**5. Delirium**

Delirium is a neurocognitive disorder characterized by an acute episode of confusion of memory, awareness, and thinking [65]. It is often a reversible state among patients undergoing maintenance hemodialysis. It could occur owing to a medical condition, uremia, intoxication, or drug adverse effect. Moreover, studies suggest that this disorder is more prevalent among elderly patients [65, 105]. A recent study found that delirium is independently associated with early mortality in the elderly after starting hemodialysis [106]. The acute delirium could lead to self-harm and death [107].

A rare kind of delirium in hemodialysis is dialysis disequilibrium syndrome, which is a serious form of complication. Headache, visual disturbance, nausea, and agitation are common symptoms of the syndrome, and in more serious cases, delirium, lethargy, seizures, or even coma may also occur [65]. It was noted during or following the initial round of dialysis. Additionally, long-term hemodialysis has increased reports of dialysis disequilibrium syndrome [65].

#### **5.1 Screening and diagnostic measures**

Nurses and physicians should be on the lookout for any signs of delirium and screen their patients for any changes in cognition or behavior. Any concerns or suspicions of delirium should be investigated further using a validated tool. The Confusion Assessment Method (CAM) is one of the most valuable tools for detecting delirium. It is designed to help medical professionals without backgrounds in psychiatry or mental health and recognize patients with delirium quickly in high-risk situations [108]. The assessment includes questions that aim to assess delirium through four criteria: (1) acute onset and fluctuating course; (2) intention; (3) disorganized thinking; and (4) altered level of consciousness. The CAM algorithm for the diagnosis of delirium requires having criteria 1 and 2 and either 3 or 4 [108]. Other available tools to assess

delirium include the Mini-Mental State Examination. As nurses provide frequent direct care for patients on hemodialysis, assessment of delirium using a validated tool should be integrated into renal nursing care for early detection of delirium.

#### **5.2 Management of delirium in hemodialysis**

Starting hemodialysis slowly and gently, using a high dialysate sodium concentration and adding osmotic agents (sodium, mannitol, and glucose) to the blood stream are all ways to avoid delirium in hemodialysis [109]. Other preventive measures include active communication with the patient, avoiding medication interactions, maintaining hydration, and managing the pain [65].

Management of underlying factors is a key for management of delirium [65]. Supportive management provided as appropriate to prevent aspiration and pressure sores. When delirium endangers patient safety or interferes with crucial treatments, pharmacologic treatment is necessary [65]. Antipsychotic medications, such as haloperidol, are drug of choice in the beginning. Benzodiazepines and some antidepressants have also been used for treatment of delirium. The management of underlying factors is critical in the treatment of delirium [65]. Supportive management is provided as appropriate to prevent aspiration and pressure sores. When delirium endangers patients' safety or interferes with crucial treatments, pharmacologic treatment is necessary [65]. In the beginning, haloperidol from antipsychotic medication is considered a drug of choice. Treatment for delirium has also included the use of benzodiazepines and various antidepressants drugs. Dialysis should be stopped in cases of seizure until vital signs stabilize [109].
