Ted’s Story – Unit 1

Section 1 – Introduction

Caring for elderly patients with altered mental states can often be an uphill journey. It is likely that you did not receive much input on this issue in your nurse training or since you qualified.  Despite this, on the general wards in your hospital, a large percentage of patients are over 70 years of age and research suggests as many as 25% of these patients will come in with, or develop an altered mental state of some degree (Schuurmans et al 2001).  Many nurses believe not much can be done about this, however evidence suggests nurses are well placed to prevent altered mental states in some cases and lessen the severity in many more.

Skilled care starts with skilled nursing assessment and Unit one is designed to enable you to differentiate between different types of mental state in the elderly.  You will be asked to review a simulated clinical case (short video) of a gentleman named Ted and answer questions about his mental state.  Subsequently you will be exposed to some information on different mental state presentations and then asked to reassess Ted.  Following this you may decide to change your assessment.  When you have accurately assessed Ted you can continue to Unit two.

Please review this video before continuing

Section 2

Next click on Ted’s observation chart, drugs chart and nursing notes and review each of these:

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Section 3 – Quiz

Your Score:  

Your Ranking:  

Section 4 – Information on the criteria for identifying delirium

A. Disturbance of consciousness with reduced ability to focus, sustain or shift attention
B. Changed cognition or the development of a perceptual disturbance
C. Disturbance develops in a short period of time and fluctuates over the course of the day
D. There is evidence from history, physical examination or laboratory findings that the disturbance is:

  1. Physiological consequence of general condition
  2. Caused by intoxication
  3. Caused by medication
  4. Caused by more than one aetiology

Some additional explanation of DSM criteria

To fall into the category of delirious a patient must have all features A-C and some evidence of a physiological cause:

  1. Can be seen by a range of behaviours from a reduced clarity of the awareness of the environment to sleeping very heavily (so that the patient is difficult to rouse) for long or intermittent periods.
  2. Can be seen by memory deficits that are not better accounted for by dementia (for example even if the patient had dementia before there has been a recent exacerbation.  Perceptual disturbance can include visual or auditory hallucinations so that you notice the patient is responding to unseen or unheard stimuli.
  3. Dementia is generally a process that develops over a long period of time (months and years rather than hours and days as with delirium).  Delirious patients can have periods of the day when they are quite lucid, more disoriented or very sleepy but the usual picture is one of fluctuation.  This is why it is important that the assessment of mental state takes place over the course of a shift rather than at one specific point in time.
  4. If your clinical assessment of the above three points leads you to believe the patient might be delirious, or if you have reason to suspect a physiological cause might be present (such as foul smelling urine indicating a possible UTI or evidence of dehydration this needs to be confirmed with laboratory results).

Section 5 – Learn about three different subtypes of delirium that can be present

Three subtypes of delirium have been identified and patients may also fluctuate between sub-types throughout the day.

  1. Hyperactive delirium is probably the picture we normally conjure up when we think of delirium. Hyperactive delirium is characterised by increased response to stimuli and psychomotor activity or agitation.
  2. Hypoactive delirium is characterised by reduced alertness and psychomotor activity.
  3. The third sub-type is described as ‘mixed’ and presents with features of both of the first two subtypes. The subtype distinction is important because a higher risk of underreporting hypoactive delirium has been found (Inouye et al., 2001). Thus it is important not to have preconceived ideas about how a person with delirium should present but to use the DSM criteria.

Section 6 – Overlapping Symptoms

Overlapping symptoms of common mental states: 

Feature Acute confusion / delirium Dementia Depression
Onset Acute, over hours of days. Often at twilight Insidious, over months of years May coincide with life changes; often abrupt
Course Fluctuating, perhaps with night time exacerbations Fairly stable, may see changes due to stress Fairly stable, may be worse in the morning
Duration Hours to less than a month, seldom longer Months to years Several weeks or months to years
Orientation Usually impaired, variable, fluctuates Often impaired (answer may be close to right) Usually normal, may answer ‘don’t know’
Perception Distorted; illusions, delusions and hallucinations; difficulty distinguishing between reality and misperception Can be normal or distorted usually less of a feature than in delirium Intact; delusions and hallucinations absent except in severe cases
Thinking Disorganised, hard to follow, distorted Impoverished; trouble finding words, judgements impaired Intact but with themes of hopelessness, helplessness, or self depreciation
Memory Impaired immediate or short term memory Can be globally impaired or more predominantly short term impairment Selective ‘islands’ of intact memory
Alertness Fluctuates; abnormally low or high Usually normal Generally normal
Awareness Reduced Unaffected Unaffected
Attention Short attention span, lacking in direction and selectivity, easily distracted Generally unaffected Little impairment very distractible
Speech Often incoherent, slow or rapid, loud or belligerent Tangential, repetitive, superficial, trouble finding words, confabulations May be slow
Sleep wake
cycle
Disturbed, changes hourly, can reverse day and night Disturbed can reverse day and night Disturbed often with early morning wakening
Associated
features
A physical condition such as infection or metabolic imbalance, pain, head trauma, toxicity, pre-existing dementia, advanced age Advanced age, cardiovascular deficits, substance dependence Exaggerated and detailed complaints; preoccupation with personal thoughts; insight present

Information adapted from Henry (2002) and Arnold (2004)

Section 7

Please think about how you would answer these questions:

  • Why is delirium so difficult to identify when it is superimposed on dementia?
  • What role do you think the relatives have in aiding our assessment of DSD?
  • What difference do you think it makes if we recognise DSD?

Section 8

Now go back over Ted’s clinical information and video clip and make your new assessment of Ted’s mental state in the quiz above.

Teds Clinical Information:

Section 9

Well done you have almost completed Unit one.

Please read the following before commencing on Unit two:

Under recognition of delirium or acute confusion is a major hurdle in its management and is a common feature of care.  In a well designed study, Inouye et al., (2001) compared researcher ratings and nurse ratings of delirium and found nurses accurate assessment of delirium was generally low (15-31%).  Nearly all disagreements between nurse and researcher ratings were because of under recognition of delirium by the nurses.  Similarly Laurila et al., (2004a) found delirium was diagnosed in 35.2% of patients by researchers, but it was recorded in just over half of those cases in medical records.

Some nurses feel that it is the doctor’s role to diagnose mental state.  However, the diagnosis must be based on accurate clinical information given by the nurses.  This is so important since delirium symptoms need to be considered over a period of one to two days due to its fluctuating nature.  As nurses we are the only health care providers with sufficient time in direct care with patients to make these observations accurately.  Thus the problem of delirium is an interdisciplinary one which starts with the reporting of the key features of a patient’s mental state to the responsible doctor.  If a patient developed high blood pressure over the course of a shift we would not expect the doctors to diagnose this without our input.  In this way, assessment of mental state in elderly patients should be as routine as the assessment of vital signs.

McCarthy (McCarthy, 2003b, McCarthy, 2003a) found that recognition of acute confusion was influenced by the philosophical orientation of the nurse towards health and ageing.  Three orientations were identified (i) decline perspective (regards health in ageing as detrimental); (ii) vulnerable perspective (regards health in ageing as either positive or negative); and (iii) healthful perspective (regards ‘good health’ in ageing as normal). Nurses using the healthful perspective were more likely to differentiate between acute and chronic confusion in older hospitalised patients. However, delirium is generally under reported in nursing documentation and medical documentation an it is important to note that underreporting is a multidisciplinary problem. One study investigating nursing and medical documentation found false negative reporting of up to 87.5% (Milisen et al., 2002).

There is evidence that delirium can be prevented or treated using a range of interventions, these will be explained in Unit 4, (Marcantonio et al., 2001, Milisen et al., 2001). When delirium is left unchecked it is linked with negative outcomes such as increased length of stay (Saravay et al., 2004) poor rehabilitation outcome (Olofsson et al., 2005) delayed recovery and increased mortality (Leslie et al., 2005a, Marcantonio, 2005). Leslie et al., (2005b) found that active methods to prevent delirium are associated with a 15.7% decrease in long term nursing home costs.  Quicker in hospital recovery from delirium is associated with better long term outcomes (McCusker et al., 2003). There are personal costs to those afflicted in terms of being misunderstood (Andersson et al., 1993). Not to be overlooked in considering the outcomes of delirium is the considerable strain on carers caused by the condition (Milisen et al., 2004a) and the distress caused to family members (Morita et al., 2004).

References

McCusker et al., 2003

Elie et al (1998)

(Schuurmans et al., 2001).

(Martin et al., 2000, Gruber-Baldini et al., 2003, Lou et al., 2003, Schuurmans et al., 2003a, Bellelli et al., 2005, Freteret al., 2005, Gaudreau et al., 2005b).

Marcantonio et al., 2003, Schuurmans et al., 2003a, Lou et al., 2004, Bellelli et al., 2005). Older age (Martin et al., 2000, Gruber-Baldini et al., 2003, Schuurmans et al., 2003a, Bellelli et al., 2005, Olin et al., 2005) (Gruber-Baldini et al., 2003, Schuurmans et al., 2003a, Bellelli et al., 2005