"The nurse is the bedside advocate in discerning changes in the patient's cognition. Early and prompt recognition of changes can initiate the appropriate interventions to discourage the progressive nature of delirium. Delirium is a broad category for many alterations in the cognitive realm of the person experiencing advanced disease. Becoming better acquainted with the assessment, etiology and interventions to promote an improved quality of life is essential to help ease the transition of the dying patient" (Ferrell & Coyle, 2001).

Although most cases of delirium are treatable and reversible, studies suggest that delirium is under-recognized. Clinicians often fail to look for underlying factors and therefore fail to treat these causes of delirium. Patients in home care are even more likely to have their delirium go unrecognized by visiting health personnel because visits are so intermittent.

Delirium is characterized by fluctuating disturbances in consciousness, cognition, and perception, and occurs in 28% to 83% of patients near the end of life (Ingham & Breitbart, 1997; Plonk & Arnold, 2005), depending on the population studied and the criteria used (Casarett et al., 2001). Delirium may be obvious, but as many as half of the episodes are not noted by physicians. In home care, it is essential that the nurse be attentive to its prevalence in end-stage patients and be aware that cognitive changes may signal an undiagnosed delirium.

Three types of delirium have been noted: hyperactive, hypoactive, and mixed. Hyperactive, or "agitated" delirium, is characterized by restlessness and hallucinations; hypoactive, or "quiet" delirium, presents as a decreased sensorium or increased sedation; and the "mixed" type alternates between the agitated and the sedated forms. Regardless of presentation, delirium may be difficult to recognize, as it can be multifactorial and easily confused with dementia, sedation, and near-death awareness. In most cases, delirium is reversible, so careful assessment of the patient is essential.

Once suspected, identifying the cause of delirium is crucial. The nurse should have an accurate picture of the patient's baseline status. If the nurse has not been caring for the patient on a regular basis, a determined questioning of the patient's primary caregiver and others involved in the patient's care is necessary. If the patient's cognition has changed, the nurse should review the medication history and perform a complete physical examination, with a special focus on the Mini-Mental Status exam. Changes suggesting a deeper pathology, such as a new fever, or cloudy urine, may merit laboratory tests. It is difficult to say what these tests might be given the diversity of the cause of the delirium. Likely causes of delirium include urosepsis, impaction, overmedication, drug interaction, and/or myocardial infarction. Symptom management should be initiated while results of tests are pending. The Hospice and Palliative Nurses Association has several resources that help to identify delirium in end-stage disease and can help detect a probable cause.

These resources include:

* HPNA Teaching Sheet "Managing Delirium" for patients and family

* HPNA Teaching Sheet "Dementia" for patients and family

* HPNA "Tips for Dementia"

* HPNA "Tips for Pain with Inability to Communicate Verbally"

* Core curriculum for the generalist hospice and palliative care nurse

* Core curriculum for the licensed practical/vocational hospice and palliative nurse

* Teleconference April 2006: Altered Consciousness and Cognitive Impairment: Making Distinctions Among Neurologic Pathologies

All materials listed can be accessed at http://www://hpna.org.

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