Dementia and old age are the strongest risk factors for delirium, a condition of acute confusion and rapid changes in brain function. It is important to distinguish delirium from behavioral and psychological symptoms of dementia, as delirium is a medical emergency that should be addressed immediately by the healthcare team. Delirium typically involves a vulnerable patient and often occurs after surgery, infection (such as a urinary tract infection), or due to adverse medication effects.
Core features of delirium include acute onset and fluctuating course, inattention, disorganized thinking and a change in level of consciousness (hyper-alert or drowsy). Other possible symptoms include hallucinations, delusions, restlessness, sleep disorder, inappropriate behavior, poor postural control, and a decline or low performance of self-care activities. Keep in mind that while hyperactive delirium is more obvious due to hallucinations or striking out, hypoactive delirium is more subtle, and the person may just seem very sleepy (https://acphospitalist.org/archives/2016/03/delirium-screening.htm).
When you suspect delirium, assess the resident as least once per shift using a brief assessment tool, such as the days of the week backward or months of the year backward. Keep in mind that for a person with dementia, this assessment would not be effective if the person could not do this task anyway. Instead it can be better to determine–sometimes with help of family members–what a person’s baseline cognitive function is and use this to help assess delirium, along with a more complete assessment by medical staff.
The resident with delirium may have poor judgement and difficulty focusing, switching and sustaining attention, so be sure to keep the resident safe from falls and other adverse events, and do not use physical restraints and bed alarms.
According to the Nursing Home Toolkit (http://www.nursinghometoolkit.com/delirium.html), some ways to reduce risk of delirium in nursing home residents include:
- Keep residents mobile, hydrated and engaged in activities they enjoy
- Keep eyeglasses and hearing aides in working condition and available to resident at all times to promote sensory input and communication
- Encourage use of dentures to help ensure adequate nutrition
- Use consistent assignment of staff and avoid room changes
- Treat pain with appropriate non-pharmacological and pharmacological interventions
- Encourage family involvement for re-orientation; use companions as needed
- Provide non-pharmacological sleep protocol (back rub; decaffeinated tea) and quiet room at night with low level lighting
- Don’t administer prn (as needed) sedative, antipsychotic, or hypnotic medications to prevent and/or treat delirium without first assessing for, removing and treating the underlying cause of delirium and using nonpharmacologic delirium prevention and treatment approaches.
- Don’t discharge patients with delirium form post-acute care without and appropriate delirium treatment, care management, and communication plan for transitioning care and ensuring ongoing follow-up
Find more information on this topic at: http://www.nursinghometoolkit.com/delirium.html
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