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  in older people  ISBN: 0 642 82988 8, Online ISBN: 0 642 82989 6, Publications Approval Number: 3868,Print Copyright © Commonwealth of Australia 2006, Online Copyright, © Commonwealth of Australia 2006.This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process withoutprior written permission from the Commonwealth. Requests and inquiries concerning reproduction and rights should be addressed to the Com  monwealth Copyright Administration, Attorney General’s Department, Robert Garran Of  fi ces, National Circuit, Barton ACT 2600 or posted athttp://www.ag.gov.au/cca.This work is copyright. You may download, display, print and reproduce this material in unaltered form only (retain  ing this notice) for your personal, noncommercial use or use within your organisation. Apart from any use as permitted under the Copyright Act1968, all other rights are reserved. Requests and inquiries concerning reproduction and rights should be addressed to Commonwealth Copy  right Administration, Attorney General’s Department, Robert Garran Of  fi ces, National Circuit, Barton ACT 2600 or posted at http://www.ag.gov.au/cca. Endorsed by the Royal College of Nursing, Australia. Endorsed by the Australian & New Zealand College of Mental Health Nurses. This booklet is about delirium, a term used todescribe changes to thinking and behaviour thatoccur over a very short time.It needn’t be read from beginning to end. It isdesigned for health professionals and supportworkers who work with older people – to bedipped into when you see someone in care withsudden changes to their thinking or behaviour. ,WLQFOXGHVDJORVVDU\RIOHVVIDPLOLDUWHUPVDQG a reference list for people wishing to investigatedelirium further.The fi rst section provides an overview of delirium, the current issues involved anddescriptions of various presentations.The second and third sections look at issuesin assessment and management, and presentsome tools that might be useful inidentifying delirium.However… this book is intended to provideadvice on care. It should be used in conjunctionwith recent literature and drug information. It isnot intended to replace good clinical judgement. KEY TO USING THIS BOOKLET ABOUT DELIRIUMMANAGING DELIRIUMSCREENING TOOLSTo assist in quickly locating each section,colour coding, as depicted here, has beenused to categorise each page.iPrepared by Author: Stephen HardingProject and Editorial Support by: Lynne Barnes DQG(LPHDU0XLU&RFKUDQH ACKNOWLEDGEMENTSAlzheimer’s Australia; Drug & Therapeutics InformationService (DATIS), Repatriation General Hospital, DawPark (Adelaide), ACH Group; Aged Care Association,Australia; Aged & Community Services, Australia;Australian & New Mental Health Nurses Inc; HammondCareGroup; Royal College of Nursing, Australia forfeedback on the manuscript; and Inprint Design for layoutand design. Staff from Repatriation General Hospital,Daw Park (Adelaide), Cityviews Translational CareUnit (South Australia) and InHome West (communitycare) (South Australia) for feedback and participation infocus groups.  PRÉCIS Delirium – or Acute Confusional State,as it is also known – is a reversible disorderof cognitive function. It is a common healthproblem for older people, with those in hospitalsor residential care at particular risk. De fi ned asan acute disturbance of attention and cognition,it is under recognised by health professionals. 2,38 Research suggests delirium affects up to 56%of older people admitted to hospital. 23,27 The syndrome has not been well studied inresidential care, but what data is availablesuggests a rate at least as high as that foundin acute settings. 12,13,48,49 Delirium can be precipitated by almost anymedical condition or pharmacological treatment(and occasionally, apparently, nothing at all)and may be the only symptom of illness.Delirium can be dif  fi cult to recognise, as it doesnot have a single, clear presentation, a problemfurther compounded by dif  fi culties in identifyingrisks for delirium and a lack of agreement aboutwhat core risk factors are.Levkoff et al. identi fi ed ageing, dementia, VHQVRU\LPSDLUPHQWLOOKHDOWKDQGLQVWLWXWLRQDO care as the most significant risk factors. 33 Inouye and Charpentier have identified thefollowing factors as contributing significantlyto the risk of developing a delirium: use of physical restraints, malnutrition, more thanthree medications, presence of indwellingbladder catheter, and ‘any iatrogenic event’. 25 Sleep deprivation, sensory impairment, existingcognitive impairment, poor hydration/nutritionalstatus and immobility are also seen as risk factors.Although delirium can have a short duration,to describe it as a transient disorder is to ignorethe reality that symptoms may persist formonths. 26,33,52 This can have dire consequencesfor the function and health of the patient. 18,26 It commonly leads to hospitalisation(contributing to extended lengths of stay)and increased morbidity/mortality. 33 It is alsopredictive of physical, functional and cognitivedecline, leading to a decline in independence anda need for a higher level of care. 26,33,42 It is importantthat delirium is recognised early or, better still, if those at risk can be identi fi ed, before it develops.ii  The gradual deterioration in function with increasingage is so widely perceived and so expected that alldecline in an older person tends to be attributed to age.It is illogical to say, cats have four legs, dogs havefour legs, therefore cats are dogs. However, onesees clinicians apparently reasoning along similar OLQHVPDQ\ROGHUSHRSOHDUHFRQIXVHGDQROG person is confused, they must be confused because theyare old.If a person is told by their medical practitioner thattheir kidneys are failing a series of questions willquickly follow: ‘Why have they failed? How long hasthis been going on? What does the future hold? Whatcan you do about the problem? Can you cure things?’Delirium is an acute confusional state of the brain.It is essentially acute ‘brain failure’.Our brains are more important than our kidneys.They cannot be replaced or their function replicatedby an external device. Delirium should be taken as achallenge to a thinking health professional. It requiresanswers as much as failed renal systems do.An adequate history is the fi rst step. The patientcannot supply one. A collateral history must besought from another close observer. The durationof the delirium is the key piece of information.Delirium runs its course over days and weeks;dementia over many months – more usually years.The challenge increases when one notes that deliriumcommonly supervenes in a person with reducedcerebral reserves (e.g. the very old, or those with SUHH[LVWLQJGHPHQWLDRUFKURQLFEUDLQIDLOXUH The clinician then has to know when delirium beginsto overlay previously noted symptoms of dementia.Delirium is essentially a thinking and attention de fi citdisorder. The clinician should note that in delirium,the patient cannot hold to a theme in conversation,even if it is based on old retained memories.The patient is easily distracted by external stimuli RUGLYHUWHGE\WKHLUQRQVHTXHQWLDOWKLQNLQJLQWR rapid changes of idea and theme.A dementia patient, even when advanced in theirdisease, will often give delight to their listener asthey tell of past life events, even though with a fewdistortions of truth. One feels one has made a contact.In delirium, one should appreciate early on that thepatient is as if in the next room, half hearing, half attending. and prone to move on to new themes, oftenwith language that is deranged in structure and form.A clinician can recognise more easily the agitatedrestless victim of delirium. Overlooked – withconsequent risk to life and safety – is the older personwho is quietly delirious, sitting listless and unnoticed.Brain failure or delirium needs the best of health careand diagnostic effort.A delirious patient can exhibit evidence of problemsranging from electrolyte derangements or adverse drugeffects, to occult infection, or less commonlya disorder of the brain itself. There is an old adage thatif a person under statutory old age (say 65) is delirious,the answer more often lies in the brain (e.g. encephalitis,meningitis), while for the older person above 65,the answer lies outside the brain (e.g. infection,biochemical derangement). This book draws on thebest of recent literature, pointing out that outcomescan be improved and delirium prevented by competentand quality nursing of the older potentially deliriouspatient. Drugs are not the routine answer, as they are aforce for both good and evil. They can compromise thecare of the delirious, adding to confusion, and reducingmobility and cooperation with food and fl uid intake.Past generations of gerontic nurses knew thatdehydration and constipation commonly wenttogether in those with dementia. If severe, deliriumwas an anticipated event to complete the triad.I was always impressed with the senior nurse in the ORQJVWD\ZDUGZKRWROGPHWRFKHFNDSDWLHQWLQD certain bed because ‘they were a bit off’. The nursewas telling me in code that they had discovereddelirium and my job was to identify the pneumoniaor the urinary infection, and prescribe the appropriatenew drug.This text allows those working with older peopleto move away from coded conversations and toward DSURSHUDSSURDFKWRWKHOLIHWKUHDWHQLQJIDLOXUHRI a human organ.As the U 6DQWLDJHLVWFDPSDLJQHUDQGDGYRFDWH MaggieKuhn once said ‘The most important organin the human body is wrinkled at birth ... the brain!’ Philip HenschkeGeriatricianAdelaide 2005iii PREFACE  1 USING THIS BOOKLETiAUTHOR/ACKNOWLEDGEMENTSiPRECISiiPREFACEiiiABOUT DELIRIUMIntroduction2Diagnosis2Prevention3Gathering information 3Risk factors3Summary of Risk factors4Drugs4Acute change in M[ental] S[tate]4Presenting features5Speci fi c presenting features5Hypoactive6Hyperactive6Mixed hypoactive/hyperactive6Subsyndromal delirium7Sundowning7MANAGING DELIRIUMIntroduction8Assessment8Cognitive screening8The Clock Drawing Test9Other cognitive screening tools9Assessment of ‘confusion’9Other ‘confusion’ screening tools9Differentiating delirium, 10depression and dementiaOverview of management11Drug treatment11Algorithm... Is it delirium?12Physical care for existing delirium13Interpersonal issues13Managing the symptoms13Aggressive behaviour16Working with families or16signi fi cant othersEnd of life issues16Conclusion17SCREENINGTOOLSThe Clock Drawing Test18The Heidelberg Cognitive Screen19Confusion Assessment 21Method Instrument (CAM)The Vision and Hearing Test22Glossary23References24 CONTENTS
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