Delirium Nursing Management
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Direct answer
Delirium is an acute, fluctuating disturbance of attention and awareness caused by an underlying physiological insult — infection, dehydration, drugs, hypoxia, metabolic upset, retention or surgery — and is common in hospitalised older adults after surgery and in intensive care. It is a medical emergency of the mind: often missed, frequently preventable and reversible when the cause is treated. Nursing management pairs screening with a tool such as the Confusion Assessment Method (CAM) against a baseline, immediate reporting and correction of causes, and multicomponent prevention — reorientation, sensory aids, mobility, hydration, sleep protection and avoidance of deliriogenic drugs and restraints.
What you must remember
- Core features: acute onset over hours to days, fluctuating course (typically worse at night), inattention as the hallmark, disorganised thinking and altered level of consciousness; sleep-wake reversal and visual hallucinations are common.
- Subtypes: hyperactive (agitated, pulling lines, hallucinating), hypoactive (quiet, withdrawn, drowsy — easily missed and carrying a worse outlook) and mixed.
- CAM diagnosis needs feature 1 (acute onset and fluctuation) plus feature 2 (inattention), with either feature 3 (disorganised thinking) or 4 (altered consciousness).
- Common causes to hunt: urinary infection and pneumonia, dehydration and electrolyte imbalance, hypoxia, retention of urine or faeces, pain, drugs (anticholinergics, benzodiazepines, opioids), alcohol withdrawal, and missing glasses or hearing aids.
- Prevention bundle: repeated reorientation with clock and calendar, glasses and hearing aids on and working, early mobilisation, hydration and nutrition, avoidance of catheters and restraints, clustered night care to protect sleep, pain control, and family presence.
- Safety: low bed, close or one-to-one observation, remove hazards, never restrain (restraints worsen agitation and injury); involve family to calm and accompany.
- Medication is a last resort for danger to self or others, per physician order; benzodiazepines are avoided except in alcohol withdrawal.
Common confusion
Delirium is mislabelled as dementia or dismissed as "sundowning" or stubbornness. The keys are speed and fluctuation: delirium appears acutely against the patient's baseline, wrecks attention and shifts hour to hour, while dementia worsens over years with attention intact until late. Also remember the quiet trap — the pleasantly drowsy hypoactive patient is as delirious as the shouting one, and is the one everyone misses.
Exam-focused takeaway
Scenario questions describe a postoperative elder picking at IV lines at night and drowsy by day, asking for the tool (CAM) and the first actions — check causes (bladder, oxygen, drugs), reorient, ensure glasses and hearing aids, and never restrain. MCQs test the CAM features and their combination rule, hypoactive subtype recognition, high-risk drugs and the prevention bundle. Long answers expect the differences between delirium and dementia plus a prevention plan.
Frequently asked questions
What is the Confusion Assessment Method and how is it used?
CAM screens for delirium using four features — acute onset with fluctuating course, inattention, disorganised thinking and altered level of consciousness. Delirium is indicated when features 1 and 2 are present with either 3 or 4.
What is hypoactive delirium and why is it dangerous?
Delirium presenting as drowsiness, withdrawal and slowness rather than agitation. Because the patient is quiet it is frequently missed, yet it still signals acute illness.
Which causes must be checked first in a newly confused older patient?
Infection, hypoxia, glucose and electrolyte abnormalities, dehydration, retention of urine or stool, pain, and new or changed drugs. Most cases are multifactorial.
Can delirium occur in a patient who already has dementia?
Yes — dementia is the strongest risk factor for delirium. Any sudden worsening in a known dementia patient is investigated as delirium rather than assumed to be progression.