delirium case study nursing

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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.

• 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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Center for Geriatric Medicine, Heidelberg University Hospital, AGAPLESION Bethanien Hospital Heidelberg, Rohrbacher Strasse 149, 69126, Heidelberg, Germany

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.

Corresponding author

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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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?

• Open access
• Published: 11 January 2023

Investigating nurses’ knowledge and attitudes about delirium in older persons: a cross-sectional study

• Maria Papaioannou 1 ,
• Evridiki Papastavrou 1 ,
• Christiana Kouta 1 ,
• Haritini Tsangari 2 &
• Anastasios Merkouris 1  

BMC Nursing volume  22 , Article number:  10 ( 2023 ) Cite this article

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Introduction

Delirium is the most common emergency for older hospitalized patients that demands urgent treatment, otherwise it can lead to more severe health conditions. Nurses play a crucial part in diagnosing delirium and their competencies facilitate the appropriate treatment and management of the condition.

This study aims to enhance the understanding of delirium care by exploring both knowledge and attitudes of nurses toward patients in acute care hospital wards and the possible association between these two variables.

The Nurses Knowledge of Delirium Questionnaire (NKD) and the Attitude Tool of Delirium (ATOD) that were created for the said inquiry, were disseminated to 835 nurses in the four largest Public Hospitals of the Republic. These tools focused particularly on departments with increased frequency of delirium (response rate = 67%).

Overall nurses have limited knowledge of acute confusion/delirium. The average of correct answers was 42.2%. Only 38% of the participants reported a correct definition of delirium, 41.6 correctly reported the tools to identify delirium and 42.5 answered correctly on the factors leading to delirium development. The results of the attitudes’ questionnaire confirmed that attitudes towards patients with delirium may not be supportive enough. A correlation between the level of nurses’ knowledge and their attitude was also found. The main factors influencing the level of knowledge and attitudes were gender, education, and workplace.

The findings of this study are useful for the international audience since they can be used to develop and modify educational programmes in order to rectify the knowledge deficits and uninformed attitudes towards patients with delirium. The development of a valid and reliable instrument for the evaluation of attitudes will help to further assess nurses’ attitudes. Furthermore, the results are even more important and useful on a national level since there is no prior data on the subject area, making this study the first of its kind.

Peer Review reports

The term delirium (also known as acute confusion) refers to an acute confounding state, which is due to a wide range of factors including medicinal conditions, diseases, substances, drug abuse or combined causation. Delirium is a complex clinical syndrome characterized by a disturbance of people’s consciousness, attention, cognitive function, or perception, that develops within a short period of time and its symptoms can fluctuate during the day [ 1 , 2 ]. Delirium is a medical emergency and is prevalent among older people. It is viewed as a medical condition that is severe, costly and recognized as an indicator of patient safety [ 3 , 4 ].

Unfortunately, if delirium is not promptly diagnosed and treated, it can lead to brain damage and permanent disability. Further, it constitutes a huge financial burden as it doubles hospitalization time, the probability of death and the rate of re-admission [ 5 ]. Beyond the humanistic and the social dimension of the issue, the economic cost of delirium is enormous. International organisations [ 6 ] and scientific literature report that delirium doubles the cost of nursing care [ 7 , 8 ]. This reality underlines the importance of measures towards more effective prevention [ 9 ].

The recognition and diagnosis of delirium is a difficult process that is determined mainly by the patient’s profile of symptoms. The American Psychiatric Association Diagnostic and statistical manual 2013, 5th edition [ 2 ], lists five basic criteria that characterize delirium, such as (a) disturbance in attention (b) the disturbance develops over a short period, it represents an acute change from baseline attention and awareness, and tends to fluctuate in severity during the day, (c) disturbance in cognition (d) the mentioned disturbances are not explained by a pre-existing or evolving neurocognitive disorder and (e) there is evidence that it is a direct physiological consequence of another medical condition, substance intoxication or other multiple causes. Leading scientific organizations in delirium practice, such as the American Delirium Society (ADS) and European Delirium Association (EDA) [ 10 ], through their universal approach to delirium, recommend a more comprehensive interpretation of the DSM-5 criteria for the wider prevention and detection of delirium and in turn, greater patient safety.

It is interesting to note that delirium occurs in up to 55% of older hospitalized patients [ 5 , 11 ]. Concerning 31% in patients over the age of 65 [ 12 ], it is associated with an increased risk of permanent cognitive and functional impairment. At an age greater than 90 years, the prevalence and sequelae of delirium are substantial [ 13 ]. Nevertheless, if recognized early, delirium can be prevented in a large percentage of cases [ 14 ] and is often reversible with the treatment of the underlying disease [ 15 , 16 ].

Risk factors of delirium include dementia, advanced age, comorbidities, decreased vision, depression, infections, and dehydration [ 17 , 18 ]. In fact, evidence from systematic reviews and meta-analyses report that dementia, impaired vision, the application of a urinary catheter, low albumin levels, and longer hospital stays are associated with delirium [ 19 ]. Studies since the onset of the pandemic reveal that delirium represents a common complication of COVID-19 and a marker of severe disease course, especially in older patients with neuropsychiatric comorbidity [ 20 ].

The above discussion shows the importance of recognizing delirium. Nurses, who are the health professionals spending the most time with the patient play a key role in recognizing delirium. Unfortunately, consistent scientific data indicates that there is a low level of knowledge and subsequently reduced recognition of delirium in older patients during hospitalization [ 21 , 22 ]. Parallel to the low level of knowledge, nurses’ attitudes towards older patients are particularly negative due to multiple reasons. The care of a hospitalized patient with delirium is described as stressful and exhausting [ 23 ], especially for nurses trying to identify changes in the cognitive status of patients and at the same time provide safe care [ 24 ]. Nurses also reported feelings of discomfort and frustration when providing care for delirium patients. This is arguably due to limited self-confidence in assessing delirium which amplifies the greater dislike of delirium management [ 25 ]. Data from studies comparing nurses and doctors, reported similar attitudes and perceptions of delirium [ 26 , 27 ], highlighting that this is a common and wide-reaching problem, especially in the ICU. In other research, attitudes toward patients with delirium were found to be negative and reports showed patients being viewed as underrated, ignored [ 28 ], and considered a “burden”. This can lead to negative outcomes on patients, the hospital staff, and the system of health care because of increased hospitalization, the need for expensive interventions in the event of complications as well as the necessity for long-term care. Most of the current attention focuses on nurses’ knowledge and experiences about delirium in ICU patients and less on nurses’ knowledge and attitudes towards older patients in other hospital wards.

The contribution of this study to the development of knowledge is that it can contribute to improved educational programmes. It can help address delirium knowledge deficits and cultivate positive attitudes towards patients with delirium. The development of a valid and reliable instrument for the measurement of attitudes derived from the study also offers the possibility of assessing nurses’ attitudes further. Nationally, the results are even more important and useful due to the fact that there is no prior study of this subject in the country.

The study aimed to increase the understanding of delirium care by exploring both knowledge and attitudes of nurses toward patients in acute care hospital wards and the possible association between these two variables.

This was a cross-sectional study using a descriptive correlational design that was applied to collect data from nurses working in 4 public hospitals in the Republic, between September 2018 and October 2018.

The population under study were all nurses in public hospitals of the country, who worked in acute general wards. They encountered a high number of patients over 65 years of age and therefore high incidences of delirium that is medical, orthopedics, surgical, ED, and ICUs. No exclusion criteria were applied apart from nurses with work experience less than one year. No sampling technique was used, since the questionnaires were administered to all the nurses who worked in the aforementioned wards, thus addressing any potential sampling bias.

Ethics approval and consent to participate

The study was evaluated and approved by the National Bioethics Committee (SP.2015.01.115), according to the national law, and permission for the collection and management of data was obtained by the Commissioner for Personal Data Protection. Final permission to conduct the research was granted by the Scientific Committee for the Promotion of Research of the Ministry of Health (Fac. No. 5.34.01.7.6E). Also, permission to use the NDK questionnaire was given by the author [ 29 ] via email. The participants were informed in writing about the purpose of the study. Completing and returning the questionnaire was considered as consent to participate in the study. The basic principles of ethics in research such as anonymity, informed consent, and confidentiality of data were respected and secured. All participants gave informed consent for the research and the condition that their anonymity was preserved. Participation was voluntary. The data was stored in a manner compliant with data protection regulations.

Instruments

For the collection of data, a questionnaire was created and it contained demographic information and two research tools, one for examining the level of knowledge and another for assessing nurse attitudes. The ‘Nurses Knowledge of Delirium’ [ 29 ] was used, containing 36 multiple and true/false questions referring to (a) the definition of delirium (b) the tools for delirium identification and (c) the presence of delirium and risk factors leading to delirium development.

The questionnaire was translated into Greek according to the scientific guidelines suggested by the MAPI Research Institute [ 30 ], and Medical Outcomes Trust Bulletin [ 31 ].

The validity and reliability of the Greek version were tested, including the evaluation of face validity with a group of experts and clinicians and a test-retest analysis. The Cronbach’s alpha coefficient was 0.86, an indication that the questionnaire is highly reliable.

For examining nurses’ attitudes, very few instruments were found focusing specifically on delirium (and none of the publications examined the validity and reliability of the instruments). Therefore, the development and validation of a new tool were deemed necessary. This process consisted of five steps, namely (a) content identification (b) content development (c) content critique (d) the pilot study and (e) field study consisting of psychometric testing of the tool through calculation of the internal consistency and construct validity. This work resulted in the creation of the Attitude Tool of Delirium (ATOD), consisting of 26 questions on a Likert scale of 1–5. The instrument had a Cronbach’s alpha coefficient of 0.89. Factor analysis extracted three factors, corresponding to 56.5% of the variance. These factors are “emotions”, “behavior”, and “beliefs”, corresponding to 37.025%, 12.792%, and 5.652% of the variance respectively. The whole process of the development and validation of the ATOD is presented in a separate publication [ 32 ].

Data analysis

The IBM-SPSS 23 (Statistical Package for Social Sciences) was used for the statistical analysis of the data and the statistical significance was set at p  < 0.05.

For the questionnaire measuring nurses’ knowledge, the internal consistency was determined using the Kuder-Richardson formula (KR-20) for binary questions (wrong/correct), where values close to 1 are considered satisfactory. The questions that were answered correctly were added up to calculate the level of knowledge of each participant regarding acute confusion / delirium. The percentage of correct answers for each question determined the “Difficulty Index” (DIF) of the question, where high values of DIF showed that the question was easier (i.e., it was answered correctly by more respondents). Moreover, various indexes examined the ability of each question to divide participants into those who knew the subject well and those who did not, for example the “index of divisive power”. A question was considered to have little divisive value when either barely any nurses answered it correctly or when almost everyone answered it correctly. This index was calculated with point-biserial correlations (r pb ) [ 33 ], which measured the correlation between the respondent’s score on a binary (correct/wrong) question and the total score (i.e. the total number of correct answers in the questionnaire on knowledge), indicating if a question has high divisive power (high values of r pb, with p  < 0.05) or if specific questions need improvement. Another related index was the “Item Discrimination Index” (D.I.), which shows the discriminative ability of the questions to group respondents into “strong” and “weak” based on their knowledge (Hughes, 2003). More specifically, in our study, this index indicated whether the nurses that were expected to answer correctly indeed possessed the relevant knowledge, or whether those who performed poorly on the questionnaire (low scorers) were those that were not expected to have adequate knowledge on the topic. The calculation of the D.I. of a question was as follows: The questionnaires were divided into three groups: group A (1/3 of the questionnaires) included those with the highest score (those who had more than 18 correct answers), group C (also 1/3 of the questionnaires; same sample size as group A) included those with the lowest score - meaning those with less than 13 correct answers - and group B (the remaining 1/3 of the questionnaires) included those with the average score, ranging between 13 and 18 correct answers. From each question, the correct answers of group A and group C were counted. The Discrimination Index of a question was thus calculated using the following formula*:

*Where Group A is the group with the highest score and Group C is the group with the lowest score.

Generally, a questionnaire item is considered “good” if D.I.>0.40 and 0.30 < DIF < 0.70.

For the questionnaire measuring attitudes, validity and reliability tests were performed [ 32 ]. In addition, for all items, mean values and percentages in each category indicated positive, negative, or neutral attitudes.

Significant relationships between nurses’ knowledge and attitudes were explored with Pearson correlation coefficients, where a relation is considered significant if p  < 0.05, with the corresponding sign (positive or negative). Finally, to identify differences in the level of knowledge and attitudes according to nurses’ socio-demographics, various statistical tests were done for all the scales and subscales. These included independent samples t-tests (to examine gender differences in the scales/subscales of knowledge and attitudes), ANOVA tests (to examine differences in knowledge and attitudes between hospitals, job positions, wards, education levels) and chi-square tests (for the dichotomous item 1.1 of the knowledge scale). Regression analysis was also used, to examine the effect of knowledge and personal characteristics (when entered simultaneously in the model) on attitudes (dependent variable). It is noted that no missing data existed for the attitudes’ questionnaire, whereas the missing data (around 1% of the sample) and the “Do not know” answers that existed in the knowledge questionnaire were classified as “wrong” answers.

Profile of the participants

The final questionnaire was given to 835 nurses working in departments with increased incidence of delirium and older patients such as orthopaedic, acute medical and surgical departments, intensive care units, and accident and emergency departments, in 4 Public Hospitals in the country. As shown in Fig. 1 below, most of the participants worked in ICU and medical departments (Fig.  1 ). Response rate was 67% and the final sample size was 558 nurses.

Participants- Clinical Setting ( N =558)

Age ranged from 21 to 65 years, with an average of 35.8 years and a standard deviation of 8.2 years. In terms of total experience, it was from 1 to 35 years, with an average of 13.2 years and a standard deviation of 8.2 years. The experience in the department ranged from 1 to 27 years with an average of 6.8 years and a standard deviation of 6.0 years. Most of the participants were women (312, 56.1%), had a bachelor’s degree (552, 99%), were graduate nurses without postgraduate studies (323, 58%), while 149 nurses (26.8%) reported postgraduate studies. All nurses were registered nurses who were employed in the Public Hospital as permanent staff or under a contract of indefinite duration.

The level of knowledge

The questionnaire consists of 36 questions. The analysis was performed on the overall scale but also for the three subscales – the three parts of the questionnaire: 1- definition of delirium (question 1.1), 2- tools for delirium recognition (questions 1.2–1.8), and 3- the presence of delirium and risk factors for developing delirium (questions 1.9–1.36).

The Kuder-Richardson 20 values were satisfactory, indicating overall high internal consistency for the knowledge questionnaire (KR-20 = 0.742 for the total scale, 0.722 for questions 1.9–1.36, and 0.400 for questions 1.2–1.8, where question 1.2 was the least reliable). In 25 out of 36 delirium-oriented questions, most nurses answered incorrectly or declared that they did not know the answer. The correct answer average was as high as 42.2%. Only 25.6% of the participants scored below 18, which is the average.

Table 1 below shows the results from the descriptive statistics on the number of correct responses given by participants for each subscale of the questionnaire and on the total scale (36 questions) (Table  1 ). Results show that 3 out of 4 participants (75%), answered correctly on less than 19 of the 36 questions.

In Table  2 below, a more detailed analysis of each question of the knowledge instrument is presented, showing the Difficulty Index (DIF) of each question.

In total, out of 36 questions, only 12 of those had a correct response ratio higher than 50%, i.e. only 1/3 of the questions had a high value of DIF and could be considered easy. The easiest question for respondents was question 1.7 (Assessment Tool - Depression Diagnosis, the Beck’s Depression Recording Scale) which 72.6% of participants answered correctly. The question with the lowest DIF (in other words, the most difficult question) was question 1.5, which referred to the tool for assessing delirium and alcohol use and abuse - Alcohol core Deprivation Scale - AWS, while there were several other questions with a low DIF, even below the 0.30 limit. In general, it seems that in this questionnaire there were no questions that can be considered very easy (DIF > 0.9) (without practical value or ability to separate nurses). However, there were some that can be considered as very difficult for the participants (DIF < 0.3) (such as questions 1.2, 1.5, 1.6, 1.12, 1.13, 1.14, 1.20, 1.23, 1.24, 1.32).

In addition, the index of divisive power was calculated. Most questions had high divisive power (high values of r pb with p  < 0.05), which shows that either they were answered correctly by the participants who received high total scores in the questionnaire, or they were answered wrongly by nurses who had low total scores. The only exceptions were questions 1.2, 1.5, 1.24 and 1.32 (r pb <0.1, p  > 0.05). Their low correlations showed either that the participants had correct answers to the other questions but not to those, or participants did not understand the specific questions but had a high total questionnaire score. Therefore, these questions would need improvement or require attention as to the knowledge regarding their content. As seen before, the same questions gave the most trouble to participants, since they also had a low DIF.

Another approach to the discriminative ability of the questions was the Item Discrimination Index (D.I.), which indicated if the nurses that were expected to answer correctly indeed had the knowledge, or that those who performed poorly were not expected to adequately possess the subject matter. Several questions had a Discrimination Index below 0.4, while questions 1.5 and 1.32 had their D.I. almost being zero. So, combining all the above results confirms that especially questions 1.5 and 1.32 need attention because they were particularly difficult for the participants.

Nurses’ attitudes

As regards the questionnaire for the investigation of attitudes, the 5-point Likert scale was dichotomized into negative (1–2) and positive (4–5), while 3 was considered neutral. The results showed that in 14 questions more than 50% of the participants had a negative attitude and only 9% declared a positive attitude. The highest negative results were found in questions 2.19, 2.1, and 2.14. It is also interesting that a high percentage of the participants (around 1/3 of participants) selected a neutral position in many questions (2.1. 2.2, 2.15, 2.17–2.19, 2.21–2.23). The results are shown in Table  3 :

The relation between knowledge and attitudes

Pearson’s correlation coefficients examined all the relationships between the scales of knowledge and attitudes, as well as within each scale (i.e. between the total scale and its subscales).

First, regarding the knowledge questionnaire, the correlations between the total scale and its sub-scales (i.e., subscale of items 1.2–1.8, subscale of items 1.9–1.36 and item 1.1 (dichotomous; point-biserial correlation)) were significant positive, showing that nurses who knew the correct answers to one part of the questionnaire knew them in other parts as well. Second, regarding the “attitudes” questionnaire, the significant positive relationships that were found between the overall scale and its three factors (behavior, emotion, perception) indicated that nurses who had a positive attitude in one factor had a positive attitude in the other factors as well.

Third, one of the research questions was whether there was a relationship between the knowledge and attitudes of the participants. Pearson’s correlation coefficients for the relationships between the scales of knowledge (total scale and subscales) and attitudes (total scale and three factors), showed a significant positive relationship between knowledge and attitudes (all scales and subscales). Therefore, the important result that emerges is that the better knowledge a nurse has about delirium, the more positive attitude he/she has towards patients with delirium. Table  4 shows the results regarding the relations between the scales/subscales of knowledge and attitudes.

Differences in knowledge and attitudes according to personal characteristics

First, we examined which personal characteristics affect the level of knowledge of nurses about acute confusion / delirium. Statistically significant gender differences for the knowledge subscale of items 1.2 to 1.8 were found, where women had better knowledge than men in these specific questions (mean = 3.0 and 2.8 respectively; p  = 0.030), as well as for item 1.1 (definition of delirium) ( p  = 0.015), where 42% of women answered it correctly as opposed to 32% of men. For the other scales, there were no differences (for 1.9–1.36 p  = 0.745, for 1.1–1.36 p  = 0.351). No significant differences in nurses’ knowledge were found between hospitals (p > 0.05) or job positions ( p  > 0.05). The ANOVA test for “ward” showed significant differences ( p  < 0.001 for the total scale; p  = 0.003 for 1.2–1.8; p  = 0.001 for 1.9–1.36). More specifically, Tukey’s post-hoc tests showed that nurses working in ICUs had better knowledge compared to all the other wards. Similarly, in terms of education level, significant differences were identified ( p  < 0.05 for scales and subscales), where it was evident from post-hoc tests, that the more educated nurses were, the better knowledge they had, especially if nurses had a master’s degree.

Second, concerning nurses’ attitudes, the only demographic variable that showed significant differences was “Ward”, where nurses in the ICU reported more positive attitudes (in perception) ( p  = 0.026), compared to nurses working in other wards (especially medical wards).

Finally, regression analysis additionally showed that when knowledge and personal characteristics were entered simultaneously in the model (i.e., adjusting for the confounding effect of socio-demographics), only knowledge appears to affect the attitudes of nurses ( p  < 0.001), which verifies the previous findings of a significant positive correlation between knowledge and attitudes.

Observing nurses in the public hospital sector, overall, their knowledge about acute confusion / delirium is insufficient. The average overall correct answer rate was 42.2% (15/36) and is similar to that of the equivalent study conducted in Australia by the creators of the tool (53.14%) (Hare et .al., 2008). Similar results were noted by other studies conducted to investigate the level of nurses’ knowledge of delirium [ 0 , 35 ].

Low knowledge levels were also observed in a systematic review of 10 studies where it was found that nurses did not recognize delirium in older patients [ 36 ], as well as in studies involving hospitalized older patients [ 37 , 38 ]. Similar results were found in a study of the level of delirium knowledge of nurses in Greece, from a sample of 108 nurses working in medical and surgical units in two general hospitals in Athens and three provincial hospitals. In this study, nurses reported that they were not trained and therefore unqualified in assessing patients with delirium symptoms. This finding is justified by the respondents’ reply that 67% had learned nothing about delirium [ 39 ].

The low knowledge level of nurses in our research can be partly explained by the limited focus on delirium during basic nursing education. In examining the curriculums of the five Universities in the country offering nursing studies, it was found that confusion and delirium are mentioned briefly in some sections of neurology subjects (e.g., consciousness), in psychiatric nursing modules regarding alcoholic delirium and a reference to the section on gerontological nursing, but without individual focus on delirium in hospitalized patients. The curriculums that had been examined cover the syllabi of the last two decades. We examined the titles and course descriptions of the nursing programs to see whether there were individual modules or sections on delirium. Similarly, the subject of delirium is not a priority topic in the incumbent nursing education programmes that are compulsory for renewing licences according to national law.

Nurses’ knowledge of acute confusion / delirium is largely empirical rather than theoretically based. This view is evidenced by the limited correct answers to questions concerning the risk factors of delirium development in contrast with the presence of delirium. Knowledge of the presence of delirium could be acquired empirically, while questions related to evaluation tools, - something that nurses have never use - require theoretical knowledge and experience in using the tool, something which they predominantly did not possess. In the study only 22.4% answered correctly in the question about the use of the Confusion Assessment Method (CAM) tool, which is considered the gold standard for assessing delirium [ 40 ].

The findings of this study show that the biggest gap in knowledge concerning acute confusion / delirium is the theoretical aspect (definition, assessment scales, symptoms, risk factors of development of delirium, etc.) which cannot be fulfilled with vocational experience. This should be taken into consideration when designing the curriculum content of future training and educational programmes. Educators should focus on the provision of mainly theoretical knowledge, which can enhance the existing knowledge of nurses acquired from practical experience. The implementation of such training programmes resulted in a significant improvement in the level of knowledge of delirium in nurses [ 41 , 42 ], using the NKDQ tool.

Concerning nurses’ attitudes toward delirium, the results showed that most nurses had a negative attitude, supporting previous studies [ 25 , 43 ]. A higher percentage of negative attitudes involved the use of physical restraints on the basis that they were necessary for the patient’s care (90%). Indeed, the literature confirms that conditions such as anxiety, agitation, confusion, hallucinations, aggression and changes in the severity of the disease and its unpredictability, contribute to further negative attitudes. These include the feeling of burden [ 44 ], debilitation [ 23 ] and lack of confidence when managing arousal and delirium [ 43 ]. The results also reveal that nurses do not view delirium as a serious condition and therefore it is underestimated and not prioritized in their work [ 45 , 46 ]. Although several nurses reported instances of evaluating delirium, very few of them used assessment tools in the identification process [ 47 ].

The assumption that there is a relationship between knowledge and attitudes of nurses was examined with the correlation coefficient Pearson and it was found that the better the knowledge, the more positive attitude towards delirium, agreeing with the literature, regardless of the tools used [ 27 ]. However, studies are showing that even if a strong emphasis is placed on improving knowledge, this does not mean that nurses will develop a positive attitude towards the older people or patients with cognitive decline [ 48 ].

This means that the hypothesis that increasing knowledge can lead to better care raises concerns about the methodological approach of these two concepts. Intervention strategies on improving the knowledge of nurses have yet to tackle the complexity of changing attitudes. However, according to social learning theory, environmental and cognitive factors inherently influence human learning and behaviour. For example, observing, modelling, and imitating the behaviors and emotional reactions of others can stimulate changes in attitudes [ 49 ]. The scientific approach to behaviour change needs clear and well-defined guidelines for identifying the ‘active ingredients’ and for designing, evaluating and reporting interventions [ 50 ]. Investigating the attitudes of nurses towards the care of delirium through qualitative research will identify the reasons for these attitudes and identify the educational needs of nurses in terms of care management.

Limitations of the study

This study was conducted only in public hospitals in the country. The participation of nurses from private hospitals was not possible for this inquiry and the interpretation and inferences of the results should be done carefully.

Conclusions

Based on the results of the study, it seems that the elaboration of continuous educational programmes is needed to improve the level of knowledge of nurses on acute confusion / delirium which could potentially improve their attitude towards delirium. These programmes should focus mainly on providing theoretical knowledge (definition, scales, symptoms, risk factors for delirium, etc.) – as demonstrated by the questionnaire answers – in order to boost the existing empirical knowledge of nurses.

Monitoring and evaluating nurses’ knowledge and attitudes toward patients with delirium could be the first step to detecting the gaps in treating older delirium sufferers effectively. This is useful towards a greater understanding of care management and its challenges. It is also a reminder to medical educators about the importance of ongoing education in hospitals.

Nursing managers and policymakers also need to formulate hospital policies to improve the quality of care provided for older people. The introduction of clinical guidelines, protocols, delirium care bundles and assessment scales could reduce the duration of hospitalization but also the cost of the provided care.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

The authors would like to acknowledge Mr. Malcolm Hare and Prof. Dianne Wynaden, the Fremantle Hospital, and the Curtin University of Technology for their permission to translate into Greek and use the NDK questionnaire in our study. They would also like to express their gratitude to the two anonymous reviewers for their useful comments and editorial suggestions, which improved the comprehension of the manuscript. Special thanks to the National State Scholarship Foundation for funding this project and to all nurses who participated in the study and those who contributed to English language editing.

The study was funded by the National State Scholarship Foundation as part of (MP) doctoral studies (C.S.S.F.1.2.10.107).

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Maria Papaioannou, Evridiki Papastavrou, Christiana Kouta & Anastasios Merkouris

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Contributions

The study Design was made by MP, EP, AM, and CK. MP collected the data for the study. Data were analyzed by TH, AM, and EP. The manuscript was written by MP and EP. AM, CK, and HT reviewed and provided feedback on the draft manuscript. All authors read and approved the final manuscript.

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Correspondence to Anastasios Merkouris .

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For conducting the study, approval was given (a) from the National Bioethics Committee (SP.2015.01.115), (b) Commissioner for Personal Data Protection, and (c) from the Scientific Committee for the Promotion of Research of the Ministry of Health (Fac. No. 5.34.01.7.6E), for delivering questionnaires to nurses working in Public Hospitals. Ethical standards have been followed during the research process and all participants were fully informed of the purposes of the study. Participation was voluntary. All participants gave informed consent for the research and their anonymity was preserved. The participants’ consent is concerned, after the approval of the bioethics committee, completing and returning the questionnaire was considered as consent to participate in the study. Also, permission to use the research instrument was obtained by Malcolm Hare, (via email on 7/7/2015).

All methods were carried out in accordance with relevant guidelines and regulations of the Declaration of Helsinki (as revised in Brazil 2013).

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Papaioannou, M., Papastavrou, E., Kouta, C. et al. Investigating nurses’ knowledge and attitudes about delirium in older persons: a cross-sectional study. BMC Nurs 22 , 10 (2023). https://doi.org/10.1186/s12912-022-01158-9

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• Acute confusion

BMC Nursing

ISSN: 1472-6955

• General enquiries: [email protected]

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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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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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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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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“Mr. A” is a 79-year-old man with type 2 diabetes, hypertension, and hyperlipidemia who was brought to the emergency department for confusion. His home health aide reports that Mr. A has increasingly been refusing his medications lately and has also refused to see his primary care physician for a nonhealing leg wound. On arrival at the emergency department, Mr. A has a temperature of 101.5°F, pulse of 126 bpm, respirations of 22 breaths per minute, and blood pressure of 79/52. Initial laboratory tests demonstrate leukocytosis (WBC 14.6), prerenal azotemia (creatinine, 2.1 µmol/L; blood urea nitrogen, 54 mg/dL), and a lactate level of 4.3 mmol/L. The patient’s hemoglobin A 1C is 9.6%. Blood cultures show methicillin-resistant Staphylococcus aureus in 4/4 bottles.

On physical examination, the patient is tachycardic and tachypneic; abdominal examination is benign. Skin examination demonstrates bilateral venous stasis changes, with a large, shallow ulcer along the left tibia with dusky borders and central eschar. Mental status examination reveals a disoriented, inattentive, disheveled elderly male who is picking at his hospital gown and calling out to his wife, who is deceased. He is diagnosed with sepsis and admitted to the medicine service for further workup and treatment. A psychiatric consultation is obtained to assess the patient’s mental status and assist with management of agitation.

Mr. A remained on the medical service for 6 days, during which time his sepsis was treated with intravenous antibiotics and his leg ulcer debrided and dressed. His renal function recovered with adequate hydration, and his vital signs rapidly renormalized. To address Mr. A’s delirium, his nurses provided frequent reorientation regarding the date and situation and ensured that he received plenty of light exposure during the daytime while preserving a quiet, dark, minimally disturbed environment overnight. A medication reconciliation demonstrated a previous outdated prescription for meclizine for vertigo, which was discontinued given its strong anticholinergic activity and absence of active dizziness. Mr. A’s home health aide brought in the patient’s glasses, hearing aids, and dentures for his use in the hospital. The physical therapy department worked with the patient beginning on the second day of his admission and found him increasingly able to participate in active mobilization as his medical problems and mental status improved. The patient had orders for standing melatonin, 3 mg h.s., as well as quetiapine, 12.5 mg b.i.d. p.r.n., and he required two evening as-needed doses of quetiapine. Both medications were fully discontinued before discharge.

Mr. A was discharged to acute rehabilitation before returning home. At an outpatient follow-up appointment 6 months later, his home health aide remarked that the patient was now more forgetful and appeared cognitively slower than he had been before the infection, and that he now required around-the-clock assistance with activities of daily living.

Delirium is a syndrome of acute brain failure that is the direct pathophysiologic consequence of an underlying medical condition or toxic exposure. According to DSM-5 ( 1 ), it is characterized by the acute onset of deficits in attention, awareness, and cognition that fluctuate in severity over time. Delirium represents global brain dysfunction, and thus the cognitive impairments are highly variable, including disturbances in several domains, such as memory, orientation, language, visuospatial ability, and perception. Additional features include psychomotor disturbance, altered sleep cycle, and emotional variability. The psychomotor disturbances seen in delirium have been categorized into three phenotypic subtypes: hyperactive, hypoactive, and mixed delirium. Hyperactive delirium is characterized by psychomotor agitation, restlessness, and emotional lability and is sometimes mistaken for primary psychosis, mania, or dementia. Hypoactive delirium is characterized by psychomotor retardation, lethargy, and decreased level of responsiveness and is often missed or misdiagnosed as depression. Mixed delirium presents with alternating features of both.

Characteristics Of Delirium

Epidemiology.

Delirium is the most common psychiatric syndrome observed in hospitalized patients ( 2 ). The incidence on general medical wards ranges from 11% to 42% ( 3 ), and it is as high as 87% among critically ill patients ( 4 ). A preexisting diagnosis of dementia increases the risk for delirium fivefold ( 5 ). Other risk factors include severe medical illness, age, sensory impairment, and male gender ( 5 ). Common deliriogenic medication classes include narcotics, hypnotics (such as benzodiazepines), and anticholinergics. The incidence of delirium is particularly high among burn patients (39%), nonelective postoperative patients (>50%), and patients receiving mechanical ventilation in the intensive care unit (ICU) (>70%) ( 6 – 8 ).

Although delirium is common, the diagnosis relies on a high index of suspicion, as it often goes undetected or misdiagnosed. In one study, nursing staff identified delirium in only 31% of cases identified by research staff ( 9 ). In another study, up to 40% of hospitalized patients referred for a psychiatric consultation for depression were found to be delirious ( 10 ). There are multiple challenges to establishing the diagnosis of delirium in a timely fashion, including the fluctuating course of symptoms, difficulty conducting cognitive testing during the extremes of psychomotor disturbance, overlooking the hypoactive phenotype, and the need to ascertain baseline cognitive functioning. A thorough clinical evaluation is considered the gold standard for diagnosis of delirium, as there is no clinical study or biomarker with high sensitivity and specificity. Although EEG studies typically show generalized slowing in delirium, the false negative and false positive rates approach 20%, limiting the utility of this tool ( 11 ). Multiple validated delirium screening tools with high sensitivity and specificity have been developed, including the Confusion Assessment Method and the 4AT rapid clinical test for delirium, which improve the detection of delirium by a variety of health care professionals ( 12 , 13 ).

Differential Diagnosis

Delirium in medically ill patients is often multifactorial, and while attention is importantly given to broad surveillance and monitoring of contributing variables, the role of the psychiatric consultant often involves focusing specifically on potential neuropsychiatric processes. Substance withdrawal may require a careful medication history to identify and clarify use patterns, even of prescribed benzodiazepines and opioids; this may also inform seizure risk assessment. Many commonly used agents, including some opioids, antinausea medications, antimigraine medications, mood stabilizers, linezolid, and ritonavir, have serotonergic activity. A careful medication history can clarify the risk of serotonin syndrome, particularly in patients on standing serotonergic medications who then require additional serotonergic agents to address acute medical issues. A broader differential diagnosis can be considered in the context of the patient presentation at the time of consultation. Immunosuppression increases the risk for opportunistic CNS infections, including herpes simplex virus encephalitis, as well as various cancers that may metastasize to the brain; severe metabolic derangements may prompt consideration of paraneoplastic syndromes, central pontine myelinolysis (following rapid correction of hyponatremia), hyperammonemia, and seizure; coagulopathies, atrial fibrillation, and endocarditis predispose for stroke; and extreme hypertension may trigger consideration of posterior reversible encephalopathy syndrome and stroke. In addition to the CNS etiologies of delirium mentioned above, other common etiologies include infection, reduced sensory input, urinary retention or fecal impaction, metabolic derangements, and myocardial or pulmonary disorders. Further investigation for these etiologies would depend on the patient’s clinical presentation and the results of screening laboratory tests.

While scope of practice may vary with training experience, it would be reasonable to recommend a neurologic consultation when there are focal neurologic findings, including any new asymmetry on physical examination, movement abnormalities, sustained poor mental status (concerning for status epilepticus), and abrupt deterioration in mental status after a period of delirium previously marked primarily by inattention and disorientation.

Impact of Delirium

While delirium has historically been viewed as a time-limited disorder, the morbidity (both short- and long-term), mortality, and financial costs are increasingly being recognized. A meta-analysis of delirium in the elderly showed that even after controlling for confounding factors, including age, sex, dementia, comorbid illness, and illness severity, delirium is independently associated with a twofold increase in risk of death, a 2.4-fold increase in risk of institutionalization, and a 12.5-fold increase in risk of dementia ( 14 ). Delirium has also been strongly associated with sustained decline in physical function, with the average loss of one activity of daily living per delirious episode, sustained at 6-month follow-up ( 15 ). In patients with and without dementia, multiple symptoms of delirium have been shown to persist for 12 months after the onset of delirium ( 16 ). In addition to significant patient mortality and negative functional outcomes, delirium is also associated with high health care costs. On average, hospital stays are 5–10 days longer for patients who develop delirium than for patients without delirium ( 2 ). A 1-year prospective study found that patients with delirium had significantly higher unadjusted health care costs than patients without delirium. After adjusting for demographic and clinical factors, the cost of treating a patient with delirium was 2.5 times that of a patient without delirium, and the annual national burden of delirium is estimated to be in the range of $38 billion to $152 billion ( 17 ).

Pathophysiology

While the pathophysiologic basis of delirium has yet to be fully elucidated, delirium can be conceptualized as a final common pathway resulting from multiple factors that lead to a state of impaired brain function. Inflammation, hypoxia, and oxidative stress all contribute to increased brain exposure to toxins and a hypocholinergic-hyperdopaminergic state. Inflammation creates a vulnerable physiological state, with impaired brain function and increased permeability of the blood-brain barrier. Susceptibility to circulating deliriogenic medications, endogenous toxins, and proinflammatory cytokines may cause or sustain delirium ( 18 ). Microaggregates of fibrin and neutrophils in the cerebral vasculature can cause subclinical episodes of decreased cerebral perfusion, particularly in patients with high vascular disease burden ( 19 ). Subclinical transient hypoxic states lead to decreased synthesis of acetylcholine, the primary neurotransmitter of the reticular activating system. The reticular activating system is primarily involved in regulating alertness and attention, the disruption of which are a hallmark of delirium ( 20 ). Because intact alertness and attention are a fundamental substrate for all domains of cognition, the cognitive deficits seen in delirium are diffuse and nonspecific. Thus, any specific cognitive deficits elicited on bedside testing during a delirious state should be interpreted with caution. Oxidative stress results in the release of endogenous dopamine, which is thought to be the underlying cause of perceptual disturbances seen in delirium ( 21 ). Other neurotransmitter derangements implicated in delirium include melatonin deficiency, resulting in sleep-wake cycle disruption, and excess norepinephrine and glutamate.

Brain Circuitry

Delirium is associated with aberrant resting-state neural interactions between the suprachiasmatic nucleus (the biological master clock) and cortical regions. Compared with nondelirious control subjects, in patients with delirium, functional connectivity from the suprachiasmatic nucleus is increased to the dorsal anterior cingulate cortex and decreased to the posterior cingulate cortex, parahippocampal gyrus, cerebellum, and thalamus ( 22 ). The functions of the regions showing decreased connectivity correspond with the clinical symptoms of delirium, including the role of the posterior cingulate cortex in maintaining consciousness of the external environment, the parahippocampal gyrus in memory encoding and retrieval, and the cerebellum and thalamus in mental coordination. Delirium is also associated with increased functional connectivity between the dorsolateral prefrontal cortex and the posterior cingulate cortex, as well as decreased connectivity of subcortical regions ( 23 ). Finally, aberrations in the salience network and its interaction with the default mode network and the central executive network have been demonstrated in minimal hepatic encephalopathy ( 24 ).

The association between cortical atrophy and delirium remains controversial ( 25 – 27 ). One study demonstrated that while Alzheimer’s-related cortical atrophy did not predict delirium incidence, it was associated with greater delirium severity ( 27 ). Neurovascular changes, including white matter hyperintensities and cerebral infarcts, have been consistently associated with increased risk of delirium ( 25 , 26 ). These neurovascular changes likely increase vulnerability to hemodynamic shifts during physical illness.

In clinical settings with high rates of delirium, such as critical care and postoperative units, it is helpful to predict risk of delirium to inform prognosis and the risk-benefit analysis of elective surgery. The PRE-DELIRIC (PREdiction of DELIRium in Intensive Care patients) is a delirium prediction model for intensive care patients based on nine clinical and demographic factors at the time of admission, which has been validated in seven countries ( 28 , 29 ). This model has an area under the receiver operating curve (AUC) >0.8, which is significantly higher than the AUC of 0.59 for nurses’ and physicians’ predictions, highlighting the need for validated prediction tools ( 29 ). A similar delirium prediction score (Delphi; DELirium Prediction Based on Hospital Information) developed for general surgery patients demonstrated an AUC of 0.91 ( 30 ). The utility of incorporating preoperative neuropsychologic measures, such as depression symptoms, cognitive functioning, and neuroimaging findings, as well as intraoperative parameters, into postoperative delirium risk prediction is an ongoing area of research ( 31 ).

Nonpharmacologic Strategies

Prevention is the most effective strategy for reducing the morbidity, mortality, and health care costs associated with delirium. Since the cause of delirium is typically multifactorial, delirium prevention approaches that target multiple risk factors tend to be the most effective. The Yale Delirium Prevention Trial, a randomized controlled trial, demonstrated that a multimodal nonpharmacologic strategy is feasible (87% adherence rate) and can decrease the incidence of delirium on a general teaching medical unit from 15% to 9% ( 32 ). The delirium prevention protocol in the study targeted six risk factors by focusing on orientation, early mobilization, medication reconciliation, sleep-wake cycle preservation, sensory impairment, and dehydration. This protocol has been shown to be adaptable to, and effective in, various other settings, including surgical units and nursing homes ( 33 , 34 ). Environmental strategies that promote sleep consolidation, such as minimizing nighttime noise and light exposure, also contribute to delirium prevention ( 35 ). Finally, minimization of physical restraints, which allows patients to participate in early mobilization, is critical, as the use of physical restraints increases the odds of a persistent delirium threefold ( 36 ).

Prevention strategies are equally important in intensive care settings. Many of the medications used to achieve the degree of sedation and analgesia required for mechanical ventilation, including benzodiazepines, propofol, and opioids, are deliriogenic. Daily sedation interruption has been demonstrated to be safe as well as to decrease both duration of mechanical ventilation and length of stay in the ICU ( 37 ).

Pharmacologic Strategies

The use of antipsychotics for the prevention of delirium remains controversial, with both positive and negative studies in various postoperative populations, critical care populations, and general hospital settings ( 38 – 43 ). Interpreting the positive and negative studies is challenging, however, because of their heterogeneous populations, differing measures of delirium, and varied antipsychotic selection and dosing. In the postoperative setting, however, there have been three meta-analyses, all of which support the use of antipsychotics for reducing the incidence of delirium ( 44 – 46 ). Thus, when prophylactic antipsychotic use is studied in a more homogeneous population at high risk for delirium, prophylaxis with antipsychotics appears to be helpful. This suggests that in selected clinical settings, there may be a role for the time-limited use of antipsychotics to prevent delirium. More research is needed to determine which factors predict response to antipsychotic prophylaxis. In the absence of firm evidence supporting the efficacy of antipsychotics for delirium prevention, we recommend against routine use of antipsychotics for this purpose.

The avoidance or minimization of deliriogenic medications is as important as the use of nondeliriogenic sedation agents. For example, diphenhydramine, which is often prescribed for sleep, can cause or contribute to delirium because of its anticholinergic properties.

Dexmedetomidine, a selective α 2 -adrenergic receptor agonist, has been shown to reduce the incidence of delirium and ventilator-associated events while increasing ventilator-free hours ( 47 – 49 ). Dexmedetomidine has both analgesic and sedative properties, which allows for a reduction in the amount of deliriogenic medication exposures, including opioids and benzodiazepines. Its use can be limited by the potential for hypotension and bradycardia as well as cost.

Finally, there is a small but emerging literature to support the use of melatonin and melatonin receptor agonists (e.g., ramelteon) for the prevention of delirium in medical, surgical, and intensive care settings. Melatonin is a hormone produced by the pineal gland that helps maintain circadian rhythms and regulate sleep, the disruption of which is a known risk factor for delirium. Studies of serum melatonin levels demonstrate that the circadian secretion of melatonin is disrupted in patients who develop delirium ( 50 ). A recent meta-analysis of four randomized controlled trials assessing the preventive effect of melatonin supplementation on delirium demonstrated that melatonin showed a tendency to decrease the incidence of delirium (relative risk=0.41, 95% CI=0.15–1.13) ( 51 ). A multicenter randomized controlled trial on the impact of melatonin for delirium prophylaxis in ICUs is under way ( 52 ).

Nonpharmacologic Approaches

Once delirium has developed, nonpharmacologic approaches are integral to limiting overall morbidity and mortality, including risk of long-term cognitive impairment. There is significant overlap between the nonpharmacologic strategies used in prevention and those used in treatment. These strategies target sleep-wake regulation, orientation, early mobilization, vision and hearing optimization, and nutrition and hydration. In the critical care setting, the scope of intervention expands to include daily trials of sedation reduction and spontaneous ventilation, as delineated in the ABCDEF bundle ( 53 ), an evidence-based guide for optimizing ICU patient recovery. The ABCDEF bundle’s components include assessing, preventing, and managing pain; both spontaneous awakening and spontaneous breathing trials; choice of analgesia and sedation; delirium assessment, management, and prevention; early mobility; and family engagement ( 53 ). A prospective study comparing complete ABCDEF bundle performance to proportional performance ( 54 ) demonstrated that complete performance was associated with decreased risk of hospital death within 7 days (adjusted hazard ratio=0.32, 95% CI=0.17–0.62), delirium (adjusted odds ratio=0.60, 95% CI=0.49–0.72), and coma (adjusted odds ratio=0.35, 95% CI=0.22–0.56). The ABCDEF bundle is an example of a proactive, interdisciplinary approach for mitigating delirium risk factors as well as assessing for and managing delirium. Psychiatrists can play an important role in advocating for and implementing proactive, multidisciplinary prevention programs and clinical pathways within their local institutions.

There is only limited high-quality evidence in the literature addressing nonpharmacologic treatment of delirium, highlighted in a recent systematic overview in older patients ( 55 ). Both single and multicomponent protocols have undergone trials, from bright lights, earplugs, and music therapy to more comprehensive team-based approaches that can extend to family engagement ( 55 ). The evidence for multicomponent nonpharmacological interventions preventing delirium is currently much stronger than that for the treatment of already established delirium. The primary treatment of delirium is identification and management of the underlying medical etiologies, which may be highly variable within and across treatment populations, and multimodal treatment strategies to minimize the severity and duration of delirium are thus essential.

Antipsychotics

While there are no medications approved by the U.S. Food and Drug Administration (FDA) for the treatment of delirium, antipsychotics are commonly used as a first-line pharmacologic approach to manage symptoms that threaten safety or impede care when nonpharmacologic approaches are insufficient. The efficacy of antipsychotic medications for the treatment of delirium is controversial. Although some studies suggest that the benefits of using antipsychotics outweigh the risks when used to manage specific target symptoms (e.g., agitation, paranoia, psychosis) ( 56 , 57 ), a recent meta-analysis ( 43 ) found that antipsychotics demonstrated no significant effect on delirium incidence, duration, severity, length of stay, or mortality. While the current evidence regarding the effect of antipsychotics on duration of delirium is unclear, we do not yet have studies demonstrating the impact of antipsychotics on other meaningful patient measures often seen in delirium, such as emotional distress, ability to participate in care, and long-term functional outcomes.

In the absence of conclusive data, it is recommended that antipsychotic use be limited to judicious, time-limited trials for the management of high-risk and high-distress symptoms of delirium, including agitation, paranoia, and hallucinations, which pose a safety risk to the patient or staff or impede the provision of medical care ( Table 1 ) ( 58 ). Antipsychotics can be helpful for treating clear psychotic symptoms associated with delirium, such as hallucinations, delusions, and paranoia. The sedative effects of antipsychotics can also be helpful for the acute management of agitation. It should be noted, however, that there is no clear evidence that antipsychotics have an impact on the core attentional or cognitive symptoms of delirium. Furthermore, it is critical that antipsychotic trials include careful monitoring for both treatment response and side effects. The selection of the antipsychotic agent may be guided by the agent’s pharmacodynamic and side effect profile to maximize benefit for the unique clinical presentation. For example, patients with profound circadian disturbances and perceptual disturbances may benefit from sedating antipsychotics, such as quetiapine, dosed primarily at nighttime. Patients with hyperactive delirium characterized by rapidly escalating agitation may benefit from haloperidol, which is available in intravenous and intramuscular formulations and can be administered to patients who cannot safely receive oral medications. Patients with Parkinson’s disease or Lewy body dementia are best treated with quetiapine, as first-generation and high-potency antipsychotics can worsen Parkinson’s motor symptoms. If a patient with Parkinson’s disease or Lewy body dementia requires a parenteral medication, intramuscular olanzapine or ziprasidone should be administered at the lowest effective dose. Individuals who are unable to swallow tablets may benefit from agents with oral disintegrating formulations, such as olanzapine and risperidone. Delirious cancer patients often benefit from the antiemetic properties of olanzapine.

a ODT=orally disintegrating tablet.

TABLE 1. Antipsychotics and other medications used in the treatment of delirium a

In terms of dosing, as-needed daytime doses can be initiated, as well as either an as-needed or a standing bedtime dose, depending on symptom severity. Frequent use of as-needed doses should prompt initiation of standing doses at the lowest effective dose and frequency. If the patient demonstrates only partial response, doses may be gradually titrated upward, as long as daily maximum limits are not exceeded. As the patient begins to improve, standing daytime doses should be transitioned back to as-needed doses, reserving the standing bedtime dose as the last to be transitioned back to as-needed.

The three main risks associated with antipsychotic use include QTc prolongation (which increases the risk of sudden death by torsade de pointes), extrapyramidal symptoms, and increased all-cause mortality in elderly patients with dementia. While QTc prolongation is commonly observed with antipsychotic medications, the absolute increases are modest. A study performed for the FDA by Pfizer comparing the QTc interval before and after exposure to the maximum recommended daily doses of commonly used antipsychotic medications demonstrated QTc prolongation ranging from 4.7 ms (with haloperidol) to a maximum of 20.3 ms (with ziprasidone) ( 59 ). The FDA placed a black box warning on droperidol in 2001, indicating a significant risk of QTc prolongation and cardiac arrhythmias. Many experts questioned the validity of this warning after its issuance, and a recent evidence-based review indicated that the risk of torsade de pointes is low when doses less than 10 mg are administered ( 60 ). Patients receiving antipsychotic medications during periods of delirium should have an ECG before therapy is initiated as well as after initiation to ensure that the QTc interval has not significantly lengthened. Routine monitoring of the QTc interval becomes even more critical in patients who have known heart disease and in patients receiving other QTc-prolonging medications. The incidence of torsade de pointes is 10–15 events per 10,000 person-years of observation, making it a high-risk but low-frequency incident ( 61 ). Optimization of electrolytes, particularly potassium, magnesium, and calcium, can minimize antipsychotic-associated QTc prolongation. Potassium shortens the QTc interval, and magnesium suppresses recurrent torsade de pointes without shortening the QTc interval ( 62 ).

Patients receiving antipsychotics must also be monitored for extrapyramidal symptoms, as akathisia, rigidity, and dystonias may exacerbate the underlying restlessness and disorientation seen in delirium. Akathisia is most commonly observed in patients receiving high doses of first-generation antipsychotics, although the risk of developing akathisia appears to be attenuated in patients receiving 4.5 mg/day or less of haloperidol, as well as those receiving second-generation antipsychotics ( 57 ). Patients experiencing rigidity must be monitored for the development of neuroleptic malignant syndrome, an uncommon but life-threatening condition following exposure to antipsychotic medications that is characterized by lead-pipe rigidity, elevated creatine kinase levels, fever, mental status changes, and autonomic instability ( 63 ). The differential diagnosis for neuroleptic malignant syndrome includes malignant catatonia and serotonin syndrome. The development of such symptoms should prompt immediate discontinuation of antipsychotics, as well as escalation of care to an ICU setting for close monitoring and supportive treatment, including aggressive volume resuscitation, electrolyte correction, and temperature regulation. In severe cases, additional treatment options would include benzodiazepines, dopaminergic agents, dantrolene, or electroconvulsive therapy (6–10 bilateral treatments) ( 64 ).

The FDA has issued black box warnings cautioning against the use of antipsychotic medications in elderly patients with dementia, indicating that antipsychotics are associated with increased all-cause mortality in this population ( 65 ). However, it is critical to distinguish the practice of using the lowest effective dosage of an antipsychotic for a limited period in delirious patients in a carefully monitored medical setting from the higher cumulative antipsychotic exposure observed among patient populations on which the original safety warnings were based. A subsequent study specifically examining the rate of adverse events that could be attributed to antipsychotic use among some 2,400 medical inpatients who developed delirium ( 66 ) did not find a higher mortality rate among patients receiving antipsychotics. However, a 2017 prospective placebo-controlled study of elderly patients receiving palliative care ( 67 ) demonstrated a higher survival rate among patients receiving placebo than among those receiving haloperidol. Additional multicentered, placebo-controlled studies are necessary to elucidate the risks and benefits of antipsychotic therapy in patients with delirium, as it is difficult to generalize these findings to the larger, heterogeneous, nonpalliative patient population. It cannot be emphasized strongly enough that patients receiving antipsychotics to target symptoms of delirium while in the hospital must either be fully tapered off of those agents before discharge or must have a clear discontinuation plan, as it is not uncommon for these medications to be inadvertently continued indefinitely after discharge.

Non-Antipsychotics

Antiepileptics..

Valproic acid has shown promise in case series and retrospective cohort studies for the treatment of delirium ( 68 , 69 ). Postulated mechanisms of action include modulation of a range of neurotransmitters (GABA, dopamine, glutamate, acetylcholine) and increasing melatonin levels ( 70 ). Valproic acid may be administered orally or intravenously, and it may provide secondary benefits for delirious patients with comorbid alcohol withdrawal, history of traumatic brain injury, or mood disorder. Loading doses are often, but not uniformly, utilized. In a recent retrospective study, the median dosage was 23 mg/kg per day in divided doses ( 68 ). While serum levels are useful to identify toxicity, to achieve effect for delirium, serum levels need not reach the range of 50–125 µg/mL recommended for management of mood instability. Valproic acid should be avoided in patients with significant hepatic or pancreatic dysfunction, patients with active bleeding or a low platelet count, and pregnant patients. Blood counts and liver enzyme levels should be obtained before initiating valproic acid and then monitored. Ammonia levels should be monitored, as hyperammonemia can contribute to hepatic encephalopathy, confusing the presentation of delirium. Once agitation has remitted, a taper schedule should be established, decreasing by 250–500 mg daily until discontinued ( 51 ). Because the metabolism of valproate is dependent on the cytochrome P450 system, concomitant treatment with drugs that competitively inhibit P450 enzymes, including aspirin, ibuprofen, cimetidine, and erythromycin, must be done cautiously, as they can increase serum valproate levels.

Alpha-2 agonists.

Dexmedetomidine, an alpha-2 agonist, has shown benefit in decreasing delirium-associated agitation, both directly by reducing sympathetic outflow from the CNS and indirectly by minimizing utilization of other potentially deliriogenic agents. Clonidine is another alpha-2 agonist, which has less CNS selectivity but can be administered orally in non–critical care settings. There is only limited evidence supporting the role of alpha-2 agonists in adult populations outside the ICU ( 68 ), although one randomized controlled trial is under way ( 71 ).

As with antipsychotics, a proactive down-titration strategy must be initiated to prevent prolonged administration of these symptom-focused medications beyond the course of delirium or hospitalization and to minimize the risk of rebound hypertension.

As discussed above, there is an emerging literature to support the role of melatonin and melatonin receptor agonists for the prevention of delirium in a variety of hospital settings, yet little is known about the efficacy of melatonin for the treatment of delirium once it has developed. Case studies and retrospective studies indicate that ramelteon is helpful for treating delirium, particularly the hyperactive subtype ( 72 – 74 ). However, generalization of these results is limited by small sample size, lack of randomization, and lack of a control group. Ramelteon was remarkably well tolerated in all these studies, with no significant adverse effects. A double-blind randomized placebo-controlled trial comparing a nightly dose of 3 mg of melatonin to placebo in 56 patients who developed delirium in the setting of organophosphorus compound poisoning showed that the duration of delirium was significantly reduced in the intervention group (6 compared with 3 days; p=0.001) ( 75 ). In light of the favorable tolerability and safety profile of melatonin in a medically vulnerable population, the role of melatonin and melatonin receptor agonists for the treatment of delirium warrants additional research. In the interim, a low threshold is recommended for an empirical trial of melatonin or a melatonin agonist for sleep consolidation and preservation of the sleep-wake cycle in delirious patients.

Nutritional deficiencies, particularly of the B vitamins, have been associated with delirium. Thiamine (vitamin B 1 ) deficiency can lead to a spectrum of mental status changes, including Wernicke’s encephalopathy (triad of nystagmus, ophthalmoplegia, and mental status changes), Korsakoff’s syndrome (irreversible memory impairment, usually as a consequence of untreated Wernicke’s encephalopathy), and delirium. Although the most common cause of thiamine deficiency is alcoholism, a variety of conditions that result in malnutrition, including conditions that result in poor feeding, such as anorexia nervosa and orofacial cancers; conditions that limit absorption, such as gastric bypass surgery, gastric cancer, and colon cancer; and hyperemesis gravidarum, can cause thiamine deficiency ( 76 ). If thiamine deficiency is suspected, patients should be treated with 250 mg/day of thiamine intravenously for 3 to 5 days ( 77 ). Thiamine supplementation should include magnesium repletion, as magnesium is required for the conversion of thiamine into its active form, thiamine pyrophosphate ( 77 ).

Conclusions

The patient in the vignette has many risk factors for delirium, including age, cognitive impairments, multiple medical problems, and male gender. He has physical signs of limited mobility and debilitation, and he is at risk for polypharmacy as well. A psychiatric consultation would include assessment of preadmission neurocognitive baseline and identification of underlying medical etiologies that could contribute to mental status changes (including infection, uremia, and hyperglycemia). Recommendations for intervention would include nonpharmacologic interventions, identification of possible medication-related contributors to delirium, and recommendations for adjunctive medication to manage agitation.

Given the high morbidity and mortality associated with delirium, ongoing efforts to develop and apply proactive interventions to prevent or reduce the severity and duration of delirium are essential. It is crucial to remember that the primary treatment of delirium is identification and management of the underlying medical etiologies, which may be highly variable within and across treatment populations. This adds complexity to research and application of findings across subgroups of populations, even among the geriatric populations who have been the focus of much of the delirium research to date. Safety and symptom relief, including management of the attendant risk of agitation with minimal use of restraints, are important treatment goals. Further research on additional pharmacologic and nonpharmacologic interventions is urgently needed. Meanwhile, we can provide our patients with careful application of the tools currently available to optimize outcomes.

The authors report no financial relationships with commercial interests.

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Delirium Nursing Diagnosis and Nursing Care Plan

Last updated on April 30th, 2023 at 12:01 am

Delirium Nursing Care Plans Diagnosis and Interventions

Delirium NCLEX Review and Nursing Care Plans

Delirium is best described as a disturbance which results to cognitive deficits, attentional deficits, disturbance in circadian rhythm, emotional disturbance, and altered psychomotor functions.

The full pathogenesis of this medical condition is unknown; however, it is believed that delirium occurs due to the disruption to the body’s equilibrium.

Delirium is commonly seen in hospitalized older adults, with an incidence rate ranging between 29 to 64%. It is associated with increased mortality, cognitive and functional decline, risk for falls , and prolonged hospital stay.

Types of Delirium

Delirium has been classified into three types: hyperactive delirium, hypoactive delirium, and mixed delirium.

• Hyperactive delirium – associated with agitation and hypervigilance
• Hypoactive delirium – characterized by drowsiness and apathy
• Mixed delirium – refers to the combination of both hyperactive and hypoactive delirium

Signs and Symptoms of Delirium

The signs and symptoms of delirium may not be constantly present throughout the course of the condition. The signs and symptoms are known to get worse at night and/or when the environment is less familiar to the patient. The signs and symptoms can also vary and may include the following:

• Difficulty to remain focused on a subject or the tendency to switch topics
• Being stuck on an idea with failure to respond to questions or conversations
• Being easily distracted
• Being withdrawn from the environment
• Short-term memory loss
• Disorientation
• Inability or difficulty remembering words
• Nonsense speech
• Difficulty understanding speech
• Difficulty reading or writing
• Hallucinations
• Restlessness, agitation, or combative behavior
• Making random sounds such as calling out and moaning
• Sleep disturbance
• Disturbance in circadian rhythm or sleep-wake cycle
• Mood changes
• Personality changes

Causes and Risk Factors of Delirium

Many healthcare professionals agree that delirium occurs due to the disturbance in the communication system in the brain. This disturbance can be caused by several “triggers” or factors. Delirium can be due to a single cause or a combination of several factors, such as:

• Drug toxicity
• Alcohol intoxication / alcohol withdrawal
• A critical medical condition such as stroke , heart attack , lung, or liver disease, or an injury from an accident
• Metabolic imbalances such as high or low electrolytes levels
• Terminal illness
• Acute infection
• Exposure to toxins or poison
• Malnutrition
• Dehydration
• Sleep deprivation
• Emotional distress
• Surgery or any procedure involving the use of anesthesia
• Pain medications
• Sleep medications
• Drugs to treat mood disorders
• Allergy medications
• Asthma medications
• Corticosteroids
• Parkinson’s disease drugs
• Medications for spasm and convulsions

The following are the risk factors associated with delirium:

• Brain disorders such as dementia , stroke, and Parkinson’s disease
• A previous episode of delirium
• Visual or hearing impairment
• Having multiple medical problems

Complications of Delirium

Delirium can occur rapidly and may last for a few hours to a few days or weeks. Complications of delirium commonly occur in people with a critical illness, and may include:

• General decline in health
• Poor recovery
• Possible need for institutional care
• Higher risk of death

Diagnosis of Delirium

The diagnosis of delirium does not only focus on identifying the presence of the condition, but it also aims in assessing the possible underlying cause or precipitating factors.

• DSM-5 criteria – doctors commonly follow the DSM-5 criteria in the diagnosis of delirium. The criteria require a new acute disturbance in cognition, fluctuating attention, and altered sleep-wake cycle that are related to an underlying medical condition other than dementia.
• The confusion assessment method (CAM) – a tool that is used in some hospitals to assess new confusion which can raise suspicion for the presence of delirium.

The other procedures below also involve the identification of the features of delirium to raise suspicion and come up with a diagnosis:

• A thorough patient-interview
• Physical examination
• Cognitive testing
• Neuro examination
• Review of medical chart and collateral information
• Other tests including blood and urine sample testing may be used to identify underlying medical conditions that can precipitate delirium.

Treatment of Delirium

The treatment of delirium begins by treating the underlying medical condition or other causes. After the cause has been identified and corrected, the treatment will focus on providing the brain a conducive environment for calming and healing.

• Protecting the airway
• Maintaining proper hydration and nutrition
• Mobility assistance
• Pain management
• Addressing incontinence
• Avoiding physical restraints and contraptions such as bladder tubes and intravenous lines unless necessary
• Promotes family involvement in care
• Medications use. There is no known medication available to treat delirium yet; however, there are drugs that can be used to relax and calm a person with delirium, such as anxiolytics or anti-anxiety medications, and several antipsychotics. Benzodiazepines may be used for delirium that is caused by alcohol or drug withdrawal.
• Therapies. Some cases of delirium may not respond to medications. In these cases, therapy sessions involving reorientation with a family member or caregiver to prevent agitation and aggression are recommended. Motivational enhancement therapy and cognitive behavioral therapy (CBT) can also be beneficial to patients with delirium.

Nursing Diagnosis for Delirium

Nursing care plan for delirium 1.

Nursing Diagnosis: Disturbed Thought Process related to cognitive impairment secondary to delirium as evidenced by problems with coordination and motor functions, difficulty handling complex tasks, confusion and disorientation, and inability to do activities of daily living (ADLs) as normal

Desired Outcome: The patient will be able to establish optimal mental and physical functioning.

Nursing Care Plan for Delirium 2

Nursing Diagnosis: Impaired Verbal Communication related to altered perceptions secondary to delirium as evidenced by difficulty of establishing verbal communication, inability to discern usual or normal communication patterns, cognitive disturbances such as thought blocks, hallucinations/ delusions, and poverty of speech

     Desired Outcome: The patient will be able to establish reality-based thought process and effective verbal communication.

Nursing Care Plan for Delirium 3

Nursing Diagnosis: Self-Care Deficit related to cognitive impairment with secondary to delirium, as evidenced by foul body odor, disheveled appearance, and inability to perform self-care activities as normal

           Desired Outcome: The patient will be able to perform self-care activities appropriately.

Nursing Care Plan for Delirium 4

Impaired Memory

Nursing Diagnosis: Impaired Memory related to cognitive impairment secondary to delirium as evidenced by disorientation to time, place, person, and circumstances, decreased reasoning ability, decreased attention span, easy distractibility, inability to follow simple instructions, and deterioration in personal care and appearance.

Desired Outcomes:

• The patient will be able to re-establish mental and psychological functions.
• The patient’s family members will be able to show an understanding of appropriate care and demonstrate adequate coping skills.
• The patient will be able to achieve functional ability at an optimum level and adapt to the alterations of the environment to compensate for limitations.

Nursing Care Plan for Delirium 5

Acute Confusion

Nursing Diagnosis: Acute Confusion related to cognitive impairment secondary to delirium, as evidenced by lack of motivation to initiate goal-directed behavior, a decline in psychomotor activity, misperceptions, increased agitation, restlessness, and altered level of consciousness.

• The patient will be able to have decreased delirium episodes.
• The patient will be able to have a normal reality orientation and state of consciousness.
• The patient will be able to express an understanding of the contributing factors to the disease.
• The patient will be able to make a lifestyle or behavioral modification to prevent or limit the recurrence of the condition.
• The patient will be able to exhibit proper motor behavior.
• The patient will be able to participate in daily activities (ADLs).

Nursing Care Plan for Delirium 6

      Anxiety

Nursing Diagnosis: Anxiety related to cognitive behaviors indicative of fear secondary to delirium, as evidenced by decreased attention span, restlessness, feelings of discomfort, apprehension or helplessness, delusions, and disorganized thought process.

• The patient will be able to express feelings of anxiety.
• The patient will be able to respond to relaxation techniques with a minimal anxiety level.
• The patient will be able to reduce their own anxiety level.
• The patient will be free from anxiety attacks.

More Delirium Nursing Diagnosis

• Impaired Social Interaction
• Risk for Injury
• Risk for Self or Other-directed Violence

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020).  Nursing diagnoses handbook: An evidence-based guide to planning care . St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022).  Nursing care plans: Diagnoses, interventions, & outcomes . St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020).  Medical-surgical nursing: Concepts for interprofessional collaborative care . St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020).  Saunders comprehensive review for the NCLEX-RN examination . St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines and policies and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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