March/April 2017

Detecting Delirium
By Mimi Kovaleski, MSN, RN, ACNS-BC, CCRN
Today's Geriatric Medicine
Vol. 10 No. 2 P. 12

Delirium, a life-threatening preventable complication of hospitalization affecting the elderly population, has been linked to persistent functional decline, increased length of stay with associated costs, a greater likelihood of nursing home placement, and higher mortality rates. Yet to date, delirium remains often unidentified.

Each year more than 7 million Americans will develop delirium and with it, higher mortality rates postdischarge (14% to 38%), increased length of hospital stays (21 days vs nine days without delirium), a 63% risk of developing dementia within 48 months of becoming delirious, and a 62% increase in mortality. Because delirium is a preventable syndrome, these statistics are unacceptable.1,2

Delirium, defined in 1990 as an acute disorder affecting both attention and cognition, was thought to pose significant health problems for hospitalized elderly patients.3 More than twenty-five years later, delirium remains a threat to elderly hospitalized patients as evidenced by the evolving definition of delirium, the number of tools developed to detect delirium, and the number of consequences attributed to delirium. Delirium continues to be defined as an acute reversible alteration in mental status that is now found to be prevalent across multiple care settings in the elderly population.4

As of July 2015, the elderly, or those aged 65 or older, in the United States accounted for 14.9% of the population, and this population is expected to continue to expand as the baby boomers continue to age.5 The incidence of delirium in hospitalized elderly patients is approximately 10% to 87%, costs related to delirium range between $38 billion and $152 billion per year, and approximately 22% to 76% of patients who develop delirium while hospitalized will die.6

Delirium leads to poorer surgical outcomes, higher rates of injury and complications, and may prolong a decrease in functional status for as long as six months postdischarge. Delirium also has been found to impair communication, cognition, and recovery in the elderly.7 Delirium is a syndrome with a number of multifactorial symptoms and manifestations that hinder recognition without a formal cognitive assessment. These symptoms may include impaired cognition or attention, altered sleep/wake cycles, and changes in psychomotor behavior. Delirium is often thought of as a normal part of aging, which also influences the intent to assess for delirium.8 The significance of reducing delirium's incidence and/or frequency lies in improved outcomes, including shorter lengths of stay, lower rates of injury, improved cognitive function, and fewer complications that otherwise would prolong diminished functional status both during hospitalization and upon discharge.

Inadequate Delirium Recognition
What exactly is delirium? It is a neuropsychiatric syndrome with characteristics of disturbances in cognition and attention, an altered level of consciousness, periods of inattention, and disorganized thinking. The cardinal signs of delirium are its acute and sudden onset with a fluctuating nature.9 Delirium's transient, multifactorial presentation and three distinct types—hyperactive, hypoactive, and fluctuating—make identification challenging. The hyperactive phase is the most recognizable form of patients' delirium with periods of agitation, restlessness, pulling at lines and/or tubes, hitting, biting, and at times requiring restraints for safety reasons. The hypoactive phase of delirium may present as depression or dementia, thus hindering recognition. This patient is lethargic, withdrawn, has a flat affect, and is apathetic. Patients with mixed delirium exhibit signs and symptoms of both hyper- and hypoactive delirium, which may fluctuate between the types. The fluctuating course increases the likelihood that it may be missed in the absence of a formal cognitive assessment.

Once a change in cognition occurs, a cognitive assessment is a critical next step to ensure patient safety and adequate patient care.10 However, physicians and nurses may downplay the symptoms of delirium or attribute the symptoms to other causes such as in the case of delirium superimposed upon dementia. An elderly patient often presents with higher levels of acuity, hearing, and vision deficits and multiple comorbidities, thus increasing the chance that delirium will go unrecognized. Health care practices that support delirium prevention are poorly developed, and health care providers' knowledge of delirium recognition is lacking. This may be due partially to the fact that delirium is not called delirium but rather is likely to be labeled as confusion, agitation, or a change in mental status.11

To ensure an accurate delirium diagnosis, patients need to be formally assessed for delirium upon admission with a validated tool if they present with any of the following: aged 65 or older, a history of cognitive impairment or evidence of cognitive impairment, severe illness, or hip fractures. Careful attention is necessary to discern the hypoactive form of delirium such as withdrawal, diminished alertness, or impaired concentration with slowed responses from other cognitive disorders that may not be reversible. Delirium assessment is not limited to a singular evaluation, but rather must be performed throughout the hospital admission at regular intervals such as every eight to 12 hours.12,13

Predisposing and Precipitating Factors for Delirium
A substantial proportion of delirium cases can be prevented when modifiable predisposing factors, or those evident on admission, and precipitating factors, those that provoke delirium, are identified. Something as simple as a change in environment for an elderly person may precipitate an episode of delirium. Several other factors have been found to predispose patients to delirium, including age, as delirium incidence increases with age; visual and hearing impairments; impaired nutrition; disease processes such as urinary tract infections, pneumonia, and sepsis; and a history of dementia, alcohol intake, smoking, or depression.

Polypharmacy, a significant precipitating factor, is common among the elderly and is exacerbated by renal or hepatic impairment that is concurrent with advanced age. Other precipitating factors include narcotics, sedation or anesthesia, dehydration, sleep deprivation or an alteration in day/night orientation, anticholinergic and benzodiazepine medications, invasive lines and catheters, and constipation or urinary retention.12

Because polypharmacy is a serious concern for the elderly population, the Beers criteria were developed to avoid specific drugs in this population to prevent or limit an episode of delirium. A short list of these drugs includes anticholinergics, antihistamines (first generation), antipsychotics (first and second generations), benzodiazepines and benzodiazepine receptor agonists, chlorpromazine, H2 receptor antagonists, meperidine, opioid analgesics, and skeletal muscle relaxants. Practitioners are advised to remove or limit the use of these medications in the elderly population when at all possible.14

Delirium Issues
Two of the most significant barriers to delirium recognition are its lack of visibility and the erroneous assumption that delirium is a benign, normal part of aging. Nurses and physicians typically do not formally identify delirium but instead use casual words or statements to describe delirium behaviors. This unwillingness to call delirium by name as opposed to using delirium descriptor terms is a substantial impediment to implementing established methods of improving care. Delirium will remain invisible due to sparse exposure in both the patient chart and in the media.

Patients are hesitant to speak of having been delirious for fear of embarrassment and because of their inability to fully comprehend what has occurred.11,15 Delirium survivors recount episodes of fear, pain, limited understanding of treatments, and the notion that strangers are trying to harm or kill them. Both the physical and psychiatric sequelae of delirium may persist for extended periods of time, and a patient's limited recall of his or her illness or amnesia related to illness is often replaced with erroneous recollections that result in delusional and suspicious memories.

Posttraumatic stress disorder often occurs after delirium, and these memories lead to anxiety, depression, and fear of hospitalization, in addition to which they have the potential to impede recovery.16 These effects have been found to be of longer duration than first thought and include unremitting cognitive decline that impedes quality of life, is associated with increased mortality rates, and has a direct relationship with increasing cognitive decline.17 Efforts must be made to provide psychological care to delirium survivors, in order to relieve stress and, more importantly, to safeguard the brain.16

Delirium remains imperceptible in health care settings as evidenced by appalling detection rates of 25%. There are several thought processes on methods to accurately assess for and identify delirium. For starters, we must highlight the importance of a delirium assessment and educate health care personnel on the inherent dangers of delirium—it is not a benign disease as once thought. Delirium screening needs to be incorporated into daily patient assessments, much like vital signs are for elderly patients admitted to acute care hospitals, ICUs, and long term care facilities. Detection and documentation of delirium remains erratic and falls largely to the nursing staff, as they spend more time with patients, thus putting them in the position to notice early cognitive changes in patients under their care. Since delirium is not charted or identified as such in medical records, standardized documentation is essential to ensure accuracy and to prevent compromised patient care.

The United Kingdom's National Institute for Health and Care Excellence recommends that practitioners "think delirium" to prevent, diagnose, or treat the condition. Standardized formal cognitive assessments enable practitioners to identify and treat patients with potentially reversible causes of delirium.13 Several validated and reliable tools for delirium detection have been developed, but health care providers, nurses most notably, must be knowledgeable in how to implement them. The tool used to detect delirium must be suitable for the practice area, and education on proper use of the tool is an essential factor in documenting the baseline and ongoing cognitive assessments.

Time constraints on the health care providers responsible for delirium assessment are another impediment to screening, thus prompting tools that have shorter administration times to improve their use in the clinical area. An alternate approach to identifying delirium would be to focus on the delirium descriptors and common delirium symptoms that would informally identify the condition. Routine detection of delirium is thought to improve if detecting the condition is based on the symptoms exhibited rather than standardized diagnostic instruments. The diagnostic instruments require specialized training and are thought to exclude valuable avenues of information such as family members, who are in a better position to recognize the subtle changes in a patient's cognition.10

The creation of electronic information and documentation support that is evidence based assists with recognizing complex clinical phenomena such as delirium.18 Electronic health records may assist clinicians by identifying the programmed descriptors for delirium and automatically populating an assessment protocol that supports delirium identification. This would require the formal assessment to be conducted by trained personnel who are considered competent in confirming delirium. Ongoing training and education needed to formally assess for delirium are recommended for every tool, yet perceived time constraints by staff responsible for the assessment are considered another barrier.11

Maybe it's time to start looking to the environment in which health care is practiced for our answer. Vahey et al verified that on units where nurses had adequate staffing, resources, and administrative support, patient outcomes and satisfaction were improved. The knowledge that inadequate practice environments have a negative impact upon patient outcomes should prompt administrators to provide quality patient care through adequate staffing. This would enable nurses to have both the time and resources to devote to elderly patients and enable them to provide care specific to those needs.19 Our elderly population deserves need-specific care and health care professionals who have the time, training, and resources to adequately care for them.

— Mimi Kovaleski, MSN, RN, ACNS-BC, CCRN, is a faculty specialist in nursing at the University of Scranton in Scranton, Pennsylvania, and a full-time doctoral student at Duquesne University in Pittsburgh. Her interest lies in improved delirium care for the geriatric population.

References
1. Leslie DL, Inouye SK. The importance of delirium: economic and societal costs. J Am Geriatr Soc. 2011;59(Suppl 2):S241-S243.

2. American Delirium Society. 2015 Delirium is a dangerous syndrome. https://www.americandeliriumsociety.org/resources. Published 2015. Accessed December 16, 2016.

3. Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113(12):941-948.

4. Grover S, Kate N. Assessment scales for delirium: a review. World J Psychiatry. 2012;2(4):58-70.

5. United States Census Bureau. Welcome to quick facts. https://www.census.gov/quickfacts/. Accessed December 15, 2016.

6. Steis MR, Fick DM. Delirium superimposed on dementia: accuracy of nurse documentation. J Gerontol Nurs. 2012;38(1):32-42.

7. McCaffrey R, Locsin R. The effect of music listening on acute confusion and delirium in elders undergoing elective hip and knee surgery. J Clin Nurs. 2004;13(6B):91-96.

8. Conley DM. The gerontological clinical nurse specialist's role in prevention, early recognition, and management of delirium in hospitalized older adults. Urol Nurs. 2011;31(6):337-342.

9. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). American Psychiatric; 2013.

10. Middle B, Miklancie M. Strategies to improve nurse knowledge of delirium: a call to the adult-gerontology clinical nurse specialist. Clin Nurse Spec. 2015;29(4):218-229.

11. Zalon ML, Sandhaus S, Kovaleski M, Roe-Prior P. Hospitalized older adults with established delirium: recognition, documentation, and reporting. J Gerontol Nurs. 2017;43(3):32-40.

12. Young J. The recognition and diagnosis of delirium needs improving. Guidelines Pract. 2010;13(10):19-31.

13. Duffin C. Professionals, failure to spot delirium prompts guidance. Nurs Older People. 2010;22(7):6-7.

14. The American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015;63(11):2227-2246.

15. MacLullich AM, Hall RJ. Who understands delirium? Age Aging. 2011;40(4):412-414.

16. PTSD symptoms common among ICU survivors. Johns Hopkins Medicine website. http://www.hopkinsmedicine.org/news/media/releases/ptsd_symptoms_common_among_icu_survivors. Published February 26, 2013. Accessed December 16, 2016.

17. Schwartz A. More common and more harmful than once believed, delirium takes center stage. University of California San Francisco Science of Caring website. http://scienceofcaring.ucsf.edu/patient-care/more-common-and-more-harmful-once-believed-delirium-takes-center-stage. Published February 2016. Accessed December 16, 2016.

18. Byrne MD, Lang N. Examination of nursing data elements from evidence-based recommendations for clinical decision support. Comput Inform Nurs. 2013;31(12):605-614.

19. Tei-Tominaga M, Sato F. Effect of nurses' work environment on patient satisfaction: a cross-sectional study of four hospitals in Japan. Jpn J Nurs Sci. 2016;13(1):105-113.