Delirium In The Elderly Paper

To complete Reflect on geriatric patients from your practicum site that you may have assessed for dementia, delirium, or depression. Explain the impact of these types of disorders on frail elders. Then, describe a patient case including the care plan for assessment, diagnoses, treatment, management, and patient education. Explain whether the patient’s care plan was effective. Include how you might proceed differently in the future. If you did not have an opportunity to evaluate a patient with this background during the last 6 weeks, you can select a related case study or reflect on previous clinical experiences.

Following the unprecedented increase in the number of patients aged 75 years and older in most industrialized nations, impairment of cognitive function remains a continuous problem that requires an effective and thoughtful approach in terms of diagnosis and management. Delirium, depression, and dementia are amongst the most common causes of cognitive damage in primary care settings, however, they can easily be mistaken for each other or be unrecognized.  Delirium is a common neuropsychiatric disorder among hospitalized patients. It is linked to adverse health outcomes such as prolonged hospital stays, a decline in physiologic and social functioning, high mortality, placement in nursing homes and long-term cognitive damage. For this week’s journal entry, I will discuss the assessment and management of a 72-year-old male Mr. DT who had a diagnosis of Delirium. Delirium In The Elderly Paper.

Mr. DT was found lying on the floor by his son, confused, incontinent of urine and had an abrasion on the left elbow. He had reportedly experienced a productive cough for 3 days and his oral intake of fluids had significantly reduced since the onset of the cough. He had a medical history of rheumatoid arthritis, COPD and a Myocardial Infarction in 2007.  On examination, he was disorientated in time, place and person, yelling, restless, striking out, pulling the Foley and IV, attempted to climb off the stretcher and generally fluctuated in the entire day. His son reported that he took Tylenol PRN for pain and ASA 81mgs daily.  At the ER, his vital signs were: Temp 37.0⁰c, GCS 13, BS-6.1, 0₂Sat 88%, BP (sitting) 84/42 Pulse 120, BP (lying) 102/54mmhg HR 90. A medical order to give Ativan 1mg PO stat then on a regular basis did not influence a change on his confused state.

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            Based on the fact that Ativan didn’t work for Mr. DT’s case for an entire day, I discussed with the attending physician on the need to immediately conduct a comprehensive cognitive status re-assessment using the Confusion Assessment Method tool. This tool measures the patient’s consciousness/sedation level, disorganized thinking, inattention, and cognitive status using the Richmond Agitation and Sedation Score which provides a distinct criterion for sedation and agitation levels (Hasemann, et al., 2018). This assessment confirmed the diagnosis of delirium which could possibly have resulted from dehydration, a respiratory infection or stroke that collectively contribute to an acute state of confusion. According to Oh et al (2017), potential metabolic causes of delirium in elderly patients are electrolyte imbalance and dehydration while medical causes include: pneumonia, hypoxia, and MI.

As the primary nurse who was attending to the patient, I immediately administered IV fluids to correct the dehydration. To investigate for the possible risk of stroke, I applied the GCS and recommended a CT head. For the respiratory infection, a CXR, sputum for culture and sensitivity and administration of IV antibiotics were considered. To effectively manage the delirium, haloperidol in combination with Ativan administered IM were the drugs of choice. In this case, the dosage of 0.5-5mg Haldol IM was considered. Delirium In The Elderly Paper.  According to Boettger, Jenewein & Breitbart (2015), the initial dosage of haloperidol should be as low as 0.5mg combined with benzodiazepines and gradually increased. It should, however, be noted that high doses are likely to result to extrapyramidal effects. With two days, the patient had started showing some improvement in terms of maintaining his calmness, accurately responding to instructions and was Alert and OrientedX3.

References

Boettger, S., Jenewein, J., & Breitbart, W. (2015). Haloperidol, risperidone, olanzapine, and aripiprazole in the management of delirium: A comparison of efficacy, safety, and side effects. Palliative & supportive care, 13(4), 1079-1085.

Hasemann, W., Grossmann, F. F., Stadler, R., Bingisser, R., Breil, D., Hafner, M.,  & Nickel, C. H. (2018). Screening and detection of delirium in older ED patients: the performance of the modified Confusion Assessment Method for the Emergency Department (mCAM-ED). A two-step tool. Internal and emergency medicine, 13(6), 915-922.

Oh, E. S., Fong, T. G., Hshieh, T. T., & Inouye, S. K. (2017). Delirium in older persons: advances in diagnosis and treatment. Jama, 318(12), 1161-1174.

Journal Entry: Delirium in Elderly

With the aging of our population, cognitive aging has emerged as a leading public health concern. In a 2014 AARP survey, 93% of respondents identified maintaining brain health as a top priority (Inouye, 2015). Yet a substantial void exists in the fundamental understanding of the cognitive aging process and its distinction from cognitive impairments such as delirium and dementia-related conditions. Nearly one third of the older population in the United States is hospitalized each year in relation to acute illness or surgery, and delirium is the most common complication of hospitalization in older persons, and it occurs in an estimated 2.6 million of older adults each year. Delirium has been identified as a leading contributor to short and long term cognitive decline after hospitalization, and at least 40% of these cases are preventable when identified. For this week’s journal entry, I will discuss how pharmacokinetics and pharmacodynamics affects the elderly population by discussing the case of a 70-year-old female, Mrs. W, that I had encountered, who has a diagnosis of Dementia, and other chronic health conditions.

When a patient starts expressing symptoms of agitation or trouble sleeping, or anxiety, the patient may have a standing order for Ativan to be given orally for agitation/anxiety. In most cases, this would work, the patient would calm for several hours. However, in Mrs. W’s case, the opposite outcome was noted. She instead, was experiencing an increase in agitation and exhibiting psychotic behavior such as hallucinations. Delirium In The Elderly Paper.  As the primary nurse, I called the attending physician regarding the patient’s condition, and more Ativan was ordered to be given intravenously. When administered, this second dose didn’t produce any positive outcome for the patient that she ended up having to be in restraints with the “hope” that she would not hurt herself and that she would be clear of her delirium soon. Benzodiazepines are frequently prescribed for elderly patients living in the community and for those in hospitals and institutions. Their use is more prevalent in women. Prolonged use of benzodiazepines is particularly likely in old age for the treatment not only of insomnia and anxiety, but also of a wide range of nonspecific symptoms.

The elderly population, especially those who are age 70 and older are particularly vulnerable to delirium than those younger due to changes in brain function, multiple general medical problems, polypharmacy, reduced hepatic metabolism of medications, multisensory declines, and brain disorders such as dementia. Polypharmacy, is very common in the elderly, and the possibility of drug-drug interactions must be considered as a cause of agitation. Medications such as benzodiazepines, beta-blockers, selective serotonin reuptake inhibitors (SSRIs), neuroleptics and diphenhydramine can cause more problems. Buspar can be an alternative drug to be given. Other drugs such as Trazodone (second drug of choice) could be given if the patient exhibits anxiety, depression irritability. The drug of choice to treat agitation in the elderly with dementia is Haldol starting with the lowest dose, which should suffice in treating delirium and agitation (Critical Care Nurse, 2012). Antipsychotics have been the medication of choice in the treatment of delirium. Evidence for their efficacy has come from numerous case reports and uncontrolled trials. A series of controlled trials also showed that antipsychotic medications can be used to treat agitation and psychotic symptoms in medically ill and geriatric patient populations and it demonstrated the clinical superiority of antipsychotic medications over benzodiazepines in delirium treatment (American Psychiatric Association, 2010).

Another problem that could contribute to an elderly patient to showing agitation or psychotic symptoms are Sleep-related disorders, which are common in the general adult population, with 50-70 million Americans affected by chronic sleep disorders (Hartford Institute for Geriatric Nursing, 2017). Given the high prevalence, complexity, and health implications associated with sleep disorders in older adults, increasing attention is now being focused on this topic as a multifactorial geriatric syndrome. While older adults still require as much sleep as younger adults, normal changes in sleep and circadian rhythm with age lead to increased difficulty falling asleep, poorer sleep quality, and more time awake during the night (Hartford Institute for Geriatric Nursing, 2017). In general, use of benzodiazepines in treatment of sleep disturbance in older adults is not recommended. However, non-benzodiazepines such as ramelteon and melatonin receptor agonists may be used to aid older adults in falling and staying asleep. Ramelteon is the preferred drug of choice for patients who are age 70 and older.

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The personalize plan of care that could be developed is first line of preventive measure could be including both environmental and supportive interventions, using an orientation protocol or help with visual aids. Many at times these patients do not have their glasses until the next day and they cannot see to understand where they are. For pharmacologic treatment, many doctors use neuroleptic agents such as haloperidol, this would be my first choice of treatment and what I would have done differently. Haloperidol is a potent neuroleptic and psychotropic agent belonging to the group of butyrophenones. It mediates its action through blockade of dopaminergic receptors in the mesocortex and limbic system of the brain. Secondarily, it also has antimuscarinic and anticholinergic properties. Haloperidol has a significant efficacy against delirium and hallucinations, as well as anti-nausea and anti-vomiting properties (Tagarakis et al., 2012). Haldol also has a short half-life and can be administered with repeated doses every 15 to 20 minutes. I have seen it work often and most of the time without the hang over effect that benzodiazepine’s can give a patient. Delirium In The Elderly Paper.

References

American Geriatrics Society Abstracted Clinical Practice Guideline for

Postoperative Delirium in Older Adults. (2015). Journal of the American Geriatrics Society, 63(1), 142-150 9p. doi:10.1111/jgs.13281

American Psychiatric Association (2010). Practice Guideline for the

Treatment of Patients with Delirium. Retrieved from http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/delirium.pdf

Arcangelo, V. P., & Peterson, A. M. (2013). Pharmacotherapeutics for advanced

practice: A practical approach (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Critical Care Nurse (2012). Delirium Assessment and Management.

Retrieved from http://ccn.aacnjournals.org/content/32/1/79.full

Hartford Institute for Geriatric Nursing (2017). Sleep Disorders.

Retrieved from https://consultgeri.org/patient-symptoms/sleep-problems

Midlöv P. (2013). Pharmacokinetics and pharmacodynamics in the elderly.

OA Elderly Medicine. Retrieved from http://www.oapublishinglondon.com/article/621# . Delirium In The Elderly Paper.