Delirium. Script. So what are the signs and symptoms you are likely to see in this syndrome?

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1 Delirium Script Note: Script may vary slightly from the audio. Slide 2 Index Definition About delirium Signs and symptoms of delirium Why delirium occurs Risk Factors and causes of delirium Conditions that cause delirium Treatment of delirium Slide 3 Delirium is a temporary state of mental confusion and fluctuating consciousness. It is really important for you to know and understand this condition as often people in a delirious state are misdiagnosed and treated inappropriately or not treated at all. Slide 4 You see Delirium is a medical emergency delirium is the result of a treatable condition which means once you fix the cause the person the person will return to their normal self. The other thing you need to know is that it can come on very quickly which is why it used to be called Acute Confusion. Delirium is a collection of signs and symptoms which are called a syndrome or a pattern of an illness which when identified and treated will disappear. Slide 5 So what are the signs and symptoms you are likely to see in this syndrome? Essentially it is a change in behaviour. You all know your residents really well. Some of them will have a dementia and others will not but whether they have dementia or not you will notice when they not behaving the way they usually do. There may be slight changes like saying some funny things or they may be profound or insightful to being very stupid or silly. And you don t know what is happening for them. The first time you notice any changes is the time you should be reporting it to your Registered Nurse and writing it in the person s notes or in your diary. You should never laugh it off or put it aside thinking they will come

2 right tomorrow because older people can become very unwell very quickly and your vigilance could prevent this from happening. So what sort of things should you be looking for? Well a person may appear to be more anxious than they normally are and come and say such things as I am really worried about my daughter or I think I am dying. Something that they do not usually say. They may be disoriented and not know what time of day or night it is, or where they are or which direction to go in. Something that isn t the norm for them They could be suffering from delusions where they think someone is stealing their money or their clothes have all gone missing or even think you are their mother. They may have incoherent speech which means you may not be able to understand what they are saying. They ramble on about things that don t make any sense, or their sentences may be all jumbled up which alerts you that there is something wrong or not quite right They may even go from being very alert and running around, what we call a hyper-alert state, to being unarousable and appear to be in a deep sleep. They may have difficulty focusing on one thing like you may be trying to get them dressed and they are wanting to fidget with other things in the room or look out the window. They just cannot focus on the job at hand. Some people may even have hallucinations and see things that are not there. You need to be constantly aware of a delirium as people can become very sick very quickly. While it is easy to pick it in someone who doesn t have a dementia as this state will be totally out of character for the person in your care and you know there is something wrong with them. However with a person with dementia it is sometimes more difficult to pick as they can often be in a confused state. What you need to look for with these people and be aware of is any changes in the person. Sometimes they can be really subtle meaning minor changes but no matter how minor the change you may you must report to the RN and write it down in their notes or in your diary. Whatever you do you must not pass it off. You must report it immediately before a person becomes really unwell Slide 6 Then why does delirium occur? Well it occurs when anything that can interfere with the way messages are transferred from one cell to the other. Now if you have done the dementia topic, you will have learnt how the nerve cell or neurones in the brain talk to each other. They need to travel from one neurone to another down a pathway called the axon. These messages just don t travel down by themselves, there are chemicals in the brain that make this happen. So when a sickness develops and the chemicals become unbalanced then this interferes with the way the messages are being received from one cell to the other. This is why they become more confused than normal, become all muddled with their thoughts and actions, don t know what time of day it is or who people are, become suspicious or frightened at things that may happen a whole range of things that they believe to be true which are not.

3 When the cause of the delirium is identified and fixed the excessive confused state disappears. This is why it is so important for you to be on your look out for any changes in a person s behaviour no matter how small or insignificant you may think it is. Slide 7 So what are the risk factors for a person or the causes for a delirium to occur? These are many and varied. While probably the two most common causes are infections like urinary tract or chest infections and medications. Others conditions like inflammation, an irritation or swelling on some part of their body for example when a leg ulcer become infected, or a heart attack, or constipation which is why it is so important to record accurately when a person s bowels have moved and how big the motion is. I will talk more about constipation in the constipation topic. Sleep deprivation can be another cause. This is when a person does not get sufficient sleep for the body requirements. Be careful here though. Some people may not sleep all night but have many catnaps during the day meaning that their sleep hours have accumulated to be sufficient for the whole day so don t go calling for sleep sedatives unnecessarily. This is why your observational skills are so important and why you must not only write down what you see but also report this to your Registered Nurse. Dehydration can also cause a delirium. Just think about yourself when you become thirsty. It may be a hot day and you don t have any access to water or have run out of your supply. How does your head feel? Probably fuzzy, you may even stagger when you stand up. If you have done the hydration topic I have covered this in some depth but essentially the body needs to have water. In the first instance it uses water that is extracellular which means that which flows around your body in your veins and arteries but when it has taken all the water from this system it is going to draw it from inside your cells and typically from the brain which is why you become very confused when you do not drink enough fluid. It also increases the risk of you falling over. Many older people do not drink a lot of water. They are more likely to drink tea or coffee which in itself takes fluid from the cells which can be another risk factor for them. When your fluid intake is up you are continually replacing fluid that is lost or excreted and you rehydrate yourself. So if the person in your care is showing early signs of delirium or are more confused than normal, try giving them a glass of water. If it is due to dehydration the confusion or delirium disappears. So try a glass of water first. Stress also can cause delirium. When someone is taken out of their normal environment it can be very stressful. If a person goes into hospital or is taken out of their familiar environment then they are more like to suffer a delirium. This can be misdiagnosed as dementia when in fact they just don t know where they are and they can t make any sense of the unfamiliar environment. They just don t know how to handle it. So when you look at all these factors that can cause a delirium or influence a person s mental state they are all reversible. Fix the problem or condition then the delirium or increased confusions will disappear. This is why you need to be really aware of any changes

4 in behaviour of the people in your care. Early detection and treatment can save them a lot of distress and ultimately make your role as a caregiver much easier. So please report these changes to your Registered Nurse immediately and write in their resident/client notes. If you do not report any changes in client notes then carry a note book or diary with you where you can record them so know exactly when you first noticed the changes. Don t forget to include the date and time as well. As I said before early detection and reporting can save many a person from admission to hospital as a more conservative treatment could be given. You have to be vigilant and always keep your eyes and ears open to identify any changes early. After all you usually know the person really well. Slide 8 Now you know that delirium is a condition that can be reversed or treated just how do is this done. Firstly the underlying condition needs to be identified. If they have an infection, then they need antibiotics. Have they been commenced on new medications? When were the medications last reviewed? You do not necessarily need to fully understand the medications a person is on and their actions, this is the Registered Nurses role, but you do need observe any changes in behaviour or if they have any new symptoms and report them to the Registered Nurse or in some cases, directly to the doctor. Don t underestimate the effects of alcohol withdrawal either. Many older people live on their own and may have a drink, or 2 or 3 every night. Take them out of this habit and they may suffer a delirium as a result. Often family members are not fully aware of the drinking habits of their parents. Likewise if a person is having a heart attack you need to observe the person and what is going on for them so can be treated and the person stabilised. Then the delirium will disappear. If they are constipated, once the constipation is fixed and their bowels begin to work normally, the delirium will disappear so you need to make sure that this situation doesn t occur again. So recording a person s bowel movements is really important as I mentioned before. If they are sleep deprived, then you fix the sleep deprivation and the delirium will disappear. If a person is kept well hydrated with plenty of fluid, then delirium will not occur but it can be easily fixed with a glass of water or several glasses of water so dehydration should be avoided. A glass or two or water is far better than a trip to hospital and an IV or subcutaneous infusion. Be cautious about the use of sleeping pills though. I had a man who had been put on a sleeping pill and he had such an extreme delirium he was falling over all the time and had to be kept in his room. Once I realised he was on this, I discussed the reasons with the doctor and he was taken of them. Once these were stopped his delirium disappeared and he stopped falling. A really good lesson for the RN and Caregivers who influenced the doctor s decision to try them. Being up at night and wandering around is not

5 sufficient a reason for a person to be given a sleeping pill. The consequences can often be worse than the cure. Using restraints to stop a person from acting out in confused state is highly unhelpful and likely to do more harm than good. These people need understanding and love to help them get through this state and treatment of the underlying condition. Knowing when a person is taken out of their normal and familiar environment can upset a person dramatically so you need to make allowance for a new person in your facility being confused till they get used to their environment. They may hallucinate or see things that are not there. If a person goes into a public hospital then it is highly likely they may become confused on admission. Do not laugh or growl at these people. What they are displaying is very real for them. This may last for the duration of their hospital stay or it may be just for a short time. So you need to listen to the family and find out how they are or were before their admission to residential care or acute care. Is this a normal behaviour for them? If not think delirium and know that it is very likely to be reversed once they get used to the new environment. In some cases medication may be helpful to calm a person down but I say this with caution. Medication is only a last resort. Deliriums will normally disappear if the situation is reversed or underlying condition treated. I cannot reinforce enough the important role you play when working with residents or clients. You are their life line. The Registered Nurse that you report to is highly reliant on the quality of information you give to them to make a sound clinical decision. If you do not pass on the observations you make of a person in your care this person may need to have quite aggressive treatment to reverse the problem or worse still, they may be misdiagnosed as having dementia. Registered Nurses are dependent on you and really value your skills at early detection and reporting.

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