DELIRIUM

Enriquez, Carmel Ray A.

What is Delirium?
◦ Delirium is one of the most common psychiatric conditions in frail older adults, and the most common complication of
hospitalization among people age 65 and older. Delirium refers to a transient global cognitive disorder or group of symptoms
associated with complex medical comorbidities.
◦ It is characterized by an acute onset of confusion, inattention, disordered thinkinging and altered mentation that occurs in
response to a medical condition.
Three Forms of Delirium
◦ The Hyperactive form of delirium is one of the most recognized and often manifest with psychomotor agitation, confusion,
and perceptual disturbances such as hallucinations or delusions. Manifestations of this form can include agitation, such as
pulling tubes or catheters, restlessness, attempts to climb out of bed or elope, physical aggression, or combativeness.
◦ The Hypoactive form of delirium mimics a stupor or coma and occurs more commonly than the hyperactive form.
Hypoactive has a higher mortality rate than the hyperactive, due to the complications of immobility. Also known as the “quiet”
delirium, because their behavioral symptoms aren’t problematic. Symptoms may include lethargy, inattention, and severe
somnolence. The prevalence of perceptual disturbances affects half of patients with hypoactive
◦ The Mixed form of delirium is the most frequent subtype of delirium and presents with both hyperactive and hypoactive
features. Alternatively, individuals may fluctuate between the hyperactive and hypoactive form in the course of a few hours.
Difference between Delirium and Dementia?
◦ Delirium may mimic dementia, but one key difference is the onset of symptoms.
◦ Delirium may be abrupt, while dementia has minor symptoms that gradually progress in time.
◦ Patients with delirium may be significantly impaired, while those with dementia are able to think through the day.
Risk Factors of Dementia
Predisposing Factors Precipitating Factors (Triggers)

◦ Advanced cancer ◦ Absence of a clock

◦ Acute cardiac or pulmonary events
◦ Alcoholism
◦ Bed Rest
◦ Cognitive impairment
◦ Drug withdrawal
◦ Hypoxia ◦ Fecal impaction
◦ Impaired cardiac or respiratory function ◦ Medications
◦ Malnutrition Medical comorbidities ◦ Severe anemia

◦ Metabolic disturbances, electrolyte imbalance ◦ Sleep deprivation

◦ Urinary retention
Warning Signs
◦ Agitation is a common delirium prodromal feature and a common warning sign of impeding delirium.
◦ Prodromal symptoms often occur 1 to 3 days prior to the development of delirium and include restlessness, anxiety, irritability,
distractibility, and disruption of sleep that may progress daytime somnolence and nighttime wakefulness
◦ Pain- Management of pain is crucial, as undertreated pain is a precipitating facto for delirium
◦ Combativeness- The dear that arises when the delirious individual is hallucinating and gives an example of a patient being a
world war II veteran.
◦ Inattentiveness- it is a key component of delirium and one of the defining characteristics; it may range from grossly
disordered thinking to mildly disorganized thought process.
◦ Wandering- is a common symptom in individuals with cognitive impairment.
◦ Sleep- Disruption of the sleep-wake cycle is a common delirium, as is nocturnal agitation.
Attention- refers to the ability to disengage, reengage, and sustain focus and focus and
vigilance. This can be tested with exercises such as reverse weekdays, reverse month order,
or subtraction.
Mental Status
Orientation- is a function of memory and involves awareness of the dimension of person,
place, and time. This can be tested by asking the patient to state the name of the hospital,
Examination
current age, or other indicators such as date, month, and year

Language- refers to the capacity for acquiring and using systems of communication. It can
be assessed by asking questions to determine understanding

Memory- includes primary, secondary, and tertiary memory. This can be tested by asking
the patient about salient events that occurred during their lifetime.

Reasoning- refers to abstract concept formation and executive functioning. One of the most
coming ways to assess reasoning and executive functioning is with the clock drawing hands
test.
Interventions
◦ Attention to precipitating factors
◦ Promoting sleep and comfort
◦ Avoiding unnecessary tubes and catheters
◦ Providing frequent cognitive stimulation and reorientation.
◦ Delirium treatment protocols that include mobilization, noise reduction or sleep protocols.
 ANXIETY AND
DEPRESSION IN
THE OLDER ADULT
Anxiety
◦ Anxiety can be difficult to diagnose in the
older patient due to atypical presentations.
Anxiety is one of the most common
psychiatric complaints throughout the
lifespan. Anxiety disorder occur in 10% to
29% of elders and are twice common as
dementias.
◦ Anxiety has the potential to decrease quality
of life, increase isolation, decrease
independence, worsen medical conditions, and
hasten one's death.
Common causes of Anxiety
◦ Declining abilities to perform self-care and declining social interaction due to aging, illness, and pain
◦ Hypoxia related to COPD or respiratory infection.
◦ Psychological stress
◦ Sensory changes
Anxiety Assessment
◦ Examine the overall mood, affect, and ability to maintain a conversation
◦ Assess the person’s ability to maintain a logical frame of thought in a conversation and stay focused.
◦ Ability to discuss concerns about health and illness.
◦ Assess the individual’s current state of mind, appearance, attitude, behavior, speech, though process, thought content,
perception, cognition, insight, and judgement.
Types of Anxiety and Symptoms of Anxiety
Types Symptoms

◦ Panic disorders, ◦ Irritability

◦ Anticipating the worst
◦ Phobic disorders,
◦ Concentration or memory difficulties
◦ Obsessive-compulsive disorders, ◦ Hopelessness

◦ General anxiety, ◦ Restlessness

◦ Posttraumatic stress disorder, and
◦ Substance-induced anxiety
◦ Sleep Disturbances
◦ Eating disturbances
◦ Fear of dying
◦ Fear of falling
◦ Fear of loosing controlM
Behavioral Counseling

Routine Managing
Cognitive-behavioral therapy Anxiety
Stress reduction

Getting adequate and efficient sleep

Staying active

Avoiding triggers

Support group therapy

Medication
Medication Management for Anxiety
◦ Anti-depressants are frequently used in older patients to assist in managing symptoms of anxiety.
◦ Selective serotonin reuptake inhibitors is the safest class of anti-depressant agents for older individuals.
Depression
◦ A significant number of older individuals
experience depression, which can affect
individual health and overall quality of life as
well as decrease an individual’s lifespan.
Many older adults experience chronic medical
conditions along with chronic pain and
fatigue, all of which can lead to depression.
Decline in health or new onset of illness
Common causes
of Depression
Exposure to multiple medications and their associated side
effects, as well as drug-drug interactions, can cause elders to feel
physically and mentally “down”

Having outlived spouses, loved ones, and friends

Having to move from private homes to assisted living or long-

term care because of decreasing ability to live independently
Major Depression- is a depressive episode in which
an individual experiences pervasive feelings of anxiety Types of
and sadness that coincide with anhedonia or loss of
pleasure and interest in daily activities.
Depression and
presentation

Minor depression- is a subset of major depression and

is defined as an episode of depressive thoughts that is
less severe than major depression but has a similar 2-
week time frame for presentation.

Dysthymia- is a chronic form of depression that is

often diagnosed in older adults with prolonged illness
or those who experience long-term challenges in their
daily living
◦ No interest or pleasure in enjoyable activities
Symptoms that are
◦ No interest in sexual activities indicative of
◦ Feeling sad or numb depression include the
◦ Crying easily or for no reason following.
◦ Feeling slowed down
◦ Feeling worthless or guilty
◦ Change in appetite; unintended change in weight
◦ Trouble recalling things, concentrating, or making decisions
◦ Problems sleeping, or wanting to sleep all of the time
◦ Feeling tired all of the time
◦ Thought about death or suicide
Manifestation of Depression
◦ Depression is manifested in both affective and somatic responses in varying patterns based on gender. Men often blame others
for their current depressed mood, display increased irritability and anger, and intentionally create conflicts. Males may act
suspicious and guarded, display restlessness and agitation, display an extreme desire to be in control, and perceive that
admitting self-doubt and despair are inherent weaknesses
◦ Depressed women often blame themselves for their depressed state, feeling anxious, scared, apatheric, slowed down, and
worthless. They often have trouble setting boundaries and avoid all conflicts, but do not have trouble talking with other about
their self-doubt and despair.
Different Presentations of Depression
◦ Catatonic depression- Individual is very withdrawn
◦ Melancholic depression- Individual is does not receive pleasure from usual activities
◦ Psychotic depression- Individual has false beliefs about having committed unpardonable sins or crimes.
◦ Atypical depression- Individual may appear anxious and fearful

Diagnosing depression can easily be assessed through a questionnaire

 Managing
Counseling and therapy- CBT is best performed by
advanced practice mental health clinicians who specialize in
Depression
geriatric care.

Medication Management for

Depression- Effective pharmacology SSRI Therapy
is necessary to manage major SNRI Therapy
depression or depression that lasts for
a prolonged period in older adults.
Nursing Interventions
◦ Providing a nonjudgmental atmosphere
◦ Instituting safety precautions for suicide risk for any patient who presents with severe symptoms or expresses suicidal ideation
◦ Monitoring and pronouncing nutrition, elimination, sleep/rest patterns, and physical comfort (especially pain control)
◦ Maintaining and/ or enhancing physical function
◦ Encouraging utilization of social support systems
◦ Maximizing independence and autonomy/personal control/self-efficacy by including the patient as an active participant in
making daily schedules and short-term goals
◦ Identifying and reinforcing the patient’s strengths and capabilities
◦ Providing structure to allow some familiarity in routine
◦ Provide emotional support
Suicide
◦ Older adults who are experiencing major depression are at risk for suicide. An older person may be at risk for harm to self,
which can lead to immediate or hastened death.
 Title Lorem Ipsum

LOREM IPSUM DOLOR SIT AMET, NUNC VIVERRA IMPERDIET PELLENTESQUE HABITANT
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ELIT. TELLUS. NETUS.