Despite being recognized for thousands of years, delirium remains under-diagnosed, difficult to treat and a significant risk factor in critically ill patients. Episodes of delirium are dangerous and potentially fatal because the mental stability of patients is drastically compromised. Therefore, improving delirium detection is paramount.
Nurses directly managing patient care play a leadership role in detecting delirium, reducing the incidence and effects. The tools used to assess for delirium are nurse driven.
Definition of Delirium Types
Delirium, an abrupt, fluctuating and usually reversible disruption of normal mental function, is defined in one of three ways:
1. Hyperactive - easily recognized because patients are restless, agitated, hallucinating, delusional, paranoid, disoriented, aggressive, combative and pulling at their lines or tubes;
2. Hypoactive - harder to recognize because patients have slower psychomotor function, lethargy, confusion, sedation, poor attention, reduced awareness, drowsiness and apathy.1
3. Mixed - a combination of hyperactive and hypoactive.
Tools for Detection
Several validated tools have been designed to measure and/or screen for delirium. One is the Confusion Assessment Method for the ICU (CAM-ICU). The CAM-ICU assesses four different features to determine if delirium is present: 1) Change in baseline mental status or a fluctuation in the last 24 hours; 2) Inattention; 3) Disorganized thinking; 4) Altered level of consciousness. If one and two and three or four are positive, then delirium is present.2This tool is easier to use after receiving education.
The Richmond Agitation Sedation Scale (RASS) is another tool that measures sedation and agitation. RASS scores vary from +4 extremely agitated to -5 unconscious.
Review of Research
More than 80 percent of patients experience episodes of delirium during their stay in the ICU.3,4This is notable because it impacts chances of survival and increases length of stay in the ICU.4,5
Prior to the 1990s there is little research on the effects of delirium on critically ill patients because its impact was not thought to be a contributing factor to prolonged illness and increased mortality
Current studies recognize preventing delirium in addition to treating the underlying medical condition will improve patient outcomes and length of hospital stay.6Within the past 2 years, research has focused on the need for reliable and routine monitoring of mental function and delirium in the intensive care setting.
Yet the perception remains that delirium is a less important condition for evaluation than pain, level of consciousness, and improper placement of tubes and lines.
Practice & Education
Nurses play a pivotal role in the detection and treatment of delirium. Because episodes of delirium in the ICU slow the patient's plan of care and recovery, delirium must be part of the standard assessment process and not just a nursing intervention.2The incidence of delirium in the ICU is up to 80 percent and yet there is not a standard screening protocol for patients in this setting.
Hospital-based nursing education and early detection/treatment of delirium using a standardized protocol can reduce length of stay and mortality in the ICU.4This knowledge will help nurses appreciate the magnitude of the problem as they encounter patients with delirium daily. Information to educate, reassure and comfort patients and families, by helping them understand the mental state and condition of delirium, should be applied by those caring for these patients.
Screening for delirium in the ICU is most effective if nurses are trained in the use of standardized tools.
In one study nurses' recognition of delirium was poor prior to receiving education. Only 2 percent reported the presence or absence of delirium and only 16 percent of these reports were correct. After receiving education the number of nurses who used a validated delirium screening tool correctly increased sevenfold.7At St. Agnes Hospital in Baltimore, where I am an ICU nurse, a delirium treatment protocol was developed and currently is in its early phase of implementation. With the right education and support this will be a useful tool for helping patients.
References for this article can be accessed at www.advanceweb.com/nurses. Click on Resources then References.
Teresa Flaherty, an ICU nurse at St. Agnes Hospital, Baltimore, is in the MSN program at College of Notre Dame of Maryland.