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Delirium & Dementia Group Presentation

Queens University ABSN Gerontology
by

Erin Patterson

on 28 July 2014

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Transcript of Delirium & Dementia Group Presentation

Delirium &
Dementia

These are NOT normal aging processes
References

Doenges, M., Moorhouse, M., Murr, A. (2013). Nursing diagnosis manual. Planning, individualizing, and documenting

client care. Philadelphia, PA: F. A. Davis Company.

Fletcher, K. (2012, August). Dementia geriatric nursing protocol. New York, NY: Hartford Institute for Geriatric Nursing.

Retrieved from http://consultgerirn.org/topics/dementia/want_to_know_more

Mezey, M., & Maslow, K. (n.d.). Recognition of Dementia in Hospitalized Older Adults. New York, NY: Retrieved from

http://consultgerirn.org/uploads/File/trythistry_this_d5.pdf

Mauk, K. (2014). Gerontological nursing: competencies for care. Burlington, MA: Jones & Bartlett Learning.

Parkinson's Disease Foundation, (n.d.). Statistics on Parkinson's.
Retrieved from

http://www.pdf.org/en/parkinson_statistics

Tullmann, D., Fletcher, K., Foreman, M. (2012). DELIRIUM Geriatric Nursing Protocol: Delirium: Prevention, Early

Recognition, and Treatment. Harvard Institute for Geriatric Nursing. New York, NY: Retrieved from

http://consultgerirn.org/topics/delirium/want_to_know_more#item_2,

http://consultgerirn.org/topics/delirium/want_to_know_more#item_5

Waszynski, C. M. (2012). The Confusion Assessment Method (CAM). Harvard Institute for Geriatric Nursing. New

York, NY: Retrieved from http://consultgerirn.org/uploads/File/trythis/try_this_13.pdf

The scope of this work includes two of the three “D’s” of conditions that impact older adults:
delirium and dementia.
These diseases can affect people of any age, however, older adults are primarily impacted due to increased risk factors and comorbidities.
Although both delirium and dementia
affect cognition and mental states, delirium
is typically short-lived and can be corrected
or eliminated by removal of the stimulus or
treatment of the underlying problem.

Affecting stimuli can include underlying diseases, medications or polypharmaceutical interactions, vitamin deficiencies, and other problems such as alcoholism.
A simple example of delirium is high fever secondary to infection which can cause an altered sense of reality, confusion, or hallucinations in patients.
Typically when the fever is reduced, the altered cognition diminishes as well and the patient returns to a “normal” state of mind.
There are three presentations of delirium: hypoactive, hyperactive, and mixed.
In
hypoactive
delirium, the patient presents as withdrawn or catatonic.
A patient with
hyperactive
delirium responds to “...all environmental stimuli simultaneously” (Mauk, 2014).
The
mixed
delirium patient shows signs and symptoms of both hypoactive and hyperactive presentations.
Current trends show that delirium
affects between 10-30% of inpatients although the number can be higher depending on the patient’s health
situation (for example, 50% of
intensive care patients show signs of delirium) (Tullmann, Fletcher &
Foreman, 2012).

Delirium is considered an acute state with few long-term impacts on mental status
while, by comparison, dementia is a chronic, progressive, degenerative disease.
Although Alzheimer's disease may be the most prevalent form of
dementia, there are actually many others that impact an enormous
amount of people in the United States.
Vascular dementia
Parkinson’s disease
Lewy body dementia
Frontotemporal lobe dementia
Huntington’s disease
Wernicke-Korsakoff’s disease
Creutsfeldt-Jacob disease
It is important to reiterate that as we age, we normally lose some cognition (mild cognitive impairment), however; dementia is not the same thing, it is never normal and it does not always run the same course in each form of the disease.

For example, Alzheimer patients begin to lose
cognitive ability which then progresses to physical or motor losses.


In contrast, Parkinson’s patients begin their disease with changes in motor skills which ultimately progress to cognition losses.
Although much research has been done on these chronic, incurable illnesses, no single factor has been identified as the causative agent of dementia. Genetics, lifestyle choices, and even past trauma may play a role.
Research shows that dementia, specifically Alzheimer's disease, impacts nearly five and
a half million Americans.
Within the next thirty five years
those numbers will rise to a
staggering...

11-16 million (Mauk, 2014)
Scope, Demographics
& Definition

Address any signs or symptoms immediately!

Assessment tools have been developed to help determine the presence of altered cognitive statuses. Utilizing these tools when appropriate is an important part of the nursing process.

Heather Caughley, Thomas Corey, Chelsea Ford, Amber Ijaz, Jill Jansen, and Erin Patterson

Queens University of Charlotte
Assessment Tool Rationale

Delirium is often unrecognized and undocumented
by clinicians.

Early recognition and treatment can improve outcomes; therefore, patients should be assessed frequently using a standardized tool such as the:
Confusion Assessment Method (CAM)
The CAM can be used by nurses to recognize delirium quickly and accurately.
The CAM is 89-95% reliable.
The tool identifies the presence or absence of delirium but does not assess the severity of the condition
Feature 1: Usually obtained from a family member or nurse and shown by positive responses to the questions: Is there evidence of an acute change in mental status from the patient’s baseline? Did the abnormal behavior fluctuate during the day, that is, tend to come and go, or increase and decrease in severity?
Feature 2: Shown by positive response to: Did the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was being said?
Feature 3: Shown by positive response to: Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?
Feature 4: shown by any other answer than “alert” to: Overall, how would you rate this patient’s level of consciousness? (alert [normal], vigilant [hyperalert], lethargic [drowsy, easily aroused], stupor [difficult to arouse], or coma [unarousable])
The diagnosis of delirium by CAM requires the presence of features
1
and
2
and
either

3
or
4
.
Delirium should be detected as soon as possible to prevent negative consequences such as prolonged hospitalization, functional decline, and increased mortality.
Older adults with dementia who are hospitalized are at a much higher risk for delirium, falls, dehydration, inadequate nutrition, untreated pain, and medication related problems.
Patients with dementia are more likely to wander and demonstrate aggressive behavior.
The Try This tool, Recognition of Dementia in Hospitalized Older Adults, suggests ways hospitals can increase recognition of dementia to avoid any unnecessary risks
Dementia is a possibility for every hospital patient over the age of 75
Most patients with dementia are admitted to the hospital for treatment of other medical conditions
One approach in recognizing dementia is to ask the patient and family if the patient is experiencing “severe memory loss.”
When no prior diagnosis of dementia is reported a family questionnaire and patient behavior triggers for clinical staff are two tools that are used.
The family questionnaire asks family members to think back over the past 6 months and answer the following questions:
Repeating or asking the same thing over and over.
Forgetting appointments, family occasions, holidays?
Writing checks, paying bills, balancing the checkbook
Shopping independently for clothing or groceries?
Taking medications according to instructions
Getting lost while walking or driving in familiar places?
Making decisions that arise in everyday living?

Scoring a three or more on the questionnaire, the patient should be further assessed. A score of 3-6 indicates possible dementia. A score of 7-10 indicates probable dementia
The patient behavior triggers for clinical staff identifies triggers or symptoms to offer a clue to the presence of dementia
Some triggers include:
Seems disoriented
Is a “poor historian”
Defers to a family member to answer questions directed to the patient
Repeatedly and apparently unintentionally fails to follow instructions
Has difficulty finding the right words or uses inappropriate or incomprehensible words
Has difficulty following conversations

Nurses should be familiar of such triggers to be able to identify undiagnosed dementia.
Nursing Diagnosis and Outcomes for
Delirium and Dementia in Older Adults

Risk reduction for the older adult with delirium or dementia equals health promotion for the individual. The ANA standards of practice include nursing diagnoses and the identification of desired outcomes.
Examples related to delirium and dementia:
At risk for increased susceptibility to falling that may cause physical harm related to diminished mental status affecting ability to recognize danger.

Patient will be free from injury at discharge and caregiver will understand risk factors in the home environment that may affect client safety after discharge.
At risk for dehydration related to deficient understanding regarding fluid needs as evidenced by inadequate follow-through of instructions to consume adequate liquids.

Patient will be free of evidence of fluid deficit within 24 hours.
At risk for imbalanced nutrition related to deficit of understanding of daily nutritional requirements as evidenced by significant loss of body weight.

Patient will demonstrate progressive weight gain to a goal weight within 20 days.
At risk of untreated pain related to inability to report pain due to impaired psychomotor expression. Patient will be assessed for pain based on observation of facial expressions and body language by the nurse.

Client will be able to acknowledge pain/pain relief by simple signals within two weeks.
At risk for ineffective self-medication related to delirium due to kidney infection.

Patient medications will be monitored by care-giver and home health until delirium subsides within one week.
At risk for wandering outside of safe limits related to short-term memory deficits due to dementia.

Patient will be given independence with acceptable boundaries, monitored with alarm bracelet.
At risk for social isolation related to unacceptable aggressive behavior due to Alzheimer’s disease.

Client will participate successfully in group activities for ten minutes within five days.
Difficulties Applying Assessment Tools
Difficulties in applying the Confusion Assessment Method:
1. The CAM does not assess severity but only identifies the presence or absence of delirium; therefore it is not an effective tool in detecting clinical improvement or deterioration in a patient.

The Delirium Rating Scale is the more appropriate tool to use if assessment of severity is desired.
2. General lack of knowledge of the CAM as well as the difficulty healthcare providers have distinguishing delirium from dementia pose further difficulties in application of this tool.

A study conducted at a regional hospital medicine conference found that 82% of the participants (physicians, nurse practitioners, and physician's assistants) had never heard of or used CAM, which would make it difficult for them to utilize this particular assessment tool. It was also a significant portion of these individuals who also admitted their difficulty in differentiating delirium from dementia.


Recognition of Dementia in hospitalized Older Adults:

1. Completion of either the family questionnaire or patient behavior triggers (clinical staff) portions of this assessment tool does not eliminate the need for further assessment. A positive screen does not rule out the possibility of delirium because of the many similarities between the two conditions.
2. To date, the reliability of this particular assessment tool is unknown.
Nursing Care Guidelines
Delirium
Mental status assessment:

- Establish patient baseline
Manage risk factors:

- Avoid high-risk medications
- Provide adequate nutrition and hydration
- Provide sufficient pain control

Foster a healing environment:

- Promote orientation
- Provide a calm/relaxing setting
- Assist with frequent ambulation
- Limit invasive interventions
- Educate caregivers

Dementia
Screen effectiveness and side effects of medications:

- Evaluate improvement/decline in cognitive abilities

Mental status assessment:
- Establish patient baseline
Maximize functional abilities:

- Encourage social engagement and independence
- Provide assistance when/where needed
- Establish routines and repetition

Confront behavioral issues:

- Identify internal and external triggers

Foster a healing environment:

- Promote orientation
- Include modest stimulation
- Remove safety hazards

Patient and caregiver teaching

- Advanced care planning including end of life care
- Teach caregivers necessary skills
- Highlight patient success and strengths
Full transcript