DELIRIUM

INTRODUCTION

Cognition includes a number of specific functions, such as the acquisition and use of
language, the ability to be oriented in time and space, and the ability to learn and solve
problems. • It includes judgment, reasoning, attention, comprehension, concept formation,
planning, and the use of symbols, such as numbers and letters used in mathematics and
writing.

DEFINITION

Delirium is an acute organic mental disorder characterized by impairment of consciousness

disorientation and disturbances in perception and restlessness”.

“Delirium is a disturbance in consciousness and a change in cognition that develops over a

short time”.

INCIDENCE
Delirium has the highest incidence among organic mental disorders. About 10 to 25% of

medical-surgical in-patients and about 20 to 40% of geriatric patients meet the criteria for

delirium during hospitalization. • Although delirium may occur in any age group, it is most

common among the elderly. Estimated prevalence rates range from 10% to 30% of patients

60% of those older than the age of 75 years.

RISK FACTORS
Advanced age • Pre-existing dementia • Functional dependence • Pre-existing illness • Bone

fracture • Infection • Medications (both number and type), Changes in vital signs (including

hypotension and hyper- or hypothermia) • Electrolyte or metabolic imbalance • Admission to

a long-term care institution • Post cardiotomy • AIDS

ETIOLOGY

Vascular: Hypertensive encephalopathy, intracranial haemorrhage.

Infections: Encephalitis, meningitis

Neoplastic: Space occupying lesions

Intoxication: chronic intoxication or withdrawal effect of sedative hypnotic drugs.

Traumatic: Subdural and epidural hematoma, contusion, laceration, postoperative, heatstroke.

Vitamin deficiency: For example, thiamine

Endocrine and metabolic: Diabetic coma and shock, uraemia, myxoedema, hyperthyroidism,

hepatic failure

Metals: Heavy metals (lead, manganese, and mercury), carbon monoxide and toxins

Anoxia: Anaemia, pulmonary or cardiac failure

CLINICAL FEATURES

Impairment of consciousness: clouding of consciousness ranging from drowsiness to stupor

and coma.

Impairment of attention: difficulty in shifting, focusing and sustaining attention. • Perceptual

disturbances: illusions and hallucinations, most often visual.

Disturbance of cognition: impairment of abstract thinking and Comprehension, impairment of

recent and immediate memory, increased reaction time.

Psychomotor disturbances: hypo or hyper- activity, aimless groping or picking at the bed

clothes (flocculation), enhanced startle reaction.

Disturbance of sleep wake cycle: insomnia or in severe cases total sleep loss, daytime

drowsiness, disturbing dreams or nightmares.

Emotional disturbances: depression, anxiety, fear, irritability, euphoria, apathy.

TREATMENT
Identification of cause and its immediate correction, for, example, 50 mg of 50% dextrose IV

for hypoglycaemia, O2 hypoxia, 100mg of B1 iv for thiamine deficiency, IV fluids for fluid

and electrolyte imbalance.

Symptomatic measures: benzodiazepines (10mg diazepam or 2 mg lorazepam IV) or

antipsychotics (5 mg haloperidol or 50 mg mg chlorpromazine IM) may be given.

Psychiatric management: Admit the patient in psychiatric hospital

Identify the course by taking psychiatric history, general history & mental status examination

Do the investigations to rule out other disorders

NURSING MANAGEMENT/ INTERVENTIONS

• Hospitalization: • Admit the Patient in Psychiatric Ward • Give Comfortable Bed to the

Patient. • If patient is agitated then use of physical restraint may be necessary • Check the

vital signs.

 Provide safe environment: Restrict the environmental stimuli, keep unit calm and well-

illuminated. • There should always be somebody at the patient’s bedside reassuring and

supporting • As the patient is responding to a terrifying unrealistic world of hallucinatory

illusions and delusions, special precautions are needed to protect him from himself and to

protect others.

 Alleviating patient’s fear and anxiety: • Remove any object in the room that seems to be a

source of misinterpreted perception. • As much as possible have the same person all the time

by the patient’s bedside. • Keep the room well lighted especially at the night time.

 Meeting the physical needs of the patient’s: • Appropriate care should be provided after

physical assessment. • Use of appropriate nursing measures to reduce high fever, if present •

Maintain intake and output chart. • Mouth and skin should be taken care of • Monitor vital

signs. • Observe patient for any extreme drowsiness and sleep as this may be an indication

that the patient is slipping into a coma

 Facilitate orientation: • Repeatedly explain to the patient where he is and what date, day

and time it is • Introduce people with name even is the patient misidentifies the people.
Have a calendar in the room and tell him what day it is. • When the acute stage is over take

the patient out and introduce him to others.

 Functional assessment includes physical functional status (activities of daily living), use of

sensory aids (eye glasses and hearing aids), usual activity level and any recent changes, and

pain assessment.

 Interventions for the Biologic Domain Important interventions for a patient experiencing

acute confusional state include providing a safe and therapeutic environment, maintaining

fluid and electrolyte balance and adequate nutrition, and preventing aspiration and decubitus

ulcers, which are often complications

 Safety Interventions • Behaviours exhibited by the delirious patient, such as hallucinations,

delusions, illusions, aggression, or agitation (restlessness or excitability), may pose safety

problems. • The patient must be protected from physical harm by using low beds, guardrails,

and careful supervision Support from Families. Families can be encouraged to work with

staff to reorient the patient and provide a supportive environment