Chapter 5: Communication, psychological wellbeing and safeguarding
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Delirium
Definition
Delirium is a distressing and underdiagnosed syndrome of acute alteration in mental state. The core clinical features that indicate a diagnosis of delirium are:
- impaired consciousness and attention
- disorientation, impaired recent memory, perceptual distortions and transient delusions
- psychomotor disturbances (hypoactivity or hyperactivity)
- disturbed sleep–wake cycle
- emotional disturbances (various) (WHO [287]).
Delirium can present in three forms:
- Hypoactive delirium: a subtype of delirium characterized by becoming withdrawn, quiet and sleepy.
- Hyperactive delirium: a subtype of delirium characterized by heightened arousal where people can be restless, agitated or aggressive.
- Mixed: with both hypoactive and hyperactive features.
Related theory
In most cases, delirium is caused by a general medical condition, intoxication, or withdrawal of medication or substances that act upon the neurochemical balance of the brain (Ross [246]). Causative factors such as infection, post‐anaesthesia and medication (especially analgesics) need to be considered, particularly for sudden onset of delirium in the hospital environment.
The prevalence of delirium in hospital patients is between 20% and 50% (NICE [204]). Certain factors predispose people to delirium or are risk factors for its development:
- other serious illness such as uncontrollable cardiovascular or respiratory conditions, diabetes
- multiple co‐morbidities
- older age
- alcohol dependence syndrome
- previous or existing other mental disorder, such as dementia
- hypoalbuminaemia
- infection
- taking medications that affect the mind or behaviour
- uncontrolled pain
- taking high doses of analgesia (Irving et al. [138]).
Being an inpatient in a hospital environment can contribute to the development of delirium. The following factors can increase the risk:
- patient not a UK resident and/or English is not their first language
- changing clinical environment, such as room or ward, on a number of occasions
- absence of any means of gauging the time of day
- absence of family or a close friend
- catheterization.
The greater the number of risk factors present, the greater the likelihood of delirium developing (NICE [204]).
Delirium can develop quickly and fluctuate over the course of a 24‐hour period (APA [10]). A patient's behaviour may change to indicate potential delirium before a full set of diagnostic symptoms is observable (Duppils and Wikblad [84]). Environmental cues during the daytime act as stabilizing factors and so at night‐time symptoms are typically worse. Delirium can resolve within hours or days, or it can last longer if it co‐exists with other problems, such as dementia; it is important to rule out pre‐existing neurocognitive disorders when considering treatment responses.
Delirium is associated with considerable morbidity, which can delay recovery and rehabilitation, as well as mortality (Irving et al. [138], NICE [204]). Recognizing and addressing delirium are important, not only because of the clinical impact but also because of the distress it causes patients, families and staff (Lawlor et al. [149]).
Evidence‐based approaches
Nurses play a critical role in the prevention, early detection (Milisen et al. [185]) and management of delirium. Delirium is frequently iatrogenic (i.e. caused by medical intervention) and hence can often be corrected once the causative factor has been identified.
Addressing potential causative factors as part of good nursing and medical care will help to prevent the development of delirium. This means ensuring hydration and nutritional requirements are met and any electrolyte imbalances are monitored and corrected.
Nurses need to be aware that patients over the age of 65 years (especially those having anaesthesia) will be highly prone to developing delirium so they need to be monitored carefully over a period of time to pick up any early signs. The effect of analgesia (especially opiates) also needs to be considered.
The emergence of delirium can also be significant at the end of life and can significantly complicate care provision (Delgado‐Guay et al. [62]). Terminal restlessness is a term often used to describe this agitated delirium in end‐of‐life care, where the causes may require specific management different from that of other types of delirium (Brajtman [34], White et al. [282]). A progressive shutdown of body organs in the last 2–3 days of life (Lawlor et al. [149]) leads to irresolvable systemic imbalances. The management of delirium in end‐of‐life care therefore shifts from a focus on reversing the cause to alleviating the symptoms. Nurses should avoid medicating symptoms unless this is in the patient's best interest.
Principles of care
Initial screening for any cognitive issues on admission is important to identify predictive factors and establish a baseline of cognitive functioning. Involving the family can be crucial in an accurate assessment where there are existing changes.
If risk factors are identified, nursing care for an individual with delirium should focus on minimizing hyperarousal from the environment:
- Minimize the frequency of moving the patient from one ward, bed or room to another.
- Ensure that there is cognitive stimulation – for example, make sure the television is working and that the patient is in an environment with other patients.
- Give the patient access to a means of determining the time of day (e.g. a clock or window).
- Ensure the patient has access to hearing aids, glasses, etc.
- Encourage friends, relatives and spiritual advisors (if appropriate) to visit.
In addition, nursing care should include optimizing physical health for the patient to maintain mobility (if appropriate), hydration and nutrition and to prevent constipation and incontinence. This will take place in parallel with the patient's medical management, which should initially focus on attempting to establish potential reversible causes. These include:
- newly started medications
- changes in dosage
- opioid toxicity
- withdrawal from opioids or alcohol
- use of corticosteroids
- metabolic imbalances or organ failure affecting the processing and excretion of drugs
- infections
- hypercalcaemia
- constipation.
Clinical governance
In the case of medium‐term to longer‐term delirium, another person may make decisions on the patient's behalf as long as this has been agreed as part of a best interest assessment and the principles of the Mental Capacity Act ([176]) have been applied. The best interest assessment must include the views of family or informal carers, and the decision maker is generally the lead clinician for the patient (Griffith and Tengnah [112]). However, if the patient has a lasting power of attorney for welfare and this application has been registered with the Office of the Public Guardian, then the relevant person will be able to make decisions on the patient's behalf.
The Mental Capacity Act ([176]) sets out principles relating to the protection of liberty when caring for someone with reduced capacity. This must be reliant upon accurate and suitable assessments of capacity and best interests that are well documented and reviewed.
Physical intervention
Wherever possible, nurses must attempt to create an environment where physical intervention will not be necessary. Physical intervention happens very rarely and all feasible steps to avoid it must be explored. Any action taken must be the ‘least harmful’ intervention in the circumstance. The aim is to balance the patient's right to independence with their and others’ safety. However, if physical intervention is necessary to maintain the safety of the patient, then it requires careful ethical and legal consideration.
Physical intervention takes many forms and must be meticulously judged for the potential to benefit or harm an individual. The Delirium: Diagnosis, Prevention and Management guidelines (NICE [204]) advise that the use of physical intervention should be a last resort, where the patient is putting themselves or others at risk of harm and all other means of management and deflection have been employed. When physical intervention is employed, this should be for the shortest period possible and use minimum force to ensure the patient is not harmed.
If intervention is required, nurses must explain to the patient why they are doing what they are doing (regardless of the patient's perceived capacity) and act to reduce the negative impact upon the patient's dignity as much as possible.
Documentation
Delirium is under‐reported in nursing and medical note taking (Irving et al. [138]). Documentation outlining the onset of behaviours and symptoms is instrumental in assisting the medical team to identify the cause of the problem and its likely solution. The documentation of the assessment and subsequent care must be detailed and accurate.
Pre‐procedural considerations
Psychosocial support
It is important, wherever possible, to create an environment conducive to orientation (e.g. a quiet, well‐lit environment where normal routines take place). Nurses must help patients to maximize their independence through activity, as mobilization is seen to assist with orientation (Neville [193]). Nursing interventions include creating a well‐lit room with familiar objects, limited staff changes (possibly requiring one‐to‐one nursing care), reduced noise stimulation, and the presence of family or familiar friends.
Pharmacological support
Once diagnosed, symptoms that do not respond to non‐pharmacological interventions can be treated with prescribed medication including sedatives, for example haloperidol (NICE [204]). As far as possible, benzodiazepines should be avoided as a side‐effect of these can be delirium (BNF [21]). However, they may be used if delirium is caused by alcohol withdrawal.
Use of medication for sedation in the end stages of life needs individual consideration and the family must be involved and communicated with regularly.
It is worth noting that health professionals and family members can mistake the agitation of delirium for symptoms of pain. If opioids are increased as a result, there may be worsening of the delirium (Delgado‐Guay et al. [62]).
Table 5.19 Communicating with a person with delirium
| Principle | Rationale |
|---|---|
| It is essential to ensure that aids for visual and hearing impairments are functional and being used. | To maximize the patient's ability to communicate normally. E , C |
| Adjust the environment to promote the patient's orientation, for example install a visible clock or calendar and photographs of family. | To maintain or promote orientation. E , C |
| Background noise should be kept to a minimum. | Background noise can be very distracting for the patient. E , C |
| Always introduce yourself to the patient (do not assume they remember you). If possible, limit the number of individuals involved in the person's care. | To promote consistency and reduce the potential for confusion. E |
| Give simple information in short statements. Use closed questions. | Closed questions are less taxing and only require a ‘yes’ or ‘no’ answer. E |
| Give clear explanations of any procedures or activities carried out with the individual. | To maintain respect and dignity. E , C |
Post‐procedural considerations
Liaison with the patient's family is important so that they understand what is happening and what they can do to help. It can be distressing to witness or spend time with a delirious family member. The family should therefore be given the opportunity to talk about their concerns and be updated with information about the cause and management. It is good practice to give them written information about delirium, such as the leaflet provided by the Royal College of Psychiatrists (RCPsych [237]).
