Nursing Care, Delirium, and Pain Management for the Hospitalized Older Adult

Ann M. Schreier, PhD

Disclosures

Pain Manag Nurs. 2010;11(3):177-185. 

In This Article

Nursing Care

Assessment of Risk Factors

There is no single cause of delirium and in fact, delirium results when multiple predisposing factors and precipitating incidents occur during hospitalization (Foreman, Wakefield, Culp, & Millisen, 2001). Preexisting conditions such as cognitive impairment, sensory losses (hearing, sight), alcohol, tobacco, and drug withdrawal, and age put clients at greater risk. For example, an older person with dementia is at a greatly increased risk for developing delirium. Other factors that may predispose these individuals include illness severity and environment with either too little or too much stimulation (McCusker, Cole, Abrahamoqicz, Han, Podaba, & Ramman-Haddad, 2001). Once admitted to the hospital, certain metabolic alterations can precipitate delirium, including hypoxia, dehydration/electrolyte imbalance, hypoglycemia, nosocomial infection, and multiple medications (Foreman, Wakefield, Culp, & Milisen, 2001; Voyer, Cole, McCusker, St-Jacques, & Laplante, 2008; Waszynski & Petrovic, 2008). In the severely ill hospitalized client, it is not unusual to have multiple predisposing and precipitating factors. Common to all of these precipitating factors is stress. The greater the number of predisposing factors, the more sensitive the patient is to these stressors. Therefore, it is important that these predisposing factors are recognized.

Prevention of Delirium

Although there are multiple predisposing factors, there is currently no quantitative measure of risk. And although not all factors are modifiable, there are nursing interventions that modify the risks. With awareness of predisposing and precipitation factors, prevention strategies have been developed. Research has focused on incorporating these strategies into a standardized protocol for high-risk groups. Because aging is a primary risk factor for delirium, protocols have been developed for older adults. Interdisciplinary teams including geriatric nurse specialists, geriatricians, physical therapists and psychologists are considered to be essential to these prevention protocols (Inouye, van Dyck, Alessi, Balkin, Siegal, & Horwitz, 2000; Marcantonio, Flacker, Wright, & Resnik, 2001; Neitzel, Sendelback, & Larson, 2007). Common elements of the protocols include enhancement of sensory function, environmental manipulation, support of physiologic stability, promotion of physical activity, and pharmacotherapy (Bergmann, Murphy, Kiely, Jones, & Marcantonio, 2005; Foreman, Wakefield, Culp, & Milisen, 2001; Irving & Foreman, 2006; Milisen, Lemiengre, Braes, & Foreman, 2005; Robinson, Rich, Weitzel, Vollmer & Eden, 2008). Environmental manipulations that reduce delirium include noise reduction, changes in light based on time of day, and presence of orienting objects, such as clocks and providing personal possessions (McCusker et. al., 2001). Methods to support physiologic stability included maintaining fluid balance, oxygenation, bowel and bladder function, nutrition and prevention of nosocomial infections (Bergmann Murphy, Kiely, Jones, & Marcantonio, 2005; Foremen, Wakefield, Culp, & Milisen, 2001; Irving & Foreman, 2006; Milisen et. al., 2005; Rigney, 2006). Sleep and orientation are enhanced by physical activity. A decreased incidence of delirium occurs when such protocols are introduced. Table 1 summarizes the risk factors and identifies strategies that may reduce incidence of delirium.

Unrelieved Pain and Risk of Delirium

Limited information or studies describe the relationship between pain management and delirium. Clearly, the multi-dimensional nature of delirium makes it difficult to study a single etiological factor such as pain and make conclusions and recommendations for effective pain management. Unrelieved pain is one risk factor for delirium. In the presence of severe pain, an individual's ability to pay attention and to stay on task is severely compromised (Crombez, Eccleston, Baeyens & Eelen, 1996; Eccleston & Crobez, 1999). Hearing loss is another frequently reported risk factor for delirium. Unrelieved pain and hearing loss may have an interactive effect on cognitive function. Patients with hearing loss are likely to receive lower doses of pain medication and more likely to experience delirium (Robinson, Rich,Weitzel, Vollmer, & Eden, 2008). This finding suggests that lack of effective communication may result in poorer assessment and management of pain in the hearing-impaired older adult. Therefore, nurses should be aware of hearing losses and use strategies such as hearing aids to improve communication. Nurses should face clients and speak clearly and in a normal voice.

Researchers have studied the relationship between postoperative pain, pain management, and delirium. Hospitalized adults after hip fracture who received less effective pain management were more likely to experience delirium (Milsen, Lemiengre, Braes, & Foreman, 2005; Morrison et. al., 2003). Increased postoperative pain increased the risk of delirium (Lynch, Lazor, Gellis, Orav, Goldman, & Goldman, 1998; Vaurio, Sands, Wang, Mullen, & Leung, 2006). Postoperative patients who received greater amounts of pain medication had a delayed onset of delirium (Robinson, Rich, Weitzel, Vollmer, & Eden, 2008). When long-term care patients were admitted to an acute care hospital, those who received opioids were more likely to experience mild delirium than moderate to severe delirium (Voyer, McCusker, Cole, St-Jacques, & Khomenko, 2007). These studies suggest that effective pain management reduces the risk for delirium and that nurses should implement effective individualized pain management strategies with clients at risk for or experiencing delirium.

Pharmacologic Treatment of Pain and Risk of Delirium

Other research has focused on whether the type of pain medication has an effect on delirium. Studies comparing morphine and fentanyl, morphine and hydrocodone, and morphine and tramadol demonstrated no significant difference between these medications and the development of delirium (Herrick, Ganapathy, Komar, Moote, Dobkowski, & Eliasziw, 1996; Rapp, Egan, Ross, Wild, Terman, & Ching, 1996; Silvasti, Svartling, Pitkanen, & Rosenberg, 2000). In one study, Morita, Takigawa, Onishi, Tajima, Tani, Matsubara, Miyoshi, Ikenaga, Akechi, and Uchimoto (2005) found that the rotation of morphine to fentanyl in delirium cancer patients reduced the severity of delirium. Pandharipande, Shintani, Peterson, Truman, Wilkinson, et al. (2008) found that morphine was associated with a decreased risk of delirium and fentanyl to an increased risk in ICUs. Patients receiving meperidine experienced delirium at a greater rate (Fong, Sands, & Leung, 2006; Morrison et al., 2003). These studies suggest that changing the type of opioid has little effect on delirium incidence. Moreover, adequate administration of opioids for pain is likely to decrease delirium risk.

Assessment Measures

It is challenging for nurses to distinguish between mental status changes associated with delirium and those associated with dementia. When reviewing nursing documentation, Voyer, Cole, McCusker, St-Jacques, and Laplante (2008) found that nurses often used the vague term "confused" to describe mental status changes and cognitive deficits. The term "confused" is not specific to the delirium because "confused" is also a characteristic of dementia. Dementia is a progressive cognitive disorder characterized by memory loss with impaired executive function. As stated previously, delirium and dementia share some symptoms. For older adults, a screening test of cognitive function on admission allows the nurse to determine if the patient may have dementia. There are two instruments that are available to assess for dementia. An abbreviated cognition assessment (Mini-COG) can be performed to assess dementia characteristics (Doerflinger, 2007) The Mini-COG is a simple 3-item instrument and has a sensitivity of 76% and a specificity of 89% (Borson, Scanlan, Chen, & Ganguli, 2003). Alternatively, the Brief Evaluation of Executive Function can be used to assess the older client for signs of dementia (Kennedy & Symth, 2008). The Brief Evaluation of Executive Function is composed of three tests: Royall's Clox Drawing, Controlled Oral Word Association, and the oral version of the Trail Making test (Kennedy & Symth, 2008). Both of these instruments are available through the Hartford Institute for Geriatric Nursing website: http://www.consultgerirn.com. If the findings are positive, the patient should be referred for diagnosis. Dementia severity can also be measured using the Hierarchic Dementia Scale but likely has minimal clinical usefulness (Hadjistavropoulos, Voyer, Sharpe, Verreault, & Aubin, 2008). Family caregivers can provide the nurse with valuable information that can assist in determining if the patient has dementia (Arnold, 2005). To distinguish between delirium and dementia, the nurse can question the family members about the client's usual functioning before hospitalization. Does the patient normally have difficulty with memory? Does the person forget how to get home? Does s/he have difficulty with remembering how to do familiar tasks? If the nurse determines that cognitive function is impaired, then more frequent assessments for delirium are indicated.

Some authors report that nurses lack a sufficient understanding of delirium symptoms and therefore delirium remains underdiagnosed (Foreman, Wakefield, Culp, & Milisen, 2001; Lemiengre, Nelis, Joosten, Braes, Foreman, Gastmans, & Milisen, 2006; Voyer, Cole, McCusker, St-Jacques, & Laplante, 2008). A lack of understanding and use of assessment instrumentation reduces definitive care of the delirious older adult. Therefore, the use of assessment tools is vital to effective care of older adults.

Currently, there are three evidence-based delirium instruments in use. The Confusion Assessment Method (CAM) and the Neelon and Champagne Confusion Scale (NEECHAM) detect the presence of delirium (Inouye, van Dyck, Alessi, Balkin, Siegal, & Horwitz, 1990; Neelon, Champagne, Carlson, & Funk, 1996, Rapp, Wakefield, Kundrat, Mentes, Tripp-Reimer, Culp, Mobly, Akins, & Onega, 2000). The Delirium Index (DI) is a measure of severity of delirium (McCusker, Cole, Dendukuri, & Belzile, 2004).

The CAM was based on the Diagnostic and Statistical Manual of Mental Disorders DSM-IV diagnostic criteria (American Psychiatric Association, 2000). The following elements of mental status are captured by the CAM: level of consciousness, orientation, attention or concentration, recall impairment, language, onset of symptoms, variability of symptoms, perceptual disturbances, sleep-wake disturbance, and changes in psychomotor behavior. The patient is diagnosed with delirium when the nurse identifies that the patient has an acute onset and exhibits inattention as well as either disoriented thinking or disorientation. In a systematic review of literature from 1991 to 2006, the CAM instrument was cited in 239 articles. The instrument demonstrated a sensitivity of 94% and a specificity of 89% (Wei, Fearing, Sternberg, & Inouye, 2008). The CAM has been used in a variety of settings, including long-term care.

Wei, Fearing, Sternberg, and Inouye (2008) emphasized that education is necessary for the most accurate detection of delirium. Nurses can be educated by using web-based material (Try This Series, 2008). However, routine use of the CAM is hampered by various hospitals' documentation systems. Several factors must be in place for nurses' routine use of CAM. First, the CAM needs to be a part of routine nursing documentation. Second, nursing management must identify delirium assessment as a priority and provide the specified education (30 minutes). Third, nurses must consistently use the CAM. Using these principles, Waszynski and Petrovic (2008) successfully implemented the CAM into routine documentation on two nursing units.

The Neelon-Champaigne Confusion Assessment Scale (NEECHAM) is designed specifically for nurses to assess the risk of confusion through bedside observation. The instrument includes all of the elements of the CAM (cognitive and behavioral components) as well as physiologic measures (appearance, vital sign stability, oxygen saturation, and urinary continence)(Neelon, Champagne, Carlson, & Funk, 1996). These variables of physical function distinguish it from the other instruments that measure delirium. Neelon et al. (1996) report alpha coefficient of .90 and interrater reliability of .90. Fewer nurse researchers report using the NEECHAM. Neitzel, Sendelbach, and Larson (2007) found that incorporating the scale into the electronic medical record was difficult and that during their pilot study nurses used the scale for only 13% of the patients on the orthopedic unit studied.

The DI is a measure of symptom severity based on the CAM. Patients are rated by health care provider observation of 0 symptoms to 3 severe symptoms on seven of the CAM domains (McCusker, Cole, Dendukuri, & Belzile, 2004). The DI includes the Mini Mental Status Examination, and these questions are used to determine the severity of symptoms. The severity measure may be useful in the evaluation of effectiveness of treatment measures.

Treatment for Delirium

Once delirium has occurred, the major focus of nursing care is to keep the patient safe. Some authors suggest that early recognition of delirium enhances the resolution of the condition (Rigney, 2006; Puntillo, 2007). Bergmann, Murphy, Kiely, Jones, and Marcantonio (2005) developed a standardized protocol for the treatment of delirium in a postacute nursing facility. With this protocol, once a patient was identified to be experiencing delirium, further assessment and treatment was initiated. The plan included identification and treatment of possible causes, prevention and management of complications of delirium, and restoration of function. Consistency in nursing staff is recommended (Neville, 2006). Other suggested strategies include repeated reorientation of the client, listening to music, removing catheters and IV lines as soon as possible, refraining from use of restraints, careful management of medications, scheduled pain medications, minimizing unnecessary noise and stimuli, and early ambulation (Neville, 2006; Puntillo, 2007; Rigney, 2006; Robinson, Rich, Weizel, Vollmer, & Eden, 2008).

Personal interaction is important in assuring the patient's safety when delirium occurs. Specific knowledge and skill is necessary for the effective treatment of delirium. Many authors recommend the use of a clinical nurse specialist or gerontology consultations. With the reported lack of knowledge among nursing staff, nursing specialists can educate staff on the current best practices (Foreman et. al., 2001; Lemiengre et al., 2006; Voyer et. al., 2008). Family members and educated volunteers can assist with the reorientation and vigilance needed to assure the safety of the person with delirium. It is also important that the care partners (nursing assistants) are knowledgeable about delirium prevention and treatment (Milisen et al., 2005). An interdisciplinary team supports quality care for the delirious patient.

Pharmacologic treatment of the older adult is complicated, because of alterations in metabolism and excretion of medications. Pharmacologic treatment is considered to be a last resort in the management of agitation associated with delirium (Irving & Forman, 2006; Puntillo, 2007). Pun and Dunn (2007) recommend following the Society of Critical Care Medical guidelines and use antipsychotic haloperidol to manage the agitation. Both lorazepam and midozolam are independent risk factors for delirium in intensive care unit patients, and therefore, benzodiazepines are contraindicated in the treatment of delirium (Pandharipande, Shintani, Peterson, Pun,Wilkinson, Dittus, Bernard, & Ely, 2006). When considering the possible adverse consequences of medications, nonpharmacologic options are less risky to use in treating delirium.

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