Hypoactive Type Research Articles

Cardio Delirium Day: national study on the prevalence of delirium in Italian cardiology wards

To date delirium prevalence in the adult acute Italian hospital cardiac population is unknown. In a multicenter study, we assessed the prevalence of delirium over a single day among a population of patients admitted to acute cardiac hospital wards in Italy. This is a point prevalence study (called "Cardio Delirium Day") which involved 55 Italian cardiologic centers (23 North, 18 Central, 12 South, 2 Sardinia) that collected data on 152 patients older than 65 years hospitalized on March 15, 2023. Delirium was assessed on the same day in all patients using the Confusion Assessment Method for the Intensive Care Unit algorithm, a validated and briefly administered tool which does not require specialized training. We also collected data about clinical variables, functional and nutritional status, dementia, comorbidity, medications, and physical restraints. The mean sample age was 79.0 ± 10 years (33% female). Delirium was diagnosed in 25 patients (16.4%); 17.1% were hospitalized in the intensive cardiac care unit and 13.8% in the cardiology ward (p=NS). Hyperactive was the commonest subtype (48%), followed by mixed (36%) and hypoactive type (8%). In a multivariate logistic regression, male sex (odds ratio [OR] 3.81, 95% confidence interval [CI] 1.18-12.26; p=0.025), chronic obstructive pulmonary disease (OR 0.24, 95% CI 0.063-0.66; p=0.008), sensorial deficit (OR 3.75, 95% CI 1.18-11.95; p=0.025), sleep deprivation (OR 5.81, 95% CI 1.47-22.9; p=0.012) and the presence of ≥3 precipitating factors (OR 7.63, 95% CI 2.32-25.2; p=0.001) were independent predictors of delirium. Delirium occurred in 16.4% of patients in a cardiology setting. The "Cardio Delirium Day" project might become a useful method to assess delirium over time and sensitize the interest and the culture of Italian cardiology in this important aspect of hospital care.

Prevalence and Risk Factors of Delirium and Subsyndromal Delirium in Older Adults

Background and Aim: Delirium is the most prevalent geriatric issue that is independently associated with poor outcomes in terms of discharge, length of hospital stay, and increased mortality. Subsyndromal delirium (SSD) is defined by the presence of delirium symptoms that do not yet meet the definition of full-blown delirium. The present study aimed to determine the incidence and delirium-related risk factors in older adults. Method: This prospective study was conducted on 420 elderly patients (>60 years) in the Department of Medicine of Benazir Bhutto Hospital Rawalpindi and Liaquat University Medical and Health Sciences, Jamshoro Hyderabad, from April 2021 to December 2021. Study protocol was approved from research and ethical committees of the institutions. The purpose of the study was explained to the participants after taking written informed consent. Patients were classified into three categories are as follows: delirium, subsyndromal delirium, and cases without both delirium and subsyndromal delirium. Detailed history taking, comprehensive geriatric assessment, and clinical examination from each individual were recorded. All the collected data were analyzed using SPSS version 26. Results: Of the total 420 elderly patients, the incidence of delirium and subsyndromal delirium was 96 (22.9%) and 72 (17.1%) respectively. There were 264 (62.9%) male and 156 (37.1%) females. The overall mean age was 68.4± 4.8 years. Delirium and subsyndromal delirium cases were distributed based on the patient’s age were as follows: 62 (64.6%) and 42 (58.3%) in 60-70 years, 24 (25%) and 22 (30.6%) in 71-80 years, and 10 (10.4%) and 8 (11.1%) in >81 year. Of the 96 delirium cases, the incidence of hypoactive type, hyperactive type, and mixed type was 54 (56.3%), 18 (18.8%), and 24 (24.9%) respectively. Based on cognitive assessment, about 36 (8.6%) MMSE score <23, 78 (18.6%) had MMSE score <18, and 54 (12.9%) did not respond to MMSE. The incidence of common comorbidities such as hypertension, chronic liver disease, asthma, ischemic heart disease, cerebrovascular disease, diabetes, and malignancy was 144 (34.3%), 82 (19.5%), 26 (6.2%), 120 (28.6%), 24 (5.7%), 184 (43.8%), and 14 (3.3%) respectively. Conclusion: The present study found that the incidence of delirium and subsyndromal delirium was 22.9% and 17.1% respectively. Adverse outcomes such as increase in length of hospital stay, mortality, and discharge are independently associated with delirium. Efforts to prevent disease may identify patients who require clinical attention. Keywords: Delirium, subsyndromal delirium, risk factors

Psychiatric management of Patients in intensive care units.

Psychiatric management of Patients in intensive care units.

Postoperative delirium after reconstructive surgery for oral tumor: a retrospective clinical study

The aim of this study was to perform a statistical evaluation of the risk factors for postoperative delirium after oral tumor resection and reconstructive surgery. The records of 69 consecutive patients who underwent major head and neck tumor resection and reconstructive surgery, and who received postoperative management in the high care unit (HCU) or intensive care unit (ICU) of Tsukuba University Hospital between January 2013 and December 2017, were analysed retrospectively. Delirium was diagnosed in 23 patients (33.3%) after surgery. There were significant differences in age, sex, history of diabetes mellitus and chronic obstructive pulmonary disease, recent hospitalization history, sedation period, duration of ventilator use, length of ICU/HCU stay, postoperative blood tests (haemoglobin and potassium), and postoperative medication with a major tranquilizer between those with and without delirium. Logistic regression analysis of selected independent variables revealed a hazard ratio (95% confidence interval) of 1.42 (1.09–1.86) for the sedation period. Delirium was hyperactive type in 15 cases, hypoactive type in five, and mixed type in three. There was no obvious difference in postoperative day of onset or delirium period according to subtype. In conclusion, a history of diabetes and the sedation period were found to be related to postoperative delirium. However, this study was small and retrospective, so further investigation is necessary.

Impact of skeletal muscle mass on postoperative delirium in patients undergoing free flap repair after oral cancer resection

Postoperative delirium (POD) is a major risk factor for an extended hospital stay and higher costs, and is associated with increased mortality. The incidence of POD is high in free flap procedures, and POD may also be a risk factor for flap loss and complications. Sarcopenia is a condition characterized by skeletal muscle mass (SMM) depletion and a decrease in muscle power or physical activity. The aim of this study was to investigate risk factors for postoperative delirium (POD), including SMM, in 122 patients undergoing free flap repair after oral cancer resection. All patients underwent preoperative abdominal-lumbar CT or PET-CT. Cross-sectional areas (cm2) of skeletal muscles at the third lumbar vertebra were measured on preoperative CT, normalized for height, and defined as the skeletal muscle index (SMI, cm2/m2). Risk factors for POD were investigated, including the value of SMI and taking the type of POD into consideration. POD occurred in 45 patients (36.9%), and was hyperactive in 28 (62.2%), mixed in 13 (28.9%), and hypoactive in 4 (8.9%). In multivariate analysis, high preoperative albumin (p = 0.046, adjusted odds ratio [OR] = 3.69) and postoperative insomnia (p < 0.001, OR = 6.79) were significant risk factors for POD. In a sub-analysis evaluating risk factors restricted to POD including the hypoactive type, lower SMI (p = 0.035, OR = 2.52 per 10-unit decrease) and postoperative insomnia (p = 0.003, OR = 6.37) were significant. We conclude that lower SMM increases the hypoactive and mixed types of POD. Increasing SMM by exercise and nutritional therapy preoperatively may prevent such POD in free flap repair for oral cancer.

Prevalence of delirium in elderly intensive care unit patients of a tertiary care medical college hospital

Background: Delirium is an acute disorder of attention and cognition. It occurs in 20% to 79% of hospitalized older patients. It is also common in ICU patients, occurring in 20% to 50% of non-mechanically ventilated ICU patients and in 60% to 80% of mechanically ventilated ICU patients. Hence delirium is a common, serious, and often fatal condition among older patients. The present study attempts to address the prevalence of Delirium in the Indian elderly population.Methods: A cross sectional study was conducted between January 2019 to June 2019 in a 50 bedded intensive care unit of a tertiary care hospital in Bengaluru, Karnataka. A total of 300 elderly patients aged 60 years and above, satisfying the inclusion criteria was included in the study. Patients were assessed for the presence of delirium within 24 hours of admission using Confusion Assessment Method for Intensive Care Unit (CAM-ICU). Various qualitative variables were expressed in terms of proportions.Results: Prevalence of delirium among elderly, non-ventilated ICU patients was 30% (90 out of 300 patients). Among them, 50 (55.5%) were females and remaining 40 (44.5%) were males. Mean age of the patients was 76 years. About 50 (55.5%) of them belonged to age group of 70-79 years. Most of the delirium patients (44.5%) belonged to hypoactive type of delirium followed by hyperactive (33.3%) and mixed (22.2%) type of delirium.Conclusions: Delirium in elderly ICU patients is significantly prevalent, which is a poor prognostic factor, leading to higher morbidity and mortality. Of the three subtypes- hypoactive delirium is the most common type of delirium among elderly. Yet, it is often overlooked or under-diagnosed. Hence clinicians and/or trained nursing staff managing the patients in the ICUs, should routinely screen the patients for delirium, using brief screening measures, which in turn can improve the patients’ outcome.

Factors associated with delirium in critical patients in a health institution in Bucaramanga, Colombia

ObjectiveTo determine the incidence and the factors associated with delirium in intensive care unit patients. MethodsA cohort study conducted on 134 patients in the intensive care unit at a clinic in Bucaramanga, Colombia, who were recruited in the first 24h following admission and on whom the Richmond Agitation-Sedation Scale (RASS), PRE-DELIRIC version in Spanish, and Confusion Assessment method for Intensive Care Unit (CAM-ICU) were applied; the outcome was evaluated through daily monitoring with CAM-ICU. ResultsThe incidence of delirium was 20.2%, the predominating type was hypoactive at 66.7%, followed by the hyperactive type at 7.4% and mixed at 25.9%. Fifty-two percent of the patients with delirium died. In the bivariate analysis, the use of sedatives (Relative Risk (RR) 2.4, 95% confidence interval (95% CI)=1.2–4.5), infection (RR=2.8, 95% CI=1.3–5.9), metabolic acidosis (RR=4.3, 95% CI=2.3–8.0), mechanical ventilation (RR=4.6, 95% CI=2.0–10.6), aged over 60 years (RR=2.3, 95% CI=1.09–5.3) and APACHE score greater than 14 (RR=3.0) (95% CI=1.1–8.2) were identified as risk factors for delirium. The multivariate analysis only found a relationship with infection (RR=3.8, 95% CI=1.6–9.1) and being aged over 60 years (RR=3.2, 95% CI 1.2–8.3). Conclusionsdelirium is frequent in patients in the intensive care unit, especially the hypoactive type. Half of the patients with delirium died. The main risk factors for delirium are infection and being over 60 years age, therefore, delirium prevention activities should focus on these critical patients.

Etiology and Treatment of Delirium

Delirium is a potentially life-threating acute disease accompanied by a mortality up to 30 % of all affected patients. It occurs more frequently in older patients ≥ 65 years. Delirium is defined as acute onset of disturbances in attention, awareness and cognition that develops within a short period of time and fluctuates in severity. It can be subdivided in hyperactive, hypoactive and a mixed type. The hypoactive type occurs more frequently in geriatric patients and has the highest mortality of all types. Differential diagnosis of delirium include stroke, central nervous system infection, metabolic diseases, disturbances in electrolytes as well as Wernicke encephalopathy and psychiatric diseases. Treatment should be initiated rapidly and includes non-pharmacological interventions and specific pharmacological treatments. The review summarizes diagnosis and clinical management of patients with delirium.

The Motoric Types of Delirium and Estimated Blood Loss during Perioperative Period in Orthopedic Elderly Patients.

Background Delirium is a common and serious syndrome in elderly patients. The hypoactive type of delirium is known to have different characteristics, but further studies are needed to define the specificities of these characteristics. Our study aims at finding specific risk factors, especially estimated blood loss during operations of hyper- and hypoactive delirium in orthopedic elderly patients. Methods One hundred and seventy-five elderly patients were evaluated using the Confusion Assessment Method (CAM) and the 4th edition text revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). Trained psychiatrists interviewed the subjects directly at pre- and postoperative time points. We reviewed medical records after the patients were discharged. Results Thirty-nine patients (22.3%) were diagnosed with multiple types of delirium, which included 17 hyperactive types (65.9%), 13 hypoactive types (33.3%), and 9 mixed types (23.1%). Although the mean estimated blood loss in patients with either hyper- or hypoactive symptoms was larger than in patients lacking these symptoms, the odds ratio was only significant in patients with hyperactive symptoms. In addition, age, preoperative daily function, and preoperative hyponatremia were found to be risk factors for hyperactive but not hypoactive symptoms. Conclusion Patients with hypoactive symptoms had different risk factors than patients with hyperactive symptoms of delirium. The estimated blood loss, well-known risk factors for delirium, might be risk factors for only hyperactive delirium. The acute precipitating factors seemed to show stronger correlation with the hyperactive type of delirium than with the hypoactive type.

Risk factors associated with delirium for patients with hip fracture under the orthogeriatric unit mode

Objective: To explore postoperative delirium (POD)risk factors for geriatric patients who suffered hip fracture under the care of orthogeriatric unit mode. Methods: Patients aged 65 years or older, who were admitted to the orthogeriatric unit in Beijing Jishuitan Hospital from April to October 2017 for hip fracture surgery, were eligible for this prospective cohort study. After univariable analysis, significant risk factors associated with POD were further evaluated with multivariable analysis, to establish independent risk factors associated with POD. Results: A total of 203 patients with an average age of 80(65-96)years were enrolled in the study. The overall incidence of POD was 9.4%(19/203)in which hyperactive and hypoactive type accounting for 84.2%(16/19)and 15.8%(3/19), respectively. Significant difference was found between POD and non-POD groups in patients' age (P=0.003), albumin(P=0.006), TSH(P=0.018), PaCO(2) level(P=0.003), visual analogue scale (VAS )both at rest (P=0.013)and movement(P=0.010) on post-operative day 1.The further Logistic stepwise regression analysis showed that significant differences existed between groups in age(P=0.027), albumin(P=0.003), PaCO(2)(P=0.014)and VAS at rest(P=0.002). Conclusion: The independent risk factors of POD in geriatric patients undergoing hip fracture under the orthogeriatric unit mode include patients' age, pre-operative albumin as well as PaCO(2) level and post-operative VAS at rest.

Factores asociados con el delírium en pacientes críticos de una institución de salud de Bucaramanga, Colombia

ObjectiveTo determine the incidence and the factors associated with delirium in intensive care unit patients. MethodsA cohort study conducted on 134 patients in the intensive care unit at a clinic in Bucaramanga, Colombia., who were recruited in the first 24hours following admission and on whom the Richmond Agitation-Sedation Scale (RASS), PRE-DELIRIC version in Spanish, and Confusion Assessment method for Intensive Care Unit (CAM-ICU) were applied; the outcome was evaluated through daily monitoring with CAM-ICU. ResultsThe incidence of delirium was 20.2%, the predominating type was hypoactive at 66.7%, followed by the hyperactive type at 7.4% and mixed at 25.9%. Fifty-two percent of the patients with delirium died. In the bivariate analysis, the use of sedatives (Relative Risk(RR) 2.4, 95% confidence interval (95% CI) = 1.2-4.5), infection (RR = 2. 8, 95% CI=1.3-5.9), metabolic acidosis (RR = 4 3, 95% CI=2.3-8.0), mechanical ventilation (RR = 4 6, 95% CI=2.0-10.6), aged over 60 years (RR = 2 3, 95% CI=1.09-5.3) and APACHE score greater than 14 (RR = 3. 0) (95% CI=1.1-8.2) were identified as risk factors for delirium. The multivariate analysis only found a relationship with infection (RR = 3 8, 95% CI=1.6-9.1) and being aged over 60 years (RR = 3 2, 95% CI 1.2-8.3). Conclusionsdelirium is frequent in patients in the intensive care unit, especially the hypoactive type. Half of the patients with delirium died. The main risk factors for delirium are infection and being over 60 years age, therefore, delirium prevention activities should focus on these critical patients.

Delirium: a guide for the general physician

Delirium describes a sudden onset change in mental status of fluctuating course. This is a state of altered consciousness characterised chiefly by inattention or lack of arousal, but can also include new impairment of language, perception and behaviour. Certain predisposing factors can make an individual more susceptible to delirium in the face of a stressor. Stressors include direct insults to the brain, insults peripheral to the brain or external changes in the environment of an individual. Delirium is varied in its presentation, and can be categorised by the psychomotor profile as: hyperactive type (overly vigilant, agitated, often wandersome), hypoactive type (sedate or withdrawn) or mixed types.

Delirium: a guide for the general physician

Delirium describes a sudden onset change in mental status of fluctuating course. This is a state of altered consciousness characterised chiefly by inattention or lack of arousal, but can also include new impairment of language, perception and behaviour. Certain predisposing factors can make an individual more susceptible to delirium in the face of a stressor. Stressors include direct insults to the brain, insults peripheral to the brain or external changes in the environment of an individual. Delirium is varied in its presentation, and can be categorised by the psychomotor profile as: hyperactive type (overly vigilant, agitated, often wandersome), hypoactive type (sedate or withdrawn) or mixed types.

Delirium in patients with acute ischemic stroke admitted to the non-intensive stroke unit: Incidence and association between clinical features and inflammatory markers

BackgroundStroke patients with development of delirium have unfavorable outcomes, higher mortality, longer hospitalizations, and a greater degree of dependence after discharge. Studies suggest that delirium is associated with abnormal immunological responses and a resultant increase in inflammatory markers. ObjectiveOur aim was to determine whether there is an entity relationship between delirium, inflammation and acute ischemic stroke (AIS). MethodsSixty AIS patients admitted to the hospital were consecutively recruited. Delirium was diagnosed with the clinical assessment according to the Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) criteria. Enzyme-linked immunosorbent assay (ELISA) was used to measure serum levels of Interleukin-1 beta (IL-1 beta), Interleukin 18 (IL-18), Tumor Necrosis Factor-alpha (TNF-alpha), Brain-Derived Neurotrophic Factor (BDNF), and Neuron Specific Enolase (NSE) at admission. ResultsEleven (18.3%) of 60 patients were diagnosed with delirium, and the majority (n=8, 72.7%) was the hypoactive type. Delirious and non-delirious patients had similar demographic and clinical features. Delirious patients had significantly higher lengths of hospital stay, National Institutes of Health Stroke Scale (NIHSS) at admission and discharge compared to non-delirious patients. In addition, there was no significant statistical difference between delirious and non-delirious patients with AIS in respect of levels of TNF-alpha, IL-1 beta, IL-18, BDNF and NSE. This study suggests that delirium is not scarce in patients with AIS admitted to the non-intensive stroke unit, and that delirium developing after AIS seems not to be associated with serum TNF-alpha, IL-1 beta, IL-18, BDNF and NSE but is associated with length of hospital stay and stroke severity.

Evaluation of psychomotor/motor disturbances in elderly medical inpatients

IntroductionTraditionally psychomotor subtypes have been investigated in patients with delirium in different settings and it has been found that those with hypoactive type is the largest proportion, often missed and with the worst outcomes.Aims and objectivesWe examined the psychomotor subtypes in an older age inpatients population, the effects that observed clinical variables have on psychomotor subtypes and their association with one year mortality.MethodsProspective study. Participants were assessed using the scales CAM, APACHE II, MoCA, Barthel Index and DRS-R98. Pre-existing dementia was diagnosed according to DSM-IV criteria. Psychomotor subtypes were evaluated using the two relevant items of DRS-R98. Mortality rates were investigated one year after admission day.ResultsThe sample consisted of 200 participants [mean age 81.1 ± 6.5; 50% female; pre-existing cognitive impairment in 126 (63%)]. Thirty-four (17%) were identified with delirium (CAM+). Motor subtypes of the entire sample was: none: 119 (59.5%), hypo: 37 (18.5%), mixed: 15 (7.5%) and hyper: 29 (14.5%). Hypoactive and mixed subtype were significantly more frequent to delirious patients than to those without delirium, and none subtype more often to those without delirium. There was no difference in the hyperactive subtype between those with and without delirium. Hypoactive subtype was significant associated with delirium and lower scores in MoCA (cognition), while mixed was associated mainly with delirium. Predictors for one-year mortality were lower MoCA scores and severity of illness.ConclusionsPsychomotor disturbances are not unique to delirium. Hypoactivity, this “silent epidemic” is also part of a deteriorated cognition.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Patient with insidious hypoactive delirium associated with pregabalin

AbstractPregabalin has favorable effects on several types of neurological pain, but can cause side‐effects including dizziness, somnolence and delirium. Delirium presents as two variants in terms of psychomotor disturbance: the hyperactive type, showing agitation and vigilance; and the hypoactive type, showing lethargy and decreased motor activity. Patients with delirium associated with pregabalin therapy have been reported to experience hyperactive delirium. Here, we report the case of a 68‐year‐old patient with insidious hypoactive delirium caused by pregabalin therapy for postherpetic neuralgia. Delirium improved after discontinuation of pregabalin. Hypoactive delirium is considered to be more common than the hyperactive type in older adults, and is likely to be overlooked. Attention should thus be paid to latent cases of hypoactive delirium associated with pregabalin therapy in elderly individuals.

Development and review of vignettes representing older people with cognitive impairment

This paper describes a process undertaken to develop and review five clinical vignettes to be used in geriatric nursing educational research. The purpose of this process was to provide valid depictions of delirium and its subtypes and distinguish delirium from dementia. Five vignettes depicting hospital bedside interactions between nursing staff, family, and an older patient who displayed signs of one of the following conditions: delirium (hyper and hypoactive types respectively), dementia, or delirium (both types) superimposed on dementia were constructed. Vignette accuracy and reliability were established using a multistage process that culminated in formal review by a group of ten international nursing and medical delirium experts. The final five vignettes accurately depicted the given scenario as agreed by the experts and were at an appropriate level of simplicity and clarity. Given the increased interest in vignettes for both nursing research and educational purposes, the described method of vignette development and review has the ability to assist other vignette developers in creating reliable representations of their desired clinical scenarios.

Determining delirium and risk factors of patients in cardiovascular surgery intensive care unit

Background: This study aims to determine delirium and risk factors in patients in cardiovascular surgery intensive care unit (ICU). Methods: The study included 55 patients who were hospitalized in the cardiovascular surgery ICU of a university hospital. Between March 2008 and April 2009, the study data were collected using the patient information form prepared by the researchers, confusion evaluation method in ICU, Glasgow coma scale (CKS), Richmond agitation sedation scale (RASS), acute physiology and chronic health evaluation (APACHE II) and simplified therapeutic intervention scoring system (TISS-28). Data were analyzed with chi-square, Fischer exact chi-square, t-test, and Mann-Whitney U-test. Results: Delirium occurred in 18.2% (n=10) of the patients. Eighty percent of the patients in which delirium developed had hypoactive type. The points of APACHE II, RASS, TISS-28 among ICU scores increased in the group with delirium. The mortality rate of the patients with delirium was higher compared to the patients without delirium. However, the difference was statistically significant. The length of stay in the ICU was also longer for the patients with delirium. Conclusion: Delirium is a more common pathology than estimated in cardiovascular surgery intensive care patients, particularly presenting with hypoactive type. Nurses have important roles and responsibilities in determining the signs of delirium in patients in the ICU in early stages. Therefore, educating nurses on using delirium assessment scales is essential for the safety of patients and increasing quality of care.

Tips From the CRNP Perspective

Prompt recognition of delirium is challenging and often missed in long-term care settings because of its varied presentation and fluctuating severity of symptoms in individuals over time. It also can go undetected since related cognitive changes typically are assumed to be caused by an underlying dementia. Consequently, this is a significant subject to address in long-term care. Cognitively impaired older adults in particular are at high risk for delirium as the change in cognitive status is often the first sign of an acute illness. In addition, these residents often exhibit unsafe behaviors, and the risk of mortality is high. Though widely used, the Confusion Assessment Method (CAM) was designed to detect delirium in hospitalized patients, not residents in long-term care. As a result, it often misses the symptoms of delirium among residents (see list, lower left). These are the cases that nursing assistants usually pick up on first. They may say something like, “please go check Mrs. Smith. She's not acting like herself.” They may not specifically identify that the resident is delirious, but they are great at picking up subtle changes over time. One scale that is useful in long-term care is the Delirium-O-Meter, which is a 12-item, behavioral rating scale that determines delirium severity and is designed to be used primarily by nursing staff. It has good psychometric properties, which are comparable with the CAM, is user friendly, takes about 3-5 minutes to administer, and measures the severity of both hypoactive and hyperactive symptoms of delirium (Int. J. Geriatr. Psychiatry 2005;20:1158-66). Whatever tool is used, it is important to teach staff how to approach the resident when conducting a mental status exam. Encourage them to: ▸ Understand, not interrogate. ▸ Report just the facts (what you see and hear). ▸ Extend comfort and empathy. ▸ Ensure privacy during the exam. By helping nurses to do good cognitive status evaluations which identify the patient's strengths and abnormal states, the staff better identifies dementia, delirium, and depression. Medical directors, attending physicians, and nurse practitioners can provide that training. That way, information nurses give would help the provider make a more accurate diagnosis. Medications, dehydration, infection, and hypoxia from heart failure and/or chronic obstructive pulmonary disease exacerbations are the usual culprits in mild chronic delirium. However, there are a number of factors that increase the likelihood of delirium, such as advanced age, dementia, male gender, restraint use, multiple medications, Foley catheter use, immobility, infection, and sleep deprivation. Other factors include sensory impairment, poor fluid intake, antianxiety medications, fever, low-blood sodium, kidney disease, and psychoactive medications. The goal is to identify and eliminate the cause. Obtain a thorough history by performing a physical exam, and ordering appropriate diagnostic studies, such as electrolytes, CBC, drug levels, and urinalysis. Any underlying medical problem should be treated and medications decreased, if only temporarily. While low doses of antipsychotic medications can be used in residents with hyperactive delirium with psychotic symptoms, it is often best to avoid introducing new medications. In addition, here are other helpful measures: ▸ Try to normalize the environment and routine. ▸ Limit background noise. For example, take the delirious person out of the dining room when another resident starts screaming or when the clang of dishes gets to be overwhelming. ▸ Get the resident's attention before trying to communicate. Give simple, one-step directions. ▸ Consider cutting back on medications–especially for the hypoactive type (and avoid restraints). Consider neuroleptics as a last resort, using only when the resident's safety is at risk and he or she is psychotic. It is best not to leave these individuals alone. Instead, avoid physical and chemical restraints by having the residents remain in a common area where they are more likely to encounter staff. If possible, use one-on-one supervision, calling in family members or volunteers. Knowledge of delirium and an interdisciplinary approach that emphasizes early recognition and prompt treatment will ultimately result in improved care. Symptoms of mild chronic delirium as seen in the long-term care setting include: ▸ Distraction ▸ Disorganization ▸ Frequent napping but can be aroused ▸ Poor eye contact ▸ Subtle changes to the patterns of speech Source: Dr. Galik

A practical program for preventing delirium in hospitalized elderly patients.

Delirium in hospitalized elderly patients is common and often unrecognized (especially the hypoactive type), and can lead to serious complications. A systematic program can improve the rate of recognition of this problem and decrease its incidence, and is cost-effective.