We can use a range of strategies to help manage behavioural and psychological symptoms of dementia (BPSD). Show
Non-pharmacological strategies are the first line of action and require us to identify and address internal stressors, such as illness or care needs, and external stressors, such as noise and glare. Family and carers should be included in the development and implementation of the care plan. The following strategies may assist you develop a person centred intervention plan when these symptoms arise.1,2,3 Reassure and reduce triggers
WanderingWandering is one of the most troubling behavioural symptoms reported by family and carers. There are different patterns of wandering behaviour and different management issues and levels of risk. Screening tools can help differentiate between different types of wandering and help develop an individualised person-centred intervention6. Some strategies to try include:
SundowningSundowning is restlessness, increasing confusion or changed behaviours in a patient with dementia that can occur late in the afternoon or early evening. Some strategies to try include:
Anxiety or agitationIt is important tounderstand the reality the person with dementia is experiencing and validating this may help settle the patient. Some strategies to try include:
AggressionPhysical or verbal aggression can be triggered by issues such as fatigue, an over-stimulating environment, asking the patient too many questions at one time, asking the patient to perform tasks beyond their abilities, too many strangers in a noisy, crowded atmosphere, failure at simple tasks or confrontation with hospital staff. Some strategies to try include:
Hallucinations or false ideasThese can be present in later stages of dementia. The person may hear voices or sounds or see people or objects. This can cause severe reactions such as fear, distress, anxiety and agitation. Strategies include:
Disinhibited behaviourBy understanding why a patient is behaving in this way (for example due to memory loss, disorientation or discomfort), we can help avoid triggers. A patient may have forgotten where they are, how to dress, the importance of being dressed, where the bathroom is and how to use it; they may have confused the identity of a person; they may be feeling too hot or cold or their clothes may be too tight or itchy; or are confused about the time of day and what they should be doing. Some strategies to try include:
Pharmacological treatmentPsychotropic drugs can play an important but limited role in managing BPSD; there are modest benefits and significant potential adverse events3. They should be avoided where possible and used only if there is a risk of self-harm or harm to others, and only after a thorough examination has eliminated other possible causes (for example pain or illness) and where behavioural and psychological interventions were proven inadequate1,3. Pharmacological treatment will not assist with some behaviours, such as wandering or repetitive questioning7. Work closely with doctors to monitor medication effects. Refer to a geriatrician or specialist and pharmacist as part of the care team. Be aware that:
Pharmacological treatment should always be used in conjunction with a consistent, non-pharmacological management plan. 1. Ballarat Health Services, Understanding dementia: a guide for hospital staff. , [undated]. 2. Joosse, L.L., D. Palmer, and N.M. Lang, Caring for elderly patients with dementia: nursing interventions. Nursing: Research and Reviews 2013 3: p. 107-117. 3. The Royal Australian & New Zealand College of Psychiatrists, Assessment and Management of People with Behavioural and Psychological Symptoms of Dementia (BPSD): A handbook for NSW Health Clinicians, 2013. 4. International Psychogeriatric Association. Behavioural and psychological symptoms of dementia (BPSD) educational . 1998 [cited 2014 13 November]. 5. Alzheimer's Society Reducing the use of antipsychotic drugs: A guide to the treatment and care of behavioural and psychological symptoms of dementia 2011. 6. Dewing, J., Screening for wandering among older person’s with dementia. Nursing Older People, 2005. 17: p. 20-24. 7. Osser, D. and M. Fischer, Management of the behavioural and psychological symptoms of dementia: review of current data and best practices for health care providers., 2013, National Resource Centre for Academic Detailing.
My grandfather has turned 89 years old 2 months ago. He seems to have changed from then on. He always complains of seeing ants in the ceiling, or ants on the floor beside his bed. He sometimes forgets my name. Lately, he keeps on mumbling to himself and looks agitated. He doesn’t know where he is anymore, or what the present date is. I’m really worried that he is in the early stages of delirium. I think we should have him checked. DescriptionDelirium is a disturbance of consciousness and a change in cognition that develop rapidly over a short period (DSM-IV-TR). Statistics and IncidencesDelirium is common in the United States.
CausesThe DSM-IV-TR differentiates among the disorders of delirium by their etiology, although they share a common symptom presentation. Categories of delirium include the following: Differentiating delirium from dementia.
Clinical ManifestationsThe following symptoms have been identified with the syndrome of delirium: Infographic for recognizing the signs and symptoms of delirium. Image via: publichealth.hscni.net
Assessment and Diagnostic FindingsLaboratory tests that may be helpful for diagnosis include the following:
Medical ManagementWhen delirium is diagnosed or suspected, the underlying causes should be sought and treated.
Pharmacologic ManagementDelirium that causes injury to the patient or others should be treated with medications.
Nursing ManagementNursing management for a patient with delirium include the following: Nursing AssessmentNursing assessment should include:
Nursing DiagnosisNANDA nursing diagnoses for persons with delirium include:
Nursing Care Planning and GoalsThe major nursing care plan goals for delirium are:
Nursing InterventionsNursing interventions for patients with delirium include the following:
EvaluationThe outcome criteria includes:
Documentation GuidelinesDocumentation in a patient with delirium include:
Practice Quiz: DeliriumNursing practice questions for delirium. Please visit our nursing test bank page for more NCLEX practice questions. 1. Nurse Josefina is caring for a client who has been diagnosed with delirium. Which statement about delirium is true? A. It’s characterized by an acute onset and lasts about 1 month. B. It’s characterized by a slowly evolving onset and lasts about 1 week. C. It’s characterized by a slowly evolving onset and lasts about 1 month. D. It’s characterized by an acute onset and lasts hours to a number of days. 1. Answer: D. It’s characterized by an acute onset and lasts hours to a number of days
2. Edward, a 66-year-old client with slight memory impairment and poor concentration, is diagnosed with primary degenerative dementia of the Alzheimer’s type. Early signs of this dementia include subtle personality changes and withdrawal from social interactions. To assess for progression to the middle stage of Alzheimer’s disease, the nurse should observe the client for: A. Occasional irritable outbursts. D. Inability to perform self-care activities. 2. Answer: B. Impaired communication.
3. Loretta, a newly admitted client was diagnosed with delirium and has a history of hypertension and anxiety. She had been taking digoxin, furosemide (Lasix), and diazepam (Valium) for anxiety. This client’s impairment may be related to which of the following conditions? A. Infection B. Metabolic acidosis C. Drug intoxication D. Hepatic encephalopathy 3. Answer: C. Drug intoxication.
4. Nurse Ron enters a client’s room, the client says, “They’re crawling on my sheets! Get them off my bed!” Which of the following assessment is the most accurate? A. The client is experiencing aphasia. B. The client is experiencing dysarthria. C. The client is experiencing a flight of ideas. D. The client is experiencing visual hallucination. 4. Answer: D. The client is experiencing visual hallucination.
5. Which of the following descriptions of a client’s experience and behavior can be assessed as an illusion? A. The client tries to hit the nurse when vital signs must be taken. B. The client says, “I keep hearing a voice telling me to run away.” C. The client becomes anxious whenever the nurse leaves the bedside. D. The client looks at the shadow on a wall and tells the nurse she sees frightening faces on the wall. 5. Answer: D. The client looks at the shadow on a wall and tells the nurse she sees frightening faces on the wall.
ReferencesSources and references for this study guide for delirium:
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