delirium case study nursing

• Open access
• Published: 19 November 2022

Nurses’ competence in recognition and management of delirium in older patients: development and piloting of a self-assessment tool

• Jonas Hoch 1 , 2 ,
• Jürgen M. Bauer 1 , 3 ,
• Martin Bizer 4 ,
• Christine Arnold 2 &
• Petra Benzinger 1 , 5  

BMC Geriatrics volume  22 , Article number:  879 ( 2022 ) Cite this article

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Delirium is a common condition in elderly inpatients. Health care professionals play a crucial role in recognizing delirium, initiating preventive measures and implementing a multicomponent treatment strategy. Yet, delirium often goes unrecognized in clinical routine. Nurses take an important role in preventing and managing delirium. This study assesses clinical reasoning of nurses using case vignettes to explore their competences in recognizing, preventing and managing delirium.

The study was conducted as an online survey. The questionnaire was based on five case vignettes presenting cases of acutely ill older patients with different subtypes of delirium or diseases with overlapping symptoms. In a first step, case vignettes were developed and validated through a multidisciplinary expert panel. Scoring of response options were summed up to a Geriatric Delirium Competence Questionnaire (GDCQ) score including recognition and management tasks The questionnaire was made available online. Descriptive analyses and group comparisons explores differences between nurses from different settings. Factors explaining variance in participants’ score were evaluated using correlations and linear regression models.

The questionnaire demonstrated good content validity and high reliability (kappa = 0.79). The final sample consisted of 115 nurses. Five hundred seventy-five case vignettes with an accuracy of 0.71 for the correct recognition of delirium presence or absence were solved. Nurses recognized delirium best in cases describing hyperactive delirium (79%) while hypoactive delirium was recognized least (44%). Nurses from geriatric and internal medicine departments had significantly higher GDCQ-score than the other subgroups. Management tasks were correctly identified by most participants.

Conclusions

Overall, nurses’ competence regarding hypoactive delirium should be strengthened. The online questionnaire might facilitate targeting training opportunities to nurses’ competence.

Peer Review reports

Delirium is a neuropsychiatric syndrome characterized by acute disturbance of attention, consciousness, cognitive function or perception with a fluctuating course [ 1 , 2 ]. Symptoms might present as hypoactive, hyperactive, or mixed motoric subtypes. Delirium occurs across all healthcare settings but is most common in acutely hospitalized patients. Older age is a strong predisposing factor in hospitalized patients resulting in a higher chance to suffer a delirium [ 3 ]. At the same time, multiple risk factors might trigger delirium onset like acute illness, trauma, surgery, and medications. The prevalence of delirium is variable across various departments and might be as high as > 20% in intensive care units and in emergency departments [ 1 , 4 ].

Although symptoms resolve within days in most patients, cognitive deficits might persist for months. Delirium is associated with adverse outcomes such as functional decline, institutionalization, dementia, and mortality [ 5 , 6 , 7 , 8 ]. Often, delirium is distressing for patients as well as their caregivers [ 9 ]. While treated in hospital, patients with delirium need more attention from nursing staff which leads to a higher workload [ 10 , 11 ]. Furthermore, patients suffering from delirium have a longer length of stay resulting in higher costs per case [ 7 , 12 ].

Delirium is a clinical bedside diagnosis based on recognition of its characteristic features by healthcare professionals [ 13 ]. There is sufficient evidence that a multicomponent nonpharmacological approach can effectively prevent the onset of delirium and reduce symptom duration [ 14 , 15 ]. For successful implementation and maintaining of a multi-dimensional diagnostic and therapeutic approach, interprofessional collaboration of physicians, nurses, therapists, as well as family members and trained volunteers is imperative [ 16 ]. Nurses play a key role in prevention and detection of delirium [ 17 ]. They spend more time in direct contact with patients than any other healthcare profession. Their attitudes and knowledge are critical to delirium recognition and management [ 18 ]. In Germany, there is currently only a limited focus on delirium in the national nursing education curriculum. However, gaps in nurses’ knowledge and understanding of delirium have already been demonstrated elsewhere [ 19 , 20 ]. In a response to this knowledge gap, an interdisciplinary statement of scientific societies specifically addressed the need for better training of healthcare professionals, and nurses in particular [ 16 ].

To make an impact on care, training of nurses should increase their clinical competences and clinical reasoning skills [ 21 ]. Clinical reasoning describes the process health care professionals go through in their daily routine to successfully solve simple to complex patient encounters. Clinical reasoning consists of clinical judgement and clinical decision making. While clinical judgment involves the process of recognizing what is wrong with the patient, clinical decision making includes adoption of preventive measures and the management of clinical problems [ 22 ]. Single choice questionnaires often do not sufficiently represent this complex process of clinical reasoning. To this end, case vignettes are established for training of medical students and physicians since they are more suitable to assess clinical judgement and decision making. Up to now, case vignettes are less frequently used for training of nursing students and nurses [ 23 ]. In the context of delirium, surveys conducted in Canada and the United States used case vignettes to assess nurses’ recognition of delirium [ 24 , 25 , 26 , 27 , 28 ]. So far, very few surveys focused on using case vignettes to assess the whole clinical reasoning process by nurses including recognition as well as management of delirium in this detail.

The aim of this study was to develop and to pilot a self-assessment instrument for nurses to evaluate their clinical reasoning skills in recognition and management of delirium in geriatric patients using case vignettes.

Study design and study population

The online version of the questionnaire was developed using LimeSurvey (Version 3.22.1 + 200,129, hosted by Heidelberg University). After ethical approval, participants were recruited between August 2021 and October 2021 through personal communication, professional organizations, and providers of continuing training. Respondents could access the survey via a link or a QR code. Due to the anonymous design, the survey was open to other health care professionals. Inclusion criteria were (1) a nursing degree and (2) current employment at a hospital, in post-acute or long-term facilities. Respondents not meeting the inclusion criteria were excluded from further analyses.

Development of case vignettes and questionnaire

The questionnaire was designed in order to assess delirium competence using five case vignettes describing scenarios in a general hospital characterizing patients suffering from different subtypes of delirium (hypoactive, hyperactive, and hyperactive superimposed on dementia) or diseases with overlapping symptoms (dementia, depression). Two authors (JH, MB) developed the case vignettes through an iterative process based on previously published vignette studies [ 24 , 26 , 29 ], review of literature and clinical relevance as judged by the authors. Careful consideration was given to the content of the vignettes so that they closely related to real clinical scenarios and included information that would facilitate delirium recognition. All vignettes presenting delirious patients described clinical signs as covered by the Confusion Assessment Method (CAM), a well-established instrument for detection of delirium [ 30 ]. Clinical signs were defined as acute onset, fluctuating course in mental status, and inattention with additional symptoms of disorganized thinking or altered levels of consciousness. A shortened example of a case vignette is presented in Fig.  1 , all case vignettes are provided as Supplementary Material .

Abridged example of the case vignette with hyperactive delirium (short version)

All case vignettes included questions about recognition of delirium including delirium subtypes, prevention and further management tasks. The questions were primarily based on selected response formats and included true/false, single-choice, short menu formats and multiple response questions [ 31 ]. The vignettes were reviewed by a geriatrician (PB).

For content validity, the questionnaire was reviewed by two psychiatrists, one physician and two nurses with a master’s degree. All had experience in clinical research, geriatrics, and delirium.

Feasibility and comprehension were tested by three nurses with a low level of self-reported experience in delirium management. They needed 25 to 35 minutes for completion of the questionnaire. Consequently, the questionnaire was shortened to reduce administration time.

To measure reliability of agreement, the survey was completed by five nurses with a master’s degree. Fleiss’ kappa was used for statistical analyses. They demonstrated 100% inter-rater agreement with the correct identification of delirium presence or absence for each case and an overall kappa of 0.79. Results between 0.61 and 0.80 can be considered as substantial agreement, results between 0.81 and 1.0 as almost perfect [ 32 ]. No further adaptation of the case vignettes was warranted.

Nurses who participated in the review process were excluded from the pilot study.

Measurement scales and independent variables

For further statistical analysis, questions of the case vignettes were aggregated to constitute a Geriatric Delirium Competence Questionnaire (GDCQ-score) with a score ranging from zero to 55. The score consisted of questions related to clinical judgement as well as clinical decision making (see Supplementary Material ).

After completion of the case vignettes, participants were grouped by their current work environment (‘geriatric and internal medicine departments’, ‘other acute hospital departments’, and ‘post-acute and long-term care facilities’). The subgroup ‘other acute hospital departments’ consisted of nurses working on any inpatient ward including intensive care units (ICU) and psychiatric wards.). Furthermore, they were asked about their previous delirium training (accumulated hours in total, training within the previous 12 months), work experience with delirious patients and satisfaction with delirium management at their current work place using a Likert-scale (1–5, higher = more frequent / higher satisfaction). Participants were asked to self-assess their knowledge on delirium before starting and after completion of the case vignettes using a Likert-scale (1–5, higher = more knowledge). The independent variable, frequent treatment of delirious patients in daily routine, was dichotomized (very often, often = 1, less = 0).

Statistical analysis

Statistical analyses were performed using the R Foundation for Statistical Computing 4.1.0. Descriptive variables were described by means and standard deviation, median and interquartile range, or percent. Differences between subgroups were tested by using the non-parametric Kruskal-Wallis-Test, which is distributed as a chi-square. Group comparisons of dichotomous variables and the GDCQ-score were performed using two-sided Welch T-test [ 33 ]. Five-point Likert-scales were treated as continuous variables in correlation analyses and further regression models [ 34 , 35 ]. Pearson’s correlation was used to test for correlations between GDCQ-score and independent variables. Univariate linear regression analyses were performed with GDCQ-score as dependent variable. Level of significance was set at p  < 0.05 (two-tailed) for all analyses.

Sample characteristics

Between August and October 2021, the survey was started 248 times of which 51% times respondents ( n  = 126) completed the questionnaire. Mean completion time of the survey was 22.2 minutes (SD 9.6 minutes). Case vignettes presented in this questionnaire were rated as ‘very good’ or ‘good’ by 88% of participants. Respondents who identified themselves as nurses were included for further analyses ( n  = 115). The average work experience of participants was 19.6 years. Fifty-two participants worked in geriatric or internal medicine departments, and 33% of participating nurses had a specialist nursing qualification in geriatric medicine. Of nurses working in geriatric and internal medicine departments, 61% reported frequent treatment of delirious patients in their departments while nurses working in other departments or facilities reported frequent treatment of delirious patients significantly less often (‘other acute care’ departments 40%, ‘post-acute and long-term care facilities’ 8%). Nearly every other nurse working in geriatric and internal medicine department reported participation in delirium training within the previous 12 months (Table  1 ).

Recognition of delirium

Overall, participants completed 575 case vignettes with an accuracy of 0.71 for the correct recognition of delirium presence or absence. The correct subtype of delirium was recognized by 48% of participating nurses. Nurses working in geriatric and internal medicine departments identified hyperactive delirium significantly better than nurses from post-acute and long-term care facilities ( p  < 0.01). There were no statistically significant differences between subgroups for the recognition of delirium in all other case vignettes (Table  2 ).

For recognition of delirium, most participants used clinical signs (81%) and information provided by relatives (71%). Respondents reported to use validated assessment tools including Delirium Observation Screening (DOS) (55%), Nursing Delirium Screening Scale (NuDesc) (47%), and Confusion Assessment Method (CAM) (44%). Use of no validated method to detect delirium was reported by 11% of participants.

Management tasks

Overall, most participants were able to differentiate whether suggested measures were appropriate. Nurses working in geriatric and internal medicine departments scored higher than the other subgroups and scored significantly higher than participants from non-acute care settings in all four items although differences reached statistical significance for recognition of risk factors and initiation of preventive measures only (Table  3 ).

GDCQ-score, correlations, and linear regression models

The mean score of the sample was 42.62 (SD = 4.86) out of a maximum of 55 points. Subgroups analyses demonstrated that nurses working in geriatric and internal medicine departments scored a mean of 44.34 (SD = 4.01). Participants from other acute hospital departments scored an average of 42.17 (SD = 4.98) and participants from post-acute and long-term facilities scored a mean of 37.77 (SD = 3.81). Difference between subgroups was significant ( p  < 0.01). Further post-hoc analyses by the Wilcoxon rank sum test with continuity correction by Holm showed a significant difference between all three subgroups ( p  < 0.05).

There were significant correlations with small effect sizes between GDCQ-score and some independent variables. While overall work experience shown no significant correlation, frequent care of delirious patients in daily routine and the subjective self-assessment after survey did (Table  4 ).

This pilot study describes the development and piloting of a questionnaire to self-assess competence in recognition and management of delirium in older patients by nurses. Case vignettes offer the opportunity to assess nurses’ clinical skills by reflecting realistic scenarios. Our results demonstrate feasibility of the questionnaire in a German setting and allow insights into delirium competence of nurses in Germany. To our knowledge, this study is the first to assess the abilities of nurses to recognize and manage delirium using case vignettes.

Overall, delirium was detected by most nurses participating in the pilot study. In our sample, nurses were better in recognizing the absence of signs of delirium than the presence of such signs. This finding is in line with previous studies [ 26 , 36 , 37 ]. In a study with home care nurses, 93% of participants recognized the absence of signs of delirium in a case vignette describing depression [ 26 ]. Other studies using case vignettes describing dementia without delirium reported correct recognition of absence of delirium by 68 and 83% of participating nurses [ 24 , 26 ]. Where there is uncertainty on the nature of cognitive alterations, dementia might appear to be a more obvious choice to many nurses as compared to delirium.

In the present study, presence of delirium was best recognized in a case vignette describing hyperactive delirium. Higher detection rates for hyperactive delirium as compared to other subtypes are in line with previous findings [ 24 , 26 ]. Yet, hypoactive delirium is more common than hyperactive delirium in inpatient settings [ 38 , 39 ]. It is associated with higher mortality and worse outcome as compared to other types of delirium [ 40 ]. One reason for poor clinical outcome of patients with hypoactive delirium might be the lower detection rates in clinical routine. During a busy shift, delirium might remain unrecognized in patients not seeking attention from nursing staff [ 41 ]. Delirium superimposed on dementia also seems to be challenging to evaluate for the participants of our study. This seems to reflect current clinical practice [ 42 ]. Low detection rates of hypoactive delirium and delirium superimposed on dementia in case vignettes, as seen in our study and previous studies, point towards gaps in nurses’ knowledge of delirium and suggest better training of health care professionals on delirium [ 16 ].

Among participants of the pilot study, nurses from post-acute and long-term facilities tended to recognize delirium less often than nurses from other settings and achieved the lowest overall GDCQ-score. These findings may in part be attributed to the content of the case vignettes. The situations described do not reflect scenarios of post-acute or long-term care settings and experiences of staff with delirious persons in these settings might be distinct from what was presented in the case vignettes. Yet, rates of correct diagnosis of delirium in this study is comparable to a larger study involving more than 500 staff members of various long-term care facilities in the United States [ 25 ]. In light of the substantial prevalence of delirium among nursing home residents, future research and efforts on delirium management should include nurses in non-acute health care settings [ 43 , 44 , 45 ].

Development of case vignettes should follow a robust methodology [ 29 ]. Professionals with different backgrounds were involved and pre-testing demonstrated high agreement of scoring between experts. Construct validity of the case vignettes developed was supported by univariate regression analyses. Frequent exposure to delirious patients and participation in delirium training were positively associated with higher scores indicating higher competence, while years of work experience did not explain variance of the overall score. These findings are supported by the findings of a study enrolling community health care nurses [ 46 ]. It is plausible that daily routine care for such patients and training have a strong impact on nurses’ delirium competence.

This study is the first in Germany using clinical case vignettes to assess nurses’ competence rather than knowledge of delirium [ 47 ]. So far, case vignettes focusing on delirium have been used to assess nurses’ ability to recognize delirium in various nursing settings [ 25 , 26 , 27 , 29 ]. In this study, based on previous case vignettes, we developed with the help of a multi-professional team a novel questionnaire for nurses that assesses not only recognition but also management of delirium. Unlike previous studies, case vignettes in this questionnaire combined multiple-choice, multiple-response questions as well as short menu lists in order to reduce cueing. It is well suited to the German health care setting and represents situation encounters well known to nurses.

Limitations

There are several limitations that need to be considered. First, case vignettes are developed to reflect realistic scenarios but in cases of delirium one has to acknowledge that signs of delirium often fluctuate over the course of the day, making detection of delirium even more challenging. For methodological reasons, it remains unclear how well scores obtained in the newly developed questionnaire reflect clinical reasoning in practice. Second, case vignettes developed in this questionnaire were describing older patients admitted to non-intensive care wards. They do not cover delirious patients on intensive care units, nor do they describe older patients cared for in post-acute or long-term care facilities. While there was a sufficient number of nurses from geriatric and general medical wards, the limited number of participants from other acute care departments did not allow for further exploration. A larger sample is needed to draw more generalizable conclusions. Third, we recruited a convenience sample for piloting the questionnaire. It is very likely that nurses with a particular interest in the topic visited the online site of the questionnaire. Only about half of the respondents visiting the website completed the questionnaire suggesting further selection. Due to data protection issues, we could only collect data of those completing the questionnaire and submitting the data. Therefore, we can only speculate on reasons for non-completion. Furthermore, a high proportion of participants had further qualifications or reported recent training in delirium. Hence, the results from our survey may overestimate delirium competence of nurses in Germany.

The newly developed questionnaire was feasible and well-appreciated by respondents. The results of this study suggest that the overall recognition of delirium by nurses should be improved. The questionnaire could augment existing training activities in the future. Although not addressed, our results implicated a particular need for nurses in long-term care facilities to strengthen their delirium competence. This should be addressed in further research with an appropriate sample size. The authors would welcome use of case vignettes and access to the online questionnaire by German instructors.

Availability of data and materials

The questionnaire was translated into English and can be seen in the supplementary data. The datasets used and/or analyzed during the current study are available from the corresponding author upon request.

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Acknowledgements

The authors would like to thank all persons taking part in the development and review process, helping to distribute the questionnaire, or taking part as participant. For the publication fee we acknowledge financial support by Deutsche Forschungsgemeinschaft within the funding programme „Open Access Publikationskosten“ as well as by Heidelberg University.

Open Access funding enabled and organized by Projekt DEAL. This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

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Jonas Hoch, Jürgen M. Bauer & Petra Benzinger

Department of General Practice and Health Services Research, Heidelberg University Hospital, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany

Jonas Hoch & Christine Arnold

Network Aging Research (NAR), Heidelberg University, Bergheimer Strasse 20, 69115, Heidelberg, Germany

Jürgen M. Bauer

Department of Internal Medicine, Heidelberg University Hospital, Im Neuenheimer Feld 672, 69120, Heidelberg, Germany

Martin Bizer

Institute of Health and Generations, University of Applied Sciences Kempten, Bahnhofstrasse 61, 87435, Kempten, Germany

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Contributions

JH did the conception of questionnaire, design, data collection, data analysis, preparation of manuscript, editing and review. PB contributed to conception, design, preparation of manuscript, editing and review. CA has contributed to conception, design, data analysis and review. MB participated in the conception of the questionnaire and review. JB contributed to the preparation of the manuscript and revised the final draft of manuscript. All Authors have read and approved the final manuscript.

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Correspondence to Petra Benzinger .

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The study has been performed in accordance with the Declaration of Helsinki and consistent with the underlying data protection regulation. The protocol was approved by the Ethics committee at the University of Heidelberg (S-487/2021). All participants were given written information about the project, as well the opportunity to consent or decline participation. Informed consent was obtained from all subjects.

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Hoch, J., Bauer, J.M., Bizer, M. et al. Nurses’ competence in recognition and management of delirium in older patients: development and piloting of a self-assessment tool. BMC Geriatr 22 , 879 (2022). https://doi.org/10.1186/s12877-022-03573-8

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DOI : https://doi.org/10.1186/s12877-022-03573-8

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• Delirium recognition
• Delirium management
• Clinical reasoning
• Educational intervention
• Vignette-based questionnaire
• Older adult

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Clinical case scenario

Mr. Williams is a 80 year old male who has had a fall at home and was admitted to your acute care facility for ongoing investigations and pain relief for left sided hip pain. His wife stated that she was not at home at the time of his fall and it was some hours before she returned and found him on the kitchen floor. Mr. Williams remembered the fall and all events afterwards, stating, "I couldn't get up afterwards because of the pain and was calling for help but no one heard me".

• Hypertension
• Osteoarthritis

He lives with his wife, has a moderate hearing deficit, wears glasses and is usually on multiple medications. An array of investigations are ordered by the admitting medical team.

Admission physical:

BP 160/85; Pulse 76 regular; Respiratory rate 20; Temperature 36.60C; Chest is clear. He is alert and answers questions appropriately and his MMSE is 28/30.

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The management of delirium in the older adult in advanced nursing practice

Registered Advanced Nurse Practitioner, Older Adult Care, Cherry Orchard Hospital and Dublin South Kildare and West Wicklow Community Healthcare Area, Dublin, Ireland

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Eileen Furlong

Associate Professor in Nursing, School of Nursing, Midwifery and Health Systems, University College Dublin. Ireland

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Delirium is a term used to describe an array of symptoms that indicate a disruption in cerebral metabolism, a condition that is often under-recognised, leading to delayed interventions. The condition is a common cause of older adults presenting in hospital, with significant morbidity and mortality associated with increased length of stay. A case study is used to illustrate the use of a diagnostic algorithm for older adults presenting with delirium to an advanced nurse practitioner (ANP)-led service. The clinical decision pathway provides four differential diagnoses, using the case study to put the decision-making process in context. The article demonstrates the ability of the ANP to practise at a high level of expertise as an autonomous practitioner and shows how the pathway supports the nurse to reach an accurate diagnosis. It shows that prompt and accurate diagnosis of delirium in older adults is crucial to avoiding the complications and cognitive decline associated with the condition.

Research shows that delirium, independent of age, dementia, illness severity and functional status, predicts multiple adverse outcomes for older adults, including morbidity and mortality, alongside increased length of hospital stay ( Pendlebury et al, 2015 ; Welch et al, 2019 ). For the advanced nurse practitioner (ANP) evidence-based practice (EBP) is paramount to providing the best possible care outcomes for the older adult.

This article sets out a logical approach to obtaining a comprehensive clinical history using the most effective clinical screening tools to provide accurate diagnosis of delirium in the older adult. It presents a short case study that is followed by the application of a diagnostic algorithm, to illustrate the role of the ANP. Algorithms are typically developed from evidence-based clinical guidelines and facilitate the transfer of research to practice, providing nurses with as step-by-step approach to make effective decisions ( Jablonski et al, 2011 )

The context for this older adult care service is a newly established ANP role in the Republic of Ireland. The ANP older adult care service is based in community settings, where independent ANP clinics are held with direct referral from acute hospital and community primary care teams, providing early supportive discharge from acute care. The ANP also facilitates an outreach service to residential units and undertakes home visits within Health Service Executive (HSE) areas that support reduced waiting times and hospital avoidance by enabling older adults to remain at home for treatment ( National Clinical Programme for Older People, 2019 ).

The ANP role encompasses knowledge, skills and competence to enable holistic patient assessment, along with the ability to capture, analyse and interpret patient information. These attributes are key to the assessment and diagnostic process, and demonstrate accountability and responsibility to the older adult ( Nursing and Midwifery Board of Ireland (NMBI), 2017 ).

Delirium is broadly described as a neuropsychiatric disorder of cognition, attention, consciousness or perception ( Maldonado, 2018 ). These symptoms generally develop over a short period and can fluctuate from hours to days as a result of precipitating and predisposing factors. The condition is classified into three subtypes: hyperactive, hypoactive and mixed ( Table 1 ). Categorisation relies on clinical presentation inclusive of psychomotor features and is associated with increased morbidity, mortality and increased length of hospital stay. Approximately 40% of older adults admitted to hospital have a diagnosis of delirium ( Han et al, 2010 ; Ahmed et al, 2014 ). The differential diagnosis for delirium is broad and often multifactorial ( Lorenzl et al, 2012 ; Maldonado, 2018 ). The use of an algorithm that provides a diagnostic pathway for four frequently presenting differential diagnoses of delirium in the older adult offers a systematic approach to accurate diagnosis. A case study is used to illustrate the application of an algorithm.

Source: van Velthuijsen, et al, 2018

Bob (not his real name), who is 84 years old, resides in a long-term care (LTC) residential facility. He is a bachelor and had worked as a builder on construction sites. Before moving into LTC, he lived alone and has a long history of smoking, alcohol excess and poor diet, resulting in raised cholesterol and subsequent atherosclerosis. His speech is clear, and he communicates appropriately in short, clear sentences with limited distraction such as environment and noise. He has many siblings who visit regularly and provide him with a good support network. His past medical and surgical history includes left carotid endarterectomy and dementia of Lewy body type, with associated cognitive deficits.

Bob had no diagnosed respiratory condition; however, on occasion he became breathless. When this occurred, he received oxygen therapy via nasal prongs which is documented in his advanced care plan ( Aasmul et al, 2018 ). Studies ( Wang et al, 2015 ; Armstrong and Weintraub, 2016 ) suggest that individuals with Lewy body dementia who are on antipsychotic medications can have adverse reactions; subsequent prescribing should be progressed with caution following careful consideration, including the risk benefit ratio. In Bob's case his previous presenting symptoms required prescription of quetiapine at low doses. While research in this area remains clinically debated, quetiapine has been shown to have the least adverse effects and is therefore the safest medication to use with this dementia type ( Fox et al, 2019 ; Hershey et al, 2019 ). Bob's prescribed medications prior to and following his hospital assessment and treatment decision are listed in Table 2 . This information was used to assist in building up the clinical picture and provide indicators for potential causes of delirium.

His comorbidities included type 2 diabetes mellitus, atherosclerosis, constipation and gout. More recently, Bob had been diagnosed with a 6.3 cm non-ruptured infrarenal abdominal aortic aneurysm located in the maximal axial diameter of the aorta. Following this diagnosis, Bob and his family met with the medical team and a decision was made to proceed with non-interventional treatment. Bob was transferred back to the residential setting and commenced on oral paracetamol 1 g three times a day, with a further 1 g dose as needed to alleviate his-left flank discomfort.

Three weeks later, Bob presented with confusion, limited attention span and disorganised thinking. On observation, he was restless and pacing the unit; staff reported that he was not sleeping well. On further assessment, Bob's vital signs were recorded as: blood pressure 140/80 mmHg; heart rate 98 beats per minute; respiratory rate 18 breaths per minute, temperature 37.6°C, oxygen saturation 97% in room air. His pain score was 17/30, category 4, according to the Carey (2018) pain tool, which was developed in Ireland for the residential setting; it incorporates behaviours and numeric values, including self-report. In Bob's case, only behaviour observation was recorded: the score of 17/30 indicated severe pain and required intramuscular tramadol 100 mg for relief. Full blood tests requested including full blood count (FBC), renal, liver and bone profile, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), vitamin B 12 and folate levels, blood glucose, arterial blood gases and a chest X-ray, which were undertaken in the residential facility. A head-to-toe physical examination raised a range of red flags including acute pain, distended abdomen with guarding of the left flank, pale bilateral conjunctive and mucous membranes, headache, reduced skin turgor, restlessness and an altered sleep-wake cycle. Bob had one episode of syncope and a drop in blood pressure caused by dehydration.

Differential diagnosis is essential to assist the practitioner in formulating an accurate diagnosis. Diseases often present with similar symptoms, so the practitioner will apply clinical reasoning to narrow down the differential diagnosis ( Reinoso et al, 2018 ; Rhoads and Murphy Jensen, 2015 ). The differentials in the case of the patient, Bob, are illustrated in Figure 1 , along with the red flags that presented on examination by the ANP. The blood results revealed elevated serum creatinine and blood urea nitrogen, low sodium, low fasting blood sugar and elevated ammonia, ESR and CRP; all other results were unremarkable. Following a comprehensive assessment and full review of symptoms using an evidenced-based clinical decision-making process, the ANP diagnosed hyperactive delirium with marked behaviour changes, increased pain levels, constipation and dehydration. The areas outlined were of concern and intervention was required to manage and treat the symptoms, as shown in Figure 2 .

Following his diagnosis in the acute setting Bob was prescribed oxycodone 5 mg orally three times a day by the palliative care team prior to discharge to the residential facility. The cause of the acute pain was identified as constipation, most likely related to pressure on the bowel and the abdominal aortic aneurysm. No further diagnostic testing was advised in accordance with Bob's advanced care plan. Fluid intake was set according to his typical daily intake and laxatives were required to manage constipation. Subcutaneous or intravenous fluids were not considered with reference to his advanced care plan. Bob's only wish was to have adequate pain relief. To achieve these outcomes a person-centred care approach is vital and should include alleviating possible anxiety experienced by Bob ( National Institute for Health and Care Excellence (NICE), 2019 ). His overall care was managed by the ANP with multidisciplinary team collaboration.

In this patient's case, his delirium was superimposing on his dementia. Prompt and accurate diagnosis was achieved, allowing for the most appropriate intervention with the least adverse effects, by avoiding lengthy cognitive and functional decline (see Figure 1 ). The advanced care plan was completed with Bob, which was paramount to avoid acute hospital admission and allowed for multicomponent approaches that were person-centred and provided in a familiar environment ( Martinez et al, 2015 ). Furthermore, advanced care planning allowed Bob and his family to plan care that was consistent with his personal values and preferences ( Aasmul et al. 2018 ). To ensure successful care planning, staff received education specific to delirium and its precipitating and predisposing factors to support early intervention and minimise the effects of future episodes if these presented ( Colomer and Vries, 2016 ). Professional knowledge and decision-making are central to the ANP's scope of practice, underpinning assessment and diagnosis, and ensuring accountability and responsibility ( NMBI 2015 ). The algorithm in Figure 1 sets out the decision-making process used to assess and establish the causes of Bob's delirium.

Pathophysiology

The pathophysiology of delirium remains poorly understood, with research looking into multiple hypotheses. These include pathogenesis, degenerating brain vulnerability, brain energy metabolism and a variety of precipitating factors to identify methods of convergence ( Wilson et al, 2020 ). This article includes discussion of the blood–brain barrier breakdown that occurs with ageing and the associated risk factors that contribute to delirium ( Varatharaj and Galea, 2017 ). In the older adult, alterations in the blood–brain barrier make the barrier more permeable, allowing blood and substances to pass from micro-vessels to the brain, including toxins and pathogens that will affect cognitive processes. It is thought that the downregulation of synthesis, release and inactivation of neurotransmitters play a vital part in the pathophysiology of delirium in the older adult ( McCaffrey and Davis, 2012 ). The case study illustrates the application of a diagnostic pathway for delirium with reference to Bobs' presenting symptoms.

Differential diagnosis in advanced practice

The differential diagnosis for delirium is broad and often multifactorial ( Lorenzl et al, 2012 ; Maldonado, 2018 ). According to Inouye et al (2014) the term delirium describes an array of symptoms that indicate a disruption in cerebral metabolism following transient biochemical disruptions caused by many conditions. The algorithm provides a systematic approach to four differential diagnoses of delirium: dehydration, infection, constipation and medication. In the author's clinical experience, and based on evidence, these four diagnoses present most frequently in older adults.

History taking and examination skills

Advanced health assessments that include comprehensive history taking, careful physical examination and sound clinical reasoning are crucial to the diagnostic process ( NMBI, 2017 ). These elements assist the practitioner to narrow down the differential diagnoses ( Rhoads and Murphy Jenson, 2015 ; Reinoso et al, 2018 ). In Bob's case, eliciting subjective and objective data through the health history interview using open-ended questions and active listening were demonstrated. As part of this process, it is essential to develop a rapport with the patient and family members: this is fundamental to alleviating anxiety and enabling the ANP to obtain a family history, and helps ensure that the physical examination and diagnostic tests address the relevant factors.

A patient's health history includes their medical history, treatments and risk factors for delirium, and a review of systems. A thorough review of all medications is completed with a specific focus on medication known to contribute to delirium symptoms in combination with associated risk factors; these medications ( Table 3 ) can predispose older adults to episodes of delirium ( Rhoads and Murphy Jenson, 2015 ; Bickley and Szilagyi, 2021 ). The mnemonic OLD CART (onset, location, duration, characteristics, associating factors, relieving/radiating factor, treatment) is a useful tool when obtaining information about a patient's current health status, including background and presenting complaints ( Bickley and Szilagyi, 2021 ). This tool is one of a number of available assessment instruments that use mnemonics: others include PQRST (provokes, quality, radiates, severity and time) and SOCRATES (site, onset, character, radiation, associations, time course, exacerbation/relieving factors, severity) ( Bickley and Szilagyi, 2021 ).

Source: Alagiakrishnan and Wiens, 2004

In clinical practice, the ANP assesses all risk factors associated with the onset of delirium and completes a comprehensive screening to guide diagnosis and treatment. Focused screening in relation to presenting symptoms will also be considered to narrow down the differential diagnosis. Risk factors for delirium and required investigations are presented in Table 4 .

Once a health history has been taken and a risk factor assessment made, a thorough physical examination is conducted, applying a systematic approach to obtain objective clinical information. The initial focus is on neurological assessment, followed by a focused examination relating to each differential diagnosis ( Bickley and Szilagyi, 2021 ; NMBI, 2017 ). Careful examination of the cranial nerves, and the motor and sensory systems will assist in identifying comorbidities or underlying pathology. If an underlying pathology is identified, the ANP will investigate further and consider referral onward, including to the GP if psychiatric manifestations present. A vital signs review is key and may detect the presence of red flags ( Bickley and Szilagyi, 2021 ). Identification of red flags may indicate a serious pathology and the need for further urgent investigations for underlying serious disease ( Reisner and Reisner, 2017 ). Red flags of significance in the case of Bob's presenting symptoms are shown in red in Figure 1 .

Screening tools

Screening tools are valid and reliable methods for assessing older adults presenting with delirium, enabling comprehensive assessment of the presenting symptom(s) ( Iragorri and Spackman, 2018 ). Delirium is diagnosed from its clinical manifestations using a recognised instrument such as the 4AT (arousal, attention, Abbreviated Mental Test 4 and acute change), developed by Shenkin et al (2018) . In Ireland, the RADAR ( r ecognising a cute d elirium a s part of your r outine) is used in daily practice, along with other tools ( Table 5 ), to assess the severity of delirium and determine the efficacy of treatments prescribed.

Extensive research recommends that delirium screening and surveillance be completed daily to establish onset, ensure accurate diagnosis and the best treatment outcomes with least adverse effects. Although standard diagnosis is made using the internationally recognised Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria ( American Psychiatric Association, 2013 ), other validated and recognised tools of choice available to the ANP to determine the effectiveness of interventions include the 4AT for diagnosis, and RADAR and Delirium O Meter ( de Jonghe et al, 2005 ; Voyer, et al, 2016 ; Shenkin et al, 2018 ).

Tieges et al (2020) suggested that early recognition of delirium, which can be achieved effectively by applying the 4AT screening tool, avoids cognitive and functional decline. This is a four-item observational test that is simple to use and easily applied in any setting. However, although it has been shown to detect delirium in older adults, it does not allow for diagnosis of the aetiology (Tieges et al, 2020). The tools listed in Table 5 are relatively short and assist the ANP in screening and monitoring delirium, in order to guide diagnosis and treatment. Should the underlying cause of a patient's delirium not be identified following advanced assessment and analysis of the presenting symptoms, along with the use of screening tools, a list of differential diagnoses will be drawn up by the ANP ( Rhoads and Murphy Jenson, 2015 ).

The following sections present the process of applying the decision-making pathway and the targeted investigations for each of the four differential diagnoses presented in Figure 1 : dehydration, infection, constipation and medication.

Dehydration

Dehydration results from a disruption in the body's fluid balance caused by decreased intake or increased output. The resulting negative balance reduces blood volume, and consequently blood pressure lowers, leading to a decline in glomerular filtration rate and electrolyte imbalances ( El-Sharkawy et al, 2014 ; Reisner and Reisner, 2017 ). According to Masento et al (2014) , dehydration is a common feature presenting in older adults, with intake deficits estimated to be as high as 30%. Even a 2% deficit will present with symptoms such as significant impairment in physical, visuo-motor, psychomotor and cognitive performances. Dehydration may prove fatal if left untreated, so it is crucial to be cognisant of the risk factors in older adults, which include decreased thirst response, impaired swallow and dementia. Older adults may also present asymptomatically, so careful examination with collateral information will help the practitioner identify signs ( Bickley and Szilagyi, 2021 ).

A concerning complication of dehydration is the development of life-threatening hypovolaemic shock. Clinical findings may include dry mouth, sunken eyes, dry cool skin, and reduced or concentrated urine. Collateral of intake and output is crucial in determining causative factors and aiding diagnosis for prompt intervention ( El-Sharkawy et al, 2014 ; Bickley and Szilagyi, 2021 ). Another important issue to consider are glucose levels: delirium has been associated with low blood sugar levels, particularly in acutely unwell older adults ( van Keulen et al, 2018 ). In Bob's case, targeted diagnostic investigations, the results of which would have warranted an alert, included blood serum osmolality of >290 mOsm/kg and a transient increase in electrolytes, FBC, paying attention to haematocrit of >0.460 ratio, blood urea nitrogen of >8.1 mmol/litre and creatinine of >84 μmol/litre. Blood analysis will determine the presence and severity of dehydration, along with other investigations. Reduced skin turgor is another diagnostic in dehydration, however, it may be difficult to assess in older adults whose skin loses elasticity with ageing.

Acute respiratory tract infection occurs due to the invasion of the respiratory system by Gram-negative and Gram-positive bacteria. Common pathogens include Streptococcus pyogenes, Haemophilus influenzae and Moraxella catarrhalis. They can affect many areas of the upper respiratory tract, including the pharynx and sinus. Pathogens involved in the lower tract include the latter, along with S pneumoniae ( Siegel and Weiser, 2015 ). According to Siegel and Weiser (2015) , respiratory infections lead in the ranking of burden of disease measured by years lost through death or disability.

Joints should also be assessed when considering infection in the older adult. Many joint problems present in the older adult, but in Bob's case this was gout, which is therefore discussed in the article. Gout frequently occurs in this patient group and is a common type of inflammatory arthritis that occurs when neutrophils, mononuclear phagocytes and lymphocytes invade the synovium of joints ( Dalbeth and Haskard, 2005 ). The condition typically presents with all features of the inflammatory process and is triggered by a diet of excess proteins, excess alcohol intake, trauma, surgery, comorbidity such as renal or cardiac disease, and subsequent treatment interventions. On examination of an older adult, the ANP will often identify clinical manifestations that include sudden onset of severe pain, swelling, warmth and redness at the local area of the joint affected ( Dalbeth et al, 2016 ).

The mechanism of urinary tract infection (UTI) is the presence of bacteria in the body and activation of the inflammatory response when microorganisms enter the urethra ( Reisner and Reisner, 2017 ). Older adults are more susceptible with risk factors such as impaired bladder emptying and decreased muscle contractility. Parish and Holliday (2012) estimated that Escherichia coli accounts for 90% of urinary tract infections (UTI) in older adults and up to 55% of antibiotic prescribing.

Following a diagnosis of respiratory tract infection and/or UTI, older adults can develop dehydration and constipation, and consequently require close monitoring ( NICE, 2015 ). An older adult with a respiratory tract infection may present asymptomatically, apart from delirium, or with a productive cough and shortness of breath; with a UTI, they may present with burning, frequency or urgency of micturition. The cardinal signs of inflammation in respiratory tract infection include cough, loss or changes to sense of smell, and congestion of the throat or larynx ( Alam et al, 2013 ; Reisner and Reisner, 2017 ). In UTIs, the older adult may present with pain on micturition secondary to sensory nerve ending irritation. In addition, symptoms of fever, tachycardia, confusion, hypotension and leucocytosis may be evident before localised symptoms present ( NICE, 2015 ).

With UTI identified as the most frequent recurring infection in older adults, clinical examination may discover pyuria as increased polymononuclear cells are present with infection. Cloudy or malodorous urine may also be evident. The presence of red flags such as pyrexia, rigors or back pain may indicate underlying pyelonephritis; males may present with urinary retention ( Rhoads and Murphy Jenson, 2015 ; Reisner and Reisner, 2017 ). Urine testing for culture and sensitivity will identify whether there is infection and, if present, the causative pathogen, enabling the most appropriate intervention. Blood testing to assist in confirming diagnosis include FBC with raised white cells, CRP and ESR. Blood urea nitrogen levels increase with infection, and in males there may also be a rise in prostate-specific antigen (PSA). Infection can irritate prostate cells, giving rise to PSA. According to Parish and Holliday (2012) 30% of older adults in long-term residential settings will have a recurrence of a UTI within 1 year.

Constipation

Constipation is a common gastrointestinal disorder affecting 20% of the general population and about 50% of older adults ( Vazquez Roque and Bouras, 2015 ). It can be defined as difficulty emptying the bowel and hardened faeces ( Bharucha and Lacy 2020 ). Older people are affected by age-related cellular dysfunction affecting plasticity, compliance, altered macroscopic structural changes and altered control of the pelvic floor. Delayed colonic transit constipation is typically seen in the older adult ( Lindberg et al, 2011 ). The aetiology of constipation is associated with inadequate fibre in the diet, reduced physical exercise, dehydration and medications such as anticholinergics and tricyclic antidepressants. The mechanism of constipation is associated with autonomic dysfunction, which can result from physical, chemical or emotional stress.

In addition, older adults or those with pre-existing conditions have a reduction in acetylcholine and serotonin, which affects gut motility altering peristalsis ( Rhoads and Murphy Jenson, 2015 ; Reisner and Reisner, 2017 ). Constipation results in hepatotoxicity and increased serum ammonia levels, which travel through the blood and cross the blood–brain barrier inducing confusion ( Camilleri et al, 2000 ).

Characteristic symptoms of constipation include nausea, vomiting, anorexia, crampy abdominal pain or distension. However, the practitioner must remain aware that older adults with delirium may present asymptomatically ( Vazquez Roque and Bouras, 2015 ). The clinical findings from abdominal examination may include distended abdomen, palpable faeces (predominantly of the left lower quadrant), but on examination the patient may have active bowel sounds and a digital rectal exam will identify hard faeces ( Lindberg et al, 2011 ). Red flags for constipation alert the practitioner to possible underlying pathologies such as cancer, for example when there is unexplained weight loss, unexplained altered bowel habit, blood in stool, a palpable mass or a family history of colonic cancer. Targeted investigations include a digital rectal exam ( Rao and Meduri, 2011 ) and use of the Bristol stool chart to record stool consistency and size.

Laboratory blood analysis will provide information such as increased white cell count and elevated inflammatory markers. Liver and thyroid function will be assessed to rule out underlying conditions that may be precipitating factors to the delirium episode. An abdominal X-ray may show faecal loading and obstruction.

Polypharmacy is commonly seen in older adults, with reduced renal flow and delayed metabolism associated with ageing. This can lead to toxicity due to medication or higher concentrations of circulating drug ( Lorenzl et al, 2012 ). Depression is also common in the older adult and involves imbalances in the brain, most notably the neurotransmitters serotonin, norepinephrine (noradrenaline) and dopamine ( Martins and Fernandes, 2012 ). The chemical basis of delirium is seen as an excess of dopaminergic activity and a deficit of cholinergic activity), with delirium occurring as a result of medication accounting for 40% of cases presenting in the older adult ( Alagiakrishnan and Wiens, 2004 ).

Drug withdrawal is another factor to be considered in relation to alcohol ( Lucas et al, 2019 ), benzodiazepines ( Gould et al, 2014 ) and selective serotonin reuptake inhibitors as these are known to precipitate delirium in the older adult ( Herron and Mitchell, 2018 ). Features that may present in the aetiology of delirium as a result of medication include drowsiness, agitation, fluctuating confusion, inattention, visual disturbances and hallucinations ( Alagiakrishnan and Wiens, 2004 ). Following history taking, careful review of all medication, including over-the-counter medications, is essential for narrowing down the differential diagnosis. Review of pain medication including drug-to-drug and drug-to-disease interactions is crucial for accurate diagnosis. The review should include newly prescribed or de-prescribed medication. A focused review of medications such as psychotropics, anticholinergic and deliriants is required in this population as listed in Table 3 . Anticholinergic burden is an important aspect of the medication review by the ANP when assessing for cognitive decline and delirium. These medications, along with alterations in blood–brain barrier and hormone imbalances, are known to play a role in medication-induced delirium ( Inouye et al, 2014 ).

The ANP must be familiar with red flags such as drug interactions, drug withdrawal, falls and dehydration as possible indicators of serious disease. Targeted investigations involve excluding dehydration, infection or constipation. Laboratory blood tests will be guided by the full assessment and an assay of drug levels may be indicated.

This article has outlined an evidenced-based decision-making pathway used by the ANP to establish possible causes of the clinical presentation of delirium in the older adult. The disease entities of delirium are overly broad, and often multifactorial, and in general present with similar symptoms. A thorough and detailed history including collateral with accompanying focused physical assessment is therefore fundamental to ensure accurate selection of diagnostic modalities. Using a structured approach enables the ANP to narrow the differential diagnosis of delirium to dehydration, infection, constipation and medication.

The article has also discussed underlying pathological processes and diagnostic modalities. An algorithm to assist the diagnostic evaluation of the presenting symptom of delirium in an older adult has been presented and critiqued using the case study of patient Bob. This algorithm is currently used by the author to guide practice and it is anticipated that colleagues in Ireland, the UK and internationally may find the algorithm useful. Additionally, they may incorporate it as part of their evidenced-based nurse-led service, enabling optimal advanced care of the older adult presenting with delirium.

A person presenting with signs and symptoms of acute delirium requires expert care and management, regardless of their demographic background.

• The ANP working in older adult care is competent and capable to effect evidence-based change in complex care settings
• The differential diagnosis of delirium is broad and multifactorial, requiring advanced comprehensive clinical decision-making, knowledge and skills
• Evidence-based algorithms guide clinical practice and facilitate the transfer of research to practice, providing nurses with a step-by-step approach for effective decision-making
• Advanced care planning is essential to achieve person-centred care for the older adult in the care setting of their choice

CPD reflective questions

• Think about the likely causes of delirium in the older adult. How would an algorithm assist with determining the cause(s)?
• Consider how you would manage a patient once you have the underlying diagnosis? Is the patient best managed in the acute or community setting?
• Consider the clinical scenario in the article. Is it useful for you practice?
• What can you do to improve your skills in the assessment and diagnostic processes?

My grandfather has turned 89 years old 2 months ago. He seems to have changed from then on. He always complains of seeing ants in the ceiling, or ants on the floor beside his bed. He sometimes forgets my name. Lately, he keeps on mumbling to himself and looks agitated. He doesn’t know where he is anymore, or what the present date is. I’m really worried that he is in the early stages of delirium . I think we should have him checked.

Delirium is an acute neuropsychiatric syndrome characterized by rapid-onset confusion , altered consciousness, and impaired cognitive function. It often results from underlying medical conditions, substance use, or medication effects.

This nursing guide provides a concise overview of delirium and its significance in psychiatric nursing practice .

Table of Contents

What is delirium, statistics and incidences, clinical manifestations, assessment and diagnostic findings, pharmacologic management, nursing assessment, nursing diagnosis, nursing care planning and goals, nursing interventions, documentation guidelines.

Delirium is a disturbance of consciousness and a change in cognition that develop rapidly over a short period (DSM-IV-TR).

• Delirium is an acute and reversible condition that often occurs as a result of an underlying medical condition, substance intoxication or withdrawal , or medication side effects.

Delirium is common in the United States.

• In a systematic review of 42 cohorts in 40 studies, 10-31% of new hospital admissions met the criteria for delirium and the incidence of developing delirium during the admission ranged from 3-29%.
• For patients in intensive care units, the prevalence of delirium may reach as high as 80%.
• Prevalence of postoperative delirium following general surgery is 5-10% and as high as 42% following orthopedic surgery .
• As many as 80% of patients develop delirium death .
• Delirium can occur at any age, but it occurs more commonly in patients who are elderly and have compromised mental status.
• In patients who are admitted with delirium, mortality rates are 10-26%.
• Patients who develop delirium during hospitalization have a mortality rate of 22-76% and a high rate of death during the months following discharge.

The  DSM-IV-TR  differentiates among the disorders of delirium by their etiology, although they share a common symptom presentation. Categories of delirium include the following:

• Delirium due to a general medical condition. Certain medical conditions, such as systemic infections, metabolic disorders, fluid and electrolyte imbalances , liver or kidney disease, thiamine deficiency, postoperative states, hypertensive encephalopathy, postictal states, and sequelae of head trauma , can cause symptoms of delirium.
• Substance-induced delirium. The symptoms of delirium can be induced by exposure to a toxin or the ingestion of medications, such as anticonvulsants , neuroleptics, anxiolytics, antidepressants , cardiovascular medications, antineoplastics, analgesics, antiasthmatic agents, antihistamines , antiparkinsonian drugs, corticosteroids, and gastrointestinal medications.
• Substance-intoxication delirium. Delirium symptoms can occur in response to taking high doses of cannabis , cocaine , hallucinogens, alcohol, anxiolytics, or narcotics .
• Substance-withdrawal delirium. Reduction or termination of long-term, high dose, use of certain substances, such as alcohol, sedatives, hypnotics , or anxiolytics, can result in withdrawal delirium symptoms.
• Delirium due to multiple etiologies. Symptoms of delirium may be related to more than one general medical condition or to the combined effects of a general medical condition and substance use.

The following symptoms have been identified with the syndrome of delirium:

• Altered consciousness ranging from hypervigilance to stupor or semicoma.
• Extreme distractibility with difficulty focusing attention.
• Disorientation to time and place.
• Impaired reasoning ability and goal-directed behavior.
• Disturbance in the sleep -wake cycle .
• Emotional instability as manifested by fear , anxiety , depression , irritability, anger, euphoria, or apathy.
• Misperceptions of the environment , including illusions and hallucinations .
• Automatic manifestations , such as tachycardia, sweating , flushed face, dilated pupils, and elevated blood pressure .
• Incoherent speech .
• Impairment of recent memory .

Laboratory tests that may be helpful for diagnosis include the following:

• Complete blood cell count with differential. Helpful to diagnose infection and anemia .
• Electrolytes . To diagnose low or high levels.
• Glucose . To diagnose hypoglycemia , diabetic ketoacidosis , and hyperosmolar nonketotic states.
• Renal and liver function tests.   To diagnose renal and liver failure.
• Thyroid function studies. To diagnose hypothyroidism .
• Urine analysis. Used to diagnose urinary tract infection .
• Urine and blood drug screen. Used to diagnose toxicological causes.
• Thiamine and vitamin B12 levels. Used to detect deficiency states of these vitamins.
• Serum marker for delirium. The calcium -binding protein S-100 B could be a serum marker for delirium. Higher levels are seen in patients with delirium when compared to patients without delirium.

Medical Management

When delirium is diagnosed or suspected, the underlying causes should be sought and treated.

• Fluid and nutrition . Fluid and nutrition should be given carefully because the patient may be unwilling or physically unable to maintain a balanced intake; for the patient suspected of having alcohol toxicity or alcohol withdrawal, therapy should include multivitamins, especially thiamine.
• Reorientation techniques. Reorientation techniques or memory cues such as a calendar, clicks, and family photos may be helpful.
• Supportive therapy. The environment should be stable, quiet, and well-lighted; sensory deficits should be corrected, if necessary, with eyeglasses or hearing aids; family members and staff should explain proceedings at every opportunity, reinforce orientation, and reassure the patient.

Delirium that causes injury to the patient or others should be treated with medications.

• Antipsychotics . This class of drugs is the medication of choice in the treatment of psychotic symptoms of delirium.
• Benzodiazepines . Reserved for delirium resulting from seizures or withdrawal from alcohol or sedative hypnotics.
• Vitamins. Patients with alcoholism and patients with malnutrition are prone to thiamine and vitamin B12 deficiency, which can cause delirium.
• Hypnotic, miscellaneous. Agents in this class may be useful in the prevention and management of delirium (e.g. melatonin, ramelteon).

Nursing Management

Nursing management for a patient with delirium includes the following:

Nursing assessment should include:

• Psychiatric interview. The psychiatric interview must contain a description of the client’s mental status with a thorough description of behavior, the flow of thought and speech, affect, thought processes and mental content, sensorium and intellectual resources, cognitive status, insight, and judgment.
• Serial assessment . Serial assessment of psychiatric status is necessary for determining the fluctuating course and acute changes in mental status.

Sample nursing diagnoses for persons with delirium include:

• Disturbed thought processes related to delusional thinking.
• Chronic Confusion related to cognitive impairment .
• Impaired verbal communication related to cognitive impairment .
• Risk for injury related to suicidal ideations, illusions, and hallucinations.
• Impaired memory related to cognitive impairment .
• Risk for other-directed violence related to suspiciousness of others.

The major nursing care plan goals for delirium are:

• Client will maintain agitation at a manageable level so as not to become violent.
• Client will not harm self or others.

Nursing interventions for patients with delirium include the following:

• Assess the level of anxiety . Assess the client’s level of anxiety and behaviors that indicate the anxiety is increasing; recognizing these behaviors, the nurse may be able to intervene before violence occurs.
• Provide an appropriate environment. Maintain a low level of stimuli in the client’s environment (low lighting, few people, simple decor, low noise level) because anxiety increases in a highly stimulating environment.
• Promote patient safety . Remove all potentially dangerous objects from the client’s environment; in a disoriented, confused state, clients may use objects to harm self or others.
• Ask for assistance from others when needed. Have sufficient staff available to execute a physical confrontation, if necessary; assistance may be required from others to provide for the physical safety of the client or primary nurse, or both.
• Stay calm and reassure the patient. Maintain a calm manner with the client; attempt to prevent frightening the client unnecessarily; Provide continual reassurance and support.
• Interrupt periods of unreality and reorient . Client safety is jeopardized during periods of disorientation ; correcting misinterpretations of reality enhances the client’s feelings of self-worth and personal dignity.
• Medicate or restrain patient as prescribed. Use tranquilizing medications and soft restraints , as prescribed by physician, for protection of client and other during periods of elevated anxiety.
• Observe suicide precautions. Sit with the client and provide one-to-one observation if assessed to be actively suicidal; client safety is a nursing priority, and one-to-one observation may be necessary to prevent a suicidal attempt.
• Teach relaxation exercises to intervene in times of increasing anxiety.
• Teach prospective caregivers to recognize client behaviors that indicate anxiety is increasing and ways to intervene before violence occurs.

The outcome criteria include:

• Prospective caregivers are able to verbalize behaviors that indicate an increasing anxiety level and ways they may assist clients to manage their anxiety before violence occurs.
• With assistance from caregivers, the client is able to control the impulse to perform acts of violence against self or others.

Documentation in a patient with delirium includes:

• Individual findings include factors affecting, interactions, the nature of social exchanges, and specifics of individual behavior.
• Cultural and religious beliefs, and expectations.
• Plan of care.
• Teaching plan.
• Responses to interventions, teaching, and actions performed.
• Attainment or progress toward the desired outcome.

Sources and references for this study guide for delirium:

• Black, J. M., & Hawks, J. H. (2005).  Medical- surgical nursing . Elsevier Saunders,.
• Videbeck, S. L. (2010).  Psychiatric- mental health nursing . Lippincott Williams & Wilkins.

4 thoughts on “Delirium”

Good notes…more questions for quiz if possible

Excellent information. Thanks a lot

Accurate and appropriate study. Thanks

Hi Vikas, Thank you so much! It’s great to hear that the study was spot on for you. If there’s anything else you’d like to dive into or any feedback to make it even better, just let me know!

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Development of a scripted unfolding case study focusing on delirium in older adults

Affiliation.

• 1 School of Nursing, University of North Carolina at Chapel Hill, Carrington Hall, Chapel Hill, NC 27599-7460, USA.
• PMID: 20481424
• DOI: 10.3928/00220124-20100423-05

This article describes the process of developing and implementing a scripted unfolding case study about delirium as part of a continuing education program for nursing staff. This innovative instructional strategy allows learners to evaluate a situation as it unfolds, practice assessment and communication skills, and reflect on potential problems and solutions. Using the detection and treatment of delirium as an example, the authors describe a template for developing a low-cost, low-fidelity case simulation that includes identifying the key concepts and competencies; writing behavioral learning objectives; creating the story; and identifying clinical decision-making points for discussion. Positive evaluations by program participants (registered nurses, licensed practical nurses, and nursing assistants) indicate that this methodology encourages interactive learning of key concepts in geriatric nursing among participants with varying years of experience.

Copyright 2010, SLACK Incorporated.

• Delirium / nursing*
• Education, Nursing, Continuing / organization & administration*
• Geriatric Nursing / education*
• Program Development

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Basic science: neuropathogenesis of delirium, approach to postoperative delirium in the elderly: the view of the geriatrician and current concepts, knowledge gap, case scenario: postoperative delirium in elderly surgical patients.

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Jean Mantz , Hugh C. Hemmings , Jacques Boddaert; Case Scenario: Postoperative Delirium in Elderly Surgical Patients. Anesthesiology 2010; 112:189–195 doi: https://doi.org/10.1097/ALN.0b013e3181c2d661

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• Ris (Zotero)
• Reference Manager

DELIRIUM is increasingly recognized as a major adverse event occurring postoperatively in elderly surgical patients. Once the diagnosis has been established, the main goal of delirium therapy is to identify important, potentially life-threatening, treatable, organic causes responsible for this syndrome. The purpose of this clinical pathologic conference is to highlight key points essential for the diagnosis and treatment of delirium occurring after anesthesia and surgery.

An 81-yr-old woman presented with delirium 4 days after undergoing laparoscopic colon surgery under general anesthesia. She had a history of major tobacco consumption (2 cigarette packs/day for 45 yr) and still smokes. She also had moderate hypertension and peripheral vascular disease for which she had been treated with bare metal stents in both iliac arteries and the left femoral artery 3 yr ago. Chronic medications consisted of clopidogrel (75 mg/day), simvastatin (20 mg/day), bromazepam (6 mg/day), valsartan (160 mg/day), and bisoprolol (10 mg/day). She was admitted for laparoscopic surgical treatment of sigmoid diverticulitis complicated by sigmoido-vaginal fistula. Several episodes of polymicrobial urinary tract infections had been treated with antibiotics before admission. Preoperative examination revealed satisfactory cardiopulmonary status. Blood electrolytes were normal, troponin Ic was less than 0.04 ng/ml, hemoglobin was 12.9 g/dl, and platelet count was 260 g/l. Electrocardiogram showed regular sinus rhythm, blood pressure was 168/78 mmHg, and stress-echocardiography was negative for ischemia but showed left ventricular diastolic dysfunction with left ventricular hypertrophy. Doppler ultrasound examination of the carotid arteries was normal.

Clopidogrel, simvastatin, bromazepam, and bisoprolol were continued until the day of surgery, whereas valsartan was discontinued 2 days before surgery. Anesthesia was induced with propofol, sufentanil, and atracurium, and it was maintained with desflurane in O 2 /N 2 O 50:50. After an uneventful 3-h operation that consisted of sigmoidectomy, colorectal anastomosis, and ileostomy, residual neuromuscular blockade was reversed with neostigmine and atropine, the trachea was extubated, and the patient was transferred to the postanesthesia care unit (PACU) and then to the surgical ward. Postoperative analgesia consisted of intravenous propacetamol (500 mg 4 doses per day), nefopam (20 mg 3 doses per day), and morphine titration in the PACU. Patient-controlled analgesia with morphine hydrochloride (bolus = 1 mg, refractory interval = 7 min) was used during the first 48 postoperative hours. Epidural analgesia was not used in this case.

On postoperative day 4, the patient experienced several episodes of confusion, logorrhea, and disorientation. Glasgow Coma Scale score was 15. Temperature was 37.2°C but had a transient peak to 38.4°C the day before. Physical examination revealed slight abdominal tenderness, diarrheic stool in the ileosotomy, and normal cardiac and pulmonary auscultation. Blood leukocytes were 10,000/ml, hemoglobin was 12.9 g/dl, blood electrolytes were normal, and computed tomographic scan revealed a 3-cm diameter fluid collection at the colorectal anastomosis ( fig. 1 ).

Fig. 1. Abdominal computed tomography scan performed on the fourth postoperative day revealing a 3-cm diameter fluid collection at the colorectal anastomosis ( arrow  ).

Important issues to consider in this case include the following.

1. How Is Delirium Diagnosed in the Postoperative Period?

Delirium, defined as an acute decline in attention and cognition, represents a serious complication in patients after anesthesia and surgery and is predictive of mortality at 6 months in intensive care unit (ICU) patients. 1 There is increasing evidence that delirium precedes development of postoperative cognitive dysfunction after ICU admission. 1 Delirium exhibits both hyperactive and hypoactive forms, the latter being more common in the elderly and more often unrecognized. 2 The main clinical features of delirium are summarized in table 1 . Diagnosis in the postsurgical setting is based on validated clinical scales. However, to date, most postoperative patients admitted to the PACU or the ICU have not been formally assessed for delirium or cognitive dysfunction with appropriate preoperative tests, which makes the time of onset of symptoms uncertain. The Confusion Assessment Method for Intensive Care Unit Patients Scale has been validated in medical and coronary ICU patients as a reliable tool to detect delirium. 3 Diagnostic criteria include abrupt onset and fluctuating course, inattention, and either disorganized thinking or coma. However, the capacity of Confusion Assessment Method for Intensive Care Unit Patients Scale for detecting delirium in the PACU is inferior to recently reported scales. 4 The Nursing Delirium Screening Scale includes five items scored 0–2: disorientation, inappropriate behavior, inappropriate communication, illusions/hallucinations, and psychomotor retardation. Delirium is indicated by a score ≥ 2. The Delirium Detection Score has been adapted to the PACU and includes five items scored 0–7: orientation, hallucination, agitation, anxiety, and paroxysmal sweating. Diagnosis of delirium is based on a Delirium Detection Score ≥ 7. The Nursing Delirium Screening Scale and Delirium Detection Score might be useful as additional tools to pain scores for ensuring patient comfort and restoration of postoperative brain function in the PACU. In this case, delirium was indicated by each of these scales (Confusion Assessment Method for Intensive Care Unit Patients Score = 3/4, Nursing Delirium Screening Scale Score = 6, Delirium Detection Score = 12).

2. What Is the Pathophysiology of Postoperative Delirium in the Elderly?

The pathophysiology of delirium after anesthesia and surgery remains obscure and is multifactorial. Hypothetical mechanisms for postoperative delirium include disordered neurotransmission, inflammation, and stress. Evidence supports the role of reduced cholinergic transmission or excessive dopaminergic tone in delirium. Proinflammatory cytokines such as tumor necrosis factor-α or interleukin-1, which have also been implicated, can alter neurotransmission, enhance neurotoxicity, and increase blood-brain barrier permeability. 5 Genetic factors have also been identified as risk factors for developing postoperative delirium in the elderly. 6 The aging brain exhibits both quantitative and qualitative changes in neuronal circuitry 7,8 that could account for the greater sensitivity of elder patients to delirium.

3. What Are the Causes of Postoperative Delirium?

On diagnosis of delirium, efforts turn to identification of the cause. Factors contributing to delirium in the postoperative period are listed in table 1 . Factors related to the patients include pain, hypoxemia, hypotension, metabolic disorders, sepsis, and drug or alcohol withdrawal. Intense postoperative pain is a cause of hyperactive delirium with agitation. 9 Pain-induced delirium caused by undiagnosed urinary retention is common because residual bladder volume is elevated after anesthesia and surgery in the PACU 10 Hypoxemia and hypotension can cause delirium. Electrolyte disorders can also cause delirium, as with hyponatremia, because of absorption of water during endourologic or endogynecologic surgery. Hypernatremia and hypoglycemia in diabetic patients can also cause postoperative delirium. Hypoactive delirium can occur in patients with Parkinson disease because levodopa is given only orally. Patients addicted to nicotine, ethanol, opioids, or benzodiazepines are at high risk of developing delirium in the postoperative period. The incidence of postoperative confusion is increased in older persons taking chronic benzodiazepines. 11 Delirium tremens must also be considered and prevented in the case of alcoholic patients.

Factors not related to the patient include use of physical restraints, cardiac surgery, drugs (including anesthetics), and sleep deprivation. Perioperative acute ischemic stroke is an important cause of morbidity and mortality associated with both cardiac and noncardiac surgery, particularly in elderly patients. 12 Delirium without any sensory or motor deficit can be the only clinical manifestation of stroke in this context. Residual effects of muscle relaxants can contribute to delirium/agitation because of depression of pharygolaryngeal muscle activity and hypoxemia. Residual paralysis is frequently observed in the patients in PACU because of the underuse of neuromuscular function monitoring and incomplete antagonism of the effects of neuromuscular blockers, which increases postoperative respiratory complications, particularly hypoxemic episodes. 13 Drug-induced delirium is an obvious concern after anesthesia, because many drugs used in the perioperative period can contribute to delirium in older persons. 14 The use of anticholinergic agents is associated with delirium, particularly in older patients. 15 Delirium induced by ketamine has also been reported in this context. 16 Propofol has been associated with an increased incidence of emergence delirium in children. 17 In long-duration laparoscopic surgery performed in elderly patients under an anesthetic regimen with propofol-based anesthesia, an increase in the severity, but not incidence, of delirium on postoperative days 2 and 3 has been reported in comparison with a sevoflurane-based anesthetic regimen. 18 Although the use of nitrous oxide in elderly patients has been challenged recently, no data support an increase in the incidence of postoperative delirium in high-risk surgical patients undergoing anesthesia and surgery. 19 On the other hand, statins have been reported to attenuate delirium in patients undergoing cardiac surgery. 20  

4. What Was the Probable Cause of Delirium in This Case?

The most likely explanation of acute postoperative delirium in this case was postoperative peritonitis, which can precipitate delirium. 21 The fever the day before surgery supports this diagnosis, a nonspecific but frequent physical sign present in peritonitis. Fever as a sign of infection can be blunted or absent in older patients with infection. 22 Although the pathophysiology of sepsis-induced delirium remains poorly understood, several lines of evidence suggest that sepsis can alter the blood-brain barrier through the production of proinflammatory cytokines, such as interleukin 1-β, promoting leukocyte endothelial adhesion, and endothelial damage. 5 Interestingly, patients with sustained septic shock exhibit abnormal magnetic resonance imaging findings with various degrees of encephalopathy and damage to white matter tracts. 23 Altered synaptic transmission and excitability of hippocampal pyramidal neurons have been reported in an animal model of sepsis. 24 Sepsis-induced delirium might also be explained in part by an increase in oxygen requirements or hypoxia.

Table 1. Clinical Features and Factors Contributing to Postoperative Delirium in Elderly Surgical Patients

Subsequent Course

The patient received broad spectrum antibiotics and returned to surgery for exploratory laparotomy. Peritonitis caused by leakage of the colorectal anastomosis was confirmed by peritoneal fluid cultures positive for Escherichia coli  . The postoperative course was complicated by respiratory, circulatory, and renal failure requiring mechanical ventilation with continuous intravenous sedation (midazolam and fentanyl) and inotropic support. The patient's condition slowly improved and she was extubated 8 days later. The day after extubation, a second episode of delirium ensued with disorganized thinking, inattention, and olfactory hallucinations. Her physical status remained stable, with no fever, normal electrolytes and no recurrence of circulatory, respiratory, or renal failure. Abdominal computed tomography scan was normal. Current medications, including antibiotics, could not account for the delirium.

5. What Was the Cause and Treatment of the Second Delirium Episode?  

Because organic causes and persistent intraabdominal sepsis were unlikely, withdrawal syndrome was considered the most likely cause of this delirium episode. Benzodiazepine withdrawal syndrome could also have contributed to the first episode of delirium as a predisposing factor in addition to sepsis. The patient had been taking bromazepam chronically but had not received it since the second operation. She had also received 8 days of continuous intravenous sedation with midazolam while being mechanically ventilated. She was therefore at high risk of developing benzodiazepine withdrawal syndrome. 25 Opioid withdrawal could not be excluded, because fentanyl was administered intravenously for 8 days. 25 Nicotine withdrawal has also been reported in ICU patients, 26 but a nicotine patch failed to reverse the delirium in this case. Bromazepam was then administered orally and the delirium resolved within 2 h. The patient was discharged from the hospital 8 days later and remains well 1 yr later.

6. How Can Postoperative Delirium Be Treated or Prevented in Elderly Patients?  

Only dangerous agitation associated with delirium requires emergent pharmacologic intervention, whereas alternative strategies, including searching for an organic cause, must be considered first. Because of increased sensitivity of elderly persons to drugs, starting with small dosages and titration to effect is advised. 14 Neuroleptics such as haloperidol, a well-tolerated, easily titratable, nonrespiratory depressant butyrophenone antipsychotic, can be used for sedation. 27 In a randomized placebo-controlled trial, haloperidol prophylaxis decreased the severity and duration, but not the incidence, of postoperative delirium in high-risk elderly patients undergoing hip replacement. 28 Implementation of a delirium assessment tool in the ICU can reduce haloperidol use by allowing considerable reduction in the dosage and duration of treatment. 29 Reduced incidence of delirium in hospitalized elderly patients can be achieved by management of cognitive dysfunction, sleep deprivation, immobility, visual and hearing impairment, and dehydration. 30 Preventive strategies, such as preservation of sleep and multimodal physiotherapy, should be considered as well. Recently, a strategy for rehabilitation consisting of interruption of sedation and physical and occupational therapy during the early days of critical illness resulted in a reduction in the duration of delirium in ICU patients. 31 Sleep deprivation is also a common cause of delirium in ICU patients, who exhibit both qualitative and quantitative alterations of sleep. 32 Sleep disorders predispose to development of cognitive dysfunction in ICU patients, 2 such that improving sleep quality is an important goal. The α2-adrenoceptor agonist dexmedetomidine increases the number of delirium-free days in mechanically ventilated ICU patients and could become the preferred strategy for sedation in the ICU. 33  

The etiology of delirium, particularly in the postoperative period, is most often multifactorial and difficult to diagnose. 34 Interactions between patient risk factors, medical illness, and therapy can produce such a complex neuropsychiatric syndrome. Drugs are one of the most common causes and one of the most treatable. The risk of drug-induced delirium is high in hospitalized elders in whom polypharmacy, altered pharmacokinetics and pharmacokinetics, and underlying pathology all interact to cause delirium. 14 Many drugs have been implicated, but central nervous system active drugs, all commonly used in the perioperative period, are most often implicated.

Although the mechanisms of drug-induced delirium are not well defined, imbalances in major cortical and subcortical neurotransmitter systems are probably important. Disturbances in multiple neurotransmitters have been implicated in delirium, but the neurochemical basis of delirium is most often explained by a deficit in cholinergic transmission (“cholinergic hypothesis”). 35 Acetylcholine plays important roles in attention, consciousness, and memory, and it is critically affected in dementia. Alterations in cholinergic system function are supported by the observations that anticholinergic intoxication produces a delirium that can be reversed by cholinesterase inhibitors and by the propensity of antimuscarinic drugs to induce delirium. Indeed, a number of drugs associated with delirium have marked antimuscarinic side effects. Serum anticholinergic activity can be used to indicate a patient's net anticholinergic load from drugs and endogenous sources and has been positively correlated with delirium symptoms. 36 Anticholinergic effects have also been implicated in postoperative cognitive impairment. 37 But the pathophysiology is clearly more complicated because cholinesterase inhibitors do not typically treat or prevent postoperative delirium. Nonpharmacologic factors, such as ischemia or inflammation, can also contribute to postoperative delirium ( fig. 2 ).

Fig. 2. Hypotheses for neuropathogenesis of delirium in elderly surgical patients. Activation ( ascending arrows  ) or inhibition ( descending arrows  ) of neurotransmitters, cytokines, and hormones by various factors (medications, withdrawal syndrome, sleep disorders, organ failure, inflammation, sepsis, and so on) can contribute to postoperative delirium in elder patients undergoing anesthesia and surgery. GABA =γ-aminobutyric acid.

Alterations in neurotransmission involving the γ-aminobutyric acid, glutamate, and the monoamines (serotonin, norepinephrine, and dopamine) have also been linked to the pathogenesis of delirium, which is not that surprising, given the multiple interactions between these systems. A number of sedative/hypnotics including inhaled anesthetics, propofol, and benzodiazepines potentiate γ-aminobutyric acid-mediated transmission through γ-aminobutyric acid type A receptors in the central nervous system. The monoamine transmitters have prominent neuromodulatory roles in regulating cognitive function, arousal, sleep, and mood, and they are modulated by cholinergic pathways. An excess of dopaminergic transmission has been implicated in hyperactive delirium, which can respond to antipsychotic dopamine receptor antagonists such as haloperidol. There seems to be an inverse relationship between acetylcholine and dopamine system activity in delirium, and the terminal fields of these transmitters overlap extensively in the brain. Antiparkinsonian drugs such as levodopa can induce delirium, and dopamine antagonists can treat its symptoms. Both increases and decreases in serotonin signaling have been associated with delirium, which can be induced by selective serotonin reuptake inhibitors. Excessive norepinephrine has also been associated with hyperactive delirium.

For elderly patients, a surgical procedure is an acute event with potential life- and autonomy-threatening adverse outcomes. Prevention of cardiovascular events and stroke, postoperative delirium, poor nutrition, and loss of autonomy represent associated challenges for frail elderly patients in the perioperative period.

Delirium occurs more frequently with advancing age, but the underlying mechanisms are not clearly understood. Patients with increased postoperative delirium risk require specific attention. Numerous conditions are associated with postoperative delirium, which require specific attention as well. 34 A validated model of delirium prediction has been reported based on four criteria evaluated using specific scales, including illness severity (Acute Physiology and Chronic Health Evaluation Score), 38 visual impairment (Snellen test), 39 cognitive impairment (Mini Mental State Evaluation Score), 40 and serum urea/creatinine ratio. 41 For hip fracture surgery, postoperative delirium was reported in 37% of patients in the high-risk group compared with 3.8% in the low-risk group. 42  

In addition to these factors, cognitive impairment is the strongest factor associated with postoperative delirium; dementia and delirium are closely related. First, their symptoms strongly overlap, and time is required to get a valuable neuropsychological evaluation far from the acute episode. Second, patients with dementia are highly prone to delirium. 43 Third, half the patients undergoing delirium will develop dementia. 44 Finally, dementia can sometimes be difficult to diagnose, because elderly patients with a starting dementia can erroneously be considered normal because of compensatory mechanisms. Delirium was reported as a sign of undetected dementia with a 55% incidence 2 yr later in a small study 44 and might accelerate the trajectory of cognitive decline in patients with Alzheimer disease. 45  

Preoperative depression increases the risk for postoperative delirium. 46 In vascular surgery, patients with postoperative delirium had higher preoperative scores of depressive symptoms, using the Hamilton Depression Scale. 47 In younger patients, delirium was associated with depression using the preoperative Geriatric Depression Scale—Short Form Score 48 or the Beck Depression Inventory. 49 Recently, patients with an overlap syndrome of delirium and depressive symptoms had a particularly poor outcome prognosis including nursing home placement, 1 yr death, and 1 month functional decline. 50 Simple questions about memory complaints, activities of daily living, depressive symptoms, excessive familial or professional help, as well as previous postoperative delirium or drug-induced delirium provide crucial information for anesthesiologists. Some scales give clear information about global cognitive function (Mini Mental State Evaluation), 40 depression (Geriatric Depression Scale-short form), 51 and autonomy (Activity of Daily Living and Instrumental Activity of Daily Living Scales). 52,53 They are the cornerstones of most geriatric assessments, but physicians must be trained in their use.

A focus about assessment of autonomy in elderly patients is crucial for global and cognitive evaluation. First, a loss of physical or cognitive autonomy is always a disease-associated condition. Ageing people without any disease do not need help for reading (look for the glasses and search for cataract or macular degeneration), hearing (look for hearing aids and search for ear wax), feeding (search for depression or underlying disease or treatment), or thinking (search for dementia and depression) for example. Second, dementia criteria require loss of autonomy, and attention of physician to dementia is frequently drawn by loss of autonomy. Finally, use of validated scales (Activity of Daily Living or Instrumental Activity of Daily Living) highlights points frequently considered as nonsignificant by family or caregivers. However, evaluation of autonomy depends on the sociocultural level and requires specific questions depending on individual past activities or hobbies. Most importantly, a loss of autonomy is never an age-related normality but always a disease-associated symptom. For example, in this case, a cognitive assessment could have been discussed in the presence of difficulties for financial or medication management, looking for possible cognitive dysfunction related to vascular disease or age-related neurodegenerative disease. Whether a diagnosis of dementia should be made before surgery remains unclear because there is no evidence that preoperative treatment of dementia prevents postoperative delirium. This issue is a challenge for future research.

Medication use is another important concern. The role of anesthetics has been discussed previously. Preoperative benzodiazepines are associated with postoperative delirium. 11 Such prescriptions should always be questioned during preoperative assessment, because they are associated with falls or memory complaints. If preoperative medication is chosen, hydroxyzine or small doses of mianserine may be considered. Sudden withdrawal of benzodiazepines is a classic cause of delirium and must be avoided.

Numerous perioperative complications can trigger postoperative delirium. A randomized study reported a reduction of postoperative delirium in patients with hip fracture using a geriatric assessment and care plan (relative risk 0.64, 95% confidence interval 0.37–0.98). 54 This assessment included all parameters considered essential in the perioperative period: central nervous system oxygen delivery, fluid and electrolyte balance, treatment of severe pain, elimination of unnecessary medications, regulation of bowel and bladder function, nutritional intake, early mobilization and rehabilitation, management of postoperative complications, and appropriate environmental stimuli. A recent study in a large cohort confirmed and extended these findings. 55 Those patients could require cognitive assessment at regular intervals after surgery by geriatricians or neurologists.

Although the pathophysiological mechanisms underlying delirium are poorly understood and clearly multifactorial, drugs acting on the cholinergic, γ-aminobutyric acid-mediated, and monaminergic neurotransmitter pathways are frequently involved. Future efforts to clarify these mechanisms and their relationship to other patient factors such as dementia should enhance diagnosis, treatment, and prevention. Collaborative approaches, including anesthesiologists, surgeons, and geriatricians, are essential for optimal management. The link between the perioperative period, postoperative delirium, and long-term postoperative cognitive dysfunction in elderly surgical patients represents an important research area. Finally, data suggest that assessment and early intervention can predict and avoid postoperative delirium in elderly patients. Future directions for preventing postoperative delirium in elderly patients should encourage combined anesthetic/geriatric approaches. The impact of such strategies as the use of pharmacologic agents, the evaluation of preoperative memory and executive functions, or the control of environmental factors on postoperative delirium in elderly surgical patients represent important challenges for future investigations.

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Delirium (nursing).

María de Lourdes Ramírez Echeverría ; Caroline Schoo ; Manju Paul ; Chaddie Doerr .

Affiliations

Last Update: November 19, 2022 .

• Learning Outcome
• List the causes of delirium
• Describe the presentation of delirium
• Summarize the treatment of delirium
• Introduction

Delirium, also known as an acute confessional state, is a clinical syndrome that usually develops in the elderly. It is characterized by an alteration of attention, consciousness, and cognition, with a reduced ability to focus, sustain or shift attention. It develops over a short period of time and fluctuates during the day. The clinical presentation can vary, usually demonstrating psychomotor behavioral disturbances such as hyperactivity or hypoactivity and with impairment in sleep duration and architecture. [1]  

By definition, delirium is caused by an underlying medical condition and is not better explained by another preexisting, evolving, or established neurocognitive disorder. The underlying cause of delirium can vary widely and involve anything that stresses the baseline homeostasis of a vulnerable patient. Examples include substance intoxication or withdrawal, medication side effects, infection, surgery, metabolic derangements, pain, or even simple conditions such as constipation or urinary retention. The diagnosis is often missed due to its subtle clinical manifestation, especially in the hypoactive type. [1]  

Delirium is dangerous, often preventable, and associated with a significant cost burden and increased morbidity and mortality. [2]  Efforts should focus on prevention, early detection, and treatment of the underlying cause. This activity reviews the evaluation and management of delirium and the role of interprofessional team members in collaborating to provide well-coordinated care and improve patient outcomes.

• Nursing Diagnosis
• Belligerent
• Unable to sleep
• Refusing treatment
• Causing disturbance
• Not aware of the reality

Delirium is a manifestation of stress on the function of the central nervous system in a vulnerable patient. The pathophysiology is not fully understood, and there is likely no single etiology. Multiple theories describe potential pathophysiologic causes of delirium, and any single case of delirium probably involves one or more of these theories in a complex and interconnected process. Multifactorial models have been accepted, describing delirium as an interaction of a vulnerable patient with predisposing factors exposed to noxious insults or precipitant factors. [3]

There are two groups of risk factors related to delirium: predisposing and precipitant factors. The most common predisposing factors are older age (older than 70 years), dementia (often not recognized clinically), functional disabilities, male gender, poor vision and hearing, and mild cognitive impairment. Alcohol use disorder and laboratory abnormalities have also been associated with an increased risk. [4]

Precipitating factors will vary. However, medication side effects account for up to 39% of delirium cases. [5]  Many medications can precipitate delirium, especially psychoactive medications or anticholinergic drugs. Helpful references have been developed to aid health care providers in avoiding medications that can precipitate delirium. The American Geriatric Society has published the "2019 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults". [6]  It is a list of medications with potentially harmful side effects for the elderly population, including those likely to cause delirium. A second helpful resource is the website "ACBcalc.com." This website will report the cumulative anticholinergic burden of a patient's medications and offer alternatives with lower anticholinergic activity. [7]  

Other precipitating factors include surgery, anesthesia, hypoxia, untreated pain, infections, acute illness, and an acute exacerbation of chronic illness. If the patient is highly vulnerable, possibly a patient with advanced dementia, smaller disturbances such as constipation, dehydration, sleep deprivation, urinary retention, or minor medical procedures can also precipitate delirium. 

The nature of delirium is transient but can persist in patients with predisposing factors. A systematic review showed that hospital delirium persisted to the time of discharge in 45% of cases and persisted one month later in 33% of cases. [8]

• Risk Factors

The prevalence of delirium is higher in the elderly population. It is a common surgical complication among older adults, with an incidence reported up to 10% to 20% after major elective surgery and up to 50% after high-risk procedures (cardiothoracic and hepatic surgeries). Postoperative delirium is associated with a 7 to 10% increased risk of 30-day mortality and increases hospital stay by 2 or 3 days. [9]  

Delirium in the general population increases health care utilization and is associated with increased complications and poor outcomes. The total health care cost attributable to delirium is estimated at $164 billion annually. In patients presenting to the emergency department with delirium, there is a 70% increased risk of death at six months, and delirium in the ICU is associated with a 2 to 4-fold increased risk of overall mortality. [10]  

Delirium is a potential indicator of a life-threatening illness, and every episode of delirium should be appropriately evaluated. The evaluation involves taking a thorough history, a complete physical exam, laboratory tests, and possible imaging. The test selections should be based on information obtained from the history and physical examination, keeping in mind that delirium is often multifactorial in etiology and can be influenced by a number of predisposing factors, precipitating factors, or both.

Delirium is often referred to in 3 main manifestations. 

1) Hyperactive Delirium: Patients present with increased agitation and sympathetic activity. They can present with hallucinations, delusions, and occasionally combative or uncooperative behavior.

2) Hypoactive Delirium: Patients have increased somnolence and decreased arousal. Hypoactive delirium is dangerous as it is often unrecognized or mistaken for fatigue or depression. It is associated with higher rates of morbidity and mortality. 

3) Mixed Presentation: Patients can fluctuate between Hyperactive and Hypoactive presentations. [3]

Two additional manifestations can be further delineated due to their unique treatment requirements. 

1) Delirium at the End of Life: Also referred to as terminal delirium, it occurs in the final hours to days of life. 

2) Delirium secondary to substance intoxication or withdrawal. For example, delirium is associated with alcohol withdrawal.

Delirium is defined by the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders Fifth Edition) and includes the presence of all of the following criteria: 

• Disturbance in attention and awareness develops acutely and tends to fluctuate in severity.
• At least one additional disturbance in cognition
• Disturbances are not better explained by preexisting dementia.
• Disturbances do not occur in the context of a severely reduced level of arousal or coma.
• Evidence of an underlying organic cause or causes.

Other features include alterations in the sleep-wake cycle, perceptual disturbances, delusions, inappropriate or unsafe behavior, and emotional lability. [11]

When evaluating a patient with delirium, it is crucial to speak with caregivers or other people who know the patient well. Many patients with delirium have underlying dementia, and knowing the baseline functional status of a patient is critical to knowing if acute changes have occurred. Other important questions to ask while taking the history include:

Have there been any changes to medications? Drug-related causes account for up to 39% of delirium cases. [12]  

Have there been any new symptoms such as cough, fever, headache, dysuria, expressions of pain, change in eating, or bowel and urinary habits?

Has there been any sleep deprivation or changes to their environment? 

Have there been any falls? This may prompt the need for brain imaging, particularly in patients that are anticoagulated or have head trauma related to the fall. It may also suggest the need for X-rays to evaluate for bone fractures. 

It is also imperative to carefully review recent and current medications. If possible, avoid drugs known to precipitate and perpetuate delirium, including psychoactive or anticholinergic medications. 

A head-to-toe physical examination should be performed, including but not limited to a cardiac, pulmonary, neurological, mental status, abdominal, musculoskeletal, and skin exam. Vital signs should be evaluated. It is advised to take a targeted approach in the assessment, letting the physical exam findings and medical history inform the type of evaluation performed.

Detection is the first step in evaluation and treatment. The syndrome of delirium presents over hours to days. A recent study estimated that delirium is unrecognized in up to 60% of cases. It is much easier to detect hyperactive delirium because patients will often cause a disturbance in their environment. However, hypoactive delirium is often missed as patients are less disruptive. Caregivers may provide clues to the presence of hypoactive delirium with comments such as "they are sleeping more than usual," "they haven't eaten much in the last few days," or "I'm worried they are depressed, they just stay in their room all day." 

In a monitored setting, several tools have been developed to help detect delirium. One of the tools with the most widespread use is the Confusion Assessment Method (CAM). It has been validated with a sensitivity of 94% to 100% and specificity of 90% to 95% in the  diagnosis of delirium, and it includes the following criteria:

The presence of delirium requires features 1 and 2 and either 3 or 4:

• Acute change in mental status with a fluctuating course
• Inattention (reduced ability to sustain attention and follow conversations)
• Disorganized thinking (problems with memory, orientation, or language)
• Altered level of consciousness (hypervigilance, drowsiness, or stupor) 

The CAM has been adapted for target populations, including the CAM-ICU, which added nonverbal tasks for ventilated patients. Adaptations have also been made for the emergency department and those residing in nursing homes. [13]

Subjecting a delirious patient to medical evaluations can be stress-inducing and perpetuate delirium. It is advised to focus on the most probable diagnostic suspicions first. As an initial step, a complete blood count, arterial blood analysis (if appropriate), complete metabolic panel, and urinalysis are often recommended. Chest radiography, electrocardiography, and bladder scan are also recommended. Additional tests such as a lumbar puncture, electroencephalography, and toxicology studies are useful in select cases. Blood cultures should be taken if the clinician suspects sepsis of an indeterminate origin. Brain imaging may be indicated in some cases but is not routinely required. It is also recommended to evaluate for untreated sources of pain, including constipation. [14]

The diagnosis of delirium is clinically based. There have been studies looking for biomarkers to help diagnose delirium, including inflammatory markers, cortisol, interleukins, and C-reactive protein. However, none have been validated for clinical application, such as diagnosis or monitoring. [15]

• Medical Management

The main treatments for delirium are based on non-pharmacologic interventions as there are no FDA-approved medications for the treatment or prevention of delirium. Preventing delirium from occurring is the most efficacious intervention. Identifying patients at risk for delirium and taking special precautions to prevent delirium is crucial. Non-modifiable risk factors include a history of an underlying neurodegenerative disorder such as dementia and increasing age. Modifiable factors include medications, infections, environmental factors, and reduced sensory input. 

The American Geriatrics Society has supported the Hospital Elder Life Program (HELP), which has been shown to reduce the incidence of delirium in elderly patients. This is an interdisciplinary program with many components. Interventions include decreasing environmental disturbances and prioritizing uninterrupted sleep. During the day, guidelines encourage the use of eyeglasses or hearing aids to optimize hearing and vision, the use of tools to improve orientation, including clocks, calendars to remind individuals where they are, early morning rise times, and adequate fluid intake. It supports frequent mobilization and reduction in "tethers" such as urinary catheters or IV lines that limit mobility. Therapeutic activities such as music therapy are encouraged when appropriate. These strategies are cost-effective and remain the primary treatment for delirium. The HELP program has also been shown to reduce the rate of falls by 42% and reduce hospital costs per patient by $1600 to $3800 (2018 U.S. dollars) and over $16,000 (2018 U.S. dollars) per person-year of long-term care costs in the year following a delirium episode. [16]

While prevention and nonpharmacologic interventions are the mainstays of treatment for delirium, it may occasionally be necessary to utilize pharmacologic treatments, which are only considered appropriate in limited circumstances. Patients suffering from delirium due to substance withdrawal may need the appropriate pharmacologic treatments, for example, using benzodiazepines to treat alcohol withdrawal. Delirium at the end of life can require pharmacologic treatments to alleviate the patient's pain and suffering at the end of life. There are no recommended pharmacologic treatments for hypoactive delirium. A patient with hyperactive delirium whose behavior is a threat to themselves or others may need pharmacologic treatment. It is always appropriate to treat the underlying cause of delirium with necessary medications, such as antibiotics, in the instance of infection. In the case of hyperactive delirium with behaviors presenting a risk to the patient or others, antipsychotics are the recommended first-line treatment if not contraindicated due to another comorbidity. Frequently used options include haloperidol, quetiapine, and risperidone. [17]  

The agent of choice depends on mitigating side effects and the patient's underlying comorbidities. For example, quetiapine would be preferred, and haloperidol would be avoided in patients with Parkinson's disease. [18]  The dose of antipsychotic medications should be optimized and adjusted every day until no longer needed. It is important to monitor a patient's QTc interval with an electrocardiogram as antipsychotics can cause QTc prolongation.

Many medications have been evaluated for the prevention and treatment of delirium; however, multiple studies have shown no clear evidence that they reduce the incidence of delirium compared with placebo, possibly due to the multifactorial etiology of delirium. Melatonin is sometimes used for the desired benefit of regulating sleep patterns and its anti-inflammatory properties. Some studies have shown melatonin use to decrease the incidence of delirium; however, another large metanalysis has shown it has no significant effect. Cholinesterase inhibitors have also been evaluated, but there is minimal evidence to support their efficacy, and potential risks may outweigh the benefits of their use. [2] [17]

• Nursing Management
• Assess mood and behavior
• Educate the family
• Make patient comfortable
• Monitor neurologic exam and vitals
• Ensure the room is quiet
• Diminish stress
• Monitor ECG
• Communicate gently with patient
• Administer prescribed medications
• Provide bowel and bladder care
• Ensure patient is safe
• Ensure patient is hydrated
• Promote sleep hygiene
• Ensure patient has no pain
• Monitor intake and output
• Avoid unnecessary maneuvers
• Watch patient 24/7 to prevent falls
• Re-orient patient during interactions
• Ensure use of visual and hearing aids if needed
• When To Seek Help
• Altered mental status
• Unresponsive
• Unstable vital signs
• Combative behavior
• Outcome Identification
• Alert and stable
• Communicate gently with the patient and re-orient when able
• Coordination of Care

Delirium is a common disorder seen in hospitalized and clinic-based patients and is associated with increased morbidity and mortality. The diagnosis and management of delirium are complex and best done with an interprofessional team that could include a geriatrician, neurologist, psychiatrist, internist, intensivist, nurses, and physical and occupational therapists. Nurses are often the first to detect the presence of delirium and should communicate their concerns as soon as possible with the healthcare team. All providers should maximize efforts to maintain a quiet environment for the patient, maximize sleep at night, encourage mobility, and nutrition, ensure patient safety, and communicate with the patient and family.

Pharmacists and physicians should ensure the patient is not receiving medications that precipitate delirium whenever possible, including psychoactive drugs or anticholinergic effects. Nurses can monitor for signs of pain, encourage consistent use of hearing and visual aids, and minimize nighttime disturbances. Physical and occupational therapists can optimize patient mobility. 

The primary treatment for delirium is based on prevention and non-pharmacologic interventions because there are no FDA-approved medications for the treatment or prevention of delirium.

The Hospital Elder Life Program (HELP) has been shown to reduce the incidence of delirium in elderly patients and reduce falls and overall health care costs. These interventions include identifying at-risk patients, decreasing environmental disturbances, increasing re-orientation interventions, and maximizing mobility. 

Pharmacological agents are used in cases of substance withdrawal-associated delirium, delirium at the end of life, and cases of hyperactive delirium where the patient's behavior is a threat to themselves or others. There should be open communication between the interprofessional team members to ensure that the patient is receiving goal-directed treatment. [Level 5]

The overall prognosis for patients with delirium is guarded.

• Health Teaching and Health Promotion

Delirium is a sign that something may be wrong and should be appropriately evaluated. 

Preventing delirium is important, and monitoring intake and output, treating pain, optimizing sleep, and using hearing and visual aids as needed can help prevent and treat delirium. 

It is essential to monitor for hypoactive as well as hyperactive delirium. 

• Discharge Planning
• Alert and mentally stable
• No confusion
• Pearls and Other issues

Early detection is essential, and delirium is often first detected by nursing staff. The nursing staff plays a significant role in preventing and managing delirium, and nonpharmacologic and environmental interventions are the mainstay of treatments. 

• Review Questions
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• Comment on this article.

Disclosure: María de Lourdes Ramírez Echeverría declares no relevant financial relationships with ineligible companies.

Disclosure: Caroline Schoo declares no relevant financial relationships with ineligible companies.

Disclosure: Manju Paul declares no relevant financial relationships with ineligible companies.

Disclosure: Chaddie Doerr declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Ramírez Echeverría MdL, Schoo C, Paul M, et al. Delirium (Nursing) [Updated 2022 Nov 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Delirium or Dementia?

Case objectives.

• State the key diagnostic differences between delirium and dementia.
• Describe the Confusion Assessment Method for workup of suspected delirium.
• Explain the risks associated with using physical restraints in geriatric inpatients.
• Describe the initial workup of delirium in a hospitalized patient.

Case & Commentary: Part 1

An 86-year-old woman, admitted with complaints of shortness of breath and cough, was found to have pneumonia. Her past medical history included cataract surgery, hypertension controlled with medications, and type 2 diabetes controlled by diet. She was ambulatory, lived alone, and at baseline completed all activities of daily living independently. According to her daughter, the patient was never disoriented. At admission, the patient appeared mildly dehydrated on physical examination. Her oxygen saturation was 94% on 2 liters oxygen by nasal cannula, and an arterial blood gas showed a normal pCO2 of 40 mmHg. Her daughter requested to spend the night at the bedside but was told she could not stay.

Overnight, the patient was noted to be disoriented by the nursing staff. She began pulling at her intravenous lines and attempting to get out of bed. The covering physician was called and ordered that the patient be placed in four-point restraints.

The following morning, the daughter returned to find her mother in restraints, speaking incoherently and severely short of breath. Upon finding her mother confused, the daughter asked the nurse what had happened and reiterated to the nurse that her mother had never been confused before.

Elderly hospitalized patients frequently develop altered mental status as a complication of their illness. Distinguishing delirium from dementia is a common problem for physicians, particularly those who work in hospitals or long-term care facilities. Up to 25% of geriatric general ward patients and as many as 80% of intensive care unit patients experience delirium during hospitalization.( 1 ) Upon presentation to the emergency department, 26% of geriatric patients meet diagnostic criteria for delirium.( 2 )

Given the frequency of delirium, all patients should be screened for cognitive functioning at the time of hospital admission. Screening serves two important purposes: to assess for delirium upon admission and to provide a baseline if delirium subsequently develops during the hospitalization.

Delirium in the Hospital

In the inpatient setting, any change in mental status should be considered delirium until proven otherwise. In fact, published guidelines preclude making the diagnosis of dementia in the setting of delirium ( 3 ); thus, diagnosis of dementia should be reserved for the outpatient setting. Although it is not mentioned whether formal cognitive screening was performed in this patient, the patient's excellent functional status and the corroborating information obtained from her daughter make it unlikely that the patient suffered from dementia at baseline.

Prediction rules for delirium have been validated in medical ( 4 ), and non-cardiac ( 5 ) and cardiac surgery ( 6 ) patients. While each patient population has unique attributes, there are several common, important factors. First, preexisting cognitive deficits are the strongest risk factor for delirium.( 4-6 ) Patients with higher burden of illness, as measured by Acute Physiology, Age, and Chronic Health Evaluation (APACHE) scores ( 7,8 ), or comorbidities ( 5,6 ) are at higher risk of delirium. Those with laboratory abnormalities, such as a BUN/creatinine ratio ≥ 18 (a marker of dehydration), decreased albumin, or abnormal sodium, potassium, or glucose ( 4-6 ), are also predisposed to develop delirium. Additionally, patients with preexisting sensory deficits (visual or hearing) are at risk for delirium due to decreased cognitive input. For medical patients, cognitive impairment, acuity of illness, visual changes, and dehydration were combined into a validated prediction rule ( Table ).( 4 ) This patient's pneumonia and dehydration placed her at moderate risk of delirium, even in the absence of preexisting cognitive or visual impairment.

Delirium poses several risks to the patient. First, a delay in diagnosis and assessment of underlying causative factors can cause the underlying condition to fester, resulting in worse physiological function when delirium is discovered. Patients with the hyperactive and mixed variants of delirium (see below for explanation) are at risk for overmedication (particularly sedation). Delirium amplifies the risks of hospitalization and bedrest in older patients, including malnutrition, deconditioning, dehydration, iatrogenic infection (such as catheter-associated urinary tract infection or aspiration pneumonia), pressure ulcers, falls, and iatrogenic events.( 9-11 ) On a larger scale, delirious patients require more staff time ( 12 ), resulting in less staff time for other patients.

As a result of all of these factors, delirium is associated with severe consequences for patients. In fact, the diagnosis of delirium carries a mortality risk equivalent to that of sepsis or an in-hospital acute myocardial infarction.( 11 ) Patients who develop delirium have longer length of stay, increased hospital costs, and increased post-hospitalization costs.( 13,14 ) In a recent analysis, patients who developed delirium accrued $16,000 to $64,000 in additional medical costs over the year following hospitalization compared to age-, gender-, and comorbidity-matched controls.( 15 )

There are three psychomotor variants of delirium: hyperactive (prevalence, 25%), hypoactive (prevalence, 50%), and mixed disorder, with features of both (prevalence, 25%).( 16 ) This patient appeared to have the hyperactive form of delirium. As mentioned above, patients with the hyperactive and mixed disorders are more likely to be physically and chemically restrained. Indeed, this patient was placed in physical restraints when she became confused and hyperactive. The Joint Commission has published standards for restraint use. The key elements of the standards' implementation are "the device's intended use (such as physical restriction), its involuntary application, and/or the identified patient need that determines whether use of the device triggers the application of these standards."( 17 ) As such, consideration should be given to the following questions prior to restraining a patient:

• What is the intended effect of the restraint?
• Is there another means by which the intended effect can be achieved?
• Is this the least invasive restraint?
• Is the use of restraints in the patient's best interest?
• Am I restraining the patient for secondary benefits (to limit phone calls/pages, to assuage nursing requests, too busy to see patient, etc.)?
• When is the restraint going to be removed?

Although necessary at times, the use of restraints must be considered carefully prior to application for three key reasons. First, restraints have been found to be independently associated with the development of delirium.( 18,19 ) Second, restraints may exacerbate underlying hyperactive behavior. Finally, by restricting patients to bedrest, restraints further limit external stimuli, which in itself may increase the risk for delirium.( 20 )

Case & Commentary: Part 2

The doctor was called, and an arterial blood gas was performed. The patient's PaO2 was 91 mmHg, but the PaCo2 was 58 mmHg, a marked increase since admission. Despite the patient's deteriorating clinical condition, the patient's worsening level of consciousness was attributed to "senile dementia" and not impending respiratory failure (as evidenced by the significant carbon dioxide retention). No further action was taken. Over the course of the day, the patient developed worsening respiratory distress and became comatose, and eventually was transferred to the intensive care unit. She subsequently developed respiratory failure requiring intubation and renal failure requiring dialysis. Her condition did not significantly improve, and she eventually died 2 weeks later.

This patient was incorrectly diagnosed with dementia, despite a presentation most consistent with delirium. The diagnosis of delirium follows the diagnostic algorithm of the Confusion Assessment Method (CAM) and involves elements of history and physical examination.( 21 ) The CAM algorithm has four features ( Figure ):

• Feature 1 is acute onset and fluctuating course . Presence of this feature can generally be obtained from family and nursing history.
• Feature 2, inattention , is assessed through brief cognitive assessment such as serial 7s (take the number 100 and subtract 7, keep going until I tell you to stop); digit span (I am going to read you some numbers and I want you to repeat them to me backwards); or asking the patient to recite months of the year or days of the week backwards.
• Feature 3, disorganized thinking , can be assessed via response to interview questions. For example, does the patient respond inappropriately or tangentially?
• Feature 4, disturbance of consciousness , helps identify the three psychomotor variants (hyperactive, hypoactive, mixed disorder).

Patients demonstrating features 1 and 2 along with either feature 3 or 4 should be considered to have delirium until proven otherwise.( 11 ) The diagnosis of "senile dementia" is not appropriate in the setting of acute illness. The acute onset of confusion and hyperactivity in this case should have prompted cognitive assessment for inattention and disorganized thinking; such an assessment would likely have led to the correct diagnosis of delirium.

A thorough history and physical examination are required for patients suspected of having delirium. The neurological examination is especially important because while acute, focal neurological changes require neuroimaging, patients without such changes can usually have neuroimaging deferred, reserved for situations in which the cause cannot be determined from a medical/metabolic workup.( 22 ) Core laboratory tests to identify electrolyte abnormalities, renal function, and infection (complete blood count and urinalysis) are warranted in all patients. The history and physical examination should guide further laboratory testing. An arterial blood gas was appropriately performed in this case, but it appears that the physician failed to tie the results (marked carbon dioxide retention) together with the patient's delirium.

All patients should have a thorough review of medications that may contribute to delirium, particularly benzodiazepines, anticholinergic medications, and psychoactive medications.( 23 ) All medications that can precipitate delirium should be discontinued or have dosages lowered. Further consideration should be given to drugs that have recently been stopped and may cause a withdrawal syndrome (alcohol, chronic opioids, antidepressants, etc.).

Delirium is treated by identifying and remedying the underlying causes. Because of the associated morbidity and mortality, multiple causative pathways and treatments may need to be pursued and/or instituted simultaneously. Such causes might include electrolyte abnormalities, assessment of renal function, additional workup for other sources of infection (urinalysis or lumbar puncture if indicated), fecal impaction, and other myocardial/pulmonary causes of hypoxemia.

In this case, the best single explanation for the patient's deterioration is progressive pneumonia resulting in worsened gas exchange and carbon dioxide retention. Thus, delirium was likely the presenting symptom of impending hypercarbic respiratory failure. More aggressive treatment of the pneumonia and associated CO2 retention was warranted. Additionally, medication review should have been conducted, resulting in the removal of sedative or anticholinergic medications. It is unclear why further workup or treatment was not pursued in this case.

In this case, the patient's daughter was able to inform clinicians that her mother had never been confused or disoriented prior to hospitalization. In addition to their role in establishing the historical, behavioral, and cognitive baseline, family members and caregivers are an underutilized resource in the treatment of patients with delirium. For example, family members serve as a re-orienting stimulus for patients. In an average day on a hospital medical ward, 20-30 different staff members will enter a patient's room (nursing, nutrition, housekeeping, housestaff, consultants, attending physicians, etc.). As a result, patients with impaired cognition may misinterpret the in-room presence of these staff members, leading to paranoid thoughts and delusions. Family members or caregivers may be the only people whom the patient recognizes and, thus, can serve to reassure the patient about his or her current location and medical situation. Family or caregivers can also provide cognitive stimulation for the patient, such as by playing cards, doing crossword puzzles together, or viewing family photos. Additionally, family may be willing to participate in the care of the patient, which may reduce patient agitation, provide a constructive outlet for family concern, and decrease staff requirements.( 24 ) As a result, family should be involved in the care of the delirious patient to the extent possible. Formal "visiting hours" may need to be relaxed or eliminated to ensure that the family is able to be present to calm the patient during periods of confusion.

The failure to recognize delirium in this patient may have delayed recognition of her worsening pneumonia, which in turn led to a failure to escalate the level of care. Cognitive assessment at admission and appropriate use of collateral information from the patient's daughter might have helped the physician realize that the patient's altered mental status represented delirium and not dementia. Delirium is associated with severe clinical consequences, so earlier recognition of delirium should have prompted a thorough search for precipitants and aggressive treatment of the underlying illness. Actively encouraging the family's participation in care may have helped identify delirium earlier and may have obviated the need for physical restraints in this case. In short, this patient's death may have been preventable with optimal care; as such, this case represents an instructive cautionary note.

Take-Home Points

• Delirium, an acute change in cognition and attention, is common, morbid, and costly.
• All change in mental status should be assumed to be delirium until proven otherwise.
• The treatment of delirium is to identify and remedy the underlying causes.
• Elements of the hospital environment can contribute to delirium and expose patients to safety risk.
• Family members and caregivers are crucial to the diagnosis and management of delirium. Incorporating their contribution into the plan of care is strongly recommended.

James L. Rudolph, MD, SM Assistant Professor of Medicine

Harvard Medical School

Associate Physician

Brigham and Women's Hospital

Staff Physician

VA Boston Healthcare System

Faculty Disclosure: Dr. Rudolph has declared that neither he, nor any immediate member of his family, has a financial arrangement or other relationship with the manufacturers of any commercial products discussed in this continuing medical education activity. In addition, the commentary does not include information regarding investigational or off-label use of pharmaceutical products or medical devices.

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15. Leslie DL, Marcantonio ER, Zhang Y, Leo-Summers L, Inouye SK. One-year health care costs associated with delirium in the elderly population. Arch Intern Med. 2008;168:27-32. [go to PubMed]

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17. Provision of care, treatment, and services. Standards 11.10-100. In: Comprehensive Accreditation Manual for Hospitals. The Joint Commission; 2008: PC-25-26. ISBN: 978-1599401263.

18. McCusker J, Cole M, Abrahamowicz M, Han L, Podoba JE, Ramman-Haddad L. Environmental risk factors for delirium in hospitalized older people. J Am Geriatr Soc 2001;49:1327-1334. [go to PubMed]

19. Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA. 1996;275:852-857. [go to PubMed]

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21. Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113:941-948. [go to PubMed]

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23. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med. 2003;163:2716-2724. [go to PubMed]

24. Cole MG, Primeau FJ, Bailey RF, et al. Systematic intervention for elderly inpatients with delirium: a randomized trial. CMAJ. 1994;151:965-970. [go to PubMed]

Table. Delirium Prediction Rule for Patients Based on Admission Characteristics.( 4 )

The points are added. The incidence of delirium in patients scoring 0 points is 3-9%, 1-2 points is 16-23%, and for ≥ 3 points is 32-83%. MMSE, Mini Mental State Examination; APACHE, Acute Physiology, Age, and Chronic Health Evaluation.

Figure. The Confusion Assessment Method (CAM) for the diagnosis of delirium. Diagnosis of delirium using the CAM requires the presence of both features 1 and 2, and either feature 3 or 4.

This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers

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• Introduction
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The group with moderate to severe dementia included 10 999 community-dwelling people; the group with mild dementia, 16 265 community-dwelling people. SMD indicates standardized mean difference. An absolute SMD of 0.10 or less was considered an acceptable balance of covariates between surgical and nonsurgical treatment groups. ECI indicates Elixhauser Comorbidity Index.

eFigure 1. Cohort Selection Flowchart

eFigure 2. Covariate Balance Before and After IPTW for Patients With Pertrochanteric Fracture

eFigure 3. Covariate Balance Before and After IPTW for Patients With Subtrochanteric Fracture

eFigure 4. Covariate Balance Before and After IPTW for Patients With Fractures in Multiple Locations

eTable 1. Standardized Mean Difference for Crude and IPTW Data by Fracture Location

eTable 2. Unadjusted and Adjusted Likelihood of Outcomes of Community-Dwelling People With Moderate to Severe Dementia Treated Surgically vs Nonsurgically, by Hip Fracture Location

eTable 3. Unadjusted and Adjusted Likelihood of Outcomes of Community-Dwelling People Mild With Dementia Treated Surgically vs Nonsurgically, by Hip Fracture Location

eTable 4. Unadjusted and Adjusted Likelihood of Outcomes of Community-Dwelling People With Dementia Treated Surgically vs Nonsurgically, by Hip Fracture Location and Dementia Severity

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Adler RR , Xiang L , Shah SK, et al. Hip Fracture Treatment and Outcomes Among Community-Dwelling People Living With Dementia. JAMA Netw Open. 2024;7(5):e2413878. doi:10.1001/jamanetworkopen.2024.13878

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Hip Fracture Treatment and Outcomes Among Community-Dwelling People Living With Dementia

• 1 Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
• 2 Division of Vascular Surgery, University of Florida, Gainesville
• 3 Division of Surgical Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina
• 4 Hebrew SeniorLife, Marcus Institute for Aging Research, Boston, Massachusetts
• 5 Mongan Institute Health Policy Center, Mass General Research Institute, Boston, Massachusetts
• 6 Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
• 7 Health Decision Sciences Center, Massachusetts General Hospital, Harvard Medical School, Boston
• 8 Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts

Question   What are the outcomes among community-dwelling people with dementia who are treated surgically compared with nonsurgically for hip fracture?

Findings   In this cross-sectional study of 56 209 community-dwelling patients living with dementia, those treated surgically for fracture of the femoral neck and head experienced reduced mortality; no significant differences were found for other hip fracture locations.

Meaning   These data can help inform discussions around values and goals with patients and caregivers when determining the optimal treatment approach in this population.

Importance   The decision for surgical vs nonsurgical treatment for hip fracture can be complicated among community-dwelling people living with dementia.

Objective   To compare outcomes of community-dwelling people living with dementia treated surgically and nonsurgically for hip fracture.

Design, Setting, and Participants   This retrospective cross-sectional study undertook a population-based analysis of national Medicare fee-for-service data. Participants included community-dwelling Medicare beneficiaries with dementia and an inpatient claim for hip fracture from January 1, 2017, to June 30, 2018. Analyses were conducted from November 10, 2022, to October 17, 2023.

Exposure   Surgical vs nonsurgical treatment for hip fracture.

Main Outcomes and Measures   The primary outcome was mortality within 30, 90, and 180 days. Secondary outcomes consisted of selected post–acute care services.

Results   Of 56 209 patients identified with hip fracture (73.0% women; mean [SD] age, 86.4 [7.0] years), 33 142 (59.0%) were treated surgically and 23 067 (41.0%) were treated nonsurgically. Among patients treated surgically, 73.3% had a fracture of the femoral head and neck and 40.2% had moderate to severe dementia (MSD). Among patients with MSD and femoral head and neck fracture, 180-day mortality was 31.8% (surgical treatment) vs 45.7% (nonsurgical treatment). For patients with MSD treated surgically vs nonsurgically, the unadjusted odds ratio (OR) of 180-day mortality was 0.56 (95% CI, 0.49-0.62; P  < .001) and the adjusted OR was 0.59 (95% CI, 0.53-0.66; P  < .001). Among patients with mild dementia and femoral head and neck fracture, 180-day mortality was 26.5% (surgical treatment) vs 34.9% (nonsurgical treatment). For patients with mild dementia who were treated surgically vs nonsurgically for femoral head and neck fracture, the unadjusted OR of 180-day mortality was 0.67 (95% CI, 0.60-0.76; P  < .001) and the adjusted OR was 0.71 (95% CI, 0.63-0.79; P  < .001). For patients with femoral head and neck fracture, there was no difference in admission to a nursing home within 180 days when treated surgically vs nonsurgically.

Conclusions and Relevance   In this cohort study of community-dwelling patients with dementia and fracture of the femoral head and neck, patients with MSD and mild dementia treated surgically experienced lower odds of death compared with patients treated nonsurgically. Although avoiding nursing home admission is important to persons living with dementia, being treated surgically for hip fracture did not necessarily confer a benefit in that regard. These data can help inform discussions around values and goals with patients and caregivers when determining the optimal treatment approach.

Hip fracture among older adults often results in decreased independence and quality of life. 1 , 2 Surgery is a potential treatment option, yet people living with dementia undergoing this operation experience higher mortality, 2 - 4 delirium, 2 , 5 and postoperative complications, 2 , 6 with a consequent greater loss of mobility compared with persons without cognitive difficulties. 2 , 7 Much less is known about what happens to patients with hip fractures who do not have surgery. Among patients with advanced dementia residing in nursing homes, one study found that patients who are treated surgically live longer than those who are treated nonsurgically. 8 However, the majority of people with dementia reside in the community. 9 Therefore, this study examined the outcomes of surgical treatment compared with nonsurgical treatment of hip fracture among community-dwelling people living with dementia. In line with prior research, we hypothesized that community-dwelling people living with dementia who received surgical intervention for hip fracture would experience superior survival and patient-centered outcomes compared with those managed nonsurgically. To provide further insight into potential impacts on clinical care, we examined outcomes by fracture location and dementia severity. Results from this study may inform treatment decisions around fracture care for people living with dementia, which must balance cognition, mobility, and survival while accounting for baseline cognitive and physical functioning. 10

In this retrospective cross-sectional study of Medicare claims data, we identified community-dwelling people living with dementia who had new hip fracture diagnoses between January 1, 2017, and June 30, 2018, with a look-back period of 1 year. Data were accrued from the following Medicare data files covering claims from January 1, 2016, to December 31, 2018: Master Beneficiary Summary File, Carrier, Inpatient, Outpatient, Skilled Nursing Facility (SNF), Home Health, Outcome and Assessment Information Set, Minimum Data Set (MDS; which tracks patients in SNFs and nursing homes), Durable Medical Equipment, Hospice, and Medicare Data on Physician Practice and Specialty. The Institutional Review Board of Mass General Brigham, Boston, Massachusetts, approved this protocol and granted a waiver of consent for the use of claims data under a data use agreement. We followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

We used the Inpatient, Outpatient, Carrier, Hospice, Home Health, and SNF files to determine dementia diagnosis, and the Inpatient files to identify hip fracture diagnoses. To identify people living with dementia, we used a validated list of International Statistical Classification of Diseases, Tenth Revision ( ICD-10 ), diagnosis codes. 11 To identify hip fractures, we used an established list of International Classification of Diseases, Ninth Revision ( ICD-9 ), diagnosis codes 8 , 12 that were converted to ICD-10 codes and reviewed by one of the authors (A.J.S.), an orthopedic surgeon. Our algorithm for hip fractures followed best practices to optimize identification of fractures that indicate surgery. 13 Because surgical and rehabilitation strategies may vary by fracture location, we categorized hip fractures into 4 location types: femoral neck and head, pertrochanteric, subtrochanteric, and multiple (>1). We identified patients treated surgically using an established list of ICD-10 procedure codes that were converted from ICD-9 codes 12 and reviewed by the orthopedic surgeon (A.J.S.). For each patient, the earliest admission with hip fracture diagnosis during the study period was defined as index admission. We considered patients with no MDS assessment in the 180 days before the hip fracture diagnosis to be community-dwelling. The MDS assessment is conducted on admission, at discharge, and at a minimum quarterly during an SNF or a nursing home stay, 14 and lack of MDS assessment has been used to identify community-dwelling patients. 15 We included beneficiaries 66 years or older at the index admission and with 6 months of continuous fee-for-service postfracture coverage and 1 year of continuous fee-for-service prefracture coverage, allowing for a 1-month gap in the year prior. We excluded beneficiaries with invalid or missing dates, invalid admission type, or missing urbanicity information from the analysis. A flowchart of cohort selection is found in eFigure 1 in Supplement 1 .

We used the Master Beneficiary Summary File and Inpatient file to identify mortality. In-hospital delirium was identified in Inpatient files using established ICD-10 diagnosis codes. 16 , 17 We defined hospice referral as a new hospice claim in the 180 days after discharge 8 among patients discharged alive, and home health services as a new home health claim within 10 days after discharge 18 among patients still alive at 10 days post discharge. Intensive interventions included new dialysis, intubation, resuscitation, mechanical ventilation, or feeding tube insertion 19 in any Inpatient, SNF, or Outpatient claims any time after hip fracture diagnosis until death or end of the follow-up period. We identified persons admitted to SNF and nursing homes, respectively, using Medicare Parts A and B data to differentiate between SNF stays with rehabilitation services and plans to return to the community compared with nursing home admissions in which persons reside in a nursing home without plans for rehabilitation and return to living in the community. 20

To provide comparability between the surgical and nonsurgical treatment groups, inverse propensity for treatment weighting (IPTW) for patients were calculated in 8 study subgroups. The subgroups were determined by hip fracture location type and dementia severity 21 (mild or moderate to severe). The Claims-Based Frailty Index 22 has been validated to categorize dementia severity 21 based on Functional Assessment Staging Test stages. In the logistic models to estimate IPTW, we controlled for patient characteristics included in Medicare database files that may have influenced the decision to operate, including admission source, age, dual eligibility status, Elixhauser Comorbidity Index for mortality, 23 geographic location (metropolitan or nonmetropolitan), race and ethnicity, and sex. Race and ethnicity were included as covariates because they have been linked to risk for surgery. The range for the Elixhauser Comorbidity Index for mortality is −59 to 171, where a higher score indicates more comorbidities present on admission during the index hospitalization.

Analyses were conducted between November 10, 2022, and October 17, 2023. Continuous data were described using means and SEs, while categorical data were described using frequencies and percentages. Standardized mean differences were used to assess the differences in variables between surgical and nonsurgical treatment groups. An absolute standardized mean difference of 0.10 or less was considered acceptable balance. Unadjusted and adjusted analyses were conducted to examine the associations between treatment groups and outcomes, stratified by hip fracture location and dementia severity. Love plots were generated to compare the balance of covariates between treatment groups before and after IPTW. For ease of display, we present results for head and neck fractures in the Figure and results for other fracture locations in eFigures 2 to 4 in Supplement 1 .

Generalized estimation equations were used to account for clustering within hospitals in examining the unadjusted and adjusted associations between surgical treatment and binary outcomes of mortality, in-hospital delirium, new hospice referral, and new home health services use. Kaplan-Meier curves and IPTW Kaplan-Meier curves, 24 accounting for death as a competing risk, were calculated to obtain the unadjusted and adjusted proportions of intensive interventions, 19 SNF admission, 20 and nursing home admission 20 at 3 points (30, 90, and 180 days) after discharge from the index admission (maximum follow-up time, 180 days). To provide a more interpretable outcome, we conducted survival analysis first, and then instead of hazard ratios, we reported the probabilities (cumulative incidence function estimates) of outcomes within 30, 90, and 180 days by extracting numbers from a cumulative incidence table derived from survival analysis using the BASELINE statement in SAS. Because our analyses were based on preplanned hypotheses, we did not adjust the P values 25 and therefore considered a 2-sided P < .05 to be statistically significant. All data and Love plots were analyzed using SAS, version 9.4 (SAS Institute Inc).

We identified 56 209 community-dwelling individuals with dementia who had a hip fracture diagnosis in Inpatient claims during the study period. The mean (SD) age of the cohort was 86.4 (7.0) years; 73.0% were women, and 27.0% were men. In terms of race and ethnicity, 2.2% of the individuals were Alaska Native, American Indian, or Asian; 4.2% were Hispanic; 4.0% were non-Hispanic Black; 89.0% were non-Hispanic White; and 0.6% were of other (ie, not further identified) or unknown race or ethnicity. Among the study population, 33 142 (59.0%) were treated surgically, and 23 067 (41.0%) received nonsurgical treatment. Among patients treated surgically, most had a femoral head and neck fracture (73.3%), while most patients treated nonsurgically had a pertrochanteric fracture (78.5%). Among patients who were treated surgically, 40.2% had MSD, whereas 42.8% who were treated nonsurgically had MSD. The Elixhauser Comorbidity Index mortality score was similar in each group, with a mean (SD) of 12.4 (15.8) among patients who were treated nonsurgically and 11.6 (15.1) among patients who were treated surgically ( Table 1 ). The Figure shows the covariate balance before and after IPTW for patients with femoral head and neck fracture; eFigures 2 to 4 in Supplement 1 show the covariate balance before and after IPTW for patients with pertrochanteric, subtrochanteric, and multiple fracture locations. eTable 1 in Supplement 1 reports the crude and weighted standardized mean difference for each fracture location.

Among people living with dementia who had femoral head and neck fracture, surgery was associated with lower unadjusted odds of death compared with no surgery for patients with both MSD and mild dementia at 30, 90, and 180 days after hip fracture diagnosis ( Table 2 ), with 180-day mortality of 31.8% of those receiving surgical treatment compared with 45.7% for those receiving nonsurgical treatment (unadjusted odds ratio [OR], 0.56 [95% CI, 0.49-0.62]; P  < .001). Among patients with mild dementia and femoral head and neck fracture, 180-day mortality was 26.5% for those receiving surgical treatment vs 34.9% for those receiving nonsurgical treatment (unadjusted OR, 0.67 [95% CI, 0.60-0.76]; P  < .001). After applying the IPTW model for adjustment, relative odds of death for people living with dementia treated surgically vs nonsurgically remained lower for both groups at 30 days (adjusted OR [AOR] for MSD, 0.33 [95% CI, 0.29-0.38; P  < .001]; AOR for mild dementia, 0.39 [95% CI, 0.34-0.45; P  < .001]), 90 days (AOR for MSD, 0.50 [95% CI, 0.44-0.56; P  < .001]; AOR for mild dementia, 0.60 [95% CI, 0.53-0.67; P  < .001]), and 180 days (AOR for MSD, 0.59 [95% CI, 0.53-0.66; P  < .001]; AOR for mild dementia, 0.71 [95% CI, 0.63-0.79; P  < .001]) ( Table 2 ). There were few differences in mortality for patients treated surgically vs nonsurgically for pertrochanteric, subtrochanteric, or multiple fracture locations (eTables 2 and 3 in Supplement 1 ).

In patients with femoral head and neck fractures, surgery was associated with higher odds of in-hospital delirium (AOR, 1.23 [95% CI, 1.06-1.44]; P  = .008) compared with no surgery only for those with MSD ( Table 2 ); there were no significant differences for in-hospital delirium among patients with mild dementia ( Table 2 ) or other fracture locations (eTables 2 and 3 in Supplement 1 ). Patients with both MSD and mild dementia who were treated surgically for femoral head and neck fracture had lower odds of hospice referral compared with those treated nonsurgically (AOR for MSD, 0.69 [95% CI, 0.61-0.79; P  < .001]; AOR for mild dementia, 0.86 [95% CI, 0.77-0.97; P  = .02]) ( Table 2 ). Patients with mild dementia who were treated surgically vs nonsurgically for pertrochanteric and subtrochanteric fractures also had lower odds of hospice referral (eTable 3 in Supplement 1 ). Additionally, only patients with mild dementia who were treated surgically vs nonsurgically for femoral head and neck fracture had lower odds of new home health services use (AOR, 0.78 [95% CI, 0.64-0.95]; P  = .01). There were no differences in new home health services use for patients with MSD who were treated surgically vs nonsurgically for femoral head and neck fracture ( Table 2 ).

In models adjusting for competing risk of death, there were no significant differences in intensive interventions for patients with MSD or mild dementia who were treated surgically vs nonsurgically for any fracture location ( Table 3 and eTable 4 in Supplement 1 ). The risk of admission to an SNF for rehabilitation services within 90 days was significantly higher for people living with dementia who were treated surgically vs nonsurgically for femoral head and neck fractures in both the MSD (surgical management, 66% [95% CI, 65%-67%]; nonsurgical management, 51% [95% CI, 50%-53%]; P  < .001) and mild dementia groups (surgical management, 6% [95% CI, 65%-66%]; nonsurgical management, 58% [95% CI, 56%-60%]; P  < .001) ( Table 3 ); however, there were no significant differences for admission to a nursing home with no rehabilitation services for people living with dementia who were treated surgically vs nonsurgically by dementia severity or any hip fracture location subgroup ( Table 3 and eTable 4 in Supplement 1 ).

In this large national cross-sectional study of community-dwelling people living with dementia who had hip fracture, we found that 59.0% of people living with dementia with hip fracture were treated surgically and 41.0% were treated nonsurgically. Surgical treatment and outcomes varied by fracture location and dementia severity. Surgical treatment of femoral head and neck fractures were associated with reduced mortality and fewer hospice referrals for patients, regardless of dementia severity, but was not associated with improved outcomes for hip fracture location.

Previous studies have reported varying proportions of nonsurgical treatment for hip fracture in similar populations, ranging among 8.1% of patients with advanced dementia 26 to 10.6% of older adults, 27 11.8% of nursing home residents, 28 and 15.2% of nursing home residents with advanced dementia. 8 Though the present study found a greater proportion of people living with dementia who were receiving nonsurgical management (41.0%) than previous studies, it aligns with prior work highlighting a higher prevalence of dementia among patients treated nonsurgically for hip fracture. 27 , 29 In a retrospective study analyzing outcomes of adults older than 70 years, Ishimaru et al 29 reported that 50% of patients treated nonsurgically for hip fractures (femoral neck and pertrochanteric fractures) had dementia compared with 38.2% of patients treated surgically at a single institution. In a similar study of patients older than 65 years who were treated surgically vs nonsurgically for hip fracture (femoral head and neck and pertrochanteric fractures), Jain et al 27 used a population database supplemented with hospital record review and found that 35.5% of the group treated nonsurgically had dementia compared with 25.9% of the group treated surgically. Given these previous findings and the fact that the present study is limited to people living with dementia, it is not surprising that a relatively high proportion of our cohort received nonsurgical management.

Our findings align with and extend previous research indicating lower mortality among older adults treated for hip fracture surgically, 28 , 30 including among nursing home residents with advanced dementia. 8 The findings of the present study suggest that surgery was associated with reduced mortality compared with nonsurgical treatment, but only among community-dwelling people living with dementia who had fracture of the femoral head and neck. This was consistent for both patients with MSD and mild dementia. These findings are in line with those of Berry et al, 8 who reported reduced mortality among nursing home residents with advanced dementia treated surgically for hip fracture compared with patients treated nonsurgically. Interestingly, we found little difference in mortality between patients treated surgically vs nonsurgically for other hip fracture locations. This may stem from differing levels of surgical intensity that may vary depending on the location of hip fracture (eg, femoral head and neck vs pertrochantric) and differences in postoperative rehabilitation strategies, which may contribute to higher risks of complications and other adverse events. 13 , 31 , 32 Femoral head and neck fractures are often treated by arthroplasty, which results in more predictable mobility and thus may have contributed to improved rehabilitation and lower mortality in our cohort.

Delirium is an important outcome because it affects a patient’s quality of life 33 and ability to engage in rehabilitation to improve function and mobility following hip fracture. We found odds of delirium higher for patients with MSD treated surgically vs nonsurgically for fractures of the femoral head and neck, but no differences in delirium for patients with mild dementia or those treated surgically vs nonsurgically with other fracture locations. Delirium in post–acute care settings is associated with poorer functional status recovery 34 and may limit a person’s ability to engage in rehabilitation. These are important considerations given that our study found that more patients who were treated surgically vs nonsurgically were sent to a skilled nursing facility for rehabilitation after the index hospitalization.

Our findings suggest that surgery among people living with dementia who had femoral head and neck fractures was associated with reduced mortality, regardless of dementia severity. When treated surgically, these patients experienced fewer hospice referrals through the end of the study period, and patients with mild dementia experienced less new use of home health services within 10 days of discharge. However, we found little to no survival benefit following surgery or changes among other outcomes among people living with dementia who had hip fractures in other locations. Additionally, we found no difference in nursing home admission (compared with SNF admission) among people living with dementia treated surgically vs nonsurgically for hip fractures in any location, regardless of dementia severity. People living with dementia typically want to remain in the community for as long as possible. 35 , 36 Although many persons treated surgically for hip fracture must transition to SNFs temporarily for rehabilitation purposes, our findings suggest that being treated surgically for hip fracture does not necessarily confer a benefit in terms of avoiding nursing home admission, where rehabilitation services are not offered with the plan for the resident to transition back to living in the community.

Strengths of this study include the large national sample and focus on community-dwelling people living with dementia. Comparing surgical outcomes between people living with dementia and people without dementia is informative but may not provide the data needed for surgical decision-making for people living with dementia, given that clinicians often expect people living with dementia to have poorer outcomes due to the high-risk nature of the patient, and not the procedure. By focusing our analyses solely on outcomes among people living with dementia treated surgically vs nonsurgically for hip fracture and examining differences by fracture location and dementia severity, we provide important information that can be used by people living with dementia, their caregivers, and their clinicians to support shared decision-making regarding optimal care in the period immediately following a hip fracture.

This study has some limitations. First, we relied on administrative data, which has the potential for confounding from unmeasured variables. While data from medical records often contain more clinical context, these data likewise have inherent limitations, including incomplete or missing records, lack of standardized interpretation of structured fields, data stored in unretrievable notes, and lack of national perspective as well as lack of standardized recording practices across health systems. 37 Second, we were unable to assess individual functional status or mobility in relation to treatment strategy or outcomes, which may have influenced management choices or changed as an outcome of the treatment; however, we attempted to mitigate this limitation by incorporating the Claims-Based Frailty Index, which has been validated against physical performance and activities of daily living dependence. 38 , 39 Third, we were unable to examine recovery time, engagement in rehabilitation, or quality of life. Last, we do not have information about care preferences or goals of care, which may have influenced both decisions about surgery and certain outcomes, such as hospice.

In this cohort study of community-dwelling Medicare beneficiaries living with dementia, surgical treatment and outcomes varied by fracture location, with a clear benefit of surgery for people living with dementia who had femoral head and neck fracture and few differences in outcomes between surgical and nonsurgical treatment among other types of hip fractures. These data can help inform discussions around values and goals with patients and caregivers when determining the optimal treatment approach in this population.

Accepted for Publication: March 28, 2024.

Published: May 30, 2024. doi:10.1001/jamanetworkopen.2024.13878

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Adler RR et al. JAMA Network Open .

Corresponding Author: Rachel R. Adler, ScD, RD, Center for Surgery and Public Health, Brigham and Women’s Hospital, One Brigham Circle, 1620 Tremont St, Suite 2-016, Boston, MA 02120 ( [email protected] ).

Author Contributions: Drs Adler and Weissman had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Adler, Clark, Mitchell, Kim, Weissman, Schoenfeld.

Acquisition, analysis, or interpretation of data: Adler, Xiang, Shah, Clark, Cooper, Kim, Hsu, Sepucha, Chunga, Lipsitz, Weissman, Schoenfeld.

Drafting of the manuscript: Adler, Xiang, Shah, Mitchell, Chunga, Lipsitz, Weissman, Schoenfeld.

Critical review of the manuscript for important intellectual content: Shah, Clark, Cooper, Kim, Hsu, Sepucha, Chunga, Lipsitz, Weissman, Schoenfeld.

Statistical analysis: Xiang, Lipsitz, Schoenfeld.

Obtained funding: Adler, Clark, Weissman.

Administrative, technical, or material support: Adler, Shah, Chunga, Weissman, Schoenfeld.

Supervision: Mitchell, Chunga, Weissman, Schoenfeld.

Conflict of Interest Disclosures: Dr Kim reported receiving grant funding from the National Institutes of Health (NIH) and consulting fees from Alosa Health and VillageMD outside the submitted work. Dr Hsu reported receiving consulting fees from Cambridge Health Alliance and AltaMed and fees for keynote speeches from the University of South Carolina and Invitrx outside the submitted work. Dr Schoenfeld reported receiving grant funding from the US Department of Defense and the Orthopedic Research and Education Foundation and personal fees from Wolters Kluwer NV, Springer Nature, and Vertex Pharmaceuticals Incorporated outside the submitted work; and serving as editor in chief of Spine , the editorial board of the Journal of Bone and Joint Surgery , and the board of directors of the North American Spine Society. No other disclosures were reported.

Funding/Support: This study was supported by grant R01AG067507 from the National Institute on Aging (NIA) of the NIH; grant AARF-22-974113 from the Alzheimer’s Association (Dr Adler); and grants P01AG032952, R01AG062282, RF1AG083033, and U01AG076478 from the NIA of the NIH (Dr Hsu).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIA, the NIH, or the Alzheimer’s Association.

Meeting Presentation: This paper was presented at the Annual Research Meeting of the Academy Health; June 24, 2023; Seattle, Washington.

Data Sharing Statement: See Supplement 2 .

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Young El Pasoan balances high school and college to achieve nursing degree from UTEP

Graduating from college is an accomplishment at any age, but for 18-year-old Paris Chacon, it was no easy feat — it took determination, tenacity and sacrifice.

The El Paso native walked across the stage and received her Bachelor of Science in Nursing degree from UTEP on May 12.

“I always loved going to school,” Chacon said. “I truly love to learn.”

Chacon simultaneously earned her college degree while in high school. While at Mission Early College High School, Chacon graduated at just 16 with an associate degree from El Paso Community College.

In her junior year of high school, she began taking the prerequisites necessary for UTEP’s nursing program.

“It had its obstacles,” she said. “There were nights when I would study for hours on end. I think the hardest part of it all was time management.”

Maintaining balance in her life helped her succeed, Chacon said. Even while studying for exams and shadowing nurses in clinicals, she was involved in extracurricular activities and never missed out on big events, like prom and homecoming.

She always had the drive to learn since she was young, often having her nose in a book, Chacon said. It was also as a little girl she realized — through a game of make believe — nursing was her calling.

More: Here are the 5 best scenic spots for graduation photos in El Paso

“I have a little sister, we would always play nurse and patient,” Chacon said. “One day she really did get injured, and I was able to take care of her. That really sparked an interest in me.”

Her parents also instilled a work ethic in Chacon, who is proud of her Lebanese and Mexican roots. Her father was nurse and climbed the ladder in the medical field by immersing himself in his education — something Chacon wants to follow.

The teen is already looking at requirements to become a CRNA, or certified registered nurse anesthetist.

For others looking to take her route, she said the road is difficult, but confidence is key.

“Believe in yourself,” she said. “I struggled with self-doubt; everyone was a little older, so it was intimidating. But follow your dreams, have tenacity, and believe in you – that’s number one.”

2024 high school commencement ceremony schedule, by district:

El Paso Independent School District:

Monday, June 10

Jefferson High School/Silva Health Magnet School: 9 a.m., UTEP Don Haskins Center, 151 Glory Road

Young Women’s Academy: 11:30 a.m., UTEP Magoffin Auditorium, 151 Glory Road

Burges High School: 2 p.m., UTEP Don Haskins Center, 151 Glory Road

Franklin High School: 6 p.m., UTEP Don Haskins Center, 151 Glory Road

Tuesday, June 11

Andress High School: 9 a.m., UTEP Don Haskins Center, 151 Glory Road

Transmountain Early College High School: 11:30 a.m., UTEP Magoffin Auditorium, 675 Circle Drive

Bowie High School: 2 p.m., UTEP Don Haskins Center, 151 Glory Road

Coronado High School: 6 p.m., UTEP Don Haskins Center, 151 Glory Road

Wednesday, June 12

Irvin High School: 9 a.m., UTEP Don Haskins Center, 151 Glory Road

Austin High School: 2 p.m. UTEP Don Haskins Center, 151 Glory Road

Chapin High School: 6 p.m., UTEP Don Haskins Center, 151 Glory Road

Thursday, June 13

College Career Technology Academy: 2 p.m., El Paso High Auditorium, 800 E. Schuster Ave.

El Paso High School: 7 p.m., El Paso High Jones Stadium, 1600 N Virginia St.

Socorro Independent School District

Friday, May 31

Mission Early College High School: 8 a.m., Don Haskins Center, 151 Glory Road

El Dorado High School: 11 a.m., Don Haskins Center, 151 Glory Road

Montwood High School: 3 p.m., Don Haskins Center, 151 Glory Road

Pebble Hills High School: 7 p.m., Don Haskins Center, 151 Glory Road

Saturday, June 1

Socorro High School: 9 a.m., Don Haskins Center, 151 Glory Road

Americas High School: 1 p.m., Don Haskins Center, 151 Glory Road

Eastlake High School: 5 p.m., Don Haskins Center, 151 Glory Road

Ysleta Independent School District:

Thursday, May 30

Young Women’s Leadership Academy: 10 a.m., Plaza Theater, 125 Henry Trost Court

Valle Verde Early College High School: 2 p.m., Plaza Theater, 125 Henty Trost Court

Friday, March 31

Ysleta High School: 8 p.m., Hutchins Stadium, 8600 Alameda Ave.

Monday, June 3

Parkland High School: 9 a.m., Don Haskins Center, 151 Glory Road

Del Valle High School: 1:30 p.m., Don Haskins Center, 151 Glory Road

Bel Air High School: 6 p.m., Don Haskins Center, 151 Glory Road

Tuesday, June 4

Eastwood High School: 9 a.m., Don Haskins Center, 151 Glory Road

Riverside High School: 1:30 p.m., Don Haskins Center, 151 Glory Road

Hanks High School: 6 p.m., Don Haskins Center, 151 Glory Road

This article originally appeared on El Paso Times: El Paso teen balances high school, college to get nursing degree

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There's a showdown between Deontay Wilder and Zhilei Zhang set for Saturday afternoon. Here's what to know.

Trump's legal team plans to appeal his guilty verdict. Here's a timeline of how that could play out.

Hours after a Manhattan jury found Trump guilty of 34 felony counts of falsifying business records, his legal team vowed to appeal. Here's a timeline of what that could look like.

Are fish oil supplements good or bad for you? 7 things experts want you to know.

Despite the fact that 1 out of every 5 people over age 60 takes fish oil supplements, they may not be beneficial in some cases.

Top quarterbacks for 2024 fantasy football, according to our experts

The Yahoo Fantasy football analysts reveal their first quarterback rankings for the 2024 NFL season.

The 10th-gen Apple iPad hits a low of $300, plus the rest of the week's best tech deals

This week's best tech deals include the Apple iPad for $300, the PS5 for $450, a year of Peacock for $20 and several discounts on Sonos speakers.

Adam Hadwin meets security guard who tackled him at 2023 Canadian Open: 'Water under the bridge'

Hadwin was tackled during the celebrations following Nick Taylor's winning putt last year.

DJT stock drops again after volatile post-Trump conviction rout

Shares in Donald Trump's social media company have been on a wild ride after the former president was convicted on all counts in his hush money trial.

2024 Kicker fantasy football rankings

The Yahoo Fantasy football analysts reveal their first kicker rankings for the 2024 NFL season.

Nicole Brown Simpson's final days: 'Angry' over legal letter from O.J., missing set of keys and more from Part 1 of new docuseries

Here's what we learned watching the first two episodes of Lifetime's Nicole Brown Simpson doc.

Trump verdict: Here's how newspapers across the world covered the historic hush money trial

Trump is the first former U.S. president to be convicted of a crime. Here's how publications around the world announced the guilty verdict.

The Scorecard: 5 starting pitchers making waves in fantasy baseball

Fantasy baseball analyst Dalton Del Don highlights a quintet of starting pitchers we should focus on a lot more.