Delirium

Overview: 
  • Delirium is a neuropsychiatric syndrome characterized by acute changes in cognition, attentional deficits and altered arousal with a fluctuating course. It affects 11–42% of older people in medical inpatient settings
    • This acute brain dysfunction is associated with an increased risk of death and hospital readmissions within 12-months
  • In contrast, dementia is a chronic neurodegenerative syndrome with multiple causes, typically characterized by progressive cognitive changes including memory and executive deficits, and functional decline
    • Approximately 40% of hospitalized adults have dementia or other cognitive impairment (Feast et al., 2018)
    • People with dementia are six times more likely to be admitted to hospital with a delirium
    • Dementia is a significant risk factor for hospital-acquired (incidence) delirium
Special Considerations: 

There are many identified Risk Factors that may contribute to delirium, including:

  • Advanced age (>80)
  • Pre-existing neurocognitive disorders (e.g., dementia, Parkinson’s, stroke)
  • Functional impairment (inability to independently perform ADLs)
  • Sensory impairment (e.g., hearing or vision loss/impairment)
  • Undertreated pain
  • Dehydration/malnutrition
  • Alcohol misuse
  • Infections (e.g., pneumonia, UTI)
  • Medications (e.g.: opioids, anticholinergics, corticosteroids, benzodiazepines, antipsychotics, anticonvulsants, antidepressants, quinolones) 

Challenges 

Both pain and pain management interact with delirium in various ways:

  • Pain may trigger and maintain delirium
  • Pain medication such as opioids and gabapentinoids are frequently seen as triggers for delirium. Drug-induced sedation is often difficult to distinguish from hypoactive delirium.
  • Not all delirious patients can report pain or other symptoms
  • Opioids can cause Opioid-Induced Neurotoxicity (OIN), a neuropsychiatric adverse effect exacerbated by large or rapid increase in opioid doses and dehydration
    • Features include severe sedation, cognitive impairment, delirium, hallucinations, myoclonus, seizures, hyperalgesia, and allodynia
      • Manage with opioid reduction, an opioid rotation, and hydration

Treatment

  • Multicomponent nonpharmacological delirium prevention interventions can effectively reduce delirium incidence
  • Antipsychotics are not recommended treatment for patients experiencing or at high-risk for delirium
  • Assess and treat pain with the appropriate pain tools; when uncertain, conduct an analgesic trial 
  • Opioids can and should be considered for pain treatment
    • Start slow and monitor for efficacy or side effects, reducing or eliminating as needed

Prevention

  • Assess (and document) frequently for pain, agitation, & delirium
  • Assess for fluctuations in alertness and orientation 
  • Engage patients in cognitive stimulation and self-care
  • Avoid medications known to provoke or exacerbate delirium 
  • Promote uninterrupted nighttime sleep/daytime wakefulness
  • Minimize sensory deprivation by applying glasses and hearing aids/pocket talker
  • Maximize safe mobility 
  • Provide adequate hydration and nutrition (ensure balanced I&O)
References: 

Bush, S. H., Tierney, S., & Lawlor, P. G. (2017). Clinical assessment and management of delirium in the palliative care setting. Drugs (New York, N.Y.), 77(15), 1623-1643. doi:10.1007/s40265-017-0804-3

Feast, A. R., White, N., Lord, K., Kupeli, N., Vickerstaff, V., & Sampson, E. L. (2018). Pain and delirium in people with dementia in the acute general hospital setting. Age and Ageing, 47(6), 841-846. doi:10.1093/ageing/afy112

Johansson, Y. A., Bergh, I., Ericsson, I., & Sarenmalm, E. K. (2018). Delirium in older hospitalized patients—signs and actions: A retrospective patient record review. BMC Geriatrics, 18(1), 43-43. doi:10.1186/s12877-018-0731-5

Maldonado, J. R. (2017). Acute brain failure: Pathophysiology, diagnosis, management, and sequelae of delirium. Critical Care Clinics, 33(3), 461-519. doi:10.1016/j.ccc.2017.03.013

Sampson, E. L., West, E., & Fischer, T. (2020). Pain and delirium: Mechanisms, assessment, and management. European Geriatric Medicine, 11(1), 45-52. doi:10.1007/s41999-019-00281-2

Tsang, J. L. Y., Ross, K., Miller, F., Maximous, R., Yung, P., Marshall, C., . . . Law, M. (2019). Qualitative descriptive study to explore nurses’ perceptions and experience on pain, agitation and delirium management in a community intensive care unit. BMJ Open, 9(4), e024328-e024328. doi:10.1136/bmjopen-2018-024328

UCSF Delirium Reduction Program:  https://delirium.ucsf.edu/

Author: 
Marilyn A Bazinski
Sasha Binford