Delirium:

 Recognition
 Assessment
 Prevention
 Management

WRHA Surgical Program

Delirium Guidelines
 Delirium
Definition:
A disturbance of
consciousness
with inattention
that develops
over a short
time &
fluctuates
 What is Delirium?
• An acute confusional
state
• Usually has a
reversible cause
• Characterized by:
– Inattention
– Sudden onset
– ………………..
 Why Should We Use Delirium
Guidelines ?
• Delirium can result in:
–  morbidity and mortality
–  length of stay
–  rates of admission to long term care
facilities
– 20% of patients discharged post hip # still
had evidence of delirium (Journal of American Geriatric
Society 2001 May;49(5):678-9).
 Outcomes of Delirium

35%
40%

25%

Recovery Permanent Cognitive Impairment Mortality

(even with complete recovery, 30% dementia within 3 years =

decreased brain reserve)
 Recognition of Delirium

• Previous studies 32%-66% of cases are

unrecognized by Medical Staff
Yale- New Haven study (Inouye S. Ann Intern Med 1993: 119-
474)

– 65% unrecognized by Physicians

– 43% unrecognized by Nurses
Top 4 Independent Risk Factors for
Delirium
Vision impairment:

Any severe illness:

Cognitive impairment:

High Urea/Creatinine
ratio:

Inouye S. Ann Intern Med 1993: 119-474

4 Independent Risk Factors for Nurse
Under-Recognition
• Hypoactive Delirium

• Age 80 yrs and over

• Visual Impairment

• Dementia
 Types of Delirium
• Hyperactive

• Hypoactive

• Mixed
 Causes of Delirium?

• Anything that hurts the brain or impairs its

proper functioning can provoke a delirium!

• Brain’s way of demonstrating “acute organ

dysfunction”
 Causes of Delirium:

1. Drugs
2. Infection
3. System failure/events
4. Metabolic Imbalance
5. Dehydration/Poor Nutrition
6. Surgery or general anaesthetic within the
last 5 days
 Causes of Delirium:
7. Pain 12. Sleep disruption

8. Uncorrected sensory or 13. No factors can be identified

language impairment 20% of the time

9. Fecal Impaction 14. Recent severe illness or event

10. Urinary Retention/Catheter involving hypoxia

11. Restraints
Causes of Delirium Related to Surgery

Perioperative
Drugs Risk Factors
Anesthetics Predisposing
 Opioids Precipitating
 Benzodiazepines
Etc…

Comorbidities
Diabetes
MI
Etc…
 Theories for Post Op Delirium
• Acetylcholine interaction with medications
used during surgery
• Increase of neurotransmitters, serotonin and
dopamine during surgery
• Previous abnormality levels of melatonin
• Damage to neurons by oxidative stress or
inflammation caused by a surgical procedure
• Post op abnormal brain waves
Medications Associated with
Delirium
• Any drug can potentially cause confusion

• Take a careful history of any new drug

STARTED or any old drug STOPPED
recently
 Medications Associated with
Delirium
• Over the counter
drugs
– Cimetidine
– Cough/Cold Remedies
– Gravol/Maxeran
– Sleeping medications
– Herbal meds
 Reference List of Drugs with
Anticholinergic Effects
• Antidepressants • Opioids
• Antipsychotics
• Anticonvulsants
• Antihistamines/
• Antibiotics
Antipruritics
• Corticosteroids
• Antiparkinsonian
• Antispasmotics • Anticholinergics
• Antiemetics
 Studies
In studies, drugs with anticholinergic side effects have
been shown to:
• Lower cognitive scores in elderly subjects
• Cause/worsen severity of delirium
• Associated with more ADL decline in patients with
dementia
• Associated with faster MMSE decline in patients with
dementia
• If drugs reduced, be associated with improvements in
dementia and delirium.
 Full List of Safe Medications for the
Older Adult
Please see attachment at
the end of this
presentation
Assessing for Delirium
 Pre-Admission Assessment
• Decision Tree
 CAM – Confusion Assessment Method
– Sensitivity (94 to 100%), specificity (90 to 95%)

Requirement for delirium = 1, 2 AND either 3 OR 4

1. Abrupt change?

2. Inattention, can’t focus?

3. Disorganized thinking? Incoherent, rambling, illogical?

4. Altered level of consciousness? (Hyper-alert to stupor?)

AND
 Trigger Questions
1. Acute change in behaviour?

2. Changes in function?

3. Changes in cognition? MMSE

4. Changes in medications?

5. Physiologically stable?
 How Do We Assess for Inattention
• Recite the months backwards or days
backwards

• Have the patient count backwards from

20 to 1.

• Use the CAM

 Once You Identify Delirium, Now
What?

• Identify the acute medical problems that

could be either triggering the delirium, or
prolonging it!

• Clarify pre-morbid functional status,

sequence of events and previous
admission cognitive baseline

• Identify all predisposing and precipitating

factors, and consider the differential
 Physical Exam
– Vitals: normal range of BP, HR, Temp and pain

– Good physical exam: particular emphasis on

Cardiac, pulmonary and neurologic systems

– Hydration status

– Also rule out

• fecal impaction
• urinary retention
• Infected pressure ulcer, UTI or pneumonia
Delirium workup: Lab testing
• Basic labs most helpful!
– CBC, lytes, BUN/Cr,
glucose,CO2, Ca+, Mg,
PO4
– TSH, B-12, LFTs &
albumin

• Infection workup
(Urinalysis, CXR) +/-
blood cultures

• EKG

• O2 sat/ABG
What About Prevention?
 Yale Delirium Prevention Trial
Risk Factors Intervention
Cognitive Impairment Reality orientation / therapeutic
activities program
Vision/Hearing impairment Vision / hearing aids / adaptive
equipment
Immobilization Early mobilization / Reduce
immobilizing equipment
Psychoactive medication Non pharmacologic approaches to
sleep / anxiety / Restricted use of
sleeping medication
Dehydration Early recognition / Volume
expansion
Sleep deprivation Noise reduction strategies/sleep
enhancement program
Ref: Inouye SK, NEJM. 1999;340:669-676
 Prevention and Pre-Op Assessment
• Pre-op Clinic Form
• Pre- op- Questionnaire
What about Management?
 Non Pharmacological Interventions
• Always apply non-pharmacological
interventions in your Care Plan. Examples
– Initiate toileting routines
– Mobilize ASAP
– Quiet room, soothing music
 Pharmacological Interventions
• Only use medication if:
– Non-pharmacological interventions are not
successful
– The patient is a danger to themselves or others

• You may see the physician order or a pharmacist

suggest the following medications:
– Low dose Haloperidol or
– Low dose Risperidone or
– Low dose Olanzapine
– ** Avoid the use of benzodiazepines
 Pharmacological Interventions

• It is important to
remember that:
– Dosing is best given prn
when agitation
becomes a concern or
becomes a safety issue
– Medications must be
discontinued once the
agitation from the
delirium is resolved
 Delirium Pamphlet
• This is to be given to Families so that they may
better understand what their family member
is going through.
• It is also recommended that it be displayed in
any Pamphlet Holders for Patient and Family
Education.
• A copy of the pamphlet is found at the back of
the presentation
Pre-Admission Clinic Forms
Questions ??????