The ED's Vital Role in Delirium: Insights for All Nurses with Kevin and Lisa from the How Not to Kill Your Patient Podcast

Up My Nursing Game is partnering with VCU Health Continuing Education to offer FREE continuing education credits for registered nurses. Click here to obtain nursing credit (1.00) or here for detailed instructions.

Claim free CEs | Listen on Apple Podcasts | Listen on Spotify

Defining Delirium

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

Risk Factors

Baseline conditions

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

Precipitating causes

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)

Perpetuating factors

Inadequate pain control
Sleep deprivation or disruption
Malnutrition or dehydration
Medication toxicity or interactions
Urinary retention or fecal impaction
Prolonged immobilization or physical restraints

Assessment

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

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.

It is part of a week-long Nurses' Podcrawl in which nurse podcasters including:

Learn more about NTI, the American Association of Critical Care Nurses (AACN) premiere conference for progressive and critical care nurses on May 22-24, 2023: http://www.aacn.org/nti23

Check out Nicole Kupchik's exam reviews and practice questions at nicolekupchikconsulting.com. Use the promo code UPMYGAME20 to get 20% off all products.

Up My Nursing Game is partnering with VCU Health Continuing Education to offer FREE continuing education credits for registered nurses. Click here to obtain nursing credit.

See the show notes at upmynursinggame.com.