbances in perception and
restlessness”.

“Delirium is a disturbance in
consciousness and a change in
cognition that develops over a
short time”.

Incidence:
Delirium has the highest incidence among
organic mental disorders. About 10 to 25%
of medical-surgical inpatients, and about
20 to 40% of geriatric patients meet the
criteria for delirium during hospitalization.
• Although delirium may occur in any age
group, it is most common among the
elderly

• Estimated prevalence rates
range from 10% to 30% of
patients
• 60% of those older than the
age of 75 years.

Etiology:
• Vascular: Hypertensive
encephalopathy, intracranial
hemorrage.
• Infections: Encephalitis, meningitis
• Neoplastic: Space occupying lesions
• Intoxication: chronic intoxication or
withdrawal effect of sedative hypnotic
drugs.

• Traumatic: Subdural and epidural
hematoma, contusion, laceration,
postoperative, heatstroke.
• Vitamin deficiency: For example,
thiamine
• Endocrine and metabolic: Diabetic coma
and shock, uremia, myxedema,
hyperthyroidism, hepatic failure

• Metals: Heavy metals (lead,
manganese, mercury), carbon
monoxide and toxins
• Anoxia: Anemia, pulmonary or
cardiac failure

Clinical features &
findings:
• Impairment of consciousness: clouding
of consciousness ranging from
drowsiness to stupor and coma.
• Impairment of attention: difficulty in
shifting, focusing and sustaining
attention.
• Perceptual disturbances: illusions and
hallucinations, most often visual.

Disturbance of cognition: impairment of
abstract thinking and Comprehension,
impairement of recent and immediate
memory, increased reaction time.
Psychomotor disturbances: hypo or hyper-
activity, aimless groping or picking at the
bed clothes (flocculation), enhanced startle
reaction.

• Disturbance of sleep wake cycle:
insomnia or in severe cases total
sleep loss, daytime
drowsiness,disturbing dreams or
nightmares.
• Emotional disturbances: depression,
anxiety, fear, irritability, euphoria,
apathy.

Diagnostic criteria:
• History collection: any history of head injury,
meningitis etc.
• Mental status examination
• Neurological examination
• Haematological investigation
• Blood “Rh” type (blood grouping)
• Blood glucose
• ESR
• CBC
• Urine examination

• Tests for memory: i.e immediate, recent
and remote
• Radiological examination
• X-ray skull
• CT scan of skull
• MRI of skull
• Electroencephalography
• Brain biopsy

Risk factors:
• Advanced age
• Pre-existing dementia
• Functional dependence
• Pre-existing illness
• Bone fracture
• Infection
• Medications (both number and type)

• Changes in vital signs (including
hypotension and hyper- or
hypothermia)
• Electrolyte or metabolic imbalance
• Admission to a long-term care
institution
• Post cardiotomy
• AIDS

Treatment:
 Identification of cause and its
immediate correction, for, example,
50 mg of 50% dextrose IV for
hypoglycemia, O2 hypoxia, 100mg of
B1 iv for thiamine deficiency, IV fluids
for fluid and electrolyte imbalance.

Symptomatic measures:
benzodiazepines (10mg
diazepam or 2 mg lorazepam IV)
or antipsychotics (5 mg
haloperidol or 50 mg mg
chlorpromazine IM) may be
given.

Management:
Psychiatric management:
• Admit the patient in psychiatric
hospital
• Identify the course by taking
psychiatric history, general history &
mental status examination
• Do the investigation

Nursing management/interventions:
• Hospitalization:
• Admit The Patient In Psychiatric Ward
• Give Comfortable Bed To The Patient.
• If patient is agitated then use of
physical restraint may be necessary
• Check the vital signs.

Therapeutic need:
• Give the drugs prescribed by the
psychiatrist regularly
• Keep the 6 rights in mind
• When we give oral medicine to the
patient see that whether patient
swallows the medicine or not.
• Observe for any side effects.
• Record the dose frequency in nurse
record

 Provide safe environment:
Restrict the 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 illusions and
delusions, special precautions are needed to
protect him from himself and to protect
others.

 Alleviating patient’s fear and
anxiety:
• Remove any object in the room that
seems to be a source of misinterpreted
perception.
• As much as possible have the same
person all the time by the patien’s
bedside.
• Keep the room well lighted especially at
the night time.

 Meeting the physical needs of the
patient’s:
• Appropriate care should be provided after
physical assessment.
• Use of appropriate nursing measures to
reduce high fever, if present
• Maintain intake and output chart.
• Mouth and skin should be taken care of
• Monitor vital signs.
• Observe patient for any extreme drowsiness
and sleep as this may be an indication that the
patient is slipping into a coma

 Facilitate orientation:
• Repeatedly explain to the patient
where he is and what date, day
and time it is
• Introduce people with name even
is the patient misidentifies the
people.

• Have a calendar in the room and
tell him what day it is.
• When the acute stage is over take
the patient out and introduce him to
others.

NURSING MANAGEMENT:
Biologic Assessment
• To assess the symptoms, the nurse needs to
know what is normal for the individual.
• Caregivers, family members, or significant
others should be interviewed because they
can often provide valuable information. Family
members may be the only resource for
accurate information.

Current and Past Health Status
• History should include a
description of the onset,
duration, range, and intensity of
associated symptoms

Physical Examination and
Review of Systems
If the patient is cooperative, a physical
examination will be conducted in the
emergency room. Vital signs are
crucial. A review of systems must be
conducted in each patient suspected
of having delirium or other organic
mental disorders.

Physical Functions
Functional assessment includes
physical functional status (activities of
daily living), use of sensory aids (eye
glasses and hearing aids), usual activity
level and any recent changes, and pain
assessment.

Interventions for the
Biologic Domain
Important interventions for a patient
experiencing acute confusional state include
providing a safe and therapeutic environment,
maintaining fluid and electrolyte balance and
adequate nutrition, and preventing aspiration
and decubitus ulcers, which are often
complications

 Safety Interventions
• Behaviours exhibited by the delirious
patient, such as hallucinations, delusions,
illusions, aggression, or agitation
(restlessness or excitability), may pose
safety problems.
• The patient must be protected from
physical harm by using low beds,
guardrails, and careful supervision

Psychological Domain
Assessment
• Mental status examination

 Interventions for the Psychological
Domain
• Staff should have frequent interaction with
patients and support them if they are
confused or hallucinating.
• Patients should be encouraged to express
their fears and discomforts that result from
frightening or disconcerting psychotic
experiences.

 Interventions for the Social Domain
The environment needs to be safe to protect the
patient from injury. A predictable, orienting
environment will help to re-establish order to
the patient’s life. That is, a calendar, clocks, and
other items may be provided to help orient the
patient to time, place, and person

 Support from Families
Families can be encouraged to work with staff to
reorient the patient and provide a supportive
environment

 EVALUATION AND TREATMENT
OUTCOMES
• Correction of the underlying physiologic
alteration
• Resolution of confusion family member
verbalization of understanding of confusion
• Prevention of injury.

 CONCLUSION
• Delirium often persists beyond discharge from
the hospital. Discharge planning should
routinely include family education and
referrals to community health care providers.
If the patient will return to a residential long-
term care setting, communication with facility
staff about the patient’s hospital stay and
treatment regimen is crucial.

SUMMARY
• Introduction
• Definition
• Etiology
• Clinical features
• Diagnostic features
• Risk factors
• Treatment
• Management (psychiatric and other)
• Nursing management

Bibliography:
• R Sreevani, a guide to mental health and psychiatric
nursing,
jaypee publishers,
3rd edition, pg.no: 310-311
• Ahuja Niraj, Vyas JN, A Text of Postgraduate Psychiatry,
Jaypee Publications,
2nd Edition. Pg.no: 712-789
• Townsend c Mary, text book on “Psychiatric Mental
Health Nursing.”
Jaypee publications.
5th edition, page 387-405

Delirium

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Delirium