Delirium

Key Points

• Delirium is an acute, fluctuating confusional state that often signals serious underlying medical illness.
• Rapid identification and treatment of cause are critical to reduce morbidity and mortality.
• Delirium differs from dementia by sudden onset and variable attention/awareness changes.
• Nursing priorities include safety, reorientation support, family involvement, and prevention of complications.

Pathophysiology

Delirium reflects acute brain dysfunction from systemic or neurologic disruption, commonly involving infection, metabolic imbalance, medication effects, intoxication/withdrawal, hypoxia, or postoperative stress.

Older adults and medically complex clients are at high risk, and untreated delirium can rapidly worsen outcomes.

Classification

• Time course: Acute onset, fluctuating course.
• Subtype pattern: Hyperactive, hypoactive, or mixed delirium presentations.
• Cause pattern: Medical, toxicologic, withdrawal-related, or multifactorial etiologies.

Nursing Assessment

NCLEX Focus

New confusion in an older adult is delirium until proven otherwise.

• Assess onset pattern, attention changes, orientation, and fluctuation severity.
• Assess immediate medical contributors (infection, hypoxia, dehydration, electrolyte issues, medication change).
• Assess safety risk for falls, aspiration, line removal, and agitation-related injury.
• Assess sleep disturbance, pain, sensory deficits, and environmental overstimulation.
• Assess family observations of baseline cognition versus acute changes.

Nursing Interventions

• Escalate acute mental-status changes promptly for medical evaluation.
• Treat underlying causes while maintaining supportive, low-stimulation environment.
• Use frequent reorientation cues, hydration/nutrition support, and sleep hygiene strategies.
• Involve familiar caregivers/family to reduce distress and improve cooperation.
• Monitor closely for deterioration, withdrawal syndromes, and complication risk.

Sedation-First Pitfall

Sedating without cause-focused evaluation can mask worsening physiology and delay life-saving treatment.

Pharmacology

Pharmacologic decisions target underlying cause and severe agitation only when necessary for safety; nursing care emphasizes cautious monitoring for adverse effects and frequent reassessment of need.

Clinical Judgment Application

Clinical Scenario

A hospitalized older adult becomes abruptly disoriented overnight, pulls at lines, and alternates between agitation and drowsiness.

Recognize Cues: Sudden fluctuating cognition suggests delirium. Analyze Cues: Immediate medical causes are likely and potentially reversible. Prioritize Hypotheses: Priority is urgent medical workup plus injury prevention. Generate Solutions: Activate delirium protocol, review medications, and reduce environmental triggers. Take Action: Implement safety supports and coordinate rapid diagnostics/treatment. Evaluate Outcomes: Reassess cognition trend, cause correction, and complication prevention.

Related Concepts

• mild-neurocognitive-disorders - Differentiates gradual mild decline from acute delirium.
• dementia - Contrasts chronic progressive patterns with delirium fluctuations.
• emergency-situations-and-rapid-response - Guides urgent escalation pathways.
• violence-and-safety - Supports safe management of agitation and confusion.
• nursing-assessment-and-clinical-tools - Reinforces structured acute-status assessment.