DELIRIUM IN HOSPICE

Delirium is defined as an acute state of confusion, characterized by an inability to focus, maintain wakefulness, and/or attention. The presence of delirium leads to an increase in mortality and morbidity, misdiagnoses (particularly for dementia and/or depression), increased length of inpatient stay, and increase in symptom burden – which precipitates an increase in patient’s medication regimen. Therefore, we as a medical community must be more proactive in our recognition and assessments for delirium. Following early recognition, we can continue to follow steps to ensure reorientation, patient safety, and medication adjustments as needed (including removing medications that can contribute to delirium and/or interrupted sleep patterns). Never underestimate the power of non-pharmacologic management as well!

TYPES OF DELIRIUM

1. Hyperactive: restlessness, agitation, hallucinations, sudden change in mood, pacing, and refusal to work with others.
** One of the easiest to identify, as it typically is an abrupt change.
2. Hypoactive: reduced activity, general inactivity, withdrawn, sluggish, in a “daze”.
**Can be easily misdiagnosed or misinterpreted as depression.
3. Mixed: person can quickly switch back and forth.

DELIRIUM VS DEMENTIA

DELIRIUM SCREENING TOOLS:

• Memorial Delirium Assessment Scale (MDAS)
• Confusion Assessment Method (CAM and CAM-ICU)
• Delirium Observation Screening Scale (DOSS)
• Single Question to Identify Delirium (SQiD)

IMPORTANT NOTES REGARDING TREATMENT OF DELIRIUM:

1. Rule out infection – particularly urinary tract infection (UTI) in the older adults2. Disorientation from site/hearing impairmenta. Ensure patient has access to his/her glasses, hearing aids, etc.3. New/recent family dynamics (which can cause an abrupt change in mood and affect secondary to depression/anxiety which can be perceived as delirium).4. Current medications that patient is taking which can contribute to delirium.** PRIOR TO ORDERING NEW MED, RULE OUT THAT ANY CURRENT MEDICATIONS CAN CONTRIBUTE TO DELIRIUM**5. ETOH/opioid withdrawal – which can present as sedation (i.e. inability to focus or pay attention)6. Terminal delirium – Treatment of the underlying cause is impossible, impractical, or not consistent with goals of care.a. Ensure the patient’s safety and treat with haloperidol and/or lorazepam if patient’s safety at risk.7. Unstable sleep hygiene habits.a. Exhaustion can present as delirium..8. Continued re-orientation, especially for those who have recently moved to new facility/room/etc.** PARTICULARLY IN COVID-19 TIMES WHERE PATIENTS AREN’T SEEING FAMILIAR FACES OR BEING REORIENTED REGULARLY.9. DECREASE stimuli and bring familiarity to the patient’s environment.

Jaymie Wilson, MSN, APRN-CNP, ACHPN

Vice President of Operations, PDCRx