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 without
prior written permission from the Commonwealth. Requests and inquiries concerning reproduction and rights should be addressed to the Com-
monwealth Copyright Administration, Attorney Generals Department, Robert Garran Ofces, National Circuit, Barton ACT 2600 or posted at
http://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 Act
1968, all other rights are reserved. Requests and inquiries concerning reproduction and rights should be addressed to Commonwealth Copy-
right Administration, Attorney Generals Department, Robert Garran Ofces, 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 to
describe changes to thinking and behaviour that
occur over a very short time.
It neednt be read from beginning to end. It is
designed for health professionals and support
workers who work with older people to be
dipped into when you see someone in care with
sudden changes to their thinking or behaviour.
It includes a glossary of less-familiar terms and
a reference list for people wishing to investigate
delirium further.
The rst section provides an overview of
delirium, the current issues involved and
descriptions of various presentations.
The second and third sections look at issues
in assessment and management, and present
some tools that might be useful in
identifying delirium.
However this book is intended to provide
advice on care. It should be used in conjunction
with recent literature and drug information. It is
not intended to replace good clinical judgement.
KEY TO USING THIS BOOKLET
ABOUT DELIRIUM
MANAGING DELIRIUM
SCREENING TOOLS
To assist in quickly locating each section,
colour coding, as depicted here, has been
used to categorise each page.
i
Prepared by Author: Stephen Harding
Project and Editorial Support by: Lynne Barnes
and Eimear Muir-Cochrane.
ACKNOWLEDGEMENTS
Alzheimers Australia; Drug & Therapeutics Information
Service (DATIS), Repatriation General Hospital, Daw
Park (Adelaide), ACH Group; Aged Care Association,
Australia; Aged & Community Services, Australia;
Australian & New Mental Health Nurses Inc; Hammond
Care Group; Royal College of Nursing, Australia for
feedback on the manuscript; and Inprint Design for layout
and design. Staff from Repatriation General Hospital,
Daw Park (Adelaide), Cityviews Translational Care
Unit (South Australia) and InHome West (community
care) (South Australia) for feedback and participation in
focus groups.
PRCIS
Delirium or Acute Confusional State,
as it is also known is a reversible disorder
of cognitive function. It is a common health
problem for older people, with those in hospitals
or residential care at particular risk. Dened as
an 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 in
residential care, but what data is available
suggests a rate at least as high as that found
in acute settings.
12,13,48,49
Delirium can be precipitated by almost any
medical condition or pharmacological treatment
(and occasionally, apparently, nothing at all)
and may be the only symptom of illness.
Delirium can be difcult to recognise, as it does
not have a single, clear presentation, a problem
further compounded by difculties in identifying
risks for delirium and a lack of agreement about
what core risk factors are.
Levkoff et al. identied ageing, dementia,
sensory impairment, ill-health and institutional
care as the most significant risk factors.
33
Inouye and Charpentier have identified the
following factors as contributing significantly
to the risk of developing a delirium: use of
physical restraints, malnutrition, more than
three medications, presence of indwelling
bladder catheter, and any iatrogenic event.
25
Sleep deprivation, sensory impairment, existing
cognitive impairment, poor hydration/nutritional
status and immobility are also seen as risk factors.
Although delirium can have a short duration,
to describe it as a transient disorder is to ignore
the reality that symptoms may persist for
months.
26,33,52
This can have dire consequences
for 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 also
predictive of physical, functional and cognitive
decline, leading to a decline in independence and
a need for a higher level of care.
26,33,42
It is important
that delirium is recognised early or, better still, if
those at risk can be identied, before it develops.
ii
The gradual deterioration in function with increasing
age is so widely perceived and so expected that all
decline in an older person tends to be attributed to age.
It is illogical to say, cats have four legs, dogs have
four legs, therefore cats are dogs. However, one
sees clinicians apparently reasoning along similar
lines - many older people are confused, an old
person is confused, they must be confused because they
are old.
If a person is told by their medical practitioner that
their kidneys are failing a series of questions will
quickly follow: Why have they failed? How long has
this been going on? What does the future hold? What
can 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 replicated
by an external device. Delirium should be taken as a
challenge to a thinking health professional. It requires
answers as much as failed renal systems do.
An adequate history is the rst step. The patient
cannot supply one. A collateral history must be
sought from another close observer. The duration
of 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 delirium
commonly supervenes in a person with reduced
cerebral reserves (e.g. the very old, or those with
pre-existing dementia or chronic brain failure).
The clinician then has to know when delirium begins
to overlay previously noted symptoms of dementia.
Delirium is essentially a thinking and attention decit
disorder. 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
or diverted by their non-sequential thinking into
rapid changes of idea and theme.
A dementia patient, even when advanced in their
disease, will often give delight to their listener as
they tell of past life events, even though with a few
distortions of truth. One feels one has made a contact.
In delirium, one should appreciate early on that the
patient is as if in the next room, half hearing, half
attending. and prone to move on to new themes, often
with language that is deranged in structure and form.
A clinician can recognise more easily the agitated
restless victim of delirium. Overlooked with
consequent risk to life and safety is the older person
who is quietly delirious, sitting listless and unnoticed.
Brain failure or delirium needs the best of health care
and diagnostic effort.
A delirious patient can exhibit evidence of problems
ranging from electrolyte derangements or adverse drug
effects, to occult infection, or less commonly
a disorder of the brain itself. There is an old adage that
if 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 the
best of recent literature, pointing out that outcomes
can be improved and delirium prevented by competent
and quality nursing of the older potentially delirious
patient. Drugs are not the routine answer, as they are a
force for both good and evil. They can compromise the
care of the delirious, adding to confusion, and reducing
mobility and cooperation with food and uid intake.
Past generations of gerontic nurses knew that
dehydration and constipation commonly went
together in those with dementia. If severe, delirium
was an anticipated event to complete the triad.
I was always impressed with the senior nurse in the
long-stay ward who told me to check a patient in a
certain bed because they were a bit off. The nurse
was telling me in code that they had discovered
delirium and my job was to identify the pneumonia
or the urinary infection, and prescribe the appropriate
new drug.
This text allows those working with older people
to move away from coded conversations and toward
a proper approach to the life-threatening failure of
a human organ.
As the US anti-ageist campaigner and advocate
Maggie Kuhn once said The most important organ
in the human body is wrinkled at birth ... the brain!
Philip Henschke
Geriatrician
Adelaide 2005
iii
PREFACE
1
USING THIS BOOKLET i
AUTHOR/ACKNOWLEDGEMENTS i
PRECIS ii
PREFACE iii
ABOUT DELIRIUM
Introduction 2
Diagnosis 2
Prevention 3
Gathering information 3
Risk factors 3
Summary of Risk factors 4
Drugs 4
Acute change in M[ental] S[tate] 4
Presenting features 5
Specic presenting features 5
Hypoactive 6
Hyperactive 6
Mixed hypoactive/hyperactive 6
Subsyndromal delirium 7
Sundowning 7
MANAGING DELIRIUM
Introduction 8
Assessment 8
Cognitive screening 8
The Clock Drawing Test 9
Other cognitive screening tools 9
Assessment of confusion 9
Other confusion screening tools 9
Differentiating delirium, 10
depression and dementia
Overview of management 11
Drug treatment 11
Algorithm... Is it delirium? 12
Physical care for existing delirium 13
Interpersonal issues 13
Managing the symptoms 13
Aggressive behaviour 16
Working with families or 16
signicant others
End of life issues 16
Conclusion 17
SCREENING TOOLS
The Clock Drawing Test 18
The Heidelberg Cognitive Screen 19
Confusion Assessment 21
Method Instrument (CAM)
The Vision and Hearing Test 22
Glossary 23
References 24
CONTENTS
ABOUT DELIRIUM
INTRODUCTION
Delirium is a clinical syndrome, rather than
a disorder or disease in itself, and is frequently
confused with other conditions. It describes a
set of symptoms that impair cognitive and
physical function and can lead to severe illness
and possibly death.
Delirium is an acute medical condition, and
should be treated as a medical emergency.
40,59
Prompt identication is important, as delirium
may be the only indicator of the presence of
a physical disorder.
47
Delirium rarely has a single cause. All potential
causes should be investigated and risk factors
addressed as part of appropriate management.
It is however, often poorly recognised, and even
when symptoms are recognised they are often
misidentied and mistreated.
This section looks at the dynamics of delirium
and the need for careful investigation and
data gathering to accurately identify this
clinical syndrome.
Possible precipitants of delirium in older
people include:
disease
metabolic disorder
carcinoma
infection
neurological disorder
inammation
pain
dehydration (and constipation)
malnutrition
urinary retention
sensory impairment
drug effects (and interactions)
drug/alcohol withdrawal syndromes.
DIAGNOSIS
In the Diagnostic and Statistical Manual
of Mental Disorders (DSM)1 the American
Psychiatric Association identifies three main
criteria for the diagnosis of delirium:
1. rapid onset of symptoms and/or
uctuating sensorium
2. impairment of attention
3. change in cognitive function/development
of perceptual disturbance.
Disorientation to time and place, and disturbance
of the sleep/wake cycle are also common features.
1
The presence of cognitive impairment means
the likelihood of a diagnosis of dementia being
made is high.
47
The lack of obvious signicant physical illness
in the face of apparent mental symptoms often
leads clinicians to assume a diagnosis of a
psychiatric disorder.
47,59
The presence of perceptual
disturbance can lead to an incorrect diagnosis
of psychosis, the treatment of which will likely
exacerbate the delirium.
47,59
Equally, a somnolent or withdrawn presentation
may lead to diagnosis of, and treatment for,
depression. The resultant administration of
antidepressants with anticholinergic effects can
also exacerbate the delirium.
47,59
The uctuating nature of delirium, combined with
cognitive decline and hallucinations, are suggestive
of Lewy-Body Dementia.
39
In addition to the
cognitive features of a dementia, patients with
Lewy-Body Dementia often suffer Parkinsonian
features (particularly rigidity) visual
hallucinations, delusions and frequent unexplained
falls are common. Changes in behaviour, alertness,
and cognitive function can occur. These changes
can be quite dramatic and include attentional
defcits that may make Lewy-Body Dementia
difcult to differentiate from delirium.
2
ABOUT DELIRIUM
However, with most dementias the history will
usually show a progressive decline over many
months and years, rather than the more acute
onset seen in delirium.
39
Delirium and dementia are not mutually
exclusive, although it may be that the severity
of cognitive impairment increases the risk of
delirium.
56
Equally, it is likely that symptoms
of delirium will be missed or dismissed because
of the presence of dementia.
This is not unreasonable, as dementia can
produce similar symptoms (e.g. cognitive
decline, fluctuating behaviour).
Therefore, the existence of dementia
should alert clinicians to the possibility
of a delirium occurring.
PREVENTION
Primary prevention represents the most
effective strategy for dealing with delirium.
Work by Inouye, Bogardus, Charpentier et al.
suggests that identifying those at risk before
they develop a delirium reduces the chance
of a delirium developing, and may reduce
the severity of a delirium should it occur
(particularly for those with a moderate risk).
24
Marcantonio, Flacker, Wright et al. suggest that
it is possible to not only reduce risk but also to
reduce the incidence and severity of delirium by
focussed interventions that address risk factors.
41
Mentes, looking at high care residential care
populations, developed a nursing protocol
focussing on the presence of risk factors,
in order to reduce the incidence of
delirium occurring.
GATHERING INFORMATION
Delirium is recognised as an acute change in
a persons cognitive function, often accompanied
by changes in behaviour. Rather than arising
from a single cause, delirium often results from
a number of contributing factors.
Identication of delirium is possible by drawing
on information obtained from a history of recent
changes in the health of a person and their
circumstances. It is appropriate to assume
delirium may be the cause of cognitive impairment,
and to consider alternatives once it is excluded.
21
If cognitive impairment is excluded, depression
should be considered a possible cause and
investigated, before considering dementia.
21
It is extremely important to gather a complete
and accurate history, with corroboration from
carers, to establish the onset and a recent history
of symptoms including effects on memory,
behaviour, speech and function (including
activities of daily living ADLs).
Information gathered should include details
about recent eating habits, management of
medications, a list of current medications from
all sources, and any other pertinent information.
Primary care practitioners may order blood and
urine tests to rule out physical illness (e.g. CUE,
FBE, LFT, TFT, ESR, B12 and folate) and a
chest X-ray, and from the results plan
appropriate management.
RISK FACTORS
Inouye and Charpentier have identified the
following risk factors for delirium: use of
physical restraints, malnutrition, more than
three drugs added in 24 hours, use of urinary
catheter, iatrogenic events, cognitive impairment,
sleep deprivation, immobility, visual and hearing
impairment, and dehydration.
24,25
Major risk factors identied by others include
ageing, sensory impairment, ill-health and
institutional care.
33
3
ABOUT DELIRIUM
SUMMARY OF RISK FACTORS:
25,33
large number of medications
drug and alcohol use/misuse
or withdrawal
dehydration and poor nutrition
hepatic or renal dysfunction
electrolyte disturbance
sensory impairment
sleep deprivation
existing cognitive impairment /
brain damage
pain
respiratory/cardiovascular disease
infection
immobility.
DRUGS
The drugs most commonly associated with
the precipitation of delirium are psychotropics
and opioids, but they are by no means the only
groups of related drugs.
Any drug can precipitate a delirium, as the
prescribing information of pharmacological
agents indicates. Adverse effects are more
common when new drugs are added to a
regimen, and/or with higher doses, but can
also occur with therapeutic doses at any time
during therapy.
It is wise to consider legal and illegal drugs,
as well as prescribed and over-the-counter
agents, including herbal or complementary,
as potential causes. The mnemonic proposed
by Flaherty suggests almost all groups:
17
ACUTE CHANGE IN M[ENTAL] S[TATE]
Antiparkinsonian drugs
Cardiovascular drugs
Urinary incontinence drugs
Theophylline
Emptying (motility) drugs
Corticosteroids
H2 blockers
Antimicrobials
Narcotics
Geropsychiatry drugs
ENT drugs
Insomnia drugs
NSAIDS (including COX-2s)
Muscle relaxants
Seizure drugs
Geropsychiatry drugs include all psychotropics:
major tranquillisers (e.g. haloperidol,
pericyazine) including the newer atypicals
(e.g. olanzapine and risperidone)
minor tranquillisers and sedatives
(e.g. diazepam, clonazepam, nitrazepam); and
antidepressants (e.g. amitriptyline, imipramine,
uoxetine, paroxetine).
Other psychotropics include lithium and the
Seizure drugs (antiepileptics) which are used
as mood stabilisers. This group, including agents
such as carbamazepine and sodium valproate,
are increasingly used in the management of
behavioural problems associated with dementia.
Psychotropics are commonly used in the
management of delirium, but often cause or
contribute to the delirium, so should be used
with care.
Of the other groups, Urinary incontinence
drugs include ditropan and propantheline,
while the Emptying drugs include cisapride
and metoclopramide. Theophylline is now
little used, but other respiratory drugs
(e.g. ipratropium because of anticholinergic
effects) and cortico-steroids are recognised
precipitants of delirium.
The Australian Medicines Handbook Drug
Choice Companion: Aged Care should be a
4
ABOUT DELIRIUM
standard reference for people working with
older adults, used in conjunction with more
comprehensive information provided in the
Australian Medicines Handbook. The Aged
Care drug choice companion includes
a summary of delirium and the drugs that
might be implicated, as well as a list of drugs
with signicant anticholinergic effects (p186).
PRESENTING FEATURES
The clinical picture in a developing delirium is
often characterised by symptoms and behaviours
not previously exhibited by a person, including:
28
social withdrawal
restlessness
anxiety (or an increase in anxiety)
irritability
insomnia
nightmares.
Identifying delirium early is very important.
16
Identication should be supported by obtaining
additional information from those in frequent
contact, such as family, friends or regular
care staff. This is equally relevant for people
with or without good verbal skills. As a persons
ability to describe symptoms declines so the need
for good clinical judgement increases. Information
from people who have had frequent, recent contact
becomes vital. In all circumstances the
history of change is critical.
The most important features of delirium are:
1) the speed with which symptoms develop;
2) the way symptoms tend to uctuate; and
3) problems people have paying attention.
When speaking with the person they may:
have problems naming people, objects
be easily distracted
be irritable and/or uncooperative
be difcult to converse with due
to poor attention abilities
exhibit somnolence*
exhibit hyperactivity*
exhibit hypoactivity*
(*depending on type of delirium)
exhibit poor concentration
exhibit disorganised thinking
exhibit delusional thinking
(possibly paranoid)
experience disturbed memory
experience hallucinations
(typically visual).
For a diagnosis of delirium these features may
not be evident all the time, but must have recency,
though they will uctuate.
A person may describe episodes of confusion
or reduced mental clarity, perhaps with associated
anxiety. They could display language or behaviour
that is not like them. People with reduced
cognitive function and limited speech may
exhibit anxiety or irritability that manifests
atypically as resistiveness or withdrawal.
Carers and care staff may describe features
such as an acute change or decline in function,
including: uctuating capacity; disturbed sleep/
wake cycle or sleeplessness; uctuating activity
level over the day; rapid memory decline;
episodic confusion (particularly during the day)
and a rapid change in personality or behaviour.
SPECIFIC PRESENTING FEATURES
That delirium can present in a number of ways
has been recognised for many years,
9,36,37,57,62
with psychomotor activity the yardstick.
14
Lipowski, for example, describes two main
forms hypoactive/hypoalert and hyperactive/
hyperalert as well as an alternating form.
36,37
Similarly, Ross, Peyser, Shapiro et al. speak
of activated and somnolent types.
57
5
ABOUT DELIRIUM
HYPOACTIVE
Lipowskis 37 hypoactive/hypoalert form accounts
for perhaps 20% of cases.
35
Also described as
somnolent,
57
this presentation is marked by
psychomotor slowing and withdrawal, and may
be misidentied as depression.
58,46
The person may
be lethargic (exhibiting little spontaneous activity)
or drowsy, and may appear sedated.
Treloar and Macdonald suggest that the rate for
the hypoactive or somnolent form may in fact be
higher, but for a skewing arising from the DSM
criteria for delirium.
62
A 78-year-old man with a mild dementia
living in a low-care residential facility;
after a brief period of hot weather staff
report that he appears to be experiencing
episodes of `confusion' which are largely
episodes of disorientation to his
environment. At these times he also tends
to be unmotivated and withdrawn, needing
almost complete direction with ADLs.
HYPERACTIVE
Liptzin & Levkoff
35
suggest that the hyperactive
form the presentation most commonly attributed
to delirium accounts for approximately 25% of
cases, while Camus, Gonthier, Dubos et al. found
rates of the hyperactive form to be approximately
46%.
9
Also described as activated,
57
it is marked
by psychomotor agitation, rambling speech,
delusions, hyperarousal and hyperalertness.
It may be misidentified as anxiety, psychosis
or mania because of the incidence of
hallucinations, delusions and illusions and the
increased likelihood of agitated behaviour.
46,58
Treloar and Macdonald contend that high rates
may be an artefact of the DSM criteria that
they argue favours active phenomena like
hallucinations and delusions.
62
An 84-year-old woman with a moderate
dementia living in a high care residential
facility has recently been diagnosed with
glaucoma for which she has been treated
with timolol eye drops.
She now has episodes of uncharacteristic
agitation and aggression and appears to
be experiencing visual hallucinations
(she has been seen picking at the air).
At these times personal care is difcult
and her level of function declines.
MIXED HYPOACTIVE/HYPERACTIVE
Mixed presentations are perhaps the most common
form, accounting for up to 50% of cases.
35
This presentation is marked by obvious uctuations
in activity level, cognitive disturbance, level of
consciousness and organisation of thinking.
9
People with the mixed form can often exhibit
features of both active and somnolent forms
so it is perhaps better viewed as alternating
hypo- and hyperactive delirium.
Because visual hallucinations/illusions and
delusions are sometimes described, a mixed
delirium can be misidentied as a bipolar disorder.
A 72-year-old woman was admitted to a
medical ward with pneumonia. The history
suggests a decline in memory over the last
1218 months but her daughter describes a
signicant decline over the last 34 days with
symptoms worse at some times than others.
In hospital, staff describe her as being mostly
pleasantly confused (family add that she
seems to be a little more withdrawn than
normal) but also speak of episodes of irritability
and hyperactivity; at these times she is difcult
to reason with and assertive yet `confused'.
6
ABOUT DELIRIUM
SUBSYNDROMAL DELIRIUM
It is not uncommon for people to present with
many but not all of the symptoms described
in diagnostic classifcations such as DSM-IV.
33,34
Subsyndromal delirium is a term less commonly
seen now, describing presentations where
incomplete symptoms are exhibited.
Intervention in these cases is important, but
recognising a partial syndrome may be difcult.
There may be benet in looking at delirium as a
continuum, as, given the risks, it is probably in
the interests of the patient to be over-inclusive.
11
The inclusion of possible false positives in
management may simply be an appropriate
response to the presence of one or two primary
features, rather than the full syndrome.
11
In all of these presentations it is important to
be aware of the impact of symptoms (uctuating
sensorium, impaired attention) on the persons
day-to-day function and their capacity for any
independent activity.
SUNDOWNING
Confusion that arises in the late afternoon is
often referred to as sundowning. Drake,
Drake and Curwen describe sundowning as a
syndrome of recurring confusion and increasing
levels of agitation, which coincide with the onset
of late afternoon and early evening (p37).
15
When these symptoms occur it is important
to differentiate between: a) regularly occurring
behaviour exhibited by a person with established
dementia; and b) a similar set of features that
have arisen over a short period of time.
An assumption that behaviour is sundowning
may lead to the misidentication of a delirium.
15
Until delirium has been excluded it is prudent
to assume that all changed behaviour is delirium.
This section has explored the features and
dynamics of delirium. The next section details
practice strategies to assess and manage those
suffering from delirium.
7
MANAGING DELIRIUM
INTRODUCTION
This section explores assessment and
management strategies for those caring for
older people experiencing changes in thinking,
function and behaviour.
Assessment is the rst step in diagnosis of any
disorder. It involves the systematic evaluation
and measurement of psychological biological
and social factors presenting in an individual.
Careful assessment leads to the provision of
safe and effective management, and the
increased likelihood of an amelioration
of symptoms.
ASSESSMENT
Identifying changes (in cognition, behaviour
and function), and determining the history of
these changes, is an important step in assessment:
When did the change start? What sort of change
is there? What might be causing it?
Initial assessments should include complete
histories of recent changes, utilising
information obtained from carers and/or
care staff. The observations of family members
and care workers are very important, and may
be the first indication that something is
happening. Phrases such as a bit off...,
or off with the fairies or simply
different are not uncommon the coded
speech Dr Henschke speaks of in the
Preface. As delirium is a disorder of
cognition it is important to determine how
a persons thinking and memory are affected.
Formal cognitive screens using validated
screening tools may demonstrate cognitive
impairment (or change) and can be compared
to a baseline. Screening tools should be used as
part of a complete assessment and with a clear
purpose in mind. They do not identify the cause
of impairment, but assist in alerting treatment
teams to the presence of possible disorder or
functional change.
50
Whenever possible they
should be administered by trained health
professionals educated in their application,
use and interpretation.
Routine screening of cognitive function (and
the appropriate investigation of changes in
cognition and function) helps identify those at
risk of delirium and improve their management.
It is important to assess the cognitive function of
older (particularly frail) people, as the outcome
of an assessment can affect diagnosis, choice of
interventions and a persons ability to engage
with treatment.
Just as a persons blood pressure is taken at
intervals to provide a baseline, cognitive screening
is an integral part of the ongoing assessment of
older people. Ongoing assessment and screening
is necessary while an alteration in cognitive
function persists.
Due to the fluctuating nature of delirium it is
useful to assess people suspected of experiencing
a delirium a number of times over the course of
the day (perhaps morning and evening) and during
the period of the admission to a health service,
or while in a residential facility.
COGNITIVE SCREENING
Screening for cognitive impairment is useful
as it provides: a) some objective measure of
current cognitive function; and b) a baseline
against which subsequent screening can
be compared to demonstrate fluctuations,
improvement or decline. However, screening
tools are not diagnostic and should not be
considered so.
There is benefit in completing a cognitive
screening tool initially, and using information
drawn from that process, as well as clinical
interviews and subsequent history, however
structured professional clinical judgement
requires the use of a number of different
sources of information to reach a
comprehensive assessment.
The North of England Evidence Based
Guideline Development Project has developed
an accessible examination of cognitive screening
for the primary care context.
See http://www.nelh.nhs.uk.
8
MANAGING DELIRIUM
THE CLOCK DRAWING TEST
The Clock Drawing Test (Screening Tools p.18)
is a useful brief screening tool that will indicate
visuospatial ability, comprehension, attention,
logic and evidence of perseveration. Its use as
a screening tool is widely supported.
7,8,32
The results of such a screen for someone with
a delirium might reveal disorganised thinking,
poor planning and reasoning; poor visuospatial
ability and distractibility (in that concentration
will be diminished) i.e. they will have
difficulty focussing on the task. A particular
advantage of The Clock Drawing Test is that
it is easy to administer.
Royall DR, Cordes JA, & Polk M, 1998.
CLOX: an executive clock drawing task.
Journal of Neurology, Neurosurgery &
Psychiatry
64
(5):58894.
OTHER COGNITIVE SCREENING TOOLS
Memory tests may not always actually test
memory due to a persons impaired attention
but screening will help demonstrate an
impairment. The Heidelberg Cognitive Screen
(Screening Tools p.1920) is presented here
as it encourages clinicians to consider areas of
strength and decit, rather than focussing on a
score. It does not require operators to be trained
in its use.
Heidelberg Cognitive Screen Department
of Neuropsychology, Austin & Repatriation
Medical Centre. (Repatriation Campus) Banksia
Street, Heidelberg Western Australia, 3081.
The Mini-mental State Examination is a
commonly used screening tool in primary care,
and although designed to screen for Alzheimers
disease may contribute to the investigation of
cognitive impairment. It requires that operators
undertake some training in its use.
Folstein M, Folstein S, & McHugh P, 1975.
The Mini-mental State: a practical method
for grading the cognitive state of patients for
the clinician. Journal of Psychiatric Research
12(3):18998.
ASSESSMENT OF CONFUSION
The Confusion Assessment Method (Screening
Tools p.20-21) is a tool increasingly mentioned
in delirium literature, and is essentially an
operationalisation of the DSM diagnostic criteria.
It provides a structured format that allows
the cardinal features of delirium (fluctuating
symptoms, an acute onset and a change in
cognition) to be identified from information
derived from cognitive screening and the clinical
interview, and used to complete the screen.
Inouye S, van Dyke C, Alessi C, Balkin S, Siegal
A & Horowitz R, 1990. Clarifying confusion: the
confusion assessment method. A new method for
detecting delirium. Annals of Internal Medicine
113(12):9418.
OTHER CONFUSION SCREENING TOOLS
The Delirium Rating Scale and The NEECHAM
Confusion Scale are screening tools for delirium,
see: Trzepacz P, Baker R, Greenhouse J, 1988.
A symptom rating scale for delirium. Psychiatric
Research 23(1):8997.
Neelon VJ, Champagne MT, Carlson JR &
Funk SG, 1996. The NEECHAM Confusion
Scale: construction, validation, and clinical
testing. Nursing Research 45(6):32430.
Risk factors include:
existing cognitive impairment
more than 3 drugs or recent changes to regimen
use of urinary catheter and/or immobility
iatrogenic events
malnutrition
visual and hearing impairment
use of physical restraints
ageing
dehydration
institutional care
sleep deprivation
9
MANAGING DELIRIUM
DIFFERENTIATING DELIRIUM, DEPRESSION AND DEMENTIA
ONSET
PROGNOSIS
BEHAVIOUR
COGNITION
Memory
Attention
Reasoning
Language
Orientation
Consciousness
EARLY DEMENTIA
AFFECT
THOUGHT
PERCEPTIONS
SPEECH
CONTENT
JUDGEMENT
INSIGHT
insidious (over months); symptoms
often uctuate
relatively sudden - over hours to
days; symptoms tend to uctuate
not reversible but manageable
social skills may be preserved; withdrawal from
social activities as memory deteriorates; may get
lost in unfamiliar environments
recovery likely with treatment;
high mortality if left untreated
disturbed sleep/wake cycle; hyperactive
form may be restless; hypoactive form may
present as somnolent, withdrawn
over days to weeks
risk of suicide; recovery likely
with treatment
often slowed, occasionally
agitated; changes to sleep,
energy and appetite
impaired, especially for recent events impaired may seem impaired; actually slowed
intact poor; uctuates may appear impaired
declining poor often slowed
may have naming; word-fnding problems
may have difculties with time and place disoriented
variable intact
may appear disoriented
clear clouded clear
may be normal; may be at or withdrawn;
mildly perplexed
uctuating: may be irritable;
may be at, withdrawn
sad or withdrawn or irritable,
depressed, worried; helpless, guilty
shallow content; may appear to have
paranoid ideas due to memory problems
may lack coherence; possible delusions slowed or decreased; focus on past [guilt];
hypochondria; thoughts of death; possible
mood-congruent delusions
often no change simple misinterpretations; visual hallucinations occasional auditory hallucinations
repetitive; patient unlikely to complain
of cognitive decits
fuctuating: may be incoherent; non-fuent
or uent
coherent; often slowed; may complain
of decits
declining often impaired may seem impaired
reduced awareness of difculties poor variable
DELIRIUM DEPRESSION
10
MANAGING DELIRIUM
Begin with the rule of thumb that delirium
develops over hours, depression over days or
weeks, and dementia develops over months and
years. Information derived from the history and
screening is important for an accurate diagnosis
and should be made available to others in care
teams or provided in any referrals.
Ask yourself:
is the cognitive impairment new?
what was it like two months ago?
is it part of an established dementia?
has a cognitive screen been done?
In thinking about probable delirium
acknowledge that:
delirium is rarely caused by one thing
look for all likely causes and treat if
known/found (e.g. drug-, infection-,
metabolic disorder-, or dehydration-related)
lack of obvious pathology does not mean
it is not delirium
with new-onset cognitive impairment or
a recent acute change in mental function
there is benet in information obtained in an
organic screen (usually CUE, FBE, ESR, B12
and folate, urinalysis and chest X-ray)
to facilitate early identication of delirium
in people receiving care it is useful to create
an ongoing process of assessment and review
of cognitive function:
1) conduct cognitive screen
(e.g. Clock Drawing Test) on admission,
or three-monthly in residential care,
or when acute change occurs
2) complete further screening if acute
impairment is present
3) conduct daily cognitive screens if delirium
is thought to be present.
For people with significant impairment (acute
or chronic) regular and clear documentation of
behaviour is important.
Identify those at risk hopefully before they
develop a delirium.
OVERVIEW OF MANAGEMENT
Management of delirium can only occur if it
is recognised.
Delirium should be assumed with any change
in thinking and behaviour that occurs over a
couple of days.
The first thing to do is identify any causes and
address them. If a cause is found, look to ensure
that there are no others then look for the presence
of risk factors and address those.
It is advisable to begin assessment at the point
of first contact with a person as part of a health
assessment if nothing else it allows a baseline
against which future assessment can be compared.
This is relevant for any rst contact or as soon as
symptoms of impaired cognition become apparent.
There is evidence that people with disordered
mental and cognitive function are likely to be seen
as difcult and complex.
30,31,44
They may therefore
be less likely to receive adequate or appropriate
nursing care. Cognitive impairment and agitated
or aggressive behaviour makes this more
likely.
30,31,44
This fact should be borne in mind and
actively guarded against.
DRUG TREATMENT
The pathology of delirium appears to result,
in part at least, from a disturbance of cholinergic
function in the central nervous system, and the
clinical evidence strongly supports this view.
47
Delirium commonly occurs in drug toxicity
arising from anticholinergics and particularly
by centrally acting anticholinergic agents.
64
By inhibiting the enzyme responsible for
the breakdown of acetylcholine it has been
hypothesised that drugs (such as donepezil,
rivastigmine, galantamine or tacrine
hydrochloride) will augment cholinergic
activity in the brain and facilitate the resolution
of the delirium.
66
Whether this is supported by
controlled studies remains to be seen, and this
may not be a useful treatment in delirium arising
from other causes (i.e. metabolic).
11
ALGORITHM ... IS IT DELIRIUM? Change in thinking and behavior.
Dene the issue further
Did it happen over hours or days?
NO YES
Depression, progression
of dementia? - report
Depression screen
Are there uctuations in the presentation?
Are they unable to (or nding it difcult to)
NO YES
YES NO
Review
Begin again
Improving
Continue to monitor
Screen
Address ndings
No change, decline
Clock-test, Heidelberg
Cognitive Screen, MMSE,
Medication review -
any changes in the past
week or past year?
Organic screen (CUE, BC,
LFT, TFT, urine C&S
chest X-ray) Refer to GP
or specialist service
Dont stop looking
when you nd a cause,
keep looking as there
is usually more than
one cause.
Reducing risk
Existing cognitive impairment?
Existing sleep
More than three drugs?
Existing sensory impairment?
Existing immobility?
Existing dehydration?
Address risk factors
12
MANAGING DELIRIUM
MANAGING DELIRIUM
PHYSICAL CARE FOR EXISTING DELIRIUM
Providing care for people with delirium differs
little from care provided for any person with
cognitive impairment and reduced capacity
for self-care. The key to management is
making days more predictable and minimising
change in the environment, in care practices,
and staff and avoiding the introduction of
anything new or unfamiliar.
A rigid routine to deliver the care that a person
is unable to provide or organise for themselves
is benecial: meals, hygiene, and rising in the
morning / retiring at night at the same times
each day is recommended, with assistance from
the same people as much as possible, until the
delirium resolves.
Symptomatic treatment is as important,
as treatment of causes of delirium and care
should seek to meet the needs of individuals.
INTERPERSONAL ISSUES
It can be helpful to remember that confused older
people are commonly distressed by events they
do not understand. Rarely is difcult behaviour
intentional, personal or intended to cause injury;
it is most likely defensive or an attempt to control
their environment. It is also probably appropriate
for their reality.
Speak in a clear voice with simple instructions
and one-step directions to avoid overloading and
further confusion. Remember that the uctuating
nature of delirium means patients may be lucid at
some times and confused at others, or anywhere
in-between.
When lucid they may have good recall of events
and conversations that have occurred whilst they
were confused. Equally, they may have no memory
at all.
60
When providing care avoid hurrying or
rushing and particularly where cognitive disorder
is present or suspected avoid extremes of
expressed emotion, as they may be misinterpreted.
A clear explanation of the disorder to the family
is important. It can be comforting to know that
delirium is largely reversible, but that it can
include delusional and perceptual disorders
(which may lead to unexpected verbal and
physical behaviour).
The management of people with delirium is much
the same as for anyone with cognitive impairment.
What is important is not so much that cognitive
impairment exists (although that does contribute
to risk and is important in management) but that
a persons thinking and behaviour is changed, that
the change occurred over a short time, and that
their capacity will uctuate.
Changes may affect their ability to care for
themselves or receive care from others.
This is as relevant for people who perform
relatively well on screening tools as for people
who do not.
MANAGING THE SYMPTOMS
The following information is drawn from Inouye,
Bogardus, Charpentier et al.
24
and Rapp.
55
Both provide excellent guidelines for management.
Addressing cognitive impairment:
use single issue questions
use single issue directions
repeat information
minimise staff changes
orientate to surroundings as
appropriate (depending on tolerance)
use large face clocks
use large print calendars
discuss/converse with patients;
use games/activities as tolerated
maximise lighting during daytime
use low lighting at night
encourage visits by signicant others
or volunteers
relocate patients nearer nurses station
if necessary (especially at night) to increase
the sense of safety and contact (but staff
need to be more mindful of noise and light).
13
MANAGING DELIRIUM
HYDRATION NUTRITION
uid intake adequate?
check oral mucosa for dehydration
determine favoured uids
encourage regular uids
uids available and within reach
daily/weekly weigh as necessary
refer to dietician as necessary

is diet appropriate?

record and evaluate intake/output

determine favoured foods;

encourage family to bring
in favourite foods/uids

small frequent meals and/or

ngerfoods and/or supplements
if necessary

encourage sitting up for meals

facilitate socialisation during meals

refer to dietician as necessary

ENSURE ADEQUATE HYDRATION AND NUTRITION
(PROVIDE PROMPTS IF APPROPRIATE):
ENSURE ADEQUATE REST/SLEEP:
determine normal pattern
establish regular waketime
provide adequate pain relief
establish regular bedtime
ensure appropriate bowel management
discourage excessive daytime napping
encourage periods of activity
(standing/walking)
encourage periods of rest (need to
programme activity throughout the day?)
address lighting: more during day and
subdued at night, as necessary
reduce caffeine (including many
carbonated drinks) intake after dinner.
Sleep is often problematic due to disturbances
in the sleep wake cycle. Allow rests during the
day and encourage maintenance of routine in the
evening prior to settling. Unnecessary medication
should be avoided but where appropriate short-
term use of medium acting benzodiazepines
(e.g. oxazepam) is preferred.
Oversedation is a safety risk, resulting in a
greater likelihood of falls and increased confusion.
Sleeping with a nightlight on can be benecial,
as it reduces the likelihood of misinterpretation
of the environment should waking occur.
14
MANAGING DELIRIUM
PRIOR TO OFFERING HYPNOTICS:
offer relaxation or tape music (their choice)
encourage warm milk or herb tea at supper
provide slow backrub (5min)
provide/enforce sleep-protected time
(about 23000600)
if person awake after 1/24 (or declines
alternatives) offer usual care (e.g. sedatives)
ENSURE ADEQUATE EXERCISE
FACILITATE MOBILITY:
determine if immobility exists
determine if immobility is imposed
evaluate need for immobility
evaluate cause of immobility
arrange physiotherapy and consult
if necessary
address need/cause (e.g. use of urinary
leg bag instead of overnight bag)
facilitate mobility (e.g. walk to toilet)
determine need for aid
encourage periods of activity (standing or
walking) interspersed by periods of rest
encourage out-of-bed sitting if person seeks
bed (see sleep and nutrition sections).
For hypoactive people, exercise is important:
simply standing against a table a few times
a day can be enough to maintain tone.
For hyperactive people, rest is important:
decrease stimulation by moving to low
stimulus areas (away from noise, trafc etc).
For patients who are active, a low stimulus
environment is less likely to lead to agitation;
television should be avoided as it is distracting
and produces agitation, increasing
hallucinations, delusions and disorientation.
Soft music is comforting and relaxing for most
people, as is use of mild aromatherapy.
VISION HEARING
Do they wear glasses?
Do they need glasses?
Test vision
Are their glasses clean
and within reach?
Is lighting adequate for purpose?
If available, is a call bell within reach?
- can they fnd it easily?
Would a portable whiteboard help?

Do they wear an aid?

Test hearing

Are their aid(s) functioning and

within reach? - check the battery

Assess the need for a portable

amplifying device

Is background noise excessive?

Reduce ambient noise

to minimise stimulation

Speak in a clear and

unhurried manner
ADDRESS VISUAL AND AUDITORY IMPAIRMENT
15
MANAGING DELIRIUM
AGGRESSIVE BEHAVIOUR
If the person is aggressive (often in the form
of agitation or resistiveness):
address their safety
address the safety of carers and staff
if the situation is not safe, withdraw
provide simple, clear directions
use calm, unemotional speech
display low expressed emotion; adopt
a professional and polite manner
listen and discover what the issue is
reinforce desired behaviour
use restraints (chemical and/or physical)
as a last resort.
Aggression is one of the few issues that may
respond to pharmacological management BUT:
start low and go slow with the increases
(and only if you are sure that a drug works).
Listen to the person, ask what is wrong,
look for reasons, and try to address their
issues before using restraints:
minimise use of drugs that have a high
likelihood of causing or increasing delirium
(particularly opioids, anticholinergics).
This knowledge does not stop difficult
behaviour, but may help health professionals
consider the costs of pharmacotherapy, as well
as help them understand there may be greater
benefit in accepting that a person may be
distressed. It suggests there is more to be gained
from spending more time with an agitated or
aggressive person, to address underlying issues
that may be contributing to the persons distress.
22
WORKING WITH FAMILIES OR
SIGNIFICANT OTHERS
Family members need to know that delirium
is largely reversible, although it can take time
to resolve completely. Supporting family members
and helping them to understand and deal with
symptoms is a component of comprehensive care.
An awareness that a patients misidentication of
family members is due to their mental state can
reduce family disharmony.
Can we involve them in care? They may be
happy to become part of the management team,
visiting to provide social interaction or just
read the newspaper, for example. They may
make adjustments to the times they visit, or
arrange with other family members and friends
to visit frequently in small groups, to avoid
overstimulation but provide social contact over
a longer period. The role of family in
management needs to be negotiated with them,
so as not to add to their burden.
END OF LIFE ISSUES
Delirium occurs in up to 85% of people near
the end of life.
10,43
Risk factors are essentially
the same as for other people, but there can be
an increased risk due to the use of opioids
and psychotropics.
For any cognitive impairment and for
delirium in particular identification is vital.
However, delirium management at the end of
life should be balanced with a patients comfort.
Some features may be better left unaddressed if
they do not lead to patient distress, or would lead
to deterioration in quality of life or symptoms
if addressed.
For example, hallucinations may include
long-lost friends or family, and may provide
comfort and support, rather than distress.
Equally, reducing opioids to provide better
management of the symptoms of delirium
must be balanced by comfort needs.
16
MANAGING DELIRIUM
CONCLUSION
Delirium, rather than being a disorder,
is a clinical syndrome. It is a relatively
common health problem in old age, with those
in hospitals or residential care at particular risk.
It is marked by an acute disturbance of attention
and cognition, and often forecasts physical,
functional and cognitive decline and a need
for a higher level of care if untreated.
It is important to identify people with acute
cognitive impairment as this reversible syndrome
may be the only indicator of the presence of
physical disorder. Although it is seen as having
a short duration, to describe delirium as transient
is to ignore the evidence.
Cognitive decline must be recognised as an
abnormal event in older people, rather than as
a normal part of ageing. Comprehensive
assessment and management of alterations in
cognitive function can prevent and arrest the
incidence of delirium.
17
THE CLOCK DRAWING TEST
Examiner:
THE CLOCK DRAWING TEST (read the directions to the subject)
1. Imagine that the circle is a clock.
2. Please put the numbers on the face of the clock.
3. Draw hands on the clock to show the time as twenty minutes to four.
Note: this test could be repeated using an alternative time such
as 2.40pm.
18
SCREENING TOOLS
SCORING
The clock drawing test can be scored as pass or fail. A pass would be similar
to examples 1-5, a fail would be similar, or less well organised, to examples 6-10.
The hands need to be within the shaded area (shown in example 5) to be correct.
(Flinders Medical Centre, Bedford Park, SA)
A range of more formal scoring systems are available in Brodaty & Moore (1997).
NAME:
D. O. B:
FILE NO:
DATE:
THE CLOCK DRAWING TEST
1 2 3 4 5
6 7 8 9 10
2. Comprehension: Im going to give you some instructions to follow:
Turn over the paper, hand me the pen and point to your nose.
(check hearing versus comprehension). P/F
3. Repetition: The short fat boy dropped the china vase. P/F
4. Name: Watch, Face, Winder, Band (all correct to pass). P/F
VISUAL MEMORY/CONSTRUCTIONAL:
1. Present the two gures (page 20) for 10 seconds.
2. Then ask the patient to draw from memory
- if the patient fails, ask them to copy. P/F
VERBAL MEMORY:
Ask the patient to recall the four words that were presented earlier.
Recall If fail, prompt If fail, recognition
MAGPIE: bird sparrow, magpie, cockatoo RECALLED /4
TOMATO: vegetable tomato, potato, onion PROMPTED /4
PIANO: musical instrument violin, guitar, piano RECOGNISED /4
GREEN: colour red, green, yellow /4
CALCULATIONS:
5 14 = (must be correct within 20 seconds) P/F
REASONING:
A hat and a coat are alike because they are both clothing.
How are tennis and soccer alike? P/F
JUDGEMENT:
What would you do if you came home and found that a pipe was
ooding the kitchen? P/F
THE HEIDELBERG COGNITIVE SCREEN
Examiner:
Level of consciousness: Alert Impaired Fluctuating
ORIENTATION:
Age Location
Year Month
Day Time of Day /6
ATTENTION:
1. Digit Repetition: 8-3-5-2-9
(present at rate of one per second) P/F
2. Present at four words: Must repeat twice consecutively correct.
MAGPIE, TOMATO, PIANO, GREEN
(6-8 presentation maximum)
Number of presentations P/F
LANGUAGE:
1. Speech sample: Ask the patient to describe how they
would make a cup of tea, step by step. Record verbatim.
Any difculties? = FAIL P/F
19
NAME:
D. O. B:
FILE NO:
DATE:
SCREENING TOOLS THE HEIDELBERG COGNITIVE SCREEN
20
MEMORY (fold page)
COPY
The Heidelberg Cognitive Screen: Dept. of Neuropsychology, Austin & Repatriation
Medical Centre. (Repatriation Campus) Banksia St., Heidelberg West Australia, 3081
SCREENING TOOLS
THE HEIDELBERG COGNITIVE SCREENCONTINUED
SCREENING TOOLS
Disorganised Thinking
3. Was the patients thinking disorganised or incoherent, such as
rambling or irrelevant conversation, unclear or illogical ow of
ideas, or unpredictable switching from subject to subjects?
Altered Level of Consciousness
4. Overall, how would you rate the patients level of consciousness?
Alert (normal)
Vigilant (hyperalert, overly sensitive to
environment stimuli, startled very easily)
Lethargic (drowsy, easily aroused)
Stupor (difcult to arouse)
Coma (can not arouse)
Uncertain
Disorientation
5. Was the patient disorientated at any time during the interview,
such as thinking that he or she was somewhere other than the
hospital, using the wrong bed, or misjudging the time of day?
Memory Impairment
6. Did the patient demonstrate any memory problems during the
interview, such as inability to remember events in the hospital
or difculty remembering instructions?
Perceptual Disturbances
7. Did the patient show any evidence of perceptual disturbances,
for example, hallucinations, illusions, or misinterpretations
(such as thinking something was moving when it was not)?
CONFUSION ASSESSMENT METHOD INSTRUMENT (CAM)
Inouye et al. Clarifying Confusion: The confusion Assessment Method. Ann Intern Med,
1990; 113:941-948
Acute Onset
1. Is there evidence of an acute change in mental status from the
patients baseline?
Inattention
(The questions listed under this topic are repeated for each topic
where applicable.)
2A. Did the patient have difculty focussing attention, for example,
being easily distracted or having difculty keeping track of what
was being said?
Not present at any time during the interview
Present at some time during the interview, but in mild form
Present at some time during the interview, but in marked form
Uncertain
2B. (if present or abnormal) did this behaviour uctuate during the
interview, that is, a tendency to come and go or increase and
decrease in severity?
Yes Uncertain
No Not applicable
2C. (if present or abnormal) Please describe this behaviour.
CONFUSION ASSESSMENT METHOD INSTRUMENT (CAM)
21
Psychomotor Agitation
8.1 At any time during the interview, did the patient have an unusually
increased level of motor activity, such as restlessness, picking at
bedclothes, tapping ngers, or making frequent sudden changes
in position.
8.2 At any time during the interview, did the patient have an unusually
decreased level of motor activity, such as sluggishness, staring into
space, staying in one position for a long time, or moving very slowly?
Altered SOHHSWake Cycle
9. Did the patient have evidence of disturbance of the sleep-wake
cycle, such as excessive daytime sleepiness with insomnia at night?
SCORING - To have a positive CAM result, the patient must show:
1. Presence of acute onset and uctuating course, AND
2. Inattention, AND EITHER
3. Disorganised thinking, OR
4. Altered level of consciousness
SCREENING TOOL SCREENING TOOLSS
CACONTINUED,
THE VISION AND HEARING TEST
THE VISION AND HEARING TEST
The following screening tools are designed for use with people who
are able to follow directions and are offered here for use as part of an
assessment for baselines. It is useful to identify sensory impairment as
they are risk factors for delirium.
AVision THVW(with glasses if normally wears)
1. Can they read news print
2. Can they clearly see the face of someone 3m away
Gresset J and Baumgarten M. Prevalence of visual impairment and utilisation of rehabilitation services
in the visually impaired elderly population of Quebec. Optometry and Vision Science 2002 79:7,416-23
AHearing (whisper) THVW(In a quiet area: with aid in if normally wears)
1. Stand 600mm behind patient, out of view
2. Occlude non-test ear
3. Exhale fully
4. Ask the patient their name
5. Did they hear?
6. Repeat process for other ear
McPhee G, Crowther J. McAlpine C. A simple screening test for hearing impairment in elderly
patients Age & Ageing 1988 17:347-51
22
GLOSSARY
anticholinergic opposing or blocking
the action of acetylcholine (a chemical
in the brain involved with communication
between brain cells).
cholinergic involving or resembling the
neurotransmitter acetylcholine, especially
in physiologic action.
iatrogenic induced inadvertently by a
medical practitioner, medical treatment
or diagnostic procedures.
labile changeable, unstable;
uctuating mood.
lucid intelligible; being sound mentally,
or rational.
metabolic relating to, or resulting from
metabolism.
mnemonic having to do with
improving memory.
narcotic any derivative, natural or
synthetic, of opium or morphine or any
substance that has their effects; potent
painkillers that can cause sedation or sleep.
neuroleptic a drug from the antipsychotic
or major tranquilliser group.
opioid derived from opium or a synthetic
narcotic resembling opium (e.g. morphine).
organic pathology disease of the
body, an organ or organ system;
physical illness.
paradoxical not the normal or
expected thing.
perseveration the repetition of
a word, phrase or idea, or action.
psychomotor of, or relating to,
motor activity that arises directly
from mental activity.
psychomotor agitation an abnormal
restlessness of thought and action;
usually irresistible.
psychomotor retardation an abnormal
slowness of thought and action;
usually irresistible.
psychotropic drugs that act on the
brain (e.g. sedatives, minor and major
tranquillisers, mood-stabilisers/
anti-epileptics).
regimen treatment guide or plan often
associated with medications.
sensorium to do with the senses.
somnolence sleepiness, drowsiness;
overwhelming fatigue.
systemic relating to the system (body).
visuospatial referring or relating to the
visual perception of spatial relationships
among and between objects.
23
1. American Psychiatric Association, 1994. Diagnostic and
Statistical Manual of Mental Disorders Fourth Edition APA
Washington DC.
2. Armstrong S, Cozza K & Watanabe K, 1997. The Misdiagnosis
of Delirium Psychosomatics 38(5):4339.
3. Australian Medicines Handbook, 2003. The AMH drug choice
companion: Aged Care AMH Adelaide.
4. Australian Medicines Handbook, 2003. The Australian Medicines
Handbook AMH Adelaide.
5. Bliwise D, 1994. What is Sundowning? Journal of the American
Geriatrics Society 42(9):100911.
6. Bliwise D, Carroll J, Lee K, Nekich J & Dement W, 1993. Sleep
and sundowning in nursing home patients with dementia
Psychiatry Research 48(3):27792.
7. Bourke J & Castleden C, 1995. A comparison of clock and pentagon
drawing in Alzheimers Disease International Journal of Geriatric
Psychiatry 10(8):7035.
8. Brodaty H & Moore C, 1997. The clock drawing test for dementia
of the Alzheimers Type: a comparison of three scoring methods in a
memory disorders unit International Journal of Geriatric Psychiatry
12(6):61927.
9. Camus V, Gonthier R, Dubos G, Schwed P & Simeone I, 2000.
Etiologic and outcome proles in hypoactive and hyperactive subtypes
of delirium Journal of Geriatric Psychiatry & Neurology 13(1):3842.
10. Casarett D & Inouye S, 2001. Diagnosis and management of
delirium near end of life Annuals of Internal Medicine 135(1):3240.
11. Cole M, McCusker J, Dendukuri N & Han L, 2003. The prognostic
signifcance of sub-syndromal delirium in elderly medical patients`
Journal of the American Geriatric Society 51(6):754760.
12. Culp K, Mentes J & McConnell E, 2001. Studying acute confusion
in long-term care: clinical investigation or secondary data analysis using
the minimum data set? Journal of Gerontological Nursing 27(4):4148.
13. Culp K, Tripp-Reimer T, Wadle K, Wakefeld B, Akins J, Mobily P
& Kundradt M, 1997. Screening for Acute confusion in elderly long-
term care residents Journal of Neuroscience Nursing 29(2):8688,
95100.
14. de Rooij S, Schuurmans M, van der Mast R & Levi M, 2005.
Clinical subtypes of delirium and their relevance for daily clinical
practice: a systematic review International Journal of Geriatric
Psychiatry 20(7):609615.
15. Drake L, Drake V & Curwen J, 1997. A new account of sundown
syndrome Nursing Standard 12(7):3740.
16. Duppils G & Wikblad K, 2004. Delirium: behavioural changes before
and during the prodromal phase Journal of Clinical Nursing 13(5):
609616.
17. Flaherty J, 1998. Psychotherapeutic agents in older adults.
Commonly prescribed and over-the-counter remedies: causes of
confusion Clinics in Geriatric Medicine 14(1):10127.
18. Francis J & Kapoor W, 1992. Prognosis after hospital discharge of
older patients with delirium Journal of American Geriatric Society
40(6):6016.
REFERENCES
24
19. Furniss L, Burns A, Lloyd Craig S, Scobie S, Cooke J & Faragher B,
2000. Effects of a pharmacists medication review in nursing homes
The British Journal of Psychiatry 176:563567.
20. Harding S, 1999. Depression in Older Adults a handbook Flinders
University, Adelaide.
21. Harding S, 2004. Delirium in older People Collegian 11(4):3642.
22. Harding S, 2005. Managing delirium in older people Collegian
12(3):3236.
23. Inouye S, 1994. The dilemma of delirium: clinical and research
controversies regarding diagnosis and evaluation of delirium
hospitalized elderly medical patients American Journal of Medicine
97(3):27888.
24. Inouye S, Bogardus S, Charpentier P, Leo-Summers L, Acampora D,
Holford T & Cooney L, 1999. A multicomponent intervention to
prevent delirium in hospitalized older patients The New England
Journal of Medicine 340(9):66976.
25. Inouye S & Charpentier P, 1996. Precipitating factors for delirium
in hospitalized elderly persons: predictive model and interrelationship
with baseline vulnerability Journal of the American Medical Association
275(11):8527.
26. Inouye S, Schlesinger M & Lydon T, 1999. Delirium: a symptom of
how hospital care is failing older persons and a window to improve
quality of hospital care The American Journal of Medicine
106(5):56573.
27. Jacobson S, 1997. Delirium in the Elderly Psychiatric Clinics of North
America 20(1)91110.
28. Jacobson S & Leuchter A, (ch.5) Delirium in Reichmann E & Katz
P (eds.), 1996. Psychiatric Care in the Nursing Home Oxford University
Press, Oxford.
29. Johnson J, Sims R & Gottlieb G, 1994. Differential Diagnosis
of Dementia, Delirium and Depression. Implications for Drug Therapy
Drugs & Aging 5(6):43145.
30. Jonge P, Zomerdijk M, Huyse F, Fink P, Herzog T, Lobo A, Slaets J,
Arolt V, Balogh N, Cardoso G & Rigatelli M, 2001. Mental disturbance
and perceived complexity of nursing care in medical inpatients: results
from a European study Journal of Advanced Nursing 36(3):35563.
31. Keatinge D, Scarfe C, Bellchambers H, McGee J, Oakham R, Probert C,
Stewart L & Stokes J, 2000. The manifestation and nursing management
of agitation in institutionalised residents with dementia
International Journal of Nursing Practice 6(1):1625.
32. Kirby M, Denihan A, Bruce I, Coakley D & Lawlor B, 2001.
The clock drawing test in primary care: sensitivity in dementia detection
and specicity against normal and depressed elderly International
Journal of Geriatric Psychiatry 16(10):935940.
33. Levkoff S, Evans D, Liptzin B, Cleary P, Lipsitz L, Wetle T, Reilly C,
Pilgrim D, Schor J & Rowe J, 1992. Delirium the occurrence and
persistence of symptoms among elderly hospitalized patients
Archives of Internal Medicine 152(2):33440.
34. Levkoff S, Liptzin B, Cleary P, Wetle T, Evans D, Rowe J & Lipsitz L,
1996. Subsyndromal Delirium American Journal of Geriatric
Psychiatry 4(4):3206.
35. Liptzin B & Levkoff S, 1992. An empirical study of delirium
subtypes British Journal of Psychiatry 161:8435.
REFERENCES
25
36. Lipowski Z, 1983. Transient cognitive disorders (delirium, acute
confusional states) in the elderly American Journal of Psychiatry
140(11):142336.
37. Lipowski Z, 1989. Delirium in the elderly patient
New England Journal of Medicine 320(9):57882.
38. Lyness J, 1990. Delirium: Masquerades and Misdiagnosis in Elderly
Inpatients Journal of the American Geriatric Society 38(11):12358.
39. McKeith I, Galasko D, Wilcock G & Byrne E, 1995. Lewy Body
Dementia Diagnosis and Treatment British Journal of Psychiatry
167(6):70917.
40. Maher S, Almeida O, 2002. Delirium in the elderly another medical
emergency Current Therapeutics 3945.
41. Marcantonio E, Flacker J, Wright R & Resnick N, 2001.
Reducing delirium after hip fracture: a randomized trial
Journal of the American Geriatrics Society 49(5):1622.
42. Marcantonio E, Simon S, Bergmann M, Jones R, Murphy K & Norris J,
2003. Delirium symptoms in post-acute care: prevalent, persistent and
associated with poor functional recovery
Journal of the American Geriatrics Society 51(1):49.
43. Massie M, Holland J, Glass E, 1983. Delirium in terminally ill
cancer patients American Journal of Psychiatry 140(8):104850.
44. Mavundla T, 2000. Professional nurses perception of nursing
mentally ill people in a general hospital setting Journal of Advanced
Nursing 32(6):156978.
45. Meador K, 1998. Cognitive Side Effects of Medications
Neurologic Clinics of North America 16(1):14155.
46. Meagher D, 2001. Delirium: optimising management
British Medical Journal 322(7279):1449.
47. Meagher D & Trzepacz P, 1998. Delirium phenomenology
illuminates pathophysiology, management and course Journal
of Geriatric Psychiatry & Neurology 11(3):1506.
48. Mentes J, 1995. A nursing protocol to assess causes of delirium.
Identifying delirium in nursing home residents Journal of
Gerontological Nursing 21(2):2630.
49. Mentes J, Culp K, Maas M & Rantz M, 1999. Acute confusion
indicators: risk factors and prevalence using MDS data Research in
Nursing & Health 22(2):95105.
50. Minden S, Carbone L, Barsky A, Borus J, Fife A, Fricchione G &
Orav E, 2005. Predictors and outcomes of delirium General
Hospital Psychiatry 27(3):209214.
51. Moran J & Dorevitch M, 2001. Delirium in the hospitalised elderly
The Australian Journal of Hospital Pharmacy 31(1):3540.
52. Murray A, Levkoff S, Wetle T, Beckett L, Cleary P, Schor J, Lipsitz L,
Rowe J & Evans D, 1993. Acute Delirium and Functional Decline in
the Hospitalized Elderly Patient Journal of Gerontology 48(5):M1816.
53. Neelon V, Champagne M, Carlson J & Funk S, 1996.
The NEECHAM confusion scale: construction, validation,
and clinical testing Nursing Research 45(6):32430.
54. North of England Evidence Based Guideline Development Project
The primary care management of dementia
http://www.ncl.ac.uk/pahs/research/services/publications/guide/
dementia.pdf Centre for Health Services Research, and Department
of Primary Care, University of Newcastle upon Tyne.
REFERENCES
26
55. Rapp C J, 2001. Acute Confusion/Delirium Protocol
Journal of Gerontological Nursing 27(4):2133.
56. Robertsson B, Blennow K, Gottfries C & Wallin A, 1998.
Delirium in Dementia International Journal of Geriatric
Psychiatry 13(1):4956.
57. Ross C, Peyser C, Shapiro I & Folstein M, 1991.
Delirium: phenomenologic and etiologic subtypes
International Psychogeriatrics 3(2):135147.
58. Rummans T, Evans J, Khahn L & Fleming K, 1995.
Delirium in elderly patients: evaluation and management
Mayo Clinic Proceedings 70(10):98998.
59. Samuels S & Evers M, 2002.
Delirium: Pragmatic guidance for managing a common, confounding
and sometimes lethal condition Geriatrics 57(6):3340
60. Schoeld I, 1997. A small study of the reaction of older people to
an episode of delirium Journal of Advanced Nursing 25(5):94252.
61. Street J, Clark W, Gannon K, Cummings J, Bymaster F, Tamura R,
Mitan S, Kadam D, Sanger T, Feldman P, Tollefson G & Breier A,
for the HGEU Study Group, 2000. Olanzapine Treatment of Psychotic
and Behavioral Symptoms in Patients With Alzheimer Disease in
Nursing Care Facilities Archives of General Psychiatry 57(10):96876.
62. Treloar A & Macdonald J, 1997. Outcome of delirium:
Part 2 Clinical Features of Reversible Cognitive Dysfunction
Are They the Same as Accepted Denitions of Delirium?
International Journal of Geriatric Psychiatry 12(6):614618.
63. Trzepacz P, Baker R & Greenhouse J, 1988.
A symptom rating scale for delirium Psychiatric Research 23(1):8997.
64. Tune L, Carr S, Cooper T, Klug B & Golinger R, 1993.
Association of anticholinergic activity of prescribed medications
with postoperative delirium Journal of Neuropsychiatry 5(2):20810.
65. Wallace M, 1994. The Sundown Syndrome
Geriatric Nursing 15(3):1646.
66. Wengel S, Roccaforte W & Burke W, 1998.
Donepezil improves symptoms of delirium in dementia: implications
for future research Journal of Geriatric Psychiatry & Neurology
11(3):15961.
67. Workman R, Orengo C, Bakey A, Molinari V & Kunik M, 1997.
The Use of Risperidone for Psychosis and Agitation in Demented
Patients with Parkinsons Disease The Journal of Neuropsychiatry
& Clinical Neurosciences 9:5947.
REFERENCES
27