Delirium

Erica Newkirk, MSN, RN-BC, AGCNS-BC, CMSRN

Adult-Geriatric Clinical Nurse Specialist
Indiana University Hospital West
 This speaker has no conflict of interest.
Erica Newkirk is a Clinical Nurse Specialist at Indiana University
Health Hospital West. She graduated in 2009 with a Bachelors of
Science in Nursing and with her Masters of Science in Nursing as an
Adult-Gerontology Clinical Nurse Specialist in 2014, both from
Indiana University. She is board certified in Gerontology (RN-BC),
and Medical Surgical nursing (CMSRN), and as a Adult-
Gerontological Clinical Nurse Specialist (AGCNS-BC). Erica’s focus
has been in delirium, pain, addiction and geriatric care.
 Delirium - Barriers
Despite its high prevalence, seriousness and availability of assessment
tools, delirium is underrecognized by nurses and physicians

1. A & O x 3
 Day to day assessment focus is on orientation
 This may “normalize” some of the behaviors that are indicative of delirium
or contribute them to dementia

2. Confusion Assessment Method (CAM)

 Not done correctly
 Assessment of inattention is missed or not done

3. Delirium fluctuates
 Confusion assessment is done per nursing judgment
 Most nurses assess confusion by the aggressive behavior of the patient so
hypoactive delirium is missed
 Patients Baseline
Delirium assessment can be difficult when baseline is
known

Many patients present with delirium when admitted

Because of age and/or poor history many of these patients,

especially the older adult, are assumed to be presenting
with their normal baseline
 Case Study
 R.T.
 76-year-old male admitted for elective left knee replacement
 Medical history
 Polio has a child
 DM- controlled
 Ménière's disease
 HTN
 Medications:
 Lisinopril 5mg daily
 Cardura 4mg daily
 Independent, still drives, retired, lives at home with wife and 2
dogs
 Case Study
Post-op days 1-3

 Patient became confused, restless, wouldn’t follow commands kept

trying to get out of bed. Wife at bedside trying to feed her husband.

 2mg Ativan given at night – at first patient calmed down but then
behavior was worse

 Continued to try to get out of bed, patient would urinate in urinal about
100ml each time throughout the night

 Patient was finally bladder scanned in the morning - Urine retention

600ml– Foley anchored
 Confusion continued - patient began pulling on Foley, frank blood in
urine– restraints ordered

 Ativan still given

 Case Study
Post-op days 4-10

 Wife at bedside daily, stating patients behavior is out of the ordinary.

Wife distraught.

 Patient agitated, states he “wants his lawyer” stated how he was

being “held against his will”

 Patient kept undressing and removing blankets

 Wife requested no more Ativan. She felt like it made him worse.
Haldol given 2mg given PRN for agitation

 Patient unable to participate in PT therapy for left knee

 Patient transferred from Ortho to Med-Surg Unit

 Case study
Post-op days 10-14
 Foley removed
 High fall Risk due to confusion, weakness and patient unable to
extend left knee

 Patient agitation fluctuates still wanting to get out of bed – staff get
patient in the chair with a lap belt, he is calmer. Wife exhausted, still at
bedside.
 Haldol 2mg IV PRN agitation and Seroquel 25mg PO before bed
 Sitter ordered – but unable to keep due to staffing
 Enclosure bed ordered, Patient became increasing agitated and
became violent with staff
 Transferred to Med-Psych
 Case Study
Post-op 14

 Psych meds stopped

 Only Seroquel 25mg PO before bed

 Patient still in enclosure bed, but it is now unzipped during the day

 PT starting to work with patient. Patient now has a frozen knee

syndrome- Patient was planning on going home after surgery -
now rehab

 Discharged 21 days after surgery to rehab

 Patient passed 15 months later

 Delirium Interventions
Prevention is key –
Known your patients baseline
Assess daily with the CAM
TA-DA Method - Tolerate, Anticipate, Don’t Agitate
Work with family* - get additional history
Mobilization, OOB for meals*
Lights and blinds on during the day*
Rest at night, don’t let patient sleep all day
Increase nutrition and fluids
Removal of catheters, restraints, tele, SCDs when able
Keep eye glasses and hearing aids at bedside
Check for urine retention/bowel and bladder function
 Agitation
Behavior is a form of communication
People with dementia/delirium use behaviors to
communicate their needs:
 Wandering
 Calling out
 Repeatedly getting up
 Disrobing
 Pushing, grabbing, throwing
 What medications treat delirium?
There are no current FDA approved drugs for delirium
Start low and go slow”
When giving medications. Always monitor for any side effects
Nursing interventions have the best outcomes
 Reference
 Allen, K., Fosnight, S., Wilford, R., Benedict, L., Sabo, A., Holder, C., et al. (2011).
Implementation of a system-wide quality improvement project to prevent delirium in
hospitalized patients. jcomjournal, 18(6), 253-258.

 Flagg, B., Cox, L., McDowell, S., Mwose, J., & Buelow, J. (2010). Nursing
identification of delirium. Clinical Nurse Specialist, 24(5), 260-266.

 Flaherty, J., (2001). The evaluation and management of delirium among older
persons. Med Clin North Am. 95 (3)555-577

 Inouye S., van Dyck C., Alessi C,. (1990). Clarifying confusion: The confusion
assessment method. A new method for detection of delirium. Ann Intern Medicine
113, 941-948

 Inouye, S. (2003). The Confusion Assessment Method (CAM): Training Manual

and Coding Guide. New Haven : Yale University School of Medicine.

 Jacobi J, et al.,(2002) Critical Care Medicine; 30:119-141

 References
 Milisen, K., Foreman, M., Wouters, B., Driesen, R., Godderis, J., &
Abraham, I. (2002). Documentation of delirium in elderly patients with hip
fracture. Journal of Gerontological Nursing. 11, 23-29.

 Pandharipande, P., Shintani, A., Peterson, J., Pun, B., Wilkinson, G., Dittus,
R., Bernard, G., Ely, E. (2006). Lorazepam is an independent risk factor for
transitioning to delirium in intensive care unit patients. Anesthesiology.
104(1):21-26

 Steis, M. & Fick, D. (2012). Delirium superimposed on dementia. Journal of

Gertontological Nursing, 38(1), 32-42.

 Steis, M., & Fick, D. (2008). Are Nurses Recognizing Delirium? Journal of
Gerontological Nursing , 34 (9), 40-48.