Cause
Explanation
Medications
New or existing:
– Anticholinergic medications; antispasmodics; benzodiazepines; steroids; opioids
Underuse:
– Withdrawal from benzodiazepines, antidepressants, opioids and dementia medications; undertreated pain; alcohol withdrawal
Microorganisms
Urinary tract infection; aspiration pneumonia; pressure ulcer; venous catheter infection
Metabolic
Electrolyte abnormalities; uremia
Micturition
Urinary retention; constipation; urinary catheter
Myocardial
Myocardial infarction; pulmonary embolism; congestive heart failure; hypoxia
Mind
Acute stroke; intracranial hemorrhage; brain mass/metastases; other psychiatric diagnosis
Assessment
Serial assessments can help detect as well as monitor for further changes.
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History—Gathering history from the patient, family, or nurse is important for identifying when changes first appear. Serial assessments such as those utilized in the CAM-ICU are helpful at identifying changes during hospitalization [9]. Additional questions include: When were symptoms first detected? Time Course? Trauma? Medications changes? Recent changes in other conditions?
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Standardized Mental Status Assessment —There are many instruments that have been utilized in the literature for the diagnosis of delirium. Importantly, the sensitivity and specificity of these measures often varies depending on the performance of standardized cognitive assessment.
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Operationalized Definitions —The 4-AT is a valid diagnostic algorithm that has been validated for delirium, is available for clinical use, and has been clinically operationalized [12]. The algorithm includes attention, alertness, orientation, and alteration.
The Confusion Assessment Method is a diagnostic algorithm for delirium that has high sensitivity and specificity when accompanied by supplemental cognitive testing [13]. The CAM includes acute mental status change and fluctuating course, inattention, disorganized thinking, and altered level of consciousness [14]. The CAM ICU provides an operationalization of the CAM Criteria for nonverbal patients [15].
The Modified Richmond Agitation and Sedation Scale (mRASS ) is a valid and reliable scale of consciousness [16] that has been modified for verbal patients. While a single mRASS lacks sensitivity for delirium, monitoring the mRASS for change over time is associated with increased sensitivity and specificity [17].
Management of Delirium
Once delirium has developed, the proper treatment is to identify and treat the underlying cause. In accordance with clinical practice guidelines, nonpharmacological measures should be attempted while treating the underlying causes in an effort to reduce the agitation associated with delirium. A standardized program is described below:
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The Delirium Toolbox
A delirium risk modification program that has been associated with improved hospital outcomes and lowered costs for older patients [5]. The strategy of the delirium toolbox is fourfold:
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Identify patients at greatest risk.
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Inform treatment teams with clinical notes/education.
- c.
Intervene to reduce risk with tools to improve sensory improvement, sleep promotion, and cognitive stimulation.
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Monitor longitudinally for changes in consciousness indicative of delirium.
The risk identification process includes screening with assessment of cognition and attention, vision or hearing deficits, and dehydration. Once completed, the clinical team is informed of delirium risk via a note in the medical record.Related posts:
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