Tune your delirium radar and add some extra tools in your tool belt to get your delirious patient back on the rails.
To help navigate us through the crazy train of delirium in the ED, Kevin and Lisa from the How Not to Kill Your Patient podcast have joined me to discuss delirium assessment, risk factors, prevention, and treatment.
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Delirium is defined as a disturbance in attention and awareness that is accompanied by an acute loss in cognition that cannot be better accounted for by a preexisting or evolving neurocognitive disorder such as dementia.
Symptoms of Delirium
- Disorientation and confusion
- Fluctuating levels of consciousness
- Inattention and difficulty focusing or maintaining attention
- Perception changes such as hallucinations or delusions
- Disturbances in the sleep-wake cycle
- Advanced age, particularly those over 65
- Pre-existing cognitive impairment, dementia, or psychiatric illness
- Sensory impairment, such as vision or hearing loss
- Frailty or functional impairment
- Medical comorbidities, such as heart failure, chronic obstructive pulmonary disease (COPD), or liver disease
- History of alcohol or substance abuse
- Surgery or anesthesia
- Infection, such as pneumonia or urinary tract infection
- Metabolic disturbances, such as electrolyte imbalances or hypoglycemia
- Medication changes or side effects, particularly anticholinergic medications or benzodiazepines
- Substance withdrawal, such as alcohol or opioids
- sedatives, corticosteroids, antihistamines, anticholinergics, tricyclic antidepressants, muscle relaxants, and opioids are notorious for precipitating delirium
- Environmental changes, such as admission to the hospital or intensive care unit (ICU)
- Inadequate pain control
- Sleep deprivation or disruption
- Malnutrition or dehydration
- Medication toxicity or interactions
- Urinary retention or fecal impaction
- Prolonged immobilization or physical restraints
In the resource-limited setting of emergency departments, it is difficult to assess for delirium.
The following is an evidence based method for delirium assessment:
Confusion Assessmnet Method (CAM)
Feature 1: Acute Onset or Fluctuating Course
Is there evidence of an acute change in mental status from the patient’s baseline?
This feature is usually obtained from a family member or nurse
Feature 2: Inattention
Did the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was being said?
Feature 3: Disorganized thinking
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: Altered Level of consciousness
This feature is shown by any answer other than “alert” to the following question: 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 prevention measures in the ED
- Assess for delirium. Ask family members and caregivers about the patient’s baseline mentation
- Avoid “tethers” ie. foley catheters, telemetry, IVs
- Avoid unnessary NPO orders. Many ED patients are kept NPO by default for possible anticipatory procedures. NPO status should be reassessed to promote hydration nutrition
- Maintain good sleep hygiene. Minimize disruptions, maintain circadian rhythms
- Hallway beds should not be used for those at risk of delirium
- Mobilize: Since the decreased activity level is associated with delirium, trial of ambulation assisted ambulation with a nursing assistant or volunteer will suffice. When prolonged immobilization, consider using physical therapy (Lee et al, 2021).
The goal of care should be to maintain function, with active hydration, limited NPO time, access to food and toileting, and visual/hearing assists
Two fantastic resources about delirium in the emergency department:
Lee, S., Angel, C. & Han, J.H. “Succinct Approach to Delirium in the Emergency Department.” Curr Emerg Hosp Med Rep 9, 11–18 (2021). https://doi.org/10.1007/s40138-021-00226-9
Shenvi, Christina et al. “Managing Delirium and Agitation in the Older Emergency Department Patient: The ADEPT Tool.” Annals of emergency medicine vol. 75,2 (2020): 136-145. doi:10.1016/j.annemergmed.2019.07.023