Delirium in the Elderly

Delirium, also called ICU psychosis, ICU syndrome, or acute confusional state, is defined by Lemiengre et al (2006) as “a disturbance of consciousness with reduced ability to focus, sustain, or shift attention; a change in cognition; or development of a perceptual disturbance that occurs over a short period of time and tends to fluctuate over the course of the day” (p. 685). Advanced age is the greatest risk factor for this acute, reversible condition; however, due to medical staff’s insufficient awareness of delirium and its symptoms, an estimated 66% to 84% of the elderly in the ICU suffering from this condition are not diagnosed and, consequently, not treated (Truman & Ely, 2003). Because the incidence of delirium in the ICU is increasing as the population ages, the ICU nurse must be aware of this syndrome and improve patient outcomes by implementing strategies to reduce the common risk factors of anxiety and pain, sleep deprivation, and disorientation.
When a patient suffers from delirium, his hospital stay is extended, he is at greater risk of medical complications with increased risk of death, and, even if independent prior to admission, he is much more likely to be discharged to a nursing home. He may be depressed, withdrawn, agitated, or aggressive. He may cry and hallucinate and try to remove tubes or catheters (Truman & Ely, 2003). This situation is not acceptable when, according to Inouye et al. (2005), delirium is considered “one of the most common preventable adverse events for older hospitalized persons” (p. 312). There are many risk factors, but pain, anxiety, disturbed sleep cycle, and disorientation are the most common risk factors specifically associated with an ICU stay that can precipitate the onset of delirium (Gillis & MacDonald, 2006). The nurse who understands delirium rejects stereotypes that interpret confused behavior as the normal evidence of “old age” and carefully implements strategies to reduce risk factors for this condition.
Pain is a very stressful and fearful event associated with hospitalization and with many of the procedures common to the ICU experience. This gives rise to what is often the first observable behavior on the path to delirium—a restless anxiety that can progress to extremely agitated behavior. Adequate pain management and verbal assurance of adequate pain management is central to reducing this anxiety. Nurses must assess level of pain and pharmacologic and non-pharmacologic measures (ie. heat and cold, massage, deep breathing, guided imagery, distraction) must be taken accordingly. Explaining the purpose and steps of procedures and the goals of effective pain management reassures the patient and gains his confidence, thus reducing anxiety. Though restraints may be used as a last resort to control agitation that is a safety risk, it is most often a result of the failure to address the patient’s pain and resulting anxiety (Marshall & Soucy, 2003).
Unmanaged pain contributes to a second nursing focus in preventing delirium: sleep deprivation. When the noisy and unfamiliar environment of the ICU is superimposed on pain, sleep becomes extremely difficult. Though noise and interruptions are not always avoidable, they can be minimized by modifying the environment and grouping procedures in patient care whenever possible. The at-risk elderly should be given a single room if available, away from heavy traffic (Gillis & MacDonald, 2006). Otherwise, choosing a roommate whose care needs and disposition are compatible with the promotion of the patient’s sleep is essential. The nurse can ask the patient about his normal sleep pattern, organizing care to respect that pattern, and communicating the importance of sleep to family and friends to encourage timely scheduling of visits. Noise can be minimized by speaking softly in the hall and by keeping only essential equipment in the room with volume controls low.
Finally, the unfamiliar faces and environment of the ICU and the stressful experience of pain, anxiety, and consequent sleep disruption increase the risk for disorientation in the elderly patient. This can trigger delirium. In countering patient disorientation, the nurse can engage the family if she instructs them on their important role. Simply by their presence, they bring familiarity to an unfamiliar place and so can greatly benefit their loved one. Family should be encouraged to touch their loved one, bring in clocks, calendars, favorite music and pictures, and talk about people, places, and experiences they have in common. Patient’s glasses and hearing aids should be worn (Gillis & MacDonald, 2006). However, if symptoms of delirium do develop, the nurse must be careful to assure family members of the “temporary nature and likely fluctuation” of the distressing symptoms (Truman & Ely, 2003, p. 34). It is also very important that the nurse become a humanizing presence in the high technology ICU environment by using therapeutic touch and by patiently and continually explaining the reason for hospitalization and the procedures performed using vocabulary understandable to the patient (Hewitt, 2002).
As the elderly population increases, the ICU nurse must understand delirium and be equipped to implement strategies to reduce the incidence of delirium which Truman and Ely (2003) consider “one of the top three most important target areas for improvement in quality of care in vulnerable older adults” (p. 26). Important interventions must be directed toward reducing his anxiety and promoting sleep by managing the elderly patient’s pain and environment. Maintaining orientation by surrounding him with familiar faces and objects while explaining the reason for and process of procedures is also vital in reducing the incidence of delirium. The ‘acute confusional state’ of delirium is very distressing for both the patient and his family. If not treated, it is also potentially deadly for the patient. Managed pain, familiar faces, increased understanding of the hospital environment and procedures, and adequate sleep create an environment of comfort and a sense of security that is necessary in the prevention of delirium and in the promotion of optimal patient outcomes.
Intervention #1
Nurses need to adequately assess and effectively treat pain in the elderly patient.
Disadvantage # 1
Murphy (2007) purports that there is “a remarkable stoicism” among the elderly related to pain and that, according to a Patients Association survey of nursing home residents, “older people believe pain is an unavoidable part of aging” (p. 32). Residents also reported that nurses did not regularly ask about their pain, implying that nurses often misinterpret the calm demeanor of the elderly patient as an absence of pain or that they also hold the ageist belief that pain is an inevitable consequence of growing old. Unless this false belief is exposed through education for nurses and patients, many elderly patients will hesitate to express their pain and nurses will fail to adequately assess their patient’s pain (Murphy, 2007).
Disadvantage # 2
The use of relaxation, meditation, and guided imagery are non-pharmacological methods of pain management that avoid common side effects that contribute to the development of delirium. These include sedation, confusion, constipation, and adverse drug interactions due to polypharmacy. However, pain management of the elderly is almost entirely focused on the use of pain medication in part because nurses are not knowledgeable in these complimentary therapies. To address this, Antall and Kresevic (2004) state that “Nurses must develop expertise in this area and be able and ready to act as patient educators and advocates in the use of these interventions.” and propose that these complementary therapies be incorporated into all nursing curricula (p.340).
Intervention #2
To counter patient disorientation and promote a therapeutic environment, nurses should encourage family members to visit frequently.
Disadvantage # 1
Frequent visits from family members contribute to a therapeutic environment that counters disorientation in patients. In addition, family members can provide valuable information on the patient’s mental status prior to admission and can identify any subtle changes. However, if the patient’s condition worsens, the acute onset of delirium is “very disruptive and very upsetting to those who may have known the patient as a lucid, rational being, only hours earlier” (Litton, 2003, p.212). To avoid the anxiety this causes nurses must educate family members on delirium and its manifestations and reassure the them that appropriate treatment is being pursued. This can be very time-consuming for busy nurses but is essential if family members are to effectively participate in the patient’s recovery.
Disadvantage #2
Concerned families may visit too frequently. Nurses must ensure that the environment allows the patient to have a balance between independence and supportive care. Concerned family may become a source of anxiety to the patient rather than a source of security and comfort. Nurses may have to ask the family to reduce visits if these exacerbate excitability in the patient with hyperactive delirium. This can be a sensitive issue to address with family members who want to be continually present. Gillis and MacDonald (2006) remark that finding the balance that promotes a therapeutic environment “is both a science and an art” (22).



References
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