MDS Alert

Start with the most likely suspects and work your way from there.

When a person starts displaying  delirium, the race is on to find the cause in order to save the person from a permanent decline or even death.

First step: Start by looking at the "most suspect" causes for a particular resident, suggests Ann Marie Monahan, RN, MSN, a clinical educator in Vancouver who has helped develop educational materials on delirium. "For example, if the person just had surgery, you look at anesthetics, drugs, and pain," says Monahan. "A person who is admitted to the nursing home from the hospital may have a low-grade delirium that didn't clear up completely from the hospital stay," she adds. "In residential care, UTI is a major cause of delirium. It's probably related to dehydration but not always. Pain and medications are other common causes -- or the person's disease process may destabilize, which leads to delirium."

Use the Delirium RAP

"The facility can use the delirium RAP as an investigative tool to take a broader look at the resident and walk through all of the items on the RAP, asking: Could this apply or this?" advises Rena Shephard, RN, MHA, FACDONA, president of RRS Healthcare Consulting in San Diego, CA.

"If you don't know the answer, then you need to do more investigation," Shephard adds. And that "may require talking to the family to see if the resident has had the condition before." You may also have to enlist the assistance of the "consulting pharmacist or the physician to order lab tests and do a physical exam."

Assessment gem: "Once a person suffers from delirium, there's a high-percent chance the person will have another episode," adds Monahan. "The ideal is to develop a clear picture of what the person is like when he or she has delirium so you can identify it the next time it occurs."

Potential but often overlooked causes of delirium include:

• Poor oral health, including diseased gums or a rotted tooth, says Monahan. That "can set up a low-grade infection that leads to delirium."

• Sleep deprivation. Consultant Diane Brown reports a case involving a cognitively intact elderly gentleman who stopped sleeping after he developed post-operative infections. "He'd fall asleep and then have a myoclonic jerk and start hallucinating," says Brown, CEO of Brown LTC Consultants in Boston. "The facility sent him to the ED, which diagnosed the problem as severe sleep deprivation." The physician prescribed sleeping medication for the resident, who took it and slept for 24 hours. As a result, the resident stopped hallucinating, says Brown.

• Non-psychoactive medications that you may not think of as causing delirium. For example, because they block acetylcholine, "anticholinergic drugs are a major cause of delirium," says Monahan. "And people with Alzheimer's already have a low amount of that neurotransmitter," she adds.

Digoxin is another drug that can cause delirium. "An older person may require a lower blood level of digoxin," advises Monahan.

Provide a Supportive Environment for Delirious Patients

"The first-line approach in intervening with delirium is to identify the cause," says Monahan. At the same time, "alter the [resident's] environment to make it as comforting and understandable [to the person] as possible," she counsels. "Make it peaceful" and provide tools to orient the resident, "such as clocks and a calendar. Having a familiar caregiver or family member also helps calm the person."

Tip: Assign "a one-on-one" caregiver to be with the person while he's delirious. "That person can be a family member if the person wants to do it," says Monahan. "The facility can't call on older relatives to come in but sometimes family members want to provide one-on-one attention."

Real-world practice: When a resident is admitted to Woodbriar of Wilmington, the interdisciplinary team "obtains information from his family about the person's baseline behavior," reports Cindy Mahan, the MDS coordinator for the facility in Wilmington, DE. "If a person has signs of delirium after surgery, for example, we reorient them and provide a supportive environment. We meet with the family and social services and look at any new medications on board that may be contributing to the delirium. If the person is post-op and is taking an antibiotic he hasn't had before, we'll look at that -- or check to see if the person has UTI."

Assessment tip: Facilities can also use the Confusion Assessment Method (CAM) as a quick assessment tool to help differentiate delirium from dementia. For details and a short version of the CAM, see the November Long-Term Care Survey Alert. For subscribing information, call 1-800-508-2582.