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Managing delirium in the community



Key learning points:

  • Nurses in community settings can identify risk factors in their older patients and implement a preventive approach to support them
  • The most commonly used screening tool for delirium is the Confusion Assessment Method (CAM)
  • Interventions might be pharmacological and non-pharmacological

Delirium, also referred to as ‘acute confusional state’, has been acknowledged as an acute medical emergency that increases chances of admission to hospital with long stays, as well as admission to a care home and mortality.1-3 Patients may be discharged home while still experiencing unresolved delirium symptoms.4 And delirium may also develop in patients living at home because of exacerbation of a long-term disease, an acute illness or side-effects of medication.5
Prevalence of delirium in older adults living at home without a diagnosis of dementia or cognitive impairment has been estimated at between 0.5% and 1.3%, and is associated with higher mortality.6,7 A study in Greece identified a prevalence of delirium in a community population of 1.1% with all but one patient being successfully treated at home.8 In older adults living at home with dementia the prevalence of delirium increases and is estimated to range from 13% to 22%.4,7 This is referred to as delirium superimposed on dementia (DSD).

Defining delirium
Delirium is characterised by fluctuating levels of attention, consciousness, confusion, and a change in a person’s cognition.9 Predisposing factors include a history of cognitive impairment or dementia, age above 65 years, transient ischaemic attack, stroke, alcohol abuse, depression and functional or sensory impairment. Precipitating factors include: the development of immobility, malnutrition, three or more extra prescribed medications, or insertion of a urinary catheter.10
Types of delirium include: hyperactive, hypoactive and mixed. Hyperactive delirium is characterised by increased agitation and restlessness, due to hallucinations and illusions. A patient experiencing hyperactive delirium may demonstrate expressions of fear and anger and may become aggressive, whereas hypoactive delirium is characterised by lethargy, where the patient will be passive and drowsy. Mixed delirium is the combination of hyperactive and hypoactive delirium, the patient alternating between the two states.11
The interaction between delirium and dementia is complex, with a positive correlation between the severity of dementia and the severity of delirium.12 Healthcare professionals do not always recognise delirium because the symptoms overlap with and are often attributed to dementia.
Distinguishing factors of DSD include: fluctuating mental status, inattention and arousability. By contrast, dementia is a slow chronic decline in cognitive function.13,14 However, an acute illness with an episode of delirium might identify undiagnosed dementia or the vulnerability to develop dementia due to reduced cognitive brain reserve.15

Recognition and assessment of delirium
It is important to identify delirium early as it is considered to have an underlying acute medical cause and is a revisable condition with prompt assessment, detection and treatment.16 Nurses in community settings can identify risk factors in their older patients and implement a preventive approach to support or restore health in these vulnerable patients.17
But nurses in acute and community settings are recognising only 41% of hyperactive delirium and 21% of hypoactive delirium.17 In long-term care facilities nurses recognised DSD in only 13% to 18.7% of cases.18 A recent study in Canada suggested community nurses had limited knowledge about delirium and appropriate screening tools, although 54.4% were able to identify delirium from case studies.19

Identifying delirium in the community
Nurses remain the best-placed healthcare professionals to assess and recognise delirium in the patients they care for, although delirium remains a medical diagnosis. The term delirium in nursing literature is relatively recent, replacing ‘acute confusion’, so this may be a reason why nurses do not identify delirium or relate to appropriate delirium guidelines.20
An exploration of nursing documentation in acute settings identified the use of generic terms for patients’ cognitive status such as ‘pleasantly confused’, and ‘alert and ‘orientated’ that were often interchanged, but there was no documentation of ‘acute confusion’ or ‘delirium’.20 Delirium educational programmes for nurses working in acute settings have demonstrated a positive impact on documentation of patients’ cognitive status and on patient outcomes,17,21 but no data is available for nurses working in community settings.
Further barriers to identification of delirium in community settings include: older people living alone with no family member to recognise a sudden deterioration in cognition, fewer non-urgent home visits, lack of continuity of care to recognise a deterioration in cognition, and busy GP surgeries with time-limited appointments.22

Diagnostic tool
Recommendations for assessment of delirium in community settings include a detailed history and cognitive assessment.22 The most commonly used validated screening tool is the Confusion Assessment Method (CAM), originally developed by Inouye et al for use with older adults in hospital.23 The CAM has been specifically designed for nurses to complete with patients to detect early signs of delirium and can be used in community settings.
The CAM has four criteria, of which the first two must be present with either of the second two for a delirium diagnosis. The criteria are:

  • Acute onset and fluctuating course.
  • Inattention.
  • Disorganised thinking.
  • Altered level of consciousness.23

The CAM is necessarily brief to allow multiple assessments to detect cognitive and behavioural changes, which are paramount due to the fluctuating nature of delirium.24 Family members can support the documentation and monitoring of fluctuations if taught by community nurses to use the Family Confusion Assessment Method.25

Nonpharmacological interventions
The underlying causes of delirium are multi-factorial and interventions might be pharmacological and non-pharmacological.26
Clinical guidelines for nonpharmacological interventions focus on caring for patients with delirium in hospital, but can be applied to community settings. Nonpharmacological interventions should be tailored individually for each patient with delirium, including those with DSD, as these interventions reduce severity and duration of delirium.9,27
Nurse-led person-centred interventions for patients with delirium include four elements:

  • Monitoring – fluctuations in cognition, and also constipation, infection, impact of polypharmacy, sleep patterns, functional impairment and risk of falls, pain and exacerbation of co-morbidities.
  • Care – the development of a care plan to address activities of daily living, nursing care such as catheter or wound care, and pain management.
  • Support – for informal carers.
  • Education – an essential element to support the patient and their family to understand delirium, important aspects of healthy aging, how to prevent infections and falls, and adherence to prescribed medications.28

Pharmacological interventions
Clinical guidelines for pharmacological interventions are orientated to patients with delirium in acute settings. But regardless of the setting, a pharmacological approach to treating delirium should not be the first and only intervention. Treatment with antipsychotic medication, such as haloperidol or olanzapine should only be considered for patients who appear distressed or are a risk to themselves or others, and if prescribed their use is recommended only for a short period of time. Any antipsychotic medication should be started as the lowest clinically appropriate dose and take into consideration the patient’s age, and diagnosis of other conditions including Lewy Body dementia and Parkinson’s disease.27

References
1. Kiely DK, Jones RN, Bergmann KE et al. Association between delirium resolution and functional recovery among newly admitted postacute facility patients. Journals of Gerontology Series A: Biological Sciences and Medical Sciences 2006;61:204-8.
2. McAvay GJ, Ness PH, Bogardus ST et al. Older adults discharged from hospital with delirium: 1 year outcomes. Journal of American Geriatrics Society 2006;54:1245-50.
3. Bellelli G, Frisoni GB, Turco R et al. Delirium superimposed on dementia predicts 12-month survival in elderly patients discharged from a postacute rehabilitation facility. Journals of Gerontology Series A: Biological Science and Medical Science 2007;62:1306-9.
4. Lange E, Verhaak PFM, Meer K. Prevalence, presentation and
prognosis of delirium in older people in the population at home and in long-term care: a review. International Journal of Geriatric Psychiatry 2013;28:127-34.
5. Bond S. Delirium at home strategies for home health clinicians. Home Healthcare Nursing 2009;27:24-34.
6. Andrew MK, Freter SH, Rockwood K. Incomplete functional recovery after delirium in elderly people: a prospective cohort study. BMC Geriatrics 2005;5:5-12.
7. Fick DM, Kolanowski AM, Waller JL et al. Delirium superimposed on dementia in a community-dwelling managed care population: A 3-year retrospective study of occurrence, costs, and utilization. Journals of Gerontology, Series A, Biological Sciences and Medical Sciences 2005;60:748-53.
8. Lixouriotis C, Peritogiannis V. Delirium in the primary care setting. Psychiatry and Clinical Neuroscience 2011;65:102-4.
9. Kolanowski AM, Fick DM, Clare L et al. An intervention for delirium superimposed on dementia based on cognitive reserve theory. Aging and Mental Health 2010;14:232-42.
10. Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet 2014;382:911-22.
11. Peterson JF, Pun BT, Dittus RS et al. Delirium and its motoric subtypes: A study of 614 critically ill patients. Journal of American Geriatrics Society 2006;54:579-84.
12. Voyer P, Cole MG, McCuster J. Prevalence and symptoms of delirium superimposed on dementia. Clinical Nursing Research 2006;15:46-66.
13. Richardson S, Teodorczuk A, Bellelli G et al. Delirium superimposed on dementia: a survey of delirium specialists shows a lack of consensus in clinical practice and research studies. International Psychogeriatrics 2016;28:853-61.
14. Brooke JM. Caring for patients with dementia. Nursing in Practice 2016;89:68-71.
15. Jones RN, Manly J, Glymour MM et al. Conceptual and measurement challenges in research on cognitive reserve. Journal of International Neuropsychological Society 2011;17: 593-601.
16. Siddiqi N, Holt R, Britton AM et al. Interventions for preventing delirium in hospitalised patients. Cochrane Database Systematic Review, 2009.
17. Fick DM, Hodo DM, Lawrence F et al. Recognising delirium superimposed on dementia assessing nurses’ knowledge using case vignettes. Journal of Gerontological Nursing 2007;33:40-7.
18. Voyer P, Richard S, Doucet L et al. Detection of delirium by nurses among long-term care residents with dementia. BMC Nursing 2008;7:1-14.
19. Malenfant P, Voyer P. Detecting delirium in older adults living at home. Journal of Community Health Nursing 2012;29:121-30.
20. Steis MR, Fick DM. Delirium superimposed on dementia. Accuracy of nurse documentation. Journal of Gerontological Nursing 2012;38:32-42.
21. Meako ME, Thompson HJ, Cochrane BB. Orthopaedic nurses’ knowledge of delirium in older hospitalised patients. Orthopaedics Nursing 2011;30:241-8.
22. Stephens J. Assessment and management of delirium in primary care. Progress in Neurology and Psychiatry 2015;19:4-5.
23. Inouye SK, van Dyck CH, Alessi CA et al. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Annals of Internal Medicine 1990;113:941-8.
24. Caplan JP, Rabinowitz T. An approach to the patient with cognitive impairment: delirium and dementia. Medical Clinics of North America 2010;94:1103-116.
25. Steis MR, Prabhu V, Kolanowski A et al. Detection of delirium in community-dwelling persons with dementia. Online Journal of Nursing Informatics 2012;16:1274.
26. Raju K, Coombe-Jones M. An overview of delirium for the community and hospital clinician. Progress in Neurology and Psychiatry 2015;19:
23-7.
27. Verloo H, Goulet C, Morin D et al. Nursing intervention versus usual care to improve delirium among home-dwelling older adults receiving homecare after hospitalisation: feasibility and acceptability of a Randomized Controlled Trial. BMC Nursing 2016;15:19.