Delirium: recognizing the acute change
8 questions on this concept, from 4 angles.
The idea in full
Delirium is an acute disturbance of attention and awareness that develops over hours to days, fluctuates through the day and is always the symptom of an underlying physical cause — infection, hypoxia, dehydration, pain, urinary retention or constipation, a medication started, stopped or accumulating, alcohol or sedative withdrawal, a metabolic derangement, or sensory deprivation and lost sleep — so the nurse who knows the patient's baseline recognises the change from it, including the quiet hypoactive form of withdrawal, slowed responses and reduced movement that is mistaken for tiredness, depression or dementia, tells it apart from dementia by its abrupt onset, fluctuation and inattention and from depression by the clouding of consciousness and the disturbed perception, confirms it with a validated screening tool and reports it as a new problem, and then joins the search for the cause and removes what can be removed while keeping the patient safe, oriented, hydrated, mobile, in their glasses and hearing aids and asleep at night, with an antipsychotic reserved for the distressed patient who is a danger to themselves or others after non-drug measures have failed and never used in place of finding the cause.
Beliefs this concept corrects
- 1A confused older patient has dementia, and a confused patient who already has dementia is just being demented
- 2A quiet, withdrawn, drowsy patient who causes no trouble is tired or low in mood, not delirious
- 3A patient who is lucid and oriented this morning has recovered from last night's confusion and needs no follow-up
- 4Agitation is a behaviour problem to be settled with a sedative or a restraint before anything else is looked for
- 5Once delirium is named the assessment is finished, because the confusion is the diagnosis
- 6A relative saying the patient is not their usual self counts for less than the nurse's own orientation questions
- 7A patient who answers the orientation questions correctly cannot be delirious
- 8A benzodiazepine is the safest way to calm a confused older patient
- 9An antipsychotic treats the delirium itself, so it is started as soon as delirium is recognised
- 10The glasses, the hearing aids, the clock and the daylight are comfort measures that can wait until the patient is less confused
- 11New hallucinations mean a psychiatric illness has surfaced and a psychiatric referral is the first call
- 12Confusion that comes on at night is normal sundowning in an older patient and needs no report
Your record
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