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UT Arlington NURS 5315 - Delirium and Sleep Disturbance

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References1Delirium and Sleep DisturbanceAn average of 60-80% of older adults admitted to acute care develop a change in cognition or behavioral disturbance. Delirium is a common medical complication seen in the gravely ill population that predisposes them to increased mortality, prolonged hospital stay, and increased occurrence of long-term impairment of cognition (Lopez et al., 2020). Delirium is a type of acute confusional state characterized by an acute cognitive dysfunction that typically develops within a 2-3 day timeframe. Delirium is considered a cytokine-mediated response in which cytokines like C-reactive proteins, tumor necrosis marker alpha, interferons, and interleukins are released into the peripheral circulation precipitating disjunction of the neuron transmissions in the Central Nervous System. During the neuroinflammatory response, leukocytes attach to the blood-brain barrier's endothelial cells and disrupt cell adhesion. This action increases cytokines' permeability into the CNS, producing ischemia and neuronal apoptosis through oxidative stress (Maldonado, 2017).1Clinical manifestations of delirium have varying states. Most often exhibiting difficulty in concentration and attentiveness, behavioral disturbances, fluctuations in consciousness levels, insomnia or reversed sleep-wake cycle, hallucinations, tremors, seizures (McCance & Huether, 2019). Some risk factors contributing to delirium development are sleep disturbance, age and gender-related cerebral changes or underlying neurological disorders, pharmacological agents such as sedatives,and psychological stress (Maldonado, 2017).1The key concept discussed is sleep disturbance or deprivation and the importance of sleepin delirium prevention. Sleep plays a vital role in the recovery of patients. In the acute care setting, the critically ill often experience fragmented sleep and disturbed circadian rhythm where their sleep-wake cycle is reversed. Frequent nighttime awakening for bedside care, pain and2agitation from procedures, and noise contribute to sleep disturbance. Consequently, the loss of regular sleep-wake cycles and circadian rhythm leads to increased delirium incidence (Fontaine et al., 2020).1In the human body, as a natural response to darkness or nighttime, melatonin is synthesized from tryptophan and secreted by the pineal gland. Melatonin binds to the MT 1 and MT 2 receptors in the pituitary gland and retina, promoting nocturnal sleep and sleep-wake cycleregulation (Lopez et al., 2020). The lack of sleep or disturbance of sleep is attributed to impaired melatonin secretion. Studies regarding the relationship between sleep disturbance and delirium suggest that introducing exogenous melatonin may help lessen delirium in the critically ill through a negative feedback process, decreasing the process of breaking down melatonin and tryptophan. (Lopez et al., 2020).1It is prudent for a nurse practitioner to conduct a thorough history and physical to determine any underlying neurological disorder like dementia that can potentiate delirium. The Confusion Assessment Method tool helps identify and recognize delirium in the acute care setting when applied. Most often, these patients with delirium exhibit irregular sleep-wake cyclesthat can amplify deliriousness. The nurse practitioner can prescribe medications such as Melatonin and Ramelteon in conjunction with nonpharmacological interventions to help induce sleep and prevent or lessen the state of delirium.Based on the research conducted by Joseph (2017), exogenous melatonin appears to reduce delirium in older hospitalized patients and is well tolerated with minimal adverse effects. Another medication is Ramelteon, an MT1 and MT2 agonist, reduces sleep latency and improvessleep quality (Fontaine et al., 2020). This drug has a higher affinity for melatonin receptors than endogenous melatonin. The study conducted by Lopez et al. (2020) concluded that patients who3received Ramelteon positively impacted the number of CAM-ICU negative days. (Fontaine et al., 2020).1Sleep disturbance has shown to have a strong connection with the development of delirium. Sleep disturbance is a modifiable risk factor associated with increased delirium and extended hospital stay in gravely ill patients. Prescribing Melatonin and Ramelteon in conjunction with nonpharmacological interventions can help optimize sleep and lessen the effects of delirium or prevent the occurrence of delirium in hospitalized patients.111ReferencesFontaine, G. V., Der Nigoghossian, C., & Hamilton, L. A. (2020). Melatonin, ramelteon, suvorexant, and dexmedetomidine to promote sleep and prevent delirium in critically ill patients. Critical Care Nursing Quarterly, 43(2), 232–250. https://doi.org/10.1097/cnq.0000000000000304Joseph, S. (2017). Melatonin supplementation for the prevention of hospital-associated delirium. Mental Health Clinician, 7(4), 143–146. https://doi.org/10.9740/mhc.2017.07.143Lopez, C. N., Fuentes, A., Dhala, A., & Balk, J. (2020). Ramelteon for decreasing delirium in surgical intensive care unit patients. Clinical Medicine Insights: Psychiatry, 11, 117955732095122. https://doi.org/10.1177/1179557320951221Maldonado, J. R. (2017). Delirium pathophysiology: An updated hypothesis of the etiology of acute brain failure. International Journal of Geriatric Psychiatry, 33(11), 1428–1457. https://doi.org/10.1002/gps.48234McCance, K. L., & Huether, S. E. (2019). Pathophysiology - edited book: The biologic basis for disease in adults and children (8th ed.).


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