Delirium identification and reduction strategies

Hello everyone,

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

 

Have a great week!

Holler if it hurts? Strategies for identifying & assessing pain in people with dementia

Hello everyone,

Much research has shown that people with dementia are at an increased risk for having their pain under-assessed and under-treated, leading to serious physical and psychosocial consequences including:

  • Gait impairment (leading to increased fall risk)
  • Decreased appetite
  • Sleep disturbances
  • Agitation
  • Physical combativeness
  • Wandering
  • Decrease in daily activities
  • Impaired cognition
  • Verbal aggression
  • Depression
  • Social isolation
  • Learned helplessness

(Shega J., Emanuel L., Vargish L., Levine S.K., Bursch H., Herr K., Karp J.F. & Weiner D.K.  (2007) Pain in persons with dementia: complex, common, and challenging. The Journal of Pain 8, 373-387.)

 If you and/or staff observe some of these behaviors in a resident with dementia, do not assume it is part of the disease. Rather, take some time to assess the person for pain.

While self-reporting pain-rating scales such as Verbal Rating Scales and Facial Pain Scales remain the ‘gold standard’ when assessing pain in older adults, people experiencing moderate to severe stages of dementia may be unable to communicate the existence and severity of their pain.

 A widely used tool called “PAINAD” (Pain Assessment in Advanced Dementia, developed by Victoria Warden, Ann C. Hurley, and Ladislav Volicer) can be used to identify and assess pain in older adults who are unable to verbally communicate. Click here for the tool: http://www.mghpcs.org/eed_portal/Documents/Pain/Critical_Care/Dementia_Pain_Tool.pdf

To use the tool, caregivers observe the patient during periods of activity and record behavioral indicators of pain:

  • breathing (normal, labored, noisy?)
  • negative vocalization (none, groaning, crying?)
  • facial expression (smiling, sad, grimacing?)
  • body language (relaxed, tense, pacing, rigid?), and
  • consolability (no need to console, distracted by voice/touch, unable to console?)

 Once you’ve identified and assessed the pain in a patient, you’ll need to plan an intervention. Some behaviors, such as verbal agitation, pacing and restlessness, improve most with pain treatment. Other behaviors such as hitting, kicking, scratching respond less to treatment.

We’ll discuss some pain interventions next week. In the meantime, don’t forget to send us your DICE examples to win a prize for your facility!!!

Have great week!