Transitioning to Adult-Gerontology APRN Education: Slide Library
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1 Transitioning to Adult-Gerontology APRN Education: Slide Library APRN Assessment and Management of Older Adults with Delirium Authors: Lois Evans, PhD, RN, FAAN Pamela Z. Cacchione, PhD, APRN, GNP, BC University of Pennsylvania School of Nursing
2 Adult-Gerontology APRN Slide Library The APRN Slide Library is a resource of Transitioning to Adult-Gerontology APRN Education a project of AACN and the Hartford Institute for Geriatric Nursing The project is funded by the John A. Hartford Foundation
3 Adult-Gerontology APRN Slide Library "All materials are jointly copyrighted by the American Association of Colleges of Nursing (AACN) and The Hartford Institute for Geriatric Nursing, College of Nursing, New York University or are used with permission from the original source. Permission is hereby granted to reproduce, post, download, and/or distribute, this material for not-for-profit educational purposes only, provided that the American Association of Colleges of Nursing (AACN) and The Hartford Institute for Geriatric Nursing, College of Nursing, New York University are cited as the source. They may not be used for ANY commercial or other purpose." Available at notification of usage to: Further information about the APRN program can be found at
4 Purpose of the APRN Slide Library - Delirium To provide APRN faculty with an overview of delirium in older adults* To introduce APRN faculty to print and web resources on assessment, diagnosis & management of delirium To provide APRN faculty with slides on delirium to use in lectures & to share with APRN students * These slides have been modified by faculty from the Geropsychiatric Nursing Collaborative from slides prepared for the Geriatric Nursing Education Consortium (GNEC) program (
5 Endorsement and Support The content for these slides is endorsed by: National Gerontological Nursing Association (NGNA): American Academy of Nursing Geropsychiatric Nursing Collaborative: 5
6 Web-resources Web-Resources http: // Try This and How to Try This General Assessment Series, e.g. Confusion Assessment Method (CAM) Beers Criteria for Potentially Inappropriate Medication Use in the Elderly Mental Status Assessement of Older Adults: the MiniCog The Geriatric Depression Scale (GDS) http: // Try This and How to Try This Dementia Assessment Series, e.g. Assessing and Managing Delirium in Persons wih Dementia Recognition of Dementia in Hospitalized Older Adults 6
7 Web-resources Web-Resources http: // select Evidence-based Geriatric Topics, e.g. protocols on: Delirium Atypical Presentation of Illness Depression Sleep American Medical Directors Association (AMDA Clinical Practice Guidelines for long-term care: select Altered Mental Status
8 Source Books: Geriatrics Auerhahn, C., Capezuti, E., Flaherty, E., & Resnick, B. (eds.) (2007). Geriatric Nursing Review Syllabus: A Core Curriculum in Advanced Practice Geriatric Nursing, 2nd Edition: New York: American Geriatrics Society. (3 rd Edition, May, 2011) A concise & comprehensive text developed by the American Geriatrics Society (AGS) & the NYU Hartford Institute for Geriatric Nursing, adapted for APRNs from the AGS Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, 6th Edition Authored by > 100 interdisciplinary experts in care of older adults 59 chapters on prevailing management strategies, extensive reference, appendix with assessment instruments, 100 case-oriented, multiple choice questions and a selfassessment tool. ( Auerhahn, C. & Kennedy-Malone, L. (2010). Integrating Gerontological Content into Advanced Practice Nursing Education. New York: Springer Publishing Co. Clear, user-friendly guidelines for integrating gerontological content into non-gerontological APRN programs Detailed lists of print resources and e-learning materials Utilizes a competency-based framework Success stories written by APRN faculty who have integrated gerontological content into non-gerontological courses 8
9 Delirium: Definition A transient and nonspecific organic mental syndrome characterized by: Acute onset (hours to days), tending to fluctuate over the 24 hour period Reduced ability to focus, sustain or shift attention Disturbed level of consciousness, such as reduced clarity of awareness Change in cognition such as memory loss, disorientation and/or language disturbance Perceptual disturbance not better accounted for by a preexisting, established or evolving dementia 9
10 Delirium: Incidence in Hospitalized Older Adults 11% All patients Delirium occurrences in hospitalized patients 50% High risk cases Older Patients > Susceptibility Range 11-42%: Medical and <50%: Surgical 10
11 Delirium: Incidence, Prevalence, Outcomes Highly prevalent (11-24%) on ACH admission, with incident delirium < 56% in hospitalized older adults Incidence is < 87% for OA in ICU Incidence is 60% for older adults in post acute care and nursing homes Potentially life threatening, with 22-76% mortality rates among older adults in ACH Typically evident within 48 hours of hospital admission Course is variable, depending on pre-existing condition and cause(s ) of delirium 11
12 Delirium: Background Diagnosis of delirium is highly clinical and dependent upon clinician's level of expertise, systematic screening & careful clinical observations Progression to stupor and/or coma, seizures, and death is possible. Delirium is a cardinal sign of a geropsychiatric emergency and must be promptly identified and addressed with biopsychosocial and environmental interventions. Early recognition of delirium followed by rapid management of underlying medical and environmental factors decreases the severity and can lead to improved outcomes. 12
13 Delirium Outcomes Loss of function, falls and other complications Cost assessed at $6.9 billion a year Increased risk for longer hospital LOS & post acute or NH placement Unwarranted use of physical and chemical restraints Higher levels of premorbid function = better outcomes Frequent misdiagnosis = high morbidity and mortality 13
14 PZC1 Predisposing Factors for Delirium Advanced old age Brain injury, including Dementia Severe illness or surgery Anesthesia Hypoxia Medications/ polypharmacy (4+ medications per day) Co-morbid Illness Depression Sensory impairment Electrolyte imbalance and dehydration Infection Pain Previous episodes of delirium Alcohol Abuse 14
15 Slide 14 PZC1 Voyer, P. Richard, S., Doucet, L., Cyr, N., Carmichael, P-H. (2010) Examination of the multifactorial model of delirium among Long-term care residensw with dementia. Geriatric Nursing, 31; Inouye and Charpentier (1996) they already have Inouye, S. ( 2006). delirium in older persons. The New England Journal of Medicine, 354; Pamela Z. Cacchione, 2/5/2011
16 PZC2 PZC3 Delirium: Medication-Related Precipitating Factors Anticholinergics Opiates Benzodiazepines Corticosteriods Alcohol withdrawal Sedative-hypnotic drug withdrawal Any newly prescribed medication Over the counter (OTC) home remedies, especially those with anticholinergic effects (NSAIDS, nasal sprays, cold and flu meds) Addition of 3 newly prescribed medications 15
17 Slide 15 PZC2 PZC3 Irving, K., Fick, D. & Foreman, M. (2006). Delirium: A new appraisal of an old problem. International Journal of Older People Nursing, 1 ( ). Pamela Z. Cacchione, 2/5/2011 Tune, L., Mulsane, B. & Gharabawi, G. (2003). Anticholinergic effec of atypical antipsychotics in elderly people. European Neuropsychopharmacology, 12,; Pamela Z. Cacchione, 2/5/2011
18 PZC4 Delirium: Inouye and Charpentier Risk Model Relies on the interaction of the following 2 factors: Predisposing host baseline factors, e.g., Vision impairment Severe illness Pre-existing cognitive impairment Dehydration Treatment-related precipitating factors, e.g., Physical restraints Malnutrition Bladder catheter > Three medications Any iatrogenic event 16
19 Slide 16 PZC4 Michaund, L., Bula, C., Berney, A., Camus, V., Voellinger, R., Stiefel, F., Burnand, B. et al., (2007). Delirium: guidelines for general hospitals. Journal of Psychosomatic Research, 62; Fick, D., Kolanowski, A., Beattie, E., McCrow, J. (2009), Delirium in Early-Stage ALzheimer's Disease. Journal of Gerontological Nursing. 35(3); Pamela Z. Cacchione, 2/5/2011
20 Prevention of Delirium in Older Adults Early identification & modification of predisposing factors Early recognition & treatment of cognitive impairment Rapid identification & treatment of acute illness Assessment & appropriate management of pain Maintenance of normal sleepwake cycle Avoidance of deliriogenic medications & polypharmacy Assurance of adequate hydration & nutrition 17
21 Prevention of Delirium in Older Adults cont d Enhancement of sensory status by use of sensory aids & appropriate levels of light & sound Enhancement of cognitive reserve Provision for family presence Avoidance of urinary catheterization Avoidance of physical restraint use Assessment & management of drug and alcohol withdrawal
22 Delirium: Clinical Presentation Clinical subtype Hyperactive Hypoactive Mixed Increased psychomotor activity, such as rapid speech, irritability, and restlessness Lethargy Slowed speech Decreased alertness Apathy Shift between hyperactive and hypoactive states 19
23 Delirium: History When did the change in mental status begin? Does the condition change over a 24-hour period? Is there a change in the person s sleep patterns? What specific thought problems have been noticed? Is there a history of mental illness or similar thought disturbance? Has there been a sudden decline in physical function or a new onset of falls? Query family or collateral source from prior setting as to what is normal for this patient. 20
24 Delirium: Change in Mental Status An abnormal mental status exam that is a change from baseline for the person is the hallmark of delirium Abnormalities may include inattention, fluctuations in level of consciousness, new short term memory impairment, altered speech patterns, disorganized speech and (possibly) delusions or hallucinations Mental status screening tests are helpful in CA3 identifying cognitive deficits and should be performed routinely in older patients: on admission and at least daily during stay 21
25 Slide 21 CA3 This picture has nothing to do with the text on this slide - there must be another you can use? Carolyn Auerhahn, 12/31/2010
26 Delirium Screening Instruments Instruments specific for detecting delirium based on observation of behavior rather than formal testing: Confusion Assessment Method (CAM) diagnostic algorithm NEECHAM Confusion Scale CA4 22
27 Slide 22 CA4 same comment as the previous slide Carolyn Auerhahn, 12/31/2010
28 The CAM Diagnostic Algorithm Can be accurately administered by individuals without formal psychiatric training Based on the Diagnostic and Statistical Manual of Mental Disorders-TR criteria for delirium Captures cardinal elements of delirium & incorporates specific observations relevant to each Patients are identified as positive for delirium using the CAM if 3 out of 4 features are present: acute onset and fluctuating course* and inattention* with either disorganized thinking or altered level of consciousness *denotes required features 23
29 The NEECHAM Confusion Scale Uses a structured database derived during routine nursing assessments and interactions with patients Is sensitive to both the hyperactive and hypoactive forms of delirium Evaluates nine components of information processing, performance, and vital function Can be repeated at frequent intervals to monitor change in mental status over time Minimal response burden on the patient No learning effect from repetition of items Can detect delirium in its early stage 24
30 The NEECHAM Confusion Scale NEECHAM Confusion Scale 0-19: Moderate to Severe 20-24: Mild or Early Dev None but High Risk Range of scores is 0-30 >26 No Delirium 25
31 Rating Scales for Delirium Delirium Rating Scale Memorial Delirium Assessment Scale
32 Delirium Assessment: Vigilance A Test Helps to confirm suspected delirium After instructing the patient to raise his or her hand only when the letter A is heard, the examiner then begins saying letters from the alphabet randomly. Delirious patients have inconsistent responses. 27
33 Delirium Assessment: Direct Observation Routine and periodic observation of the older adult s level of: Alertness (alert, hyper-alert or hypo-alert) General behavior Mood & affect Speech disturbance/verbalizations Motor behavior 28
34 General Cognitive Function: Assessment Instruments MiniCog Mini-Mental Status Examination (MMSE) * MoCA Saint Louis University Mental Status Examination (SLUMS) Short Portable Mental Status Questionnaire *copyrighted 29
35 Delirium: Physical Exam Examine for signs of: Hypoxia Volume depletion/overload Cardiovascular injury Metabolic encephalopathy Alcohol withdrawal Hypo- or hyperthermia New onset incontinence Urinary retention or fecal impaction Check 30
36 Delirium: Diagnostic Tests Choice based on history and physical findings Baseline laboratory studies: Urinalysis Basic or Comprehensive Metabolic Panel Blood work: CBC, Thyroid function test Further diagnostic testing (based on exam): Head CT EKG Chest X-Ray 31
37 Delirium: Diagnostic Tests cont'd When difficult to differentiate delirium from acute psychotic state Electroencephalography The electroencephalogram reveals: Diffuse slowing in most cases of delirium Fast activity in cases of delirium related to drug withdrawal Normal patterns in patients with acute functional psychosis 32
38 Delirium: Environmental Predisposing Factors Transfers within the hospital or unit Absence of a clock or watch Absence of reading glasses, hearing aid Absence of family members Use of physical restraints 33
39 Differentiating Delirium from Dementia & Depression Chronic cognitive impairment seen in dementia typically: Occurs gradually over time Persists greater than one month Is irreversible Most older adults with dementia are alert and able to maintain attention in the early stages of dementia Depression may also present acutely with deficits in ability to sustain attention. Depression may present similar to hypo- or hyper-active delirium; therefore, it is important to screen for depression in older adults who present with a mixed picture. 34
40 Delirium: Differential Diagnosis With recent change in cognition, an older person should be presumed delirious until proven otherwise Sudden cognitive and/or functional deterioration in a patient with dementia suggests delirium superimposed on dementia Apathy, slowed speech and mood disturbance may be indicative of hypoactive delirium rather than depression 35
41 Delirium: Differential Diagnosis Functional psychosis Acute functional psychosis can resemble delirium Onset at an earlier age Most older patients with functional psychosis have a history of psychiatric illness Hallucinations tend to be auditory Delusions are more elaborate than those associated with delirium Dementia with Lewy Bodies includes fluctuating cognition and visual hallucinations Consultation with a psychiatrist or a neurologist may be necessary in difficult cases 36
42 Delirium: General Management Multi-component interventions are most effective Prompt recognition & treatment of underlying cause Creation of a maximum supportive environment Immediate medical treatment as necessary Discontinuation or reduced doses of medications thought to be deliriogenic Use of environmental interventions such as a delirium room Ensure 37
43 Delirium: General Management- Nutrition & Hydration Ensure Accurate 24 hour I & O Avoidance of depletion-dehydration syndrome Enteral tube feeding or hyperalimentation as necessary Address any excess output issues such as polyuria or diarrhea 38
44 Delirium: General Management Pulmonary care to ensure adequate oxygenation, avoid atelectasis and pneumonia Bowel and bladder protocols to prevent or treat constipation, diarrhea, and urinary incontinence Vigilence for fall risk and patient safety Use cognitive stimulation Avoid complications of immobility Minimize skin breakdown 39
45 Delirium: Managing the Environment Presence of family members Inclusion of familiar items from home Use of glasses & hearing aids Avoidance of physical restraints Delirium room for high risk patients Night-light and minimization of noise Interrupt sleep only when absolutely necessary 40
46 Delirium: Maximizing Cognition Re-orientating strategies Inclusion of orienting facts in normal conversation Discussion of current events Discussion of specific interests Structured reminiscence Word games Cognitive stimulation 41
47 Delirium: Medication Management Use medications when: behaviors associated with psychotic thinking and perceptual disturbances (e.g., hallucinations) pose a safety risk or are distressing to the individual. delirium interferes with needed medical therapies and behavioral interventions fail Do Not use medications as a substitute for detection, correction, or elimination of underlying causes of delirium Use low doses of medications over the shortest possible time period 42
48 Delirium: Medication Management First line therapy: Low doses high-potency neuroleptics (e.g.,haloperidol) Associated with extrapyramidal symptoms (EPS) Newer antipsychotics (e.g., olanzapine and risperidon) have a lower incidence of EPS and may be better tolerated in older patients Neuroleptic Malignant Syndrome, a more serious side effect of antipsychotic therapy, can occur with high-potency as well as with novel anti-psychotics Benzodiazepines (e.g., lorazepam) are recommended with alcohol withdrawal or withdrawal from benzodiazepines. In non-alcohol withdrawal, benzodiazepines potentially worsen delirium and should be used with caution 43
49 Delirium Management: Aftercare Help the patient and family understand the bizarre and bewildering experience Psychiatric care to facilitate resolution through: Sensitive retrospective exploration of the experience Increasing patient s understanding and acceptance Encouraging patients to report risk of delirium for subsequent hospitalizations Comprehensive discharge planning Home care referral Physical and occupational therapy Psychiatric nursing home care services 44
50 Delirium: Conclusion Historically seen as: A benign and expected condition related to hospitalization Currently seen as: A serious health problem with significant negative consequences APRNs are frontline in early identification of patients most at risk for delirium and early detection of symptoms Routine and systematic assessment for confusion is key 45
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