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B.E.A.T. Delirium Amy E. Seitz Cooley, MS, RN, ACNS-BC Clinical Nurse Specialist York College of Pennsylvania DNP Student

B.E.A.T. Delirium - WordPress.com...• Add this to the incidence yields an overall occurrence of 29-64% in these types of units Inouye, et al., 2014 • Siddiqi et al. (2006) reported

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Page 1: B.E.A.T. Delirium - WordPress.com...• Add this to the incidence yields an overall occurrence of 29-64% in these types of units Inouye, et al., 2014 • Siddiqi et al. (2006) reported

B.E.A.T.Delirium

AmyE.SeitzCooley,MS,RN,ACNS-BC

ClinicalNurseSpecialist

YorkCollegeofPennsylvaniaDNPStudent

Page 2: B.E.A.T. Delirium - WordPress.com...• Add this to the incidence yields an overall occurrence of 29-64% in these types of units Inouye, et al., 2014 • Siddiqi et al. (2006) reported

SITUATION

“Theveryfirstrequirementinahospitalisthatitshoulddothesick

noharm!” FlorenceNightingale:NotesonNursing

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Deliriumwasfirstdescribedmorethan2500yearsago…

Itremainspoorlyunderstoodandisfrequentlyunrecognized!

Page 4: B.E.A.T. Delirium - WordPress.com...• Add this to the incidence yields an overall occurrence of 29-64% in these types of units Inouye, et al., 2014 • Siddiqi et al. (2006) reported

Nurses…

•  Arekeytodetectingandreportingdelirium

symptomssincetheyspendtimewith

patients...yetmanytimestheconditiongoes

unrecognizedandthereforeispoorly

managed! Bakeretal.,2015

Page 5: B.E.A.T. Delirium - WordPress.com...• Add this to the incidence yields an overall occurrence of 29-64% in these types of units Inouye, et al., 2014 • Siddiqi et al. (2006) reported

Storytime…Haveyouexperienced?

Page 6: B.E.A.T. Delirium - WordPress.com...• Add this to the incidence yields an overall occurrence of 29-64% in these types of units Inouye, et al., 2014 • Siddiqi et al. (2006) reported

BACKGROUND

“Whydoesthishappentopatientsthat

comeinwithaUTI?” YorkHospitalTower3RN

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AACNHartford-sponsoredFacultyDevelopment

Delirium:Background•  Diagnosisofdeliriumishighlyclinicalanddependent

uponclinician'slevelofexpertise,systematicscreening&carefulclinicalobservations

•  Progressiontostuporand/orcoma,seizures,anddeathispossible.

•  Deliriumisacardinalsignofageropsychiatricemergencyandmustbepromptlyidentifiedandaddressedwithbiopsychosocialandenvironmentalinterventions.

•  Earlyrecognitionofdeliriumfollowedbyrapidmanagementofunderlyingmedicalandenvironmentalfactorsdecreasestheseverityandcanleadtoimprovedoutcomes.

Page 8: B.E.A.T. Delirium - WordPress.com...• Add this to the incidence yields an overall occurrence of 29-64% in these types of units Inouye, et al., 2014 • Siddiqi et al. (2006) reported

Delirium…

•  Isanacutedeclineofcognitivefunctioning Inouyeetal,2014

•  Itiscommon,serious,costly,under-recognized

andoftenfatal Inouyeetal,2014

•  Itaffectsasmanyas50%ofhospitalizedadults

65yearsandolder Leslieetal.,2014

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DeliriumOutcomes…

•  Oneofthemostpreventableadverseeventsforolder

patients Inouye,2006

•  Longerhospitalstays

•  Morehospitalacquiredcomplications--falls

•  Morelikelytobeadmittedtolongtermcare

•  Increasedincidenceofdementia

•  Increasedmortality NationalInstituteforHealthandCareExcellence(NICE),2010

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DeliriumCosts…

•  Estimatedtodeliriumrangefrom$16,303to

$64,421perpatientwiththenationalburdenon

healthcarerangingfrom$38to$152billionyearly

Leslieetal.,2008

•  Morethan$182billionperyearin18European

countriescombined OECD,2014;WHO,2012

Thecosttopatients…immeasurable…

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eSlide-P3562-AACNHartford-sponsoredFacultyDevelopment

Delirium:Definition

Atransientandnonspecificorganicmentalsyndromecharacterizedby:

§  Acuteonset(hourstodays),tendingtofluctuateoverthe24hourperiod

§  Reducedabilitytofocus,sustainorshiftattention§  Disturbedlevelofconsciousness,suchasreduced

clarityofawareness§  Changeincognitionsuchasmemoryloss,

disorientationand/orlanguagedisturbance§  Perceptualdisturbancenotaccountedforbypre-

existing,establishedorevolvingdementia

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Delirium…•  Prevalenceofdelirium(onadmission)ingeneralmedical

and“oldage”medicalunitsis18-35%

•  Addthistotheincidenceyieldsanoveralloccurrenceof29-64%inthesetypesofunits

Inouye,etal.,2014

•  Siddiqietal.(2006)reportedoccurrencerateperadmissionof11-42%

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DeliriumCauses…

•  Usuallymultifactorial;thismodelhasbeen

wellvalidatedandwidelyacceptedInouyeetal.,2015

•  Dependoncomplexitiesofrelationshipswith

predisposingfactorsinvulnerablepatients

withprecipitatingfactors Inouyeetal.,2015

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DeliriumRiskFactorsPredisposing

•  Baselinecognitiveimpairment;

dementia

•  Underlyingillnessorco-morbidity

•  Functionalimpairment

•  Advancedage

•  Chronicrenalinsufficiency

•  Dehydration

•  Malnutrition

•  Sensoryimpairment—visionorhearing

•  Malesex

Precipitating•  Medication

•  Immobilization

•  Indwellingcatheters

•  Restraints

•  Dehydration

•  Malnutrition

•  Illnesses—infection,electrolyte

imbalances

•  Hospitalization—environmental

•  Psychosocialfactors

•  Alcohol

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PredictiveModel

Inouyeetal,2014

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Delirium:Medication-RelatedPrecipitatingFactors

§  Anticholinergics§  Opiates§  Benzodiazepines§  Corticosteriods§  Alcoholwithdrawal§  Sedative-hypnoticdrugwithdrawal§  Anynewlyprescribedmedication§  Overthecounter(OTC)“homeremedies,”especiallythosewith

anticholinergiceffects(NSAIDS,nasalsprays,coldandflumeds)§  Additionof3newlyprescribedmedications

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UnrecognizedbyNurses•  Continuestobeattributedtonormalageingprocess—

lackofunderstandingdifferencesbetweendelirium,

dementia,anddeliriumsuperimposedondementia

(DSD)

•  Fluctuatingnatureofdelirium

•  Impactofdeliriumeducationonrecognition

•  Communicationbarriers

•  Inadequateuseofdeliriumassessmenttools

Husseinetal.,2014

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ASSESSMENT

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DeliriumSigns

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eSlide-P3562-AACNHartford-sponsoredFacultyDevelopment

Delirium:ClinicalPresentationClinicalsubtype

MixedHypoactiveHyperactive

§  Increasedpsychomotoractivity,suchasrapidspeech,irritability,andrestlessness

§  Lethargy§  Slowedspeech•  Decreased

alertness§  Apathy

§  Shiftbetweenhyperactiveandhypoactivestates

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RECOMMENDATIONS

Page 22: B.E.A.T. Delirium - WordPress.com...• Add this to the incidence yields an overall occurrence of 29-64% in these types of units Inouye, et al., 2014 • Siddiqi et al. (2006) reported

HereiswheretheB.E.A.T.ComesintoPlay…

•  B=EstablishthePatient’sBaseline

•  E=Evaluatecurrentcognitionandscreen

•  A=Assessfordeliriumriskfactors

•  T=Treattherisk!!

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•  Earlyidentification&modificationofpredisposingfactors

•  Earlyrecognition&

treatmentofcognitiveimpairment

•  Rapididentification&

treatmentofacuteillness

•  Assessment&appropriatemanagementofpain

•  Maintenanceofnormalsleep-

wakecycle•  Avoidanceofdeliriogenic

medications&polypharmacy

•  Assuranceofadequatehydration&nutrition

PreventionofDeliriuminOlderAdults

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•  Enhancementofsensorystatusbyuseofsensoryaids&appropriatelevelsoflight&sound

•  Enhancementofcognitive

reserve•  Provisionforfamily

presence

•  Avoidanceofurinarycatheterization

•  Avoidanceofphysical

restraintuse•  Assessment&management

ofdrugandalcoholwithdrawal

PreventionofDeliriuminOlderAdults

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Delirium:History

•  Whendidthechangeinmentalstatusbegin?•  Doestheconditionchangeovera24-hourperiod?•  Isthereachangeintheperson’ssleeppatterns?•  Whatspecificthoughtproblemshavebeennoticed?•  Isthereahistoryofmentalillnessorsimilarthought

disturbance?•  Hastherebeenasuddendeclineinphysicalfunctionora

newonsetoffalls?•  Queryfamilyorcollateralsourcefrompriorsettingas

to‘whatisnormal’forthispatient.

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Delirium:ChangeinMentalStatus

§  Anabnormalmentalstatusexamthatisachangefrombaselineforthe

personisthehallmarkofdelirium

§  Abnormalitiesmayincludeinattention,fluctuationsinlevelof

consciousness,newshorttermmemoryimpairment,alteredspeech

patterns,disorganizedspeechand(possibly)delusionsor

hallucinations

§  Mentalstatusscreeningtestsarehelpfulinidentifyingcognitive

deficitsandshouldbeperformedroutinelyinolderpatients:on

admissionandatleastdailyduringstay

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DeliriumAssessment:DirectObservation

§  Routineandperiodicobservationoftheolder

adult’slevelof:

§  Alertness(alert,hyper-alertorhypo-alert)

§  Generalbehavior

§  Mood&affect

§  Speechdisturbance/verbalizations

§  Motorbehavior

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Delirium:PhysicalExam

Examineforsignsof:§  Hypoxia§  Volumedepletion/overload§  Cardiovascularinjury§  Metabolicencephalopathy§  Alcoholwithdrawal§  Hypo-orhyperthermia§  Newonsetincontinence§  Urinaryretentionorfecalimpaction

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Delirium:DiagnosticTests

Choicebasedonhistoryandphysicalfindings

Baselinelaboratorystudies:

•  Urinalysis

•  BasicorComprehensiveMetabolicPanel

•  Bloodwork:CBC,Thyroidfunctiontest

Furtherdiagnostictesting(basedonexam):

•  HeadCT

•  EKG

•  ChestX-Ray

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Delirium:DiagnosticTestscont'd

•  Whendifficultto

differentiatedelirium

fromacutepsychotic

state

Electroencephalography

Theelectroencephalogramreveals:

Diffuseslowinginmostcasesofdelirium

Fastac:vityincasesofdeliriumrelatedtodrugwithdrawal

Normalpa=ernsinpa:entswithacutefunc:onalpsychosis

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Delirium:EnvironmentalPredisposingFactors

•  Transferswithinthehospitalorunit

•  Absenceofaclockorwatch

•  Absenceofreadingglasses,hearingaid

•  Absenceoffamilymembers

•  Useofphysicalrestraints

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DifferentiatingDeliriumfromDementia&Depression

•  Chroniccognitiveimpairmentseenindementiatypically:

–  Occursgraduallyovertime

–  Persistsgreaterthanonemonth

–  Isirreversible

•  Mostolderadultswithdementiaarealertandabletomaintain

attentionintheearlystagesofdementia

•  Depressionmayalsopresentacutelywithdeficitsinabilitytosustain

attention.

•  Depressionmaypresentsimilartohypo-orhyper-activedelirium;

therefore,itisimportanttoscreenfordepressioninolderadultswho

presentwithamixedpicture.

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Delirium:DifferentialDiagnosis

•  Withrecentchangeincognition,anolderpersonshouldbe

presumeddeliriousuntilprovenotherwise

•  Suddencognitiveand/orfunctionaldeteriorationina

patientwithdementiasuggestsdeliriumsuperimposedon

dementia

•  Apathy,slowedspeechandmooddisturbancemaybe

indicativeofhypoactivedeliriumratherthandepression

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-AACNHartford-sponsoredFacultyDevelopment

Delirium:DifferentialDiagnosis•  Functionalpsychosis

–  Acutefunctionalpsychosiscanresembledelirium

–  Onsetatanearlierage

–  Mostolderpatientswithfunctionalpsychosishaveahistoryofpsychiatric

illness

–  Hallucinationstendtobeauditory

–  Delusionsaremoreelaboratethanthoseassociatedwithdelirium

–  DementiawithLewyBodiesincludesfluctuatingcognitionandvisual

hallucinations

–  Consultationwithapsychiatristoraneurologistmaybenecessaryindifficult

cases

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AACNHartford-sponsoredFacultyDevelopment

Delirium:GeneralManagement

•  Multi-componentinterventionsaremosteffective

•  Promptrecognition&treatmentofunderlyingcause

•  Creationofamaximumsupportiveenvironment

•  Immediatemedicaltreatmentasnecessary

•  Discontinuationorreduceddosesofmedicationsthoughttobe

deliriogenic

•  Useofenvironmentalinterventionssuchasadeliriumroom

Ensure

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AACNHartford-sponsoredFacultyDevelopment

Delirium:GeneralManagement-Nutrition&Hydration

§  Accurate 24 hour I & O

§  Avoidance of depletion-dehydration syndrome

§  Enteral tube feeding or hyperalimentation as necessary

§  Address any excess output issues such as polyuria or diarrhea

§  Toilet patient on a schedule

Ensure

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AACNHartford-sponsoredFacultyDevelopment

Delirium:GeneralManagement

•  Pulmonarycaretoensureadequateoxygenation,avoidatelectasisand

pneumonia

•  Bowelandbladderprotocolstopreventortreatconstipation,diarrhea,

andurinaryincontinence

•  Vigilenceforfallriskandpatientsafety

•  Usecognitivestimulation

•  Avoidcomplicationsofimmobility—mobilize,mobilize,mobilize!!

•  Minimizeskinbreakdown

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Delirium:ManagingtheEnvironment

§  Presenceoffamilymembers

§  Inclusionoffamiliaritemsfromhome

§  Useofglasses&hearingaids

§  Avoidanceofphysicalrestraints

§  Deliriumroomforhighriskpatients

§  Night-lightandminimizationofnoise

§  Interruptsleeponlywhenabsolutelynecessary

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AACNHartford-sponsoredFacultyDevelopment

Delirium:MaximizingCognition

•  Re-orientatingstrategies–  Inclusionoforientingfactsin

normalconversation–  Discussionofcurrentevents–  Discussionofspecificinterests–  Structuredreminiscence–  Wordgames–  Cognitivestimulation

•  Findoutwhatthepersonlikestodotooccupytime!

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Delirium: MedicationManagement

Usemedicationswhen:

§  behaviorsassociatedwithpsychoticthinkingandperceptual

disturbances(e.g.,hallucinations)poseasafetyriskorare

distressingtotheindividual.

§  deliriuminterfereswithneededmedicaltherapiesandbehavioral

interventionsfail

DoNotusemedicationsasasubstitutefordetection,correction,or

eliminationofunderlyingcausesofdelirium

Uselowdosesofmedicationsovertheshortestpossibletimeperiod

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Delirium:MedicationManagement

§  Firstlinetherapy:Lowdoseshigh-potencyneuroleptics(e.g.,haloperidol)§  Associatedwithextrapyramidalsymptoms(EPS)

§  Newerantipsychotics(e.g.,olanzapineandrisperidon)havealowerincidenceofEPSandmaybebettertoleratedinolderpatients

§  NeurolepticMalignantSyndrome,amoreserioussideeffectofantipsychotictherapy,canoccurwithhigh-potencyaswellaswithnovelanti-psychotics

§  Benzodiazepines(e.g.,lorazepam)arerecommendedwithalcoholwithdrawalorwithdrawalfrombenzodiazepines.§  Innon-alcoholwithdrawal,benzodiazepinespotentially

worsendeliriumandshouldbeusedwithcaution

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eSlide-P3562-AACNHartford-sponsoredFacultyDevelopment

DeliriumManagement:Aftercare§  Helpthepatientandfamilyunderstandthebizarreand

bewilderingexperience§  Psychiatriccaretofacilitateresolutionthrough:

§  Sensitiveretrospectiveexplorationoftheexperience§  Increasingpatient’sunderstandingandacceptance§  Encouragingpatientstoreportriskofdeliriumfor

subsequenthospitalizations§  Comprehensivedischargeplanning

§  Homecarereferral§  Physicalandoccupationaltherapy§  Psychiatricnursinghomecareservices

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Delirium:Conclusion•  Historicallyseenas:Abenignandexpectedcondition

relatedtohospitalization•  Currentlyseenas:Aserioushealthproblemwith

significantnegativeconsequences•  NursesandNAsarefrontlineinearlyidentificationof

patientsmostatriskfordeliriumandearlydetectionofsymptoms

•  Routineandsystematicassessmentforconfusioniskey

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Resources

•  Activityboxes…

•  Portal…

•  Whenwouldyouliketohavevolunteer

servicesleadactivities??

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B=BaselineChange?E=EvaluateCurrentCognitionandScreenA=AssessforDeliriumRiskT=TreattheRiskusingNonpharmacologicalInterventions


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