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“Those who are free of resentful thoughts surely find peace.”



  • Examine the origins of delirium

  • Find out how to assess patients who are cognitively impaired

  • Describe how to prevent escalation with the cognitively impaired

  • Delineate de-escalation practices for the cognitively impaired

  • Discuss how the patient’s family can help

  • Explore how to ensure the safety of cognitively impaired patients

Cognition is defined as the innate ability to think and reason (Townsend, 2015). Cognitive impairments result in alterations in a person’s perception of reality and difficulties with communication. This can lead to situations in which de-escalation is necessary for safety.

One common type of cognitive impairment is delirium. The DSM-5 describes delirium as a mental state characterized by a decreased ability to direct, focus, maintain, and shift attention (American Psychiatric Association [APA], 2013). A reduced awareness of the immediate environment, impaired memory, and difficulties with logical reasoning are other indicators of delirium. This disturbance in cognitive impairment represents a change from usual mental functions.

Delirium generally manifests as confusion, excitement, disorientation, misper-ceptions of reality (including illusions or visual misinterpretations, and hallucinations), or a clouding of consciousness (Twamley et al., 2002). Some patients with delirium may also experience a loss of inhibition (Oh, Fong, Hshieh, & Inouye, 2017; Stuart & Sundeen, 1991). Behaviors associated with delirium include fluctuating levels of awareness, restlessness, agitation, aggression, delusions, disorganized thought processes, and impaired judgment and decision-making.

Delirium usually develops over a short period of time, from a few hours to several days. The course of delirium is brief, from one week to one month. The severity of delirium may fluctuate throughout the day, depending on the underlying cause.

Delirium is a common psychiatric illness among medically compromised patients. Often it is a direct physiological consequence of another medical condition. It may also be a result of substance intoxication or withdrawal, of exposure to a toxin, or a combination of these factors. Delirium is usually reversible—especially with early recognition and treatment, as well as treatment of the underlying medical condition causing the delirium (APA, 2013). However, because of delirium’s association with other medical illnesses, its presence can be a harbinger of significant mortality and morbidity.


The prevalence of delirium is 1% to 2%. Although delirium can affect any age group, risk increases with age, rising to 14% in individuals over age 85. Delirium is most prevalent among hospitalized older adults: between 10% and 30% in emergency departments, where it often indicates an untreated medical illness (APA, 2013).


There are multiple stressors that affect brain function and may cause delirium. Some of these are hypoxias from medical conditions listed in Table 14.1.

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TABLE 14.1 Medical Conditions Associated With Delirium




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