Learning Objectives
By the end of this section, you will be able to:
- Outline the differences in the diagnosis of delirium and dementia
- Explain the role of the nurse in providing care for a client with delirium
Diagnosing Delirium
Psychosis caused by medical issues is often referred to as delirium, which is a mental state in which the client becomes temporarily confused, disoriented, and not able to think or remember clearly. It usually starts suddenly and can indicate the onset of a life-threatening medical condition. Delirium resolves upon successful treatment of the underlying condition. Each year, more than seven million Americans experience delirium (American Delirium Society, 2023).
Nurses must closely monitor the cognitive function of all clients and promptly report any changes in mental status to the health-care provider. The provider will take a medical history, perform a physical and neurological examination, perform mental status testing, and may order diagnostic tests based on the client’s medical history. After determining the cause of delirium, treatment targets the cause and attempts to reverse its effects.
Incidence and Causes of Delirium
Hospitalized older adults are at increased risk for developing delirium, especially if they have been previously diagnosed with dementia. One-third of clients aged seventy years or older exhibits delirium during their hospitalization. Delirium is the most common surgical complication for older adults, occurring in 15 to 25 percent of clients after major elective surgery and up to 50 percent of clients experiencing hip-fracture repair or cardiac surgery (Marcantonio, 2017). There are many common causes of delirium, including the following (MedlinePlus, 2021; American Delirium Society, 2023):
- dehydration and electrolyte imbalances
- dementias and other neurocognitive disorders
- hospitalization, especially intensive care
- intoxication or withdrawal from alcohol or drugs
- kidney or liver failure
- medications, such as sedatives, opioids, anesthesia, antihistamines, anticholinergics, antidepressants, antipsychotics, or anticonvulsants
- metabolic disorders, such as diabetic ketoacidosis (DKA)
- serious infections, such as urinary tract infections, pneumonia, and influenza
- severe pain
- sleep deprivation
In older adults, one of the most common causes of delirium is a urinary tract infection (UTI), so it is important to get a urine sample as soon as acute confusion is noted. Older adults may not have pain as a symptom of a UTI, like a younger person would, but acute confusion, incontinence, and shivering are telltale signs. After diagnosing a UTI, antibiotics generally resolve the confusion.
Clinical Safety and Procedures (QSEN)
QSEN Competency: Client-Centered Care of a Client Experiencing Delirium
During the care of an older client who has delirium, it is important for the nurse to:
- Assess levels of physical and emotional comfort, which may require observing body language rather than relying on a spoken answer.
- Initiate effective treatments to relieve pain and suffering in light of client values, preferences, and expressed needs. Again, this could be based on how the client is expressing their needs (grimacing, guarding, changing body positions, or even input from family members).
- Remove barriers to having families and other designated surrogates present with the client, based on the client preferences. The nurse may need to educate the family members on behavior seen in delirium and how they can best help their loved one while visiting or caring for the individual.
(QSEN Institute, n.d.)
Symptoms of Delirium
The symptoms of delirium usually start suddenly, over a few hours or a few days, and they often come and go. The most common symptoms are as follows (MedlinePlus, 2021):
- changes in alertness (usually more alert in the morning, less at night)
- changing levels of consciousness
- confusion
- disorganized thinking or talking in a way that doesn’t make sense
- disrupted sleep patterns or sleepiness
- emotional changes: anger, agitation, depression, irritability, or overexcitement
- hallucinations and delusions
- incontinence
- memory problems, especially with short-term memory
- trouble concentrating
Nursing Treatment of Delirium
The general treatment of delirium is to manage the causes and the symptoms. This might entail, for instance, discontinuing medications or treating infection or imbalances (electrolytes) in the body. There are supportive care measures provided to prevent any complications from occurring. These measures include proper diet and nutrition, treating pain, assisting with movement, taking care of incontinence issues, keeping the same caregivers as much as possible, and involving family members (Mayo Clinic, 2022). Involving family members to assist with familiarity, comfort, prevention of falls, and assistance with safety and monitoring of the client can be very helpful. Additionally, reminders, such as whiteboards with visual cues, dates and times, and names of staff members is beneficial. Promoting sleep hygiene is an important role of the nurse, and good sleep can help the client recover more expediently.
A nurse who recognizes the confusion and frustration experienced by the individual with delirium will begin to form a plan of care that will increase the individual’s comfort and sense of calm. There are some easy things nurses can do to assist the client in getting reoriented and to decrease their stress levels. Nurses can often manage the symptoms of delirium with the following nursing interventions (MedlinePlus, 2021):
- making sure the room is quiet and well lit
- having clocks and calendars within view
- inviting family members to spend time in the room
- ensuring clients are wearing hearing aids and glasses
- allowing for undisrupted sleep when possible
- getting clients up and out of bed when possible
- controlling pain with pain relievers (unless the pain medication is causing the psychosis)
- administering prescribed medications to distressed clients at risk to themselves or to others, such as haloperidol (note that sedation can worsen delirium symptoms)
- avoiding the use of restraints
The confusion that a client feels can be very scary to them, so providing a supportive environment is especially important during the acute stages of delirium.