Mental Health Practice Guidelines
The below guidelines are meant for mental health professionals to use in their clinical practices. Please be aware that there are various authoring organizations. The NGC has summarized these guidelines. Links are provided to the original source within the guideline documents.
Guideline Title
Delirium: strategies for assessing and treating.
Bibliographic Source(s)
Foreman MD, Mion LC, Trygstad L, Fletcher K. Delirium: strategies for assessing and treating. In: Mezey M, Fulmer T, Abraham I, Zwicker DA, editor(s). Geriatric nursing protocols for best practice. 2nd ed. New York (NY): Springer Publishing Company, Inc.; 2003. p. 116-40. [20 references]
Guideline Status
This is the current release of the guideline.
Disease/Condition(s)
Delirium
Guideline Category
EvaluationManagementPreventionRisk AssessmentTreatment
Clinical Specialty
GeriatricsNursing
Intended Users
Advanced Practice NursesAllied Health PersonnelHealth Care ProvidersNursesPhysician AssistantsPhysiciansSocial Workers
Guideline Objective(s)
To guide nursing care of individuals at risk of or experiencing delirium To list the most common causes of delirium To describe characteristics of the etiologic basis of delirium To identify patients at risk for an episode of delirium To provide a plan of care for a delirious patient
Target Population
Hospitalized older adults
Interventions and Practices Considered
Evaluation/Risk Assessment/Prognosis Direct questioning Family/caregiver regarding pre-morbid cognitive functioning Patient regarding changes in thinking/memory Assessment for features of delirium including alertness, attention, orientation, memory, thinking, perception, and psychomotor behavior through: Observation of behavior Naturally occurring conversation including questioning about recent and remote events, recognition of objects and persons Formal testing, including: Digit span, forward and backward Serial subtraction Spelling backwards Clock Drawing Test Review of current laboratory values and medications and monitoring of vital signs and fluid intake and output to identify potential etiologic factors Prevention Administer medications judiciously Prevent infection Maintain fluid volume Promote electrolyte balance Encourage early mobilization Provide cognitively stimulating activities Treatment/Management Treat underlying pathology and contributing factors Provide therapeutic environment, including appropriate stimulation, reassurance and reorientation, consistent caregivers, family visits, appropriate sensory aids, and minimal relocation Provide general supportive nursing care, including comfort measures, early mobilization, meeting of basic needs (e.g., toileting, feeding, hydration, pain management), clear communication, reassurance and patient/family education, and minimal invasive interventions Provide care interventions by etiology, including: Medication Review, evaluate, and monitor effects of medication use Provide analgesic and alternative nonpharmacologic therapies as indicated Infection Provide adequate fluids and monitor intake and output Use cooling techniques as needed Monitor for flushed hot skin, tachycardia, seizures, changes in body temperature, and breath sounds For respiratory infections, provide humidified air, cough, and deep breathing as indicated; provide frequent oral hygiene; use chest physiotherapy to mobilize secretions Dehydration Check medications Check ability to swallow or for mechanical problems preventing fluid intake Determine a fluid schedule Use fluid replacement and additional diagnostic and therapeutic actions as indicated Hypernatremia (>146 mEq/L) Use fluid replacement as indicated Restrict activity Hyponatremia (<136 mEq/L) Use electrolyte and fluid replacement as indicated Restrict activity Hypokalemia (<3.5 mEq/L) Use electrolyte and fluid replacement as indicated Hypoxia Use patient positioning (e.g., high Fowler's position), as tolerated Restrict/pace activity Monitor blood gas results/pulse oximetry Administer oxygen as indicated Environmental Change Provide patient education and daily orientation: clock, watch, calendar, radio, television, newspapers, and personal items from home Use patient positioning (e.g., semi-Fowler's position), as tolerated Limit relocations, unnecessary stimuli Provide continuity of staff Sensory Impairment Provide appropriate sensory aids (e.g., eyeglasses or hearing aids) Eliminate distractions (auditory and visual) Facilitate communication (e.g., use clear and simple directions, face patient, and speak into "best" ear) Provide written materials with large print with lighter colored objects on darker backgrounds Inactivity/Immobility Begin early mobilization Make minimal use of immobilizing equipment (e.g., indwelling urinary catheter) Avoid use of physical restraints Cognitive Impairment Offer daily orientation and cognitively stimulating activities Refer to appropriate advanced practitioners (e.g., geriatric resource nurse, geriatric/gerontological or psychiatric clinical nurse specialist or nurse practitioner, or consultation-liaison service) as indicated Document in hospital record
Major Outcomes Considered
Incidence, duration, severity, and recurrence of delirium Length of hospital stay Morbidity and mortality associated with delirium Overall costs
Methods Used to Collect/Select Evidence
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
Medline, Ovid, CINAHL and Ancestry were the databases used.
Number of Source Documents
147
Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Rating Scheme for the Strength of the Evidence
Not applicable
Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence
Not applicable
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
External Peer ReviewInternal Peer Review
Description of Method of Guideline Validation
Not stated
Major Recommendations
Assessment Obtain baseline or pre-morbid cognitive functioning from family, significant other(s), or another intimate source. Ask patients the following questions when assessing cognitive functioning: Have you noticed any changes in your thinking or memory recently? Recently, have you experienced any strange thoughts? Affirmative responses should arouse suspicion of the risk for delirium. To detect and diagnose delirium, see below and refer to Table 8.2 in the original guideline document: Alertness Level of consciousness: observation of behavior and naturally occurring conversation alert (normal) vigilant (hyperalert) lethargic (drowsy but easily aroused) stupor (difficult to arouse) coma (unarousable) Attention Ability to attend/concentrate: through naturally occurring conversation, observation of behavior, or formal testing using: Digit span, forward and backward Serial subtraction Spelling backwards Clock Drawing Test (Ben-Yehuda et al., 1995; Juby, 1999; Kirby et al., 2001) Orientation Questioning about orientation to person, place, and time: through naturally occurring observation or formal testing Memory Questioning about recent and remote events; day-to-day observation; Clock Drawing Test Thinking Naturally occurring conversation Perception Recognition of objects and persons; Clock Drawing Test Psychomotor Behavior Observation of behavior: hypo- or hyperkinetic unusual or inappropriate day-to-day interaction Review current laboratory values and medications, and monitor vital signs and fluid intake and output, to identify the following potential etiologic factors: acute illness, infection (e.g., upper respiratory infection, urinary tract infection), medication (e.g., anticholinergic, sedatives, psychotropics, narcotics, H2 blockers), altered homeostasis (e.g., dehydration and electrolyte imbalance), hemodynamic status (e.g., hypovolemia, hypoxia), and environmental change (sensory overload or deprivation). Care Strategies Treat the underlying pathology and contributing factors. Administer medications judiciously. Prevent/promptly and appropriately treat infections. Maintain fluid balance. Promote electrolyte balance. Provide a therapeutic environment Provide appropriate sensory stimulation. Reassure and reorient patient. Maintain consistency of caregivers. Encourage family members or familiar people to be at patient's bedside. Use sensory aids as appropriate. Minimize abrupt relocations. Provide general supportive nursing care Provide comfort measures. Protect from hazards of immobility and mobilization. Provide supportive nursing care for the meeting of basic needs (e.g., toileting, feeding, hydration, and pain management). Communicate clearly; provide explanations. Reassure and educate family. Minimize invasive interventions. Refer to appropriate advanced practitioners (e.g., geriatric resource nurse, geriatric/gerontological or psychiatric clinical nurse specialist or nurse practitioner, or consultation-liaison service). Nursing Care Strategies (By Etiology) See below and refer to Table 8.1 in the original guideline document. Medications Review medications with special attention to the following: Anticholinergic preparations Thioridazine Amitriptyline Neuroleptics Tricyclic antidepressants Atropine Theophylline Diphenhydramine Histamine-2 blocking agents Cimetidine Ranitidine Analgesics Meperidine Nonsteroidal anti-inflammatory agents Opiates Sedative-hypnotics Zolpidem Benzodiazepines Cardiovascular drugs Nifedipine Quinidine Disopyramide Amiodarone Beta blockers Corticosteroids Anti-Parkinsonian agents Nursing Actions: Monitor the effects (intended and adverse) of medications. Be especially vigilant for drug interactions. With the onset of any new symptom, first consider it an adverse reaction to a medication (refer to medication protocol in this text). Regularly evaluate each medication; use only those medications indicated by the patient's status, thereby keeping medication to a minimum. Monitor for adverse effects, drug-drug, drug-disease, and drug-nutrient interactions, as well as additive effects of drugs (e.g., more than one with anticholinergic effects). Relieve pain through adequate and appropriate administration of analgesia and alternative nonpharmacologic therapies (see pain management protocol in this text). Avoid the use of meperidine. Use nonpharmacologic sleep enhancing protocols (see sleep protocol in this text). Refer to/notify appropriate advanced practice nurse or house officer and/or pharmacologist for medication review and work-up for underlying cause. Document actions and patient's response in hospital record. Infection (e.g., urinary tract, respiratory, and cellulitis [most common]; mouth, feet [most overlooked]) Nursing Actions: Determine source and site of infection. Provide adequate fluids (2000 ml per day) unless otherwise contraindicated. Apply cooling techniques as needed and indicated (e.g., remove covers or use cooling mattress/blanket). Monitor for flushed hot skin, tachypnea, tachycardia, seizures, changes in body temperature, and breath sounds every 2 hours or as indicted by status of the patient. Monitor intake and output. For respiratory infections provide humidified air, cough and deep breath as indicated; provide frequent oral hygiene; beta agonist via nebulizer; chest physiotherapy to mobilize secretions. Administer oxygen as indicated. Refer to/notify appropriate advanced practice nurse or house officer for further evaluation for underlying medical problem. Document actions and patient response in hospital record. Dehydration Nursing Actions: Determine source of dehydration (e.g., decreased fluid intake or increased fluid output). Check medications as a cause for increased loss of fluids (e.g., diuretics). Check person's ability to swallow or for mechanical problems preventing fluid intake. Determine individual's daily fluid needs (Gaspar, 1998), and develop a fluid schedule (Weinberg et al., 1995). Make sure water is in easy reach of the individual. Determine if individual can independently meet fluid needs; if not, place on a fluid schedule. Refer to/notify appropriate advanced practice nurse or house officer. Prepare for fluid replacement and additional diagnostic and therapeutic actions. Continue surveillance of patient every 2 to 6 hours as indicated by patient status. Document actions and patient's response in hospital record. Hypernatremia (>146 mEq/L) Nursing Actions: Determine source of hypernatremia (e.g., increased water loss [fever, infection, vomiting, diarrhea, diaphoresis], decreased water intake [physical or cognitive limitations], or increased sodium intake). Evaluate for possible medication causes, e.g., osmotic cathartic (Lactulose). Prepare for possible fluid replacement. Restrict activity to maintain energy balance. Continue to monitor parameters every 2 hours or as indicated by status of patient. Refer to/notify appropriate advanced practice nurse or house officer. Document actions and patient's response in hospital record. Hyponatremia (<136 mEq/L) Nursing Actions: Determine source of hyponatremia (e.g., inadequate intake of sodium, renal disease, extrarenal fluid loss [e.g., vomiting, diarrhea, fluid restriction, overdiuresis, low-sodium tube feedings). Prepare for electrolyte and possible fluid replacement. Restrict activity to maintain energy balance. Continue to monitor parameters every 2 hours or as indicated by status of patient. Drug-disease interaction, oral hypoglycemics, diuretics, antipsychotics, SSRIs (selective serotonin reuptake inhibitor) may potentiate sodium loss further. Refer to/notify appropriate advanced practice nurse or house officer. Document actions and patient's response in hospital record. Hypokalemia (<3.5 mEq/L) Nursing Actions: Determine source of hypokalemia (e.g., poor nutritional intake of potassium-rich foods or excessive depletion; nausea, vomiting, and diarrhea; or excessive loss due to the effects of medications such as non-potassium-sparing diuretics). Refer to/notify appropriate advanced practice nurse or house officer. Prepare for electrolyte and possible fluid replacement. Document actions and patient's response in hospital record. Note drug-disease interaction: if also on digoxin, monitor for digoxin toxicity. Hypoxia Nursing Actions: Determine source of hypoxia (e.g., infection, chronic obstructive pulmonary disease [COPD], pulmonary embolism [PE], bronchospasm, anemia). Position patient to facilitate air exchange (e.g., high Fowler's position, as tolerated by patient). Restrict/pace activity to reduce additional oxygen requirements. Monitor blood gas results or pulse oximetry. Refer to/notify appropriate advanced practice nurse or house officer. Continue to monitor parameters every 2 hours or as indicated by status of patient. Prepare for oxygen administration; use long tubing to maintain mobilization. Document actions and patient response in hospital record. Environmental Change (e.g., sensory overload or sensory deprivation) Nursing Actions: Provide explanations of nursing care and all diagnostic and therapeutic activities. Position patient in a semi-Fowler's position as tolerated Minimize abrupt relocations; otherwise, prepare patient by providing explanations of the event; send a health care provider or family member to accompany patient. Offer orienting information as a normal part of daily care and activities. Provide orienting stimuli: clock, watch, calendar, radio, television, and newspapers. Include personal items from home. Encourage social interaction with friends and family. Maintain continuity of care and care environment; limit relocations. Limit the number of staff involved in the care of the patient. Remove meaningless and unnecessary stimuli as soon as possible (e.g., unneeded equipment and supplies, television off when not desired, etc.). Communicate clearly and simply (Rapp et al., 2001). Refer to/notify appropriate advanced practice nurse or house officer. Document actions and patient's response in hospital record. Sensory Impairment Nursing Actions: Assist patient in accurately interpreting environmental stimuli by having patient use appropriate sensory aids (e.g., eyeglasses or hearing aids). Also, ensure that aids are in proper working condition. Eliminate sources of distraction (auditory and visual). Determine source of impairment (e.g., malfunctioning aids or aids not in use, earwax impaction). Speak clearly and slowly; do not shout; repeat key phrases as necessary. Speak directly into the patient's "best" ear. Face the patient when speaking so that lip reading can be used to facilitate understanding as necessary. With written materials, use large print with lighter colored objects on darker backgrounds; place them directly in front of the patient, and use indirect lighting to reduce/eliminate glare. Refer to/notify appropriate advanced practice nurse or house officer. Document actions and patient's response in hospital record. Inactivity/Immobility Nursing Actions: Begin early mobilization, ambulation, or active range-of-motion exercises three times a day as tolerated. Make minimal use of immobilizing equipment (e.g., indwelling urinary catheter). Avoid use of physical restraints. Refer to/notify appropriate advanced practice nurse or house officer. Document actions and patient's response in hospital record. Cognitive Impairment Nursing Actions: Offer orienting information as a normal part of daily care and activities. Work with patient to correctly interpret the environment. Incorporate cognitively stimulating activities as normal part of daily care (e.g., discussion of current events, structured reminiscence, reality orientation, etc.). Refer to/notify appropriate advanced practice nurse or house officer. Document actions and patient's response in hospital record. Follow-up to Monitor Condition Usage of physical and pharmacologic restraints and sitters; usage to decrease The incidence, duration, and severity of delirium to decrease Patient's days with delirium to decrease Staff competence in recognition and treatment of delirium Documentation of the prompt recognition of delirium Documentation of a variety of interventions for delirium
Clinical Algorithm(s)
None provided
References Supporting the Recommendations
Ben-Yehuda A, Bentur N, Friedman G. The clock drawing test as a cognitive screening tool for elderly patients in an acute-care hospital. Aging (Milano) 1995 Jun;7(3):188-90. PubMedGaspar PM. Comparison of four standards used to determine adequacy of water intake among nursing home residents. In: 1998 Midwest Nursing Research Society conference.1998. Juby A. Correlation between the Folstein Mini-Mental State Examination and three methods of clock drawing scoring. J Geriatr Psychiatry Neurol 1999 Summer;12(2):87-91. PubMedKirby M, Denihan A, Bruce I, Coakley D, Lawlor BA. The clock drawing test in primary care: sensitivity in dementia detection and specificity against normal and depressed elderly. Int J Geriatr Psychiatry 2001 Oct;16(10):935-40. PubMedRapp CG, Mentes JC, Titler MG. Acute confusion/delirium protocol. J Gerontol Nurs 2001 Apr;27(4):21-33. PubMedWeinberg AD, Minaker KL. Dehydration. Evaluation and management in older adults. Council on Scientific Affairs, American Medical Association. JAMA 1995 Nov 15;274(19):1552-6. PubMed
Type of Evidence supporting the Recommendations
The type of supporting evidence is not specifically stated for each recommendation.
Potential Benefits
Patient Will Demonstrate: Improved outcomes of care (e.g., a lowered incidence, duration, severity, and recurrence of delirium; increased functional independence; and decreased mortality) Cognitive status returned to baseline (pre-delirious state) Discharge to same destination as pre-hospitalization Health Care Provider Will Demonstrate: Increased detection of delirium Prompt implementation of appropriate interventions for delirium Improved satisfaction in care of hospitalized elderly Institution Will Demonstrate: Decreased overall cost Decreased length of stays Decreased morbidity and mortality Increased referrals and consultation to above specified specialists Increased provision of quality care
Potential Harms
Not stated
Qualifying Statements
This practice protocol is a general approach to assessing and treating delirium that must be adapted to the specific of the health care setting (e.g., acute care, home care, or long-term care).
Description of Implementation Strategy
An implementation strategy was not provided.
IOM Care Need
Getting BetterStaying Healthy
IOM Domain
Effectiveness
Bibliographic Source(s)
Foreman MD, Mion LC, Trygstad L, Fletcher K. Delirium: strategies for assessing and treating. In: Mezey M, Fulmer T, Abraham I, Zwicker DA, editor(s). Geriatric nursing protocols for best practice. 2nd ed. New York (NY): Springer Publishing Company, Inc.; 2003. p. 116-40. [20 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Date Released
2003
Guideline Developer(s)
The John A. Hartford Foundation Institute for Geriatric Nursing - Academic Institution
Guideline Developer Comment
The guidelines were developed by a group of nursing experts from across the country as part of the Nurses Improving Care for Health System Elders (NICHE) project, under sponsorship of The John A. Hartford Foundation Institute for Geriatric Nursing.
Source(s) of Funding
Supported by a grant from The John A. Hartford Foundation.
Guideline Committee
Not stated
Composition of Group that Authored the Guideline
Primary Authors: Marquis D. Foreman, PhD, RN, FAAN; Lorraine C. Mion, PhD, RN; Lark Trygstad, MA, ARNP-c; Kathleen Fletcher, RN, C., MSN, GNP
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
Guideline Availability
Copies of the book Geriatric Nursing Protocols for Best Practice, 2nd edition: Available from Springer Publishing Company, 536 Broadway, New York, NY 10012; Phone: (212) 431-4370; Fax: (212) 941-7842; Web: www.springerpub.com.
Availability of Companion Documents
None available
Patient Resources
None available
NGC STATUS
This summary was completed by ECRI on February 2, 2004. The information was verified by the guideline developer on March 15, 2004.
COPYRIGHT STATEMENT
This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.
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