Delirium (Nursing)

by Brenda Marshall, EdD, MSN, RN

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    00:01 So what is delirium? Delirium is an acute change in brain function.

    00:05 It's usually demonstrated by a rapid onset of confusion, emotional instability, altered level of consciousness, cognitive changes, and also disorientation.

    00:20 And it is really important that we keep delirium as an emergency, a medical emergency. It needs help right away.

    00:31 When we think about it as a medical emergency, we want to understand that there is an increased mortality rate of two to 20 times higher than with other patients.

    00:44 Part of this is because we don't know why these acute changes are occurring.

    00:50 We don't know whether this person mixed medications, and suddenly those medications have become toxic to the person's brain.

    00:59 We want to make sure that this delirium, this fast onset of cognitive changes is taken very seriously.

    01:09 And that we absolutely take the steps in order to find out what's causing it, and how to stop it? And to provide any life support that is required.

    01:21 Statistics for delirium in older adults, is that maybe 1 to 2% of the population who are 65 years or younger, will have delirium.

    01:37 And as a person gets older, then that increases their likelihood and possibility, and the prevalence of delirium.

    01:47 So by the time a person is 85, we see that 10 to 14% of the population may be experiencing delirium.

    01:57 Now, substance use, withdrawal from substance use, this also can cause delirium, as kind of reaction to the polypharmacy.

    02:08 So many of our older adults are on multiple medications.

    02:12 And sometimes the different specialists are not communicating with each other.

    02:17 So we want to be aware of that.

    02:19 The other thing is, if you have an older adult who is somewhat confused, who's on multi medications, they might get mixed up and take the wrong medications.

    02:30 So these are all things that the nurse is going to keep in mind as we see somebody who may be presenting with the signs and symptoms of delirium.

    02:42 So the onset of delirium has a cardinal sign.

    02:47 And if you have heard me say, once, or three, or four times already, in this presentation, this rapid onset should really be a red flag for us.

    03:00 The change that the person is going to be having in their level of consciousness, we will see that because perhaps, their thoughts or even their speech become incoherent.

    03:13 They have a level of restlessness that brings our attention to them.

    03:19 They're confused. They don't know where they are.

    03:22 They don't know what's going on.

    03:25 They may be having some illusions, alright.

    03:28 And illusions are different from delusions.

    03:32 Your delusions are those thoughts that have no reality.

    03:36 Illusions are something that looks like something else to them.

    03:41 For example, maybe you go to start an IV, and they see the tubing and they think it's a snake.

    03:48 That would be an illusion.

    03:50 But they also with delirium might be having hallucinations.

    03:55 And hallucinations are actual, visual, or other perceptual understanding of something going on, that isn't actually happening in the environment.

    04:10 So you could have a visual hallucination, auditory hallucination, olfactory hallucination, tactile hallucination, any sense, can be affected.

    04:21 Hallucination is originating from a brain that is not functioning properly.

    04:29 And so it is really important if a person tells you that they see or hear someone that you ask them.

    04:37 What is the person saying to you? To make sure that that hallucination is not a command hallucination.

    04:46 Now, did Jai have any of these cardinal signs? Let's think back to Jai.

    04:53 Well, he had the incoherent speech and thoughts.

    04:59 He also had the confusion. He had that restlessness.

    05:05 He had hallucinations.

    05:08 I don't believe he had the illusions, but he had the rapid onset.

    05:13 So we should have a red flag up now to take care of Jai.

    05:19 Some of the other signs of delirium are hyperactivity, which comes from that restlessness, right? That confusion.

    05:27 If you can put yourself in the body of a person who not quite sure what's going on, and all of a sudden the world looks different to them.

    05:36 They may have hyperactivity, they may have some psychotic symptoms, like those hallucinations.

    05:43 They might have psychomotor agitation.

    05:47 So when we also want to be safe, they might actually be moving in such a way that we want to make sure we give them the distance that they need, so that we don't become injured when taking care of someone.

    06:02 We also want to know that they may have these verbal outbursts.

    06:07 It's not about us, it is about their confusion.

    06:10 And so they might shout.

    06:12 It might be that they are hearing something that we're not hearing, that they have voices that are occurring from internal stimuli, not from external.

    06:21 And you want to be able to understand that those verbal outbursts are not about you.

    06:27 It is about this delirium.

    06:29 It is a sign that we must take very seriously.

    06:33 Also, they may have some purposeless behaviors, rolling of the fingers, or tapping of the fingers, or straightening out the sheets, but repetitive over and over again, without any purpose to them at all.

    06:54 So as soon as we know that the delirium is happening, number one, it's a medical emergency.

    07:00 And then we look at what is causing the symptoms.

    07:04 So we have to take a good history, we would sit down, we would try and find out from the partner what is going on, and we would treat it as this medical emergency.

    07:16 In this way, we would make sure that we have an airway present, so that in the event that the person's airway, somehow it becomes not working correctly, that we are able to make sure that we keep a clear airway for them.

    07:32 We have to treat the symptoms, as soon as we make a diagnosis.

    07:37 And if the person is having hallucinations, they may actually have an order for some anti-psychotics to be used in the short-term to relieve those symptoms.

    07:52 We also need to know that there might be a need for sedation.

    07:58 So if the practitioner is ordering sedation, or anti-psychotic medications, that is to treat the symptoms of delirium.

    08:08 Finally, we need to be monitoring very closely, this level of consciousness.

    08:14 Is the person aware of time, place, and person? Is a person sleepy? Is the person awake? If the person is going from an awake state to a very sleepy state, this is one of those cardinal signs that we have to be ready to maintain that person's airway.

    08:35 So, let's think about the difference between delirium and dementia.

    08:40 When we think about delirium, we know that it is a disturbance in consciousness.

    08:46 It is a change in the person's cognition.

    08:50 It develops very quickly.

    08:53 And you know, over a short period of time.

    08:56 We also know that it's common with hospital patients, especially in older adults.

    09:05 We call it like, they may be suddenly not able to get to where they have to go.

    09:13 They may forget things.

    09:15 They may become delirious after being hospitalized.

    09:21 It's always secondary to another physiological condition.

    09:26 Delirium is telling us something else is going on here.

    09:30 And it's asking, it's pleading for us to do our due diligence and find out what has gone on that has disrupted the brain in this abrupt and acute way? It is transient. Delirium is not a long-term thing.

    09:48 Delirium is that red flag that's going to pop up, something has gone terribly wrong in the brain.

    09:55 And let's find out what it is.

    09:58 And it is usually an underlying condition.

    10:02 And so once we fix, and treat that underlying condition, there should be recovery from delirium.

    10:13 Now, how does that differentiate from dementia? Dementia is not rapid onset.

    10:18 It is a progressive deterioration of cognitive functioning, and global impairment of intellect.

    10:26 So the person is losing their capacity of thinking of memory. It is ongoing and progressive.

    10:37 We don't usually see a change in consciousness.

    10:40 With delirium, we're seeing this consciousness go from alert to sleepy to perhaps comatose.

    10:48 Whereas, in dementia, we're not seeing any change in consciousness.

    10:53 We will see a difficulty with memory, a difficulty with thinking, and also with comprehension in dementia.

    11:03 We see that also with delirium.

    11:06 Now, unlike delirium, which is reversible, dementia usually is not reversible.

    11:15 It is chronic and it is progressive.

    About the Lecture

    The lecture Delirium (Nursing) by Brenda Marshall, EdD, MSN, RN is from the course Neurocognitive and Neurodegenerative Disorders (Nursing).

    Included Quiz Questions

    1. Altered level of consciousness
    2. Disorientation
    3. Cognitive changes
    4. Emotional stability
    5. Gradual onset
    1. It is a medical emergency.
    2. The mortality rate is 2–20 times higher than other clients.
    3. It is only seen in clients with dementia.
    4. The chance of developing delirium decreases with age.
    1. 10–14%
    2. 20–25%
    3. 4–10%
    4. 31–37%
    1. The client who was calm, coherent, and oriented this morning, and suddenly started presenting as confused and restless with incoherent speech this afternoon
    2. The client who has been disoriented and confused for the last two months and is presenting with longstanding hallucinations
    3. The client who has been experiencing a three-year history of progressive cognitive decline who has been presenting as increasingly restless over the last three weeks
    4. The client who is experiencing transient difficulties with word-finding, but is otherwise calm and oriented
    1. “I need to hold all sedating medications so that my client can become more alert and less confused.”
    2. “I shouldn’t expect the treatment plan for my client to be the same as other clients with delirium I’ve cared for in the past, as delirium treatment is based on the cause.”
    3. “During my morning rounds, I made sure the suction in my client’s room was working, and there was an oral airway by the bedside, just in case their airway becomes compromised.”
    4. “My client was recently prescribed a PRN antipsychotic. I will give it to them if they appear to be hallucinating.”
    1. It is always secondary to another physiological condition.
    2. It is common in hospitalized clients.
    3. It is not reversible.
    4. It is not characterized by a change in consciousness.

    Author of lecture Delirium (Nursing)

     Brenda Marshall, EdD, MSN, RN

    Brenda Marshall, EdD, MSN, RN

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