Delirium & Dementia: Double Trouble By Denise L. Lyons, GCNS-BC, MSN; Shannon M. Grimley, GCP, PharmD; and Linda Sydnor, GCNS-BC, MSN LPN2009, March/April.
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Delirium & Dementia:
Double TroubleBy Denise L. Lyons, GCNS-BC, MSN; Shannon M. Grimley, GCP, PharmD; and Linda Sydnor, GCNS-BC, MSN
Mood Delirium: Fluctuating, labile, from fearful or
irritable to normal or depressed Dementia: Often flat, depressed
Thought processes Delirium: Disorganized; may be incoherent Dementia: Impoverished; speech gives little info
What’s the difference?
Thought content Delirium: Delusions common; often transient Dementia: Delusions may occur
Perceptions Delirium: Illusions, hallucinations (usually visual) Dementia: Hallucinations may occur
What’s the difference?
Judgment Delirium: Impaired, often to a varying degree Dementia: Increasingly impaired over illness
Orientation Delirium: Usually disoriented, especially for time. A
known place may seen unfamiliar Dementia: Fairly well maintained, but becomes
impaired in later stages of illness
What’s the difference?
Attention Delirium: Fluctuates. Patient is easily distracted and
unable to concentrate on tasks Dementia: Usually unaffected until late in illness
Memory Delirium: Immediate and recent memory impaired Dementia: Recent memory and new learning especially
impaired
Who’s at risk?
Predictable risk factors for developing delirium: Age older than 70 History of dementia Sleep deprivation Hearing or visual impairment Dehydration Severe illness or fractures Hospitalization
Who’s at risk?
Recent surgery Immobility Previous episodes of delirium Polypharmacy Alcoholism Multiple comorbidities
Common causes of delirium
Drugs prescribed, over-the-counter, and recreational alcohol withdrawal or intoxication polypharmacy (more than four medications) effects of anticholinergic drugs, psychoactive
Respond immediately to suspected physiologic causes of delirium: infection, medications etc.
Finding the cause
Observe the following: vital signs intake and output SpO2 level last bowel movement lung sound
medical device use pain level new medications blood glucose urinalysis
Medications that can cause problemsMany drugs can cause or exacerbate delirium: Alzheimer’s medications opioid analgesics nonopioid analgesics all anesthetics antianxiety/hypnotic agents, sedatives antiseizure drugs antidepressants
Medications that can cause problems antihistamines antihypertensives antimicrobials anti-Parkinson’s medications antispasmodics (urinary) cardiac medications glucocorticoids muscle relaxants
Diagnosing delirium
Two assessment tools may be helpful:
Confusion Assessment Method (CAM)
Neelon and Champagne Confusion Scale
Confusion Assessment Method (CAM) Available in long and short forms
Has 94% to 100% sensitivity rating
Key features include: acute onset, fluctuating course, inattention, disorganized thinking
Diagnosis by CAM requires first two features plus at least one of last two
Neelon and Champagne Confusion Scale Based on routine nursing assessments
Evaluates ten items divided into three levels: processing, behavior, physiologic functioning
Detects delirium in early stages
Medication management
National guidelines support using antipsychotic medications in patients with severe agitation or psychosis
Haloperidol (Haldol) is drug of choice; approved for oral and I.M. administration; has few anticholinergic effects; beware of QT changes when giving I.V.
Other drugs
Atypical antipsychotics may be given:
- risperidone (Risperdal)
- quetiapine (Seroquel)
- olanzapine (Zyprexa)
Effectiveness is uncertain; fewer adverse reactions
Benzodiazepines should only be used in alcohol withdrawal or as sedative-hypnotic
Supportive care
Maintain patient’s routine and have same care staff as much as possible