The Problem of Increased Delirium in the Skilled Population
Each day, delirium crosses facility thresholds in increasingly large numbers. Administrators who increase the portion of Part A residents at their facility face the challenge of admitting a much higher portion of residents who suffer delirium. In fact, sixteen percent of newly skilled residents are delirious at the time of nursing home admission. Furthermore, of the patients who pass through nursing home doors with delirium, less than one-third are actually diagnosed, otherwise identified as delirious or have been treated for delirium.
Delirium is a temporary change in mental state that is primarily caused and sustained by an underlying acute medical problem. The cause is often hidden from providers behind sometimes dramatic changes in behavior or personality. Few nursing home providers are trained in delirium. Delirious patients often receive a psychiatric diagnosis other than delirium while in the hospital. They are also more likely to be prescribed new psychotropic medications during their hospital stay due to behavioral management issues. A delirious patient is very likely to have more falls and other injuries than other residents in the building. The delirious patient more often winds up returning to the med-surg hospital or going to a psychiatric facility.
Although there are a host of potential causes, major sources of delirium in the elderly are urinary tract or lower respiratory infections. Delirium is also caused by new medications or a new mix of multiple medications. Even resident constipation or dehydration can produce a delirium with "false" psychiatric symptoms. As relatively few in healthcare have been trained in delirium, the condition is often regarded as a dementia or major psychiatric disorder for months or years.
Delirium sufferers are more likely to exhibit disruptive behavioral problems even though there may be no
major psychiatric history or history of dementia. False negative lab findings can result in an extension of delirium by weeks or months before the underlying medical problem is finally resolved. Families may react with distress but they can be helpful in preventing falls and in providing the reassurance of familiarity to the confused resident. Family and staff support can be far more effective in calming down a delirious resident than psychotropic medications during the delirium episode.
Delirium is not a dementia because, unlike a dementia, it is temporary. Symptoms of delirium very gradually improve once the underlying medical condition is successfully treated and the patient recovers. However, when unrecognized and untreated, delirium can cause a permanent dementia or even death. The longer a delirium goes untreated, the more likely the outcome will eventually resemble dementia. Multiple episodes of delirium over time can also create brain damage and dementia.
Training and clinical policy may require upgrading. As the proportion of skilled patients increases at a facility, administrators and nursing leaders are likely to find themselves developing procedures to deal higher rates and higher intensity of the following: