Delirium/Acute Confusion
Description of Behavior
Core features of delirium include acute and fluctuating course, inattention, disorganized thinking and change in level of consciousness (hyper-alert, drowsy, or coma). Other symptoms may include emotional labiality, hallucinations, delusions, psychomotor agitation (restlessness), psychomotor retardation (withdrawn), sleep disorder, including insomnia, hyper-somnolence, and sleep cycle disturbance, inappropriate behavior, poor postural control, and decline or low performance of self-care activities.
Why behavior might occur
We do not know the exact cause of delirium but it typically involves a vulnerable patient and a noxious insult such as surgery, infection, or adverse medication effects. Dementia and increasing age are the strongest risk factors.
How to approach the person who is delirious and specific things to try to reduce delirium
- Delirium is a medical emergency that should be communicated to the members of the healthcare team immediately.
Don't assume an older adult who has an altered mental status and/or symptoms of confusion has dementia, and don't label it as normal aging or as a dementia; instead assess for delirium or delirium superimposed on dementia (DSD).
- When delirium is suspected, assess the resident at least once a shift using a brief assessment tool, such as days of the week backward or or months of the year backward (Fick et al., 2015 In Press). For other bedside tools see: Kolanowski, A. M., Fick, D. M., Hill, N., Yevchak, A., Mulhall, P., & McDowell, J. (2012). Pay Attention! Journal of Gerontological Nursing, 38(11), 23-27; Fick, DM, Inouye, SK, Guess, J, Long, HN, Jones, RN, Saczynski, JS, Marcantonio, MD, Preliminary development of an ultra-brief 2-item bedside test for delirium. Journal of Hospital Medicine, Accepted June 9, 2015).
- The resident with delirium may have poor judgment and difficulty focusing, switching and sustaining attention. Keep the delirious resident safe from falls and other adverse events.
- Avoid use of physical restraints and bed alarms.
- Good interpersonal communication, both verbal and non-verbal, is important. Don’t use “elderspeak” (infantilizing communication) while speaking to an older adult with delirium. Research has shown that older adults find elderspeak to be demeaning. Re-orient as needed (explain where the person is, who they are, and what your role is) and provide reassurance. Stay calm and be aware of your tone of voice and body language.
Specific things to try to reduce delirium
- Good nursing care is at the core of delirium prevention. Keep residents mobile, hydrated and engaged in activities they enjoy.
- To promote sensory input and communication, keep eyeglasses and hearing aids in good working condition and make sure the resident has them on at all times.
- Encourage use of dentures to help ensure adequate nutrition.
- Use consistent assignment of staff and avoid room changes. To promote relationship-based care use an orienting board such as the All About Me Board that gives personal information about what makes the resident feel calm, what they like or don’t like, names of pets and/or family members (See Fick, D. M., DiMeglio, B., McDowell, J. A., & Mathis-Halpin, J. (2013). Do you know your patient? Knowing individuals with dementia combined with evidence-based care promotes function and satisfaction in hospitalized older adults. Journal of Gerontological Nursing, 39(9), 2-4).
- Treat pain with appropriate non-pharmacological and pharmacological interventions.
- Encourage family involvement for re-orientation; use companions as needed.
- Provide non-pharmacological sleep protocol (back rub; decaffeinated tea) and quiet room at night with low level lighting.
- Don’t administer “prn” (i.e., as needed) sedative, antipsychotic, or hypnotic medications to prevent and/or treat delirium without first assessing for, removing, and treating the underlying cause of delirium and using nonpharmacologic delirium prevention and treatment approaches.
- Don't discharge patients with delirium from post-acute care without an appropriate delirium treatment, care management, and communication plan for transitioning care and ensuring ongoing follow-up.
