Long-Term Care Survey Alert

Mistaking a case of delirium for dementia is a potentially lethal assessment error that you never want to make and one that surveyors are likely to targeting in the near future.

The Nursing Home Quality Initiative, which rolled out nationwide on Nov. 12, includes a publicly reported quality measure looking at the prevalence of the condition in short-stay residents. "So surveyors will look at delirium flagged by the QMs," predicts Barbara Miltenberger, an attorney with Husch & Eppenberger in Jefferson City, MO. "And theyll also look for delirium in their closed record reviews."

Unlike dementia or schizophrenia, delirium is an often reversible condition caused by an acute or subacute medical problem, such as infection, drug reactions, electrolyte or metabolic disturbances or hypoxia (see p. 98 for a list of causes).

"So if you assume the resident with delirium has a long-term dementia, he could die from an easily treatable cause," cautions Marilyn Mines, a nursing and survey consultant with FR&R Healthcare Consulting in Deerfield, IL.

There are a few key clues that a resident has delirium rather than dementia or a psychiatric condition. For one, symptoms of delirium normally have a sudden onset, according to Laura Gervasi, a psychiatric nurse who spoke at the recent National Association of Directors of Nursing Administration in Long Term Care. "And staff may describe the persons behavior as quite bizarre. In addition, the behaviors tend to wax and wane, where the person is himself for a few minutes," Gervasi said.

Staff should also be on the lookout for other specific manifestations of delirium. According to Gervasi, these signs include:

Disorganized thinking and speech;

Disorientation (rarely to person);

Altered perceptions (misperceptions, illusions, delusions, hallucinations);

Neurologic abnormalities (inability to write);

Decreased attention (easily distracted);

Impaired memory;

Altered arousal; and

Psychomotor abnormalities.

The earlier you catch delirium, the better. With that goal in mind, nurses at Smithfield Manor in Smithfield, NC look for red flags that may signal impending delirium, such as heightened distractibility, difficulty maintaining a conversation and following directions or incoherent speech, reports Sandra Parrish, resident assessment nurse for the facility.

Nursing notes will often describe signs of restlessness and anxiety, irritability or sleep disturbances in residents right before they develop delirium, Gervasi warned NADONA participants. "The resident may be up all night and sleep during the day," she said.

How will you know if a newly admitted resident has delirium rather than dementia or a psychiatric problem causing psychosis?

Mines suggests checking with the hospital staff who cared for the resident right before his admission to the nursing facility. Keep in mind, however, that hospital staff may have simply assumed a delirious elderly patient had chronic dementia.

But the residents long-term physician and family members should be able to fill you in on the residents usual cognitive and behavioral patterns.

"If they describe the resident as a normally lucid, independent person, you can bet he has something thats reversible," Mines says.

Also check for a past history of drug or alcohol abuse and psychiatric diagnoses, such as schizophrenia or major depression with psychotic features.

Of course, residents with dementia can develop delirium. Thus, caregivers who know their residents usual behavioral patterns will be in the best position to detect significant changes.