This assignment will examine the condition known as delirium and will focus on a clinical case study (please see appendix 1. for the full overview of the clinical case study) of a gentleman called Halim* who has presented in the emergency department with his two daughters.
This assignment will be separated into two distinct parts; the first part of this assignment will provide a clinical overview of delirium and will explore what the condition is, the common features, clinical causes and interventions available to manage and treat the condition. This will provide the reader with an understanding of the components that constitute the condition of delirium.
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The second part of the assignment will then focus on placing the acquired knowledge of delirium on to the clinical case study of Halim so that a more detailed clinical exploration can be completed; with focus being placed on the role of the practitioner and their interventions in addressing the key issues.
*To protect and respect client confidentiality all names have been changed and any identifiable data censored for the purpose of this assignment.
Delirium – Clinical Overview
Delirium, also sometimes referred to as an acute confusional state, is a common clinical condition that presents with individuals experiencing disturbances in consciousness, cognitive function and perception, which has an acute onset and fluctuating course (NICE, 2010). The important clinical characteristic of a delirium is that the onset is quite rapid; it may present and develop within a very short period of time, usually over the course of a few hours or days (Brown & Boyle, 2002).
It is not uncommon for an individual to present to hospital settings with symptoms of delirium and it is important to acknowledge that individuals who already are hospital inpatients or in a care setting may also develop delirium; it is a condition that traverses the inpatient and community settings.
Literature suggests that there are two types of delirium; hypoactive delirium is characterised by individuals experiencing withdrawal, lethargy, introversion and sleepiness whereas people with hyperactive delirium have heightened arousal, restlessness, agitation and aggression (NICE, 2010). There is also a third variation where individuals may experience a mixture of both hyper and hypoactive symptoms which can make diagnosis very difficult.
It is suggested that delirium can often be mistaken for dementia, worsening of pre-existing cognitive problems and old age; however delirium is a clinical syndrome that differs from these other conditions as it is the sudden and acute onset that tends to vary throughout the course of the day that identifies it as delirium rather than any other disorder (Meagher, 2001).
It is reported frequently within the literature (Wong et al., 2010; NICE, 2010; Meagher, 2001; Brown & Boyle, 2002; Cole, 2004 and Siddiqi & House, 2006) that patients with delirium experience a reduced ability to focus and concentrate; perceptual disturbances which includes delusions, paranoia and hallucinations; fluctuations in presentation; difficulty in following conversation or direction; rambling or changing topic; disorganised thinking and disturbances in consciousness. In addition to these clinical symptoms there also may be mood disturbances and changes in neurological presentation with individuals experiencing changes in muscle tone, tremor and involuntary jerking (Map of Medicine, 2011).
Delirium occurs due to underlying physical pathology (American Psychiatric Association, 2000) and although symptoms may present as symptoms of mental illness the condition itself has originated usually from some kind of underlying infection, disease or event that has impacted on the individuals physical health status (Wong et al., 2010). Examples of possible causes for delirium include; hypovolaemic shock, cardiac failure, myocardial infarction, head trauma, seizure, metabolic disorders such as liver or renal failure, fluid and electrolyte imbalance, infection, malignancy, dehydration, post operative state, pain, constipation or urinary retention. In addition to these common causes delirium may also be induced by individuals experiencing complications from drug interactions and withdrawal; and included in this is prescribed medications, illicit drugs and alcohol (Map of Medicine, 2010).
Delirium is a very serious condition and it cannot be underestimated as the mortality rate for individuals is very high even after discharge from hospital for up to 12 months (McCusker et al., 2002), other complications from delirium also include patients having to stay longer in hospital which means they are exposed longer to hospital acquired infections, persistent cognitive deficits and an increased risk of the individual being discharged into residential care rather than return to living independently are also factors (Wong et al., 2010).
With the symptoms of delirium presenting as the onset of an acute mental illness it is possible for debate to arise as to which clinical team should be responsible for the management of the patient; additionally; in light of the evidence presented; it would be easy for the individual with delirium to be overlooked or not be investigated for the reasons behind the onset of the condition which is probably why the mortality rate is so high; underlying physical conditions that are not assessed, treated or managed will continue to affect the health status of the individual. Statistically more than half of delirium cases go unrecognised by health professionals (Inouye et al., 1998).
Prevention of delirium is more effective than treating it once it has developed (Brown & Boyle, 2002) therefore it is important for healthcare professionals to be aware of the risk factors, symptoms and causes of delirium for individuals under their care either in hospital or in the community. If delirium has already developed then it is the responsibility of the healthcare team to manage the condition quickly and efficiently to reduce further problems and difficulties for the individual; recognizing the mortality rates associated with a diagnosis of delirium should facilitate efficiency.
To assist with obtaining a clearer clinical perspective of delirium and the impact it has on an individual a clinical case study shall now be explored.
Halim – Clinical Exploration
Halim was admitted to the emergency department and when the clinical history was obtained from his daughters it was identified that there had been a rapid change in his cognitive status which had been observed within a 24 hour period as his daughter had not been alerted to any concerns when she had spoken to him the previous evening. In light of the evidence it is possible for practitioners at this point to consider that Halim has developed an acute syndrome such as delirium and the next stage is to explore this further.
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On completion of the basic observations it was evident that there are physical abnormalities present. From visual observation of the patient it is clear he has altered mental status, dry skin and cracked lips. From clinical measurement of heart rate, blood pressure, temperature and oxygen saturation levels, there is further evidence of physical abnormalities that may contribute to changes in cognitive function to such an acute degree.
Obtaining clinical history often involves information being sought from third parties to support clinical findings particularly if the patient is impaired cognitively. Halim’s daughter’s were able to give an account of a gentleman who had experienced marital problems and divorce due to alcohol misuse and evidence remains that he continues to consume alcohol regularly. In addition to this there is a history reported of Halim neglecting his diet to the extent his daughters provide food for him when they visit, he also engages in health limiting behaviours by smoking and consuming high levels of caffeine on a daily basis.
The history obtained from Halim’s daughters identifies a gentleman who is successfully self- employed, he has hobbies and interests although his social network has reduced and although he engages in health limiting behaviours such as smoking, drinking alcohol and neglecting his dietary needs; he has remained independent within his own home. The evidence suggests there has been an acute change and with this information and the clinical evidence indicating Halim is experiencing tachycardia, high temperature, hypotension and dehydration the clinical evidence provides a strong indication that he is experiencing symptoms of delirium.
Further investigations are required to gain a greater understanding of what physical changes have occurred so that underlying causes are treated, however the practitioner should take some time to explain to the family members what tests are being completed and what the medical team are treating Halim for. The family must be very distressed by the changes to their father and by communicating the outcomes of the assessment and responding to any questions they may have will be beneficial as it is reported that the experience of delirium is frightening for both the patient and their carers and the value of reassurance cannot be underestimated (Mohta et al., 2003; Jacobson & Schreibman, 1997).
Managing Halim in terms of obtaining his consent to agree to treatment and investigations may be difficult because of the level of cognitive change and because his understanding and judgement may be impaired because of the delirium; therefore it is important that the practitioner and family are familiar with legal frameworks and hospital policies that are in place to ensure the rights of all parties are being protected. An example of this would be practitioners being familiar with the hospitals delirium policy, being well versed in patients’ rights and by having knowledge about legislation such as the Mental Capacity Act (The Stationary Office, 2005).
As stated previously the experience of delirium may be frightening for Halim and therefore the practitioner should endeavour to implement nursing and care strategies that reduce distress, improve orientation, address physical health status and ultimately minimise the duration and impact of the delirium. Examples of the interventions that can be implemented include; working with the multi disciplinary team to treat the underlying cause of the delirium. This may include providing pain control, regulation of bowel and bladder function, ensuring adequate diet and fluid intake is promoted and recorded.
Another intervention that is reported to be effective in supporting patients with delirium is for care staff to provide a safe and therapeutic environment. This would mean that Halim is offered reassurance and support, all activities are carefully explained; and for Halim this may mean that a Farsi speaking interpreter is found to facilitate communication between him and the medical team as he reverts to the language of his birth when speaking with the clinicians. In expanding the opportunity to communicate with Halim, this may increase his comprehension of what the medical team are trying to achieve and reassure him that the procedures being carried out; like attempting to obtain a urine screen.
Due to the life threatening nature of Delirium it is essential for all physical screens and assessments to be carried out to ensure early identification of the reason for the onset of the condition, if the therapeutic interventions are unable to be implemented due to Halim remaining agitated and acutely confused then as a last resort medication may be considered in an attempt to reduce his level of arousal enough to ensure clinical procedures and care can be delivered.
Psychotropic medication can be prescribed in delirium in an attempt to reduce the levels of distress and agitation and for Halim it may be beneficial to ease his levels of arousal enough so that medical interventions can take place; it is important to note however that psychotropic medications have side effects that include; extra pyramidal side effects, mobility impairment, sedation and cardiac interaction therefore they must be used with extreme caution and Halim should be monitored closely.
Halim has presented to the emergency department with a delirium and the impact of this on his health and welfare should not be underestimated by practitioners. With mortality rates in delirium being worthy to note it is essential that care pathways are developed to ensure the physical health and mental wellbeing of patients like Halim are met concurrently.
Clinical, environmental and behavioural interventions are acknowledged to reduce the impact, intensity and duration of the condition; therefore practitioners should work intensively to ensure a delirium presentation is treated efficiently and effectively to ensure mortality rates are reduced and recovery is facilitated as quickly as possible.
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