Acute Confusion/Delirium: A Comprehensive Guide for Nurses

Acute confusion, also known as delirium, is a sudden change in a person's mental state characterized by disturbances in attention, awareness, and cognition. It is a common but serious condition, especially in hospitalized and elderly patients. Prompt recognition and management are crucial to prevent long-term complications. Nurses play a pivotal role in identifying early signs, implementing interventions, and supporting patients and their families.

Definition

• Delirium: An acute neuropsychiatric syndrome marked by:
  • Disturbance in attention: Reduced ability to direct, focus, sustain, and shift attention.
  • Altered consciousness: Fluctuating levels of awareness and responsiveness.
  • Cognitive impairment: Memory deficits, disorientation, language disturbances.
  • Acute onset and fluctuating course: Symptoms develop over a short period (hours to days) and tend to fluctuate throughout the day.

Types of Delirium

1. Hyperactive Delirium:
   • Agitation, restlessness.
   • Hallucinations or delusions.
   • Increased motor activity.
2. Hypoactive Delirium:
   • Lethargy, drowsiness.
   • Reduced motor activity.
   • Withdrawal or apathy.
3. Mixed Delirium:
   • Alternating symptoms of hyperactivity and hypoactivity.

Causes and Risk Factors

Etiology (Mnemonic: DELIRIUM)

• D: Drugs (medications, intoxication, withdrawal)
• E: Electrolyte imbalances
• L: Lack of drugs (withdrawal from alcohol or sedatives)
• I: Infection (UTI, pneumonia, sepsis)
• R: Reduced sensory input (blindness, deafness)
• I: Intracranial events (stroke, hemorrhage)
• U: Urinary retention and fecal impaction
• M: Metabolic disorders (hypoxia, hypoglycemia)

Risk Factors

• Age: Elderly patients are more susceptible.
• Pre-existing cognitive impairment (e.g., dementia).
• Severe illness or multiple comorbidities.
• Hospitalization, especially in intensive care units.
• Surgery, particularly orthopedic or cardiac procedures.
• Polypharmacy: Use of multiple medications.
• Substance abuse: Alcohol or drugs.

Clinical Presentation

Symptoms:

• Attention deficits: Difficulty focusing or sustaining attention.
• Disorientation: Confusion about time, place, or person.
• Memory impairment: Short-term memory loss.
• Perceptual disturbances: Hallucinations (often visual), illusions.
• Language difficulties: Slurred speech, incoherence.
• Sleep-wake cycle disturbances: Daytime sleepiness, nighttime agitation.
• Emotional changes: Anxiety, fear, irritability.

Signs:

• Altered level of consciousness: Ranging from hyperalert to lethargic.
• Psychomotor changes: Agitation or decreased activity.
• Autonomic symptoms: Tachycardia, hypertension, sweating.

Diagnosis

Assessment Tools

• Confusion Assessment Method (CAM):
  • Feature 1: Acute onset and fluctuating course.
  • Feature 2: Inattention.
  • Feature 3: Disorganized thinking.
  • Feature 4: Altered level of consciousness.
  • Diagnosis requires the presence of features 1 and 2, plus either 3 or 4.
• Delirium Rating Scale-Revised-98 (DRS-R-98): Assesses severity and monitors changes over time.

Laboratory Tests

• Complete Blood Count (CBC): Check for infection or anemia.
• Electrolyte Panel: Identify imbalances.
• Renal and Liver Function Tests: Assess organ function.
• Glucose Levels: Detect hypoglycemia or hyperglycemia.
• Drug Levels and Toxicology Screen: Identify drug toxicity or withdrawal.
• Urinalysis: Detect urinary tract infections.

Imaging Studies

• Chest X-ray: Rule out pneumonia.
• CT or MRI of the Brain: Identify strokes, hemorrhages, or masses.
• Electroencephalogram (EEG): Differentiate delirium from seizures.

Management of Delirium

Goals:

• Identify and treat the underlying cause.
• Ensure patient safety.
• Manage symptoms.
• Prevent complications.

1. Treatment of Underlying Causes:

• Infection: Administer appropriate antibiotics.
• Electrolyte Imbalances: Correct sodium, potassium, calcium levels.
• Hypoxia: Provide supplemental oxygen.
• Hypoglycemia: Administer glucose.
• Medication Review: Discontinue or adjust medications that may contribute to delirium.

2. Symptom Management:

Environmental Modifications:

• Provide a quiet, well-lit room with minimal distractions.
• Use clocks and calendars to help orientation.
• Encourage the presence of family members.

Pharmacological Interventions (Use cautiously):

• Antipsychotics:
  • Haloperidol: Low-dose for severe agitation (monitor for extrapyramidal symptoms).
  • Atypical Antipsychotics (e.g., risperidone, olanzapine): May have fewer side effects.
• Avoid Benzodiazepines unless treating withdrawal syndromes (e.g., alcohol withdrawal).

3. Safety Measures:

Fall Prevention:

• Use bed alarms.
• Ensure the bed is in a low position.
• Keep the environment free of clutter.

Restraints:

• Use as a last resort and follow institutional policies.
• Regularly assess the need for continued use.

Monitoring:

• Frequent observation for changes in condition.
• Monitor vital signs and neurological status.

Nursing Interventions

1. Assessment and Monitoring:

• Regular Cognitive Assessments: Use CAM or other tools to detect changes.
• Vital Signs: Monitor for signs of infection or instability.
• Fluid and Nutrition: Ensure adequate hydration and nutrition.
• Pain Assessment: Untreated pain can exacerbate delirium.

2. Communication Strategies:

• Clear and Simple Instructions: Speak slowly and use short sentences.
• Reorientation Techniques: Frequently remind the patient of the date, time, and location.
• Use of Visual Aids: Clocks, calendars, and family photos.

3. Family Involvement:

• Education: Inform family about delirium and its reversible nature.
• Support: Encourage family visits to provide reassurance.
• Collaboration: Involve family in care planning and decision-making.

4. Preventive Measures:

• Avoid Sensory Deprivation: Provide hearing aids or glasses if needed.
• Promote Sleep Hygiene: Maintain a regular sleep-wake cycle.
• Minimize Use of Restraints and Sedatives: Opt for non-pharmacological interventions first.

Complications

• Increased Mortality: Higher risk during hospitalization and after discharge.
• Prolonged Hospital Stay: Leads to increased healthcare costs.
• Functional Decline: Loss of independence and decreased ability to perform daily activities.
• Long-term Cognitive Impairment: May accelerate dementia progression in vulnerable patients.

Prevention

Early Identification of At-Risk Patients:

• Screen upon admission, especially in the elderly.

Proactive Interventions:

• Implement protocols for hydration, nutrition, and mobility.

Medication Management:

• Avoid unnecessary medications.
• Use the lowest effective doses.

Environmental Optimization:

• Provide adequate lighting and reduce noise levels.

Conclusion

Acute confusion or delirium is a critical condition requiring immediate attention and a multidisciplinary approach. Nurses are at the forefront of detection, intervention, and prevention strategies. By employing evidence-based practices, providing compassionate care, and involving patients and families in the care process, nurses can significantly improve outcomes and enhance the quality of life for those affected by delirium.