Is it delirium or dementia? A life may be at stake
Is it delirium or dementia? A life may be at stake
Underlying cause can be life-threatening
After several hours of "sleeping it off," a 74-year-old intoxicated man being treated in an ED still had an altered level of consciousness. Once nurses got him undressed and monitored, they found the man to be in a severe state of septic shock due to cellulitis on his legs that had become systemic. The man spent three days in the intensive care unit and was discharged to a nursing home.
The above case shows the danger of "judging a book by its cover" when it comes to assessment of geriatric mental status, adds Stephanie J. Baker, RN, BSN, CEN, director of emergency services at Paradise Valley Hospital in National City, CA. "A full head-to-toe assessment should be done," Baker says. "We often miss other signs of injury and illness when we do not undress patients."
To improve assessment, consider the following:
• Know the difference between delirium and dementia.
These conditions may appear the same, but delirium is potentially life-threatening and if overlooked, can lead to severe adverse outcomes, says Teresa Sumner, BSN, RN, geriatric clinical nurse specialist at Lenoir Memorial Hospital in Kinston, NC.
Delirium is a sudden onset of disorientation or confusion that can be reversed with the treatment of the underlying condition, while dementia is a group of symptoms related to a decline or deterioration in the patient’s cognitive faculties, says Sumner.
"It is a steady decline and is usually not reversible," she points out. "Persons with dementia have impairments that interfere with the everyday tasks of life and interpersonal relationships."
Dementia is a slow-moving chronic disease that results from atrophy of the brain with age, and it usually is noticed when the person becomes forgetful, makes unusual comments, or exhibits odd behavior, says Baker.
"Delirium is an acute state with a definable start time that usually is associated with drug overdose, sepsis, or seizures," she explains. Along with mental status changes, the patient may have diaphoresis, cool and clammy skin, rapid heart rate, increased respiratory rate, and sometimes fever, says Sumner.
Delirium can be dangerous and the patient needs a full work-up to determine the underlying cause, adds Baker. "Generally delirium will resolve quickly once the underlying cause is treated, whereas dementia is a lifelong progressive disease without any current cure," she says.
Lab tests, an electrocardiogram, and a computed tomography scan are needed to determine if there is a metabolic reason for the delirium, says Baker. Underlying causes include overdose, stroke, sepsis, liver toxicity, meningitis, cardiac tamponade, and hypoxia, she adds.
• Take a thorough history from whomever accompanies the patient to the ED.
A thorough history can help you determine a timeframe for onset of symptoms and whether the symptoms are related to a recent acute illness, says Sumner. "Labeling a patient as having dementia without doing a thorough assessment can lead to missing an acute underlying condition that ultimately could result in a poor patient outcome," she notes.
• Remember that confusion is not a normal part of aging.
Confusion is a symptom of an underlying medical condition or diagnosis, says Sumner. "A thorough assessment and diagnostic work-up may be required to determine the cause of the sudden confusion," she says.
Possible conditions causing delirium include blood loss, congestive heart failure, myocardial infarction, stroke, vitamin B12 deficiency, thyroid deficiency, or fecal impaction, says Sumner.
"Diagnostic testing may be required to determine the cause of the delirium," she adds. "Commonly ordered tests include a complete blood count, electrocardiogram, chest X-ray, and electrolyte panels."
Mental status and behavior changes can be a warning that the patient has a urinary tract infection, is dehydrated, or has another metabolic disturbance, says Sumner. "Many older adults do not present in typical symptom patterns as do young or middle-aged adults, such as in the case of a urinary tract infection in which high fever or burning on urination are hallmark symptoms," she says.
A thorough head-to-toe assessment is indicated to note for possible signs of injury, dehydration, or cardiac abnormalities, adds Sumner.
• Rule out possible head injury.
When performing a falls assessment, it is important to use the terms "tripped," "slid down," or "slipped," says Sumner. "Many older adults use different words to describe a fall," she adds. "They may also be hesitant to disclose falls, as they see it as a decline or threat to living independently."
• Review the patient’s medications.
Many medication side effects and toxicities lead to electrolyte imbalances that may cause delirium, says Sumner. "Asking the patient about the last time he took his medications may be a more definitive way to determine if he is truly taking them as ordered," she adds.
• Reassess often.
If the patient has an acute injury or illness, mental status can change rapidly, says Baker. "Ensure a safe discharge plan for the patient if they are going home," she says. "We may be the only resources they have."
Sources
For more information on assessment of geriatric patients, contact:
- Stephanie J. Baker, RN, BSN, CEN, Director, Emergency Services, Paradise Valley Hospital, 2400 E. Fourth St., National City, CA 91950. Telephone: (619) 470-4386. E-mail: [email protected].
- Teresa Sumner, BSN, RN, BC, Clinical Nurse Specialist, Lenoir Memorial Hospital, P.O. Box 1678, Kinston, NC 28501. Telephone: (252) 522-7275. E-mail: [email protected].
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