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• To understand how agitation secondary to hyperactive delirium can affect deteriorating patients
• To learn more about the burnout experienced by nurses when caring for patients with delirium
• To enhance your knowledge of why restraint should be a last resort in patients with delirium
Delirium is an under-recognised condition which adversely affects deteriorating patients. Delirium can be an acute or long-term condition and is associated with increased morbidity and mortality, and extended length of hospital stay. The management of delirium is often reactive rather than proactive, which can lead to the inappropriate use of chemical and physical restraint to control agitation secondary to hyperactive delirium. Caring for patients with delirium presents physical and emotional challenges for nurses, who are sometimes inclined to use restraint, which should be a last resort. This article describes the challenges of caring for patients with delirium, presents the risk factors for and assessment of delirium, and describes the management of agitation secondary to hyperactive delirium. Support and education for nurses caring for patients with delirium is essential to ensure optimal patient care and avoid staff burnout.
Nursing Standard. doi: 10.7748/ns.2021.e11730
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Teece A (2021) Managing agitation secondary to hyperactive delirium in deteriorating patients. Nursing Standard. doi: 10.7748/ns.2021.e11730
AcknowledgementThis article draws on work being undertaken for a PhD at the University of Leeds, for which the author is supervised by Professor John Baker and Associate Professor Helen Smith. The author would like to thank them for their continued support
Published online: 08 November 2021
Delirium has been defined as a rapid-onset, reversible and fluctuating condition characterised by inattention, changes in cognition, disordered sleep-wake cycles and increased or decreased psychomotor activity (American Psychiatric Association 2013). Delirium is associated with increased morbidity and mortality, prolonged hospital stays and psychological issues following discharge (Salluh et al 2015). There are three main subtypes of delirium, which are characterised by various psychomotor presentations: hyperactive, hypoactive and mixed delirium. This article focuses on hyperactive delirium, which is the least common but most recognisable type of delirium and one that presents specific challenges for hospital nurses caring for patients who are deteriorating physiologically (Krewulak et al 2018).
Hyperactive delirium is characterised by agitation, hypervigilance, and intolerance of clinical interventions and monitoring (Cavallazzi et al 2012). Agitation is defined as increased psychomotor activity (Chevrolet and Jolliet 2007), and can manifest through a range of behaviours, from fidgeting and restlessness to physical and verbal aggression. Patients with hyperactive delirium may disconnect medical devices and disrupt life-sustaining therapies (Salluh et al 2015). Furthermore, agitation and reduced co-operation with isolation procedures may lead to the intra-hospital spread of infectious diseases such as coronavirus disease 2019 (COVID-19) (Kotfis et al 2020).
It is important for nurses who care for deteriorating or critically ill patients to know how to assess for and manage delirium to avoid unnecessary further physiological or psychological deterioration. This article describes the challenges of caring for patients with delirium, presents the risk factors for and assessment of delirium, and describes the management of agitation secondary to hyperactive delirium.
• Delirium is a rapid-onset condition characterised by inattention, changes in cognition, disordered sleep-wake cycles and increased or decreased psychomotor activity
• Hyperactive delirium is characterised by agitation, hypervigilance, and intolerance of clinical interventions and monitoring
• It is important for nurses to know how to assess and manage hyperactive delirium to avoid unnecessary further physiological or psychological deterioration
• Physical and chemical restraint are sometimes used in patients with delirium, the rationale being to preserve patient safety
• Education on hyperactive delirium and agitation could reduce nurses’ reliance on physical restraint
Although delirium is a form of acute brain dysfunction, clinicians often regard it as less important than other forms of organ dysfunction, such as dysfunction of the respiratory or cardiovascular systems (Zamoscik et al 2017). In critical care, delirium is often considered inevitable and treated in a reactive rather than proactive manner. Nursing patients with psychomotor agitation is physically and emotionally challenging, and being allocated a patient with delirium is not always welcomed by critical care nurses (Williams 2007). The perception that patients with delirium present with ‘difficult’ or ‘deviant’ behaviour can lead to an unwillingness to engage with these patients and the perpetuation of negative stereotypes (Carveth 1995).
Patients with delirium experience delusions, hallucinations, disturbed sleep-wake cycles and hypervigilance. The delusions can involve feelings of persecution and the resulting fear can cause patients to become agitated or aggressive. For example, patients who have experienced delirium have described remembering being asked to take part in guerrilla warfare or being held captive (Svenningsen et al 2016). Memories of such delusions can merge with factual memories of critical care interventions and cause considerable distress. A study by Wade et al (2015) found that many patients who had been discharged from critical care experienced distressing intrusive memories of hallucinations and delusions. It is important that nurses caring for patients with delirium are aware of patients’ lived experience of delusions and hallucinations. Being able to consider what patients may be perceiving or feeling can support nurses to understand why patients may be agitated or aggressive and prompt a more person-centred management approach.
Critical care nurses have reported experiencing emotional and physical exhaustion from caring for patients with delirium, particularly on longer shifts (Yue et al 2015). Patients with hyperactive delirium may repeatedly dislodge medical devices and inadvertently injure staff. Violence or the threat of violence can lead to stress and burnout among nurses (Freeman et al 2016), as well as suboptimal team cohesion (Langley et al 2011). Nurse burnout and stress are associated with reduced quality of care (Langley et al 2011), reduced engagement with patients (Yue et al 2015) and suboptimal delivery of therapeutic interventions. Burnout may lead to nurses being more inclined to use restrictive rather than therapeutic management methods when caring for patients with hyperactive delirium (Teece et al 2020).
These challenges are likely to have been exacerbated by the COVID-19 pandemic, during which staff have been less able to take short breaks or access peer support because of infection prevention and control requirements. Other challenges brought about by the pandemic include the fact that delirium may be a feature of the neuro-invasive potential of the virus. A high proportion of patients with COVID-19 who receive critical care develop delirium and encephalopathy (Helms et al 2020, Kotfis et al 2020). Furthermore, environmental factors associated with the pandemic – such as isolation, the absence of visitors and reduced opportunities to engage with staff because of high workload and the use of personal protective equipment – have been linked to an exacerbation of delirium in hospitalised patients (Pun et al 2021).
The causes of delirium are multifactorial. Risk factors for delirium can be divided into pre-admission (predisposing) factors and post-admission factors:
• Pre-admission risk factors – these include existing cognitive impairment such as that seen in dementia, mental health disorders and hypertension (Zaal et al 2015). Alcohol use and nicotine use have also been linked with the development of delirium (Van Rompaey et al 2009, Heeder et al 2015).
• Post-admission risks factors – these include emergency admission, anticholinergic medicines, mechanical ventilation, invasive-access devices, deep continuous sedation and multi-organ failure (Zaal et al 2015).
Subjective assessment – which can be described as the clinician’s opinion about the patient’s presentation – has shown a marked under-diagnosis of delirium. In their study into the diagnosis of delirium, Van Eijk et al (2009) found that subjective assessment had a sensitivity to delirium of 29%, compared with 43-83% for validated assessment tools. A reliance on subjective assessment may lead to delays in addressing reversible factors for delirium such as withdrawing from alcohol or nicotine, taking new medicines, and experiencing electrolyte disturbances (Van Eijk 2012, Zaal et al 2015). Delirium management is an essential aspect of the management of critically ill patients and the use of a validated assessment tool can enable early and appropriate treatment, thereby having positive effects on patient outcomes (Trogrlić et al 2017). The commonly used delirium assessment tools are summarised in Table 1.
Those assessment tools detailed in Table 1 that have been developed for use in the intensive care unit (ICU) enable healthcare professionals to assess intubated patients, who are unable to answer questions verbally (Chanques et al 2018). In addition, the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) has been demonstrated to have a high sensitivity for detecting delirium (Chanques et al 2018).
National Institute for Health and Care Excellence (NICE) (2019) guidance emphasises the need to regularly assess patients for delirium using a validated tool, such as those described in Table 1, which are simple and quick to use and can be easily taught. However, challenges have been reported in integrating such assessment tools for delirium into daily nursing practice due to the perceived lower importance of delirium screening in comparison to other tasks, and staff require educational support to ensure that the formal assessment of patients for delirium is part of routine clinical care (Elliott 2014).
Delirium can be a dehumanising experience that can be exacerbated by the use of restraint. Non-pharmacological management is recommended by NICE (2019) as the first-line method of managing agitation secondary to hyperactive delirium, which reflects moves to humanise ICUs and acute care wards (Wilson et al 2019). The non-pharmacological management of delirium includes the identification of risk factors and reversible factors that can contribute to delirium and the management of these factors. For example, the physical environment in acute and critical care areas can be modified to reduce the incidence of delirium by providing calm and well-lit areas in the daytime, with easily visible analogue clocks to aid orientation to time and place (Herling et al 2018).
Clear communication from clinical staff and the use of written plans for daily rehabilitative activities such as mobilisation, physiotherapy and planned visits from relatives are recommended, together with providing patients with distractions such as listening to their favourite music or enjoying media such as television or the internet (Herling et al 2018, NICE 2019). In addition, the opportunity for patients to communicate with family members has been shown to reduce the incidence of post-operative delirium (Eghbali-Babadi et al 2017), while open visiting has also been recommended as part of the move to humanise intensive care and acute care (Wilson et al 2019).
Family involvement in care, reduction in sedation, early mobilisation and regular screening for delirium are all elements included in ICU care bundles (Marra et al 2017). The assessment and treatment of any underlying causes that may be contributing to the patient’s delirium is also important; for example, the use of alcohol, drugs and nicotine have all been associated with the development of delirium (Heeder et al 2015). If the patient is assessed for delirium early in their admission, any dependences can be managed pharmacologically to prevent the subsequent development of delirium.
If a patient’s agitation begins to endanger the patient themselves, staff or others, or if it begins to compromise the patient’s care, NICE (2019) recommends using verbal and non-verbal de-escalation methods in the first instance and, if these are ineffective, to administer a small dose of haloperidol.
While the use of pharmacology to reduce the severity or duration of delirium is not supported by the evidence, some pharmacological therapies including sedatives such as midazolam and antipsychotics such as haloperidol are used to control agitation and preserve the safety of patients and staff (Bourne 2008). However, sedation should not be regarded as an effective treatment for delirium; rather, it masks the symptoms of delirium, and prolonged sedation or periods of deep sedation are associated with an exacerbation of delirium (Svenningsen et al 2013, Zaal et al 2015).
The HOPE-ICU Trial demonstrated that haloperidol had no effect on the duration or severity of delirium (Page et al 2013). The authors concluded that haloperidol should be reserved for the treatment of intractable agitation that threatens the safety of patients and staff (Page et al 2013). In addition, low-dose prophylactic haloperidol has been shown to have no effect in preventing delirium (Pu et al 2018). The antipsychotic olanzapine has been used to treat hyperactive delirium in the past, but was removed from the NICE guidance in 2019 when this was last updated (NICE 2019). A short course of haloperidol is recommended for intractable agitation when non-pharmacological approaches have been ineffective. However, as previously discussed, haloperidol has no effect on the severity or duration of delirium and should be considered a rescue measure rather than a treatment.
Physical and chemical restraint are sometimes used in critical care areas, the rationale given being to preserve patient safety (Benbenbishty et al 2010). The Mental Capacity Act 2005 defines restraint as the use of force or the threat of the use of force to make someone do something that they are resisting, or the restriction of a person’s freedom of movement whether they are resisting or not. Martin and Mathisen (2005) defined physical restraint in critical care as involving ‘all patient articles, straps, bed linen and vest, used as an intervention to restrict a person’s freedom of movement or access to their own body’. In the UK, ‘patient articles’ commonly include padded gloves designed to prevent patients grabbing and/or dislodging medical devices for example, and soft wrist restraints (Bray et al 2004).
In the ICU, continuous sedation is commonly used to enable patients to tolerate interventions such as endotracheal intubation. In addition, for ICU patients experiencing agitation secondary to hyperactive delirium, pro re nata (PRN) or bolus sedation is sometimes used in addition to standard sedation as a form of chemical restraint to reduce agitation (Bray et al 2004).
Restraint should always be a last resort in all settings, including when caring for patients with hyperactive delirium in acute and critical care areas (NICE 2019). Physical restraint is associated with the exacerbation of delirium and can cause skin damage (Dolan and Dolan Looby 2017). Critical care nurses interviewed by Dolan and Dolan Looby (2017) stated that they would only use physical restraint with a patient experiencing delirium as a last resort, acknowledging that the management of delirium should start with addressing underlying causes and applying therapeutic non-pharmacological and pharmacological approaches.
There are wide variations in the use of restraint despite the existence of UK government ‘liberty protection safeguards’ (Department of Health and Social Care 2021), which aim to ensure consistency by stating specific situations where restraint is appropriate. However, it appears to be challenging to objectively determine the point at which restraint does become clinically appropriate (Teece et al 2020), which may partly explain the variations in practice. Nursing students and registered nurses require education and training that support the effective management of hyperactive delirium. Examples of this type of education include a ‘restraint decision wheel’ that supported nurses in making restraint decisions quickly and appropriately, and which have been demonstrated to reduce the use of restraint in critical care areas (Hurlock-Chorostecki and Kielb 2006).
The use of restraint can sometimes be dependent on an individual nurse’s ability or otherwise to manage agitation. Caring for patients with agitation secondary to delirium presents physical and emotional challenges for nurses. Some nurses have acknowledged that they may use chemical and physical restraint when caring for a patient with hyperactive delirium to preserve their own safety or to create space for respite and critical thinking (Freeman et al 2016). Therefore, support and education for nurses caring for patients with delirium is essential to ensure optimal patient care and avoid staff burnout.
Nurses should seek to regularly assess patients for delirium using a validated tool appropriate to their clinical area. The minimum recommendation is to assess patients once daily (NICE 2019), but patients may require more frequent assessment if deterioration or changes in their level of delirium are suspected.
Effective delirium care is an important aspect of humanising ICUs and acute care wards. Patients who are deteriorating can experience a loss of personhood because of the interventions they receive and how these are provided. Interventions can be undertaken because of clinical need but often not in collaboration with patients. Also, agitation secondary to hyperactive delirium is challenging to manage, since the communication between patient and nurse may be complicated by the delusions and hallucinations experienced by the patient (Svenningsen et al 2016). Chemical and physical restraint further contribute to dehumanisation by restricting the patient’s freedom of movement (Nin Vaeza et al 2020). Continuous education and clinical supervision are necessary to support those nurses caring for patients experiencing hyperactive delirium.
Delirium should be recognised as a clinically important form of organ dysfunction. Delirium and agitation management are under-emphasised in nursing education, while the lack of involvement of medical staff in managing delirium and agitation can cause resentment between nurses and doctors (Palacios-Ceña et al 2016). The decision to apply restraint commonly rests with nurses (Teece et al 2020), and Hurlock-Chorostecki and Kielb (2006) demonstrated that education and a change in culture could reduce nurses’ reliance on physical restraint. Greater medical engagement with delirium and agitation, alongside objective goal-setting, bedside guidance and a management plan for acute agitation, could reduce variations in practice and increase nurses’ confidence to manage delirium and agitation using therapeutic, non-restrictive methods (Teece et al 2020).
Where possible, fatigue should be considered when allocating patients with delirium to specific nurses. Regular breaks should be offered, and senior staff and managers should acknowledge the challenges patients with hyperactive delirium present to nurses (Teece et al 2021).
Delirium is a form of organ dysfunction prevalent among deteriorating patients and patients hospitalised in critical care areas. Hyperactive delirium manifests as psychomotor agitation that can be challenging to manage, particularly during a period of acute physiological deterioration when monitoring is required. Repeatedly caring for patients with agitation secondary to hyperactive delirium without support is associated with stress and burnout among nurses. It is crucial that delirium assessment tools are used appropriately, and that medical staff and nurses collaborate in pre-emptive planning to manage any potential agitation.
Education and support for nurses can reduce their reliance on chemical and physical restraint as methods of managing agitation, emphasise the role of non-pharmacological management, and increase awareness of reversible factors, eventually leading to a humanisation of patient care in acute and critical care areas.
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