DELIRIUM

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DEFINITION

Delirium is a state of temporary but acute mental confusion.It is a common disorder in older adults who have short term illness such as lung or heart disease,infection ,poor nutrition,drug interactions ,metabolic or hormonal disorders

ETIOLOGY

• Both cortical and sub cortical structures(thalamus, basal ganglia and pontine reticular formation)are involved.
• The neurotransmitter acetylcholine plays a major important role in delirium.
• Anticholinergic drugs precipitates delirium in older adults
• Anticholinesterase agents reduces the delirium caused by anticholinergic drugs.
• Other risk factors for delirium are hypoglycaemia ,hypoxia and thiamine deficiency
• Other neurotransmitters like delta amino butyric acid,norepinephrine’dopamine and serotonin also causes delirium.
• Delirium is also associated with infection, inflammation etc..
• Patients treated with cytokine therapy(interferon for hepatitis c)can cause neuropsychiatric side effects including delirium
• Delirium can occur for a vulnerable patient most easily.
• A combination of factors like anaesthesia, major surgery, prolonged infection, prolonged sleep deprivation etc can cause delirium
• Older adults with little compensatory mechanisms with hypoxia, hypoglycaemia and dehydration causes delirium
• Older adults are more susceptible for drug induced delirium
• Medications including sedative hypnotics, narcotics especially meperidine, benzodiazepines etc causes delirium

PRECIPITATING FACTORS

• Absence of time,place and cues(eg:watch,cues),change in environment.
• Chronic illness(eg;Congestive cardiac failure)
• Dehydration
• Dementia
• Hyperthermia,hypothermia
• Hypoxia
• Immobilization
• Medications(sedative hypnotics,narcotics,benzodiazepines)
• Metabolic disorders
• Pain (untreated)
• Renal disease
• Sensory depriviation,sensory overload.
• Stress and trauma

CLINICAL MANIFESTATIONS

• Variety of manifestations ranging fromhypoactivity and lethargy to hyperactivity including agitation and hallucination
• Inability to concentrate,irritability,insomnia,loss of appetite,restlessness and confusion.
• Later manifestations may include agitation,misperception,misinterpretation or hallucination.

DIAGNOSTIC STUDIES

• Medical and psychological history and physical examination.
• Mini mental status examination.
• Laboratory tests may include CBC,serum electrolytes,serum nitrogen,and creatine levels,electrocardiogram,urine analysis,liver function test,thyroid function test and oxygen saturation should be obtained.
• If unexplained fever or nuchal rigidity is present,then meningitis is suspected,CSF examination has to be done.CSF has to be examined for glucose and protein and presence of bacteria
• If the patients history has head injury then CTScan and MRI has to be done

MEDICAL MANAGEMENT

• Drug therapy is usually initiated in patients with severe agitation(fluid replacement,intubation,dialysis)Agitation can cause the patient for falls and injury.
• Low dose antipsychotics like haloperidol is given(IM,IV or orally).
• Other antipsychotics are resperidon,olanzepine,etc..
• Short acting Benzodiazepines are given(lorazepam or Ativan).It is given in patients with sedative and alcohol withdrawal symptoms

NURSING MANAGEMENT

• Prevention is better thab cure ,the patients at risk should be identified9Stroke,dementia,CNS infection,Parkinsons disease).Other risk factors are admission in the intensive care unit and lack of watch or calendar and absence of reading glasses.
• Care of delirium is focussed on prevention of the precipitating factors.If it is caused by drugs,then the particular drug is discontinued.Delirium can also be due to alcohol withdrawal.
• If the delirium is due to environmental conditions9overstimulating or understimulating environment)then it should be altered
• If delirium is secondary to infection then appropriate antibiotics should be started.
• Fluid and electrolyte imbalance and nutritional deficiencies(Thiamine)are corrected appropriately.
• If the deliurium is related to chronic conditions like kidney failure and congestive heart failure then treatment should be focussed on this.
• Protect the patient from harm and offer a calm and quiet environment.This may include encouraging the family members to be near to the bedside of the patient,providing familiar objects,transferring the patient to private room near to the nurses station etc..
• Reorientation and behavioural interventions should be used.The patient should be reoriented to time,place and person
• Clocks ,calenders and listing the scheduled activities of the patient are also useful.
• Personal contact through touch and reorientation should be there.
• If the patient is using eyeglasses or hearing aid it should be readily available because sensory deorientation may precipitate delirium.
• The use of restraints should be avoided
• The nurse should also focus on supporting the family members and the caregivers

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