Nurses play a crucial role in the early identification of delirium in people of all ages, with research suggesting that increased delirium education and understanding can improve awareness of the condition, and potentially improve the management of people who have delirium.

Registered Nurse Dr Judy McCrow, Professional Services Leader at NewDirection Care, whose PhD investigated a model of education to improve nurse recognition of delirium, says it’s crucial that nurses understand the difference between delirium and other conditions.

“Delirium in not normal and it is not dementia,” says Dr McCrow.

“It is an acute confusional state characterised by a reduced ability to focus, sustain or shift attention.

“It is potentially reversible if the cause or causes are found and treated.”

The longer a person has delirium the harder it is to reverse, which is why early detection is so important, and nurses are well-placed to spot the signs.

“The exact pathophysiology of delirium is still poorly understood but it is usually a result of an underlying medical condition such as urinary tract infection, constipation, pain or electrolyte imbalance.

“Delirium has many causes but it has been shown to be associated with increasing cognitive decline in people with pre-existing cognitive impairment such as dementia.

“The more risks a person has, the less of an insult is required to develop a delirium.

“For example, a person who is older and has a cognitive impairment may only require a small insult, such as starting a sleeping tablet to develop a delirium, whereby a child who has no risk factors can still develop a delirium, but requires larger insults, such as a massive infection before they develop a delirium.”

Dr McCrow says lack of awareness by healthcare providers is the main reason delirium remains unidentified.

“In addition, delirium is a fluctuating and usually multifactorial thereby making diagnosis and management a little more challenging for health care workers.”

Which is why nurses would benefit from developing a deeper understanding of the signs of delirium, enabling them to identify and diagnose the condition more quickly. 

“The sooner delirium is identified and the causes or causes treated, the better the outcome for the person experiencing delirium.”

When not treated, delirium is associated with poor outcomes including significant functional decline and death.

“Early identification by nurses is crucial, as finding and treating the cause or causes can lead to reversibility of the delirium.”

Dr McCrow says any acute onset of changes in an older person’s behaviour should be suspected as a delirium.

“Delirium can be evidenced by hyper or hypoactive disturbances.

“It is fluctuating, the person’s has trouble with attention and there can also be disorganised thinking, altered level of consciousness and sleep disturbances.

The Diagnostic and Statistical Manual IV criteria diagnose the core features of delirium as the following:

1. Disturbance of consciousness - reduced clarity of awareness of the environment with reduced ability to focus sustain or shift attention;
2. A change in cognition - memory deficit, disorientation, language disturbance; or development of a perceptual disturbance (not part of a pre-existing condition such as dementia);
3. Acute onset (hours to days) and fluctuating during the course of the day;
4. Evidence from the personal history, physical examination or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition.

Dr McCrow believes there is a need for increased awareness that delirium is a significant issue for older people, and an understanding that early recognition and treatment of the underlying cause is directly associated with better outcomes for people.

Studies have shown that up to 67% of delirium cases were not recognised by general practitioners, and that 43% of cases were not recognised by the nurses who were caring for the patients.

“(I would like to see nurses) ‘think delirium’

“Be alert, recognise, respond.

“Listen to family and their concerns.”

According to Dr McCrow, while many healthcare professionals have a role to play in identifying and treating delirium, nurses are well-placed to spot the signs early, and can therefore play a significant part when it comes to minimising the long term impact on patients.

“Nurses are at the forefront of care and can see subtle changes in a person.

“They regularly see family who may alert you to a person having delirium through simple comments such as, ‘this is not how my mother/father normally behaves’.

“If you suspect delirium immediately notify the person’s GP whilst searching for potential causes.

“Do a urinalysis, check their bowels are opening, identify any pain, do a head to toe assessment to look for abnormalities or skin irritations/infections.”