Delirium. Delirium. Delirium Etiology and Pathophysiology. Fall 2018

Transcription

1 Three most common cognitive problems in adults 1. (acute confusion) 2. Dementia 3. Depression These problems often occur together Can you think of common stimuli for each? 1 1 State of temporary but acute mental confusion Life- threatening syndrome Affects as many as 50% of people older than 65 years who are hospitalized, and as many as 80% of patients in an ICU. Often preventable and/or reversible 2 2 Etiology and Pathophysiology Main contributing factor Impairment of cerebral oxidative metabolism - brain gets less oxygen and has problems using it Multiple neurotransmitter abnormalities may also be involved - Other contributors: Cholinergic deficiency Excess release of dopamine and Serotonergic activity 3 3 1

2 Etiology and Pathophysiology Dementia is leading risk factor is a risk factor for subsequent development of dementia Linked to onset Stress Surgery Sleep deprivation Pain and depression Especially in postop older patients Poorly understood pathophysiologic mechanism Rarely caused by a single factor Often result of interaction of patient s underlying condition with a precipitating event 4 4 Precipitating Factors Demographic characteristics Age 65 or older Male gender Cognitive status Dementia Cognitive impairment Depression History of delirium Environmental Admission to ICU Use of physical restraints Pain (especially untreated) Emotional stress Prolonged sleep deprivation 5 5 Precipitating Factors Functional status Functional dependence Immobility History of falls Sensory Sensory deprivation Sensory overload Visual or hearing impairment Drugs Sedative- hypnotics Opioids Anticholinergic drugs Aminoglycosides Treatment with multiple drugs Alcohol or drug abuse or withdrawal Decreased oral intake Dehydration Malnutrition 6 6 2

3 Precipitating Factors Coexisting medical conditions Severe acute or terminal illness Electrolyte imbalances Chronic kidney or liver disease History of stroke Neurologic disease Infection/sepsis/fever Fracture or trauma Surgery Orthopedic surgery Cardiac surgery Prolonged cardiopulmonary bypass Noncardiac surgery 7 7 Mnemonic for Causes Dementia, dehydration Electrolyte imbalances, emotional stress Lung, liver, heart, kidney, brain Infection, ICU Rx Drugs Injury, immobility Untreated pain, unfamiliar environment Metabolic disorders 8 8 Etiology and Pathophysiology Understanding causative factors can help determine effective interventions Many factors that can precipitate delirium are more common in older adults Older patients have limited compensatory mechanisms to deal with physiologic insults such as Hypoxia Hypoglycemia Dehydration Older patients are more often treated with multiple drugs More susceptible to drug- induced delirium 9 9 3

4 Clinical Manifestations Can present with a variety of manifestations usually develops over a 2- to 3- day period Can develop within hours Early manifestations often include Inability to concentrate Disorganized thinking Irritability Insomnia Loss of appetite Restlessness Confusion Later manifestations may include Agitation Misperception Misinterpretation Hallucinations Can last from 1 to 7 days Some manifestations may persist for months or years Some patients do not completely recover Clinical Manifestations Manifestations are sometimes confused with dementia Key distinctions of delirium rather than dementia Sudden cognitive impairment Disorientation Clouded sensorium Diagnostic Studies Diagnosis complicated by inability to communicate (poor historian) Medical history Psychologic history Physical examination Careful attention to medications Cognitive measures Confusion Assessment Method (CAM)

5 Diagnostic Studies Laboratory tests to explore the cause Serum electrolytes Blood urea nitrogen level Creatinine level Complete blood count (CBC) Drug and alcohol levels Laboratory tests Electrocardiogram (ECG) Urinalysis Liver and thyroid function tests Oxygen saturation level Lumbar puncture Rule out other etiology Case Study Audience Response Question You administer the Confusion Assessment Method (CAM) tool to differentiate among various cognitive disorders, primarily because a. delirium can be reversed by treating the underlying causes. b. depression is a common cause of dementia in older adults. c. nursing care should be based on the cause of the cognitive impairment. d. drug therapy with antipsychotic agents is indicated in the treatment of dementia. ( istockphoto/thinkstock) Treatment is important since many cases are potentially reversible Your role in caring for a patient with delirium Prevention Early recognition Treatment

6 Focus on eliminating precipitating factors must identify the underlying cause (i.e. if drug induced, DC med) Protect patient from harm Encourage family members to stay at bedside If delirium is secondary to infection, antibiotic therapy is started Drug Therapy Reserved for those patients with severe agitation Interferes with needed medical therapy Puts patient at increased risk for falls and injury Used when nonpharmacologic interventions have failed 17 Neuroleptics Haloperidol (Haldol) Risperidone (Risperdal) Quetiapine (Seroquel) Short- acting benzodiazepines Lorazepam (Ativan) May worsen delirium, use cautiously 17 Reorientation and behavioral interventions used in all patients with delirium Create a calm and safe environment Provide reassurance Pay attention to environmental stimuli Clocks, calendars, noise, and light levels It can be difficult to care for confused and combative patients, especially when it happens unexpectedly. What can you do to deal with such behavior in the hospital?

7 Patient experiencing delirium is also at risk for Immobility Skin breakdown Nurse should also focus on supporting the family and caregivers Audience Response Question An older patient is admitted to the hospital with a urinary infection and possible bacterial sepsis. The family is concerned because the patient is confused and not able to carry on a conversation. Which statement by the nurse is most appropriate? a. Depression is a common cause of confusion in older adults in the hospital. b. It is normal for an older person to have cognitive problems while in the hospital. c. The mental changes are most likely caused by the infection and most often reversible. d. Drug therapy with antipsychotic agents is indicated to slow the progression of dementia. 20 7