NURSING 3PA2 Study Guide - Final Guide: Aspiration Pneumonia, Malnutrition, Mania

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N2PF3 Module 10: Delerium
MODULE 10: DELERIUM
Learning Outcomes
Upon conclusion of this unit the student will:
1. Define delirium as a clinical syndrome.
2. Discuss the importance of delirium as a predictor of increased mortality in the elderly
hospitalized population.
3. Distinguish between delirium and other neuropsychiatric illnesses.
4. Identify the subtypes of delirium and their associated characteristics.
5. Describe the screening tools available to diagnose delirium.
6. Identify the predisposing and precipitating factors that increase a patient’s risk for delirium.
7. Discuss the pathophysiology of delirium.
8. Describe the intervention protocols used to prevent and manage delirium in the hospitalized
elderly population.
Delirium: Introduction
Delirium is a common, life threatening and potentially preventable clinical syndrome, induced by
a variety of physical causes.
What is it?
Delirium is often defined as an acute decline in the cognitive processes of the brain, namely
involving attention and cognition.
-Patients with delirium may exhibit periods of inattention, disorganized thinking,
changes in level of consciousness, disorientation, delusions, perceptual disturbances, as
well as impaired memory, speech, sleep and psychomotor activity.
-These changes in cognitive function can fluctuate in severity throughout the day (though
symptoms are often more pronounced at night)
Who is affected?
It is most strongly associated with hospitalized patients who are 65 years of age or older and
frequently accompanies acute illness
It is estimated, that of patients with delirium go unreported. This can be attributed to
both, the syndrome's fluctuating nature and the wide range of symptoms and patient
characteristics associated with the syndrome.
Why should clinicians care about delirium?
Historically, delirium was accepted as a harmless process. However, data collected over the
past 15 years, has shown that this clinical syndrome is linked to poor clinical outcomes, and
should be regarded as a marker for severe illness and mortality.
In North America, delirium complicates the hospital stays of approximately 20% of patients
65 years of age and older.
One year mortality rate associated with cases of delirium in the elderly is 35-40%.
(Textbook: this may be due to that fact that the key features of delirium, i.e. agitation,
disorientation, and fearfulness, place the individual at high risk for injuries such as fracture
from a fall
The development of delirium in hospitalized elderly, initiates a cascade of events that
culminate in the loss of patients’ independence, and an increased risk for morbidity and
mortality.
There are also associated increases in healthcare costs, due to longer hospital stays,
rehabilitation, the need for formal home health care, or long-term institutionalized care.
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2Module 10
Alterations in Mental Health: Delirium
Despite this evidence, it is estimated that only 40% of clinicians routinely screen for delirium
in hospitalized elderly patients.
Diagnosing Delirium
DSM-IV Diagnostic Criteria for Delirium
1. The presence of disturbed consciousness (e.g. reduce clarity of awareness of the
environment) with reduced ability to focus, sustain or shift attention
2. A change in cognition (such as memory deficit, disorientation, language disturbance), or the
development of a perceptual disturbance that is not better accounted for by a preexisting,
established or evolving dementia.
3. The disturbance in consciousness must develop over a short period of time (usually hours to
days), and tends to fluctuate during the course of the day.
4. There must be evidence from clinical history, physical examination and/or laboratory
findings that the disturbance is caused by the direct physiological consequences of a medical
condition.
Why is delirium under-diagnosed?
Fluctuating symptoms: Changes in cognitive function can fluctuate in severity throughout
the day and as such, delirium is often under-recognized and under-treated.
Terminology: Some clinicians continue to use the term confusional state or encephalopathy
when diagnosing delirium, further complicating the proper identification, management and
treatment of this life threatening syndrome.
Lack of screening: It is estimated that only 40% of clinicians routinely screen for delirium in
hospitalized elderly patients.
Confusion with other disorders: Many of the symptoms observed in patients with delirium
are also observed in patients with other neuropsychiatric diseases, or medical illnesses.
Therefore, patients with delirium may be difficult to identify, especially to an inexperienced
health care worker.
Clinical Features of Delirium
The clinical features shown below are also hallmark characteristics of delirium.
1. Acute Onset: Delirium occurs abruptly, usually over a period of hours or days. Reliable
information is often needed to ascertain the time course of onset.
2. Fluctuating Course: Symptoms of delirium tend to come and go or increase and decrease in
severity over a 24-hour period. Patients often have characteristic lucid intervals.
3. Inattention: Patients demonstrate difficulty focusing, sustaining, and shifting attention,
maintaining conversation or following commands.
4. Disorganized Thinking: Patients demonstrate disorganized or incoherent speech through
rambling or irrelevant conversation or an unclear or illogical flow of ideas.
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N2PF3 Module 10: Delerium
5. Altered Level of Consciousness: Patients have a clouding of consciousness, with reduced
clarity of awareness of the environment.
6. Cognitive Deficits: Patients typically have global or multiple deficits in cognition, including
disorientation, memory deficits, and language impairment.
7. Perceptual Disturbances: Illusions or hallucinations occur in about 30 percent of patients.
8. Psychomotor Disturbances: There are three psychomotor variants of delirium.
-Hyperactive: Marked by agitation and vigilance.
-Hypoactive: Marked by lethargy, with a markedly decreased level of motor activity.
-Mixed
9. Altered Sleep-Wake Cycle: Characteristic sleep-cycle disturbances typically include daytime
drowsiness, nighttime insomnia, fragmented sleep, anxiety, depression, irritability, apathy,
anger, or euphoria.
10. Emotional Disturbances: Are common and are manifested by intermittent and labile
symptoms of fear, paranoia, anxiety, depression, irritability, apathy, anger, or euphoria.
Types of Delirium
Adding to its complexity, delirium exists in three different subtypes: Hyperactive, hypoactive and
mixed subtypes.
1. Hyperactive:
-Characterized by: restlessness, constant movement and agitation, insomnia, hyper-
vigilance, irritability, distractibility, rapid speech, uncooperativeness, and wandering
behaviour
-Often be mistaken for schizophrenia, bipolar disorder, or agitated dementia
2. Hypoactive:
-Characterized by: a slowing or lack of movement, a paucity of speech (with and without
prompting), and unresponsiveness, apathy and decreased alertness
-Often mistaken for: depression
-The hypoactive subtype of delirium is more common in the elderly, with more than 50%
of elderly hospitalized patients presenting with the hypoactive form of the syndrome.
-Due to its almost silent nature, this form of delirium is the most difficult for clinicians to
identify and is associated with a higher mortality, especially if the patient’s baseline, or
normal behaviour is never established.
3. Mixed:
-Characterized by alternating hyperactive and hypoactive states
Of the three subtypes, those with severe hypoactive delirium have the lowest six months survival
rate. This may be because those with hyperactive delirium subtype are more likely to be referred
to a psychiatrist and receive appropriate therapy or interventions, due to the more disruptive
and potentially self-harming nature of the subtype. In contrast, hypoactive delirium may be
mistaken for compliance, fatigue or simply behaviours incorrectly ascribed to old age.
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