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Montgomery A, Smerdely P, Hickman L, Traynor V. Comparing the delirium objective structured clinical examination (OSCE) education package to standard education for post-registration nurses: A randomised controlled trial. NURSE EDUCATION TODAY 2024; 139:106211. [PMID: 38676962 DOI: 10.1016/j.nedt.2024.106211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 03/26/2024] [Accepted: 04/07/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND A recent pilot study demonstrated that an interactive delirium educational intervention, The Delirium OSCE Education Package, had a positive impact on self-perceptions of confidence and competence in the use of delirium assessment tools and delirium knowledge; delirium knowledge scores; clinical practice; and planned practice change for participants. However, it is not known if The Delirium OSCE Education Package is superior to standard methods of professional development education. OBJECTIVE To determine if The Delirium OSCE Education Package is superior to standard methods of professional development education on observations of delirium care in practice scores for post-registration nurses. DESIGN Clustered randomised, controlled, and observer-blinded, multisite superiority trial with two parallel groups at each site. SETTINGS Three private hospitals across New South Wales, Australia. PARTICIPANTS Registered nurses (RNs) (n = 153) or enrolled nurses (ENs) (n = 37) working in the eligible inpatient medical or surgical wards at each site. METHODS Within each hospital site wards were clusters, with wards rather than individuals being randomised for The Delirium OSCE Education Package or standard professional development education at a ratio of 1:1. The primary outcome was observations of delirium care in practice, 6-weeks post (T1) allocated intervention. Secondary outcomes were self-perceived confidence and competence (self-efficacy) in delirium assessment tools and delirium knowledge; and delirium knowledge scores. RESULTS A total of 51.3 % (n = 20) in the intervention group obtained a satisfactory observation of delirium care in practice score, compared to 34.9 % (n = 15) in the control group (p = 0.134, χ2). The odds of a satisfactory observation of delirium care in practice score for the intervention group was 10.1 times higher than the control (p = 0.009). The mean MCQ score and perceptions of confidence and competence in the intervention and control group increased from baseline to six-weeks post-intervention, however, there was no significant difference between the groups. CONCLUSION The Delirium OSCE Education Package provides the foundation for facilitating change in delirium care. It is recommended that The Delirium OSCE Education Package is implemented as part of a multicomponent strategy involving a validation delirium screening and assessment tool, hospital-specific policy, interprofessional education, and delirium champions. Future studies are needed to evaluate the sustainability of the intervention and if there is a positive impact on patient-level outcomes.
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Affiliation(s)
- Amy Montgomery
- School of Nursing, University of Wollongong, Northfields Ave, Wollongong, NSW 2522, Australia.
| | - Peter Smerdely
- School of Nursing, University of Wollongong, Northfields Ave, Wollongong, NSW 2522, Australia; Aged Care Department, St. George Hospital, Kogarah, Australia; School of Public Health & Community Medicine, University of New South Wales, Australia.
| | - Louise Hickman
- Health University of Wollongong, Northfields Ave, Wollongong, NSW, 2522, Australia..
| | - Victoria Traynor
- School of Nursing, University of Wollongong, Northfields Ave, Wollongong, NSW 2522, Australia.
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Nydahl P, Liu K, Bellelli G, Benbenishty J, van den Boogaard M, Caplan G, Chung CR, Elhadi M, Gurjar M, Heras-La Calle G, Hoffmann M, Jeitziner MM, Krewulak K, Mailhot T, Morandi A, Nawa RK, Oh ES, Collet MO, Paulino MC, Lindroth H, von Haken R. A world-wide study on delirium assessments and presence of protocols. Age Ageing 2024; 53:afae129. [PMID: 38952186 DOI: 10.1093/ageing/afae129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/26/2024] [Indexed: 07/03/2024] Open
Abstract
BACKGROUND Delirium is a common complication of older people in hospitals, rehabilitation and long-term facilities. OBJECTIVE To assess the worldwide use of validated delirium assessment tools and the presence of delirium management protocols. DESIGN Secondary analysis of a worldwide one-day point prevalence study on World Delirium Awareness Day, 15 March 2023. SETTING Cross-sectional online survey including hospitals, rehabilitation and long-term facilities. METHODS Participating clinicians reported data on delirium, the presence of protocols, delirium assessments, delirium-awareness interventions, non-pharmacological and pharmacological interventions, and ward/unit-specific barriers. RESULTS Data from 44 countries, 1664 wards/units and 36 048 patients were analysed. Validated delirium assessments were used in 66.7% (n = 1110) of wards/units, 18.6% (n = 310) used personal judgement or no assessment, and 10% (n = 166) used other assessment methods. A delirium management protocol was reported in 66.8% (n = 1094) of wards/units. The presence of protocols for delirium management varied across continents, ranging from 21.6% (on 21/97 wards/units) in Africa to 90.4% (235/260) in Australia, similar to the use of validated delirium assessments with 29.6% (29/98) in Africa to 93.5% (116/124) in North America. Wards/units with a delirium management protocol [n = 1094/1664, 66.8%] were more likely to use a validated delirium test than those without a protocol [odds ratio 6.97 (95% confidence interval 5.289-9.185)]. The presence of a delirium protocol increased the chances for valid delirium assessment and, likely, evidence-based interventions. CONCLUSION Wards/units that reported the presence of delirium management protocols had a higher probability of using validated delirium assessments tools to assess for delirium.
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Affiliation(s)
- Peter Nydahl
- Nursing Research, University Hospital Schleswig-Holstein, Arnold-Heller-Str. 3, 24105 Kiel, Germany
- Institute of Nursing Science and Development, Paracelsus Medical University, Strubergasse 21, 5020 Salzburg, Austria
| | - Keibun Liu
- Critical Care Research Group, The Prince Charles Hospital, 627 Rode Rd, Chermside QLD 4032, Australia
- Institute for Molecular Bioscience (IMB), The University of Queensland, 306 Carmody Rd, St Lucia QLD, 4067, Queensland, Australia
- Non-Profit Organization ICU Collaboration Network (ICON), 2-15-13 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Giuseppe Bellelli
- School of Medicine and Surgery, Milano-Bicocca University, Piazza dell'Ateneo Nuovo, 1, 20126 Milano, Italy
- Acute Geriatric Unit, IRCCS San Gerardo Foundation, Via Pergolesi 33, 20900 Monza, Italy
| | - Julie Benbenishty
- Hebrew University Faculty of Medicine School of Nursing, PO Box 12272, Jerusalem 91120, Israel
| | - Mark van den Boogaard
- Department Intensive Care, Radboud University Medical Center, 10 Geert Grooteplein Zuid, 6525 GA, Nijmegen, The Netherlands
| | - Gideon Caplan
- Department of Geriatric Medicine, Prince of Wales Hospital Sydney, 320-346 Barker St, Randwick NSW 2031, Sydney, Australia
- University of New South Wales, Gate 9, High St, The Chancellery Kensington, 2052, NSW Sydney, Australia
| | - Chi Ryang Chung
- Department of Critical Care Medicine and Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro Gangnam-gu. Seoul, Korea 06351, South Korea
| | - Muhammed Elhadi
- Faculty of Medicine, University of Tripoli, University Road, Al-Furnaje Tripoli, PO Box 13932, Tripoli, Libya
| | - Mohan Gurjar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Rae Bareli Road, Lucknow-226014, Uttar Pradesh, India
| | - Gabi Heras-La Calle
- Director of the International Research Project for the Humanization of Intensive Care Units (Proyecto HU-CI), Madrid, Spain
- Intensive Care Unit, Hospital Universitario de Jaén, Av. del Ejército Español, 10, 23007 Jaén, Spain
| | - Magdalena Hoffmann
- Research Unit for Safety and Sustainability in Healthcare, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Marie-Madlen Jeitziner
- Department of Intensive Care Medicine, University Hospital, Freiburgstrasse 18, 3010 Bern, Switzerland
- Inselspital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
- Institute of Nursing Science (INS), Department of Public Health (DPH), Faculty of Medicine, University of Basel, Petersplatz 1, Postfach, 4001 Basel, Switzerland
| | - Karla Krewulak
- Department of Critical Care Medicine, Alberta Health Services and University of Calgary, 3330 Hospital Drive NW Calgary, Alberta, T2N 4N1, Canada
| | - Tanya Mailhot
- Montreal Heart Institute Research Center, Faculty of Nursing, Université de Montréal, 680 Sherbrooke West, Montreal QC, H3A 2M7, Canada
| | - Alessandro Morandi
- Intermediate Care and Rehabilitation, Azienda Speciale Cremona Solidale, Via Brescia 207, 26100 Cremona, Italy
- Parc Sanitari Per Vergili, Val d'Hebron Institute of Research, Passeig de la Vall d'Hebron, 119-129, 08035 Barcelona, Spain
| | - Ricardo Kenji Nawa
- Hospital Israelita Albert Einstein, Av. Albert Einstein, 627, São Paulo, SP 05652-900, Brazil
| | - Esther S Oh
- Departments of Medicine, Psychiatry and Behavioral Sciences, and Pathology, Johns Hopkins University School of Medicine, 733 N. Broadway, MD 21205 Baltimore, ML, USA
| | - Marie O Collet
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, and Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Maria Carolina Paulino
- Department of Intensive Care, Hospital da Luz Lisboa, 1150-082 Lisbon, Portugal
- NOVA Medical School, New University of Lisbon, 1150-199 Lisbon, Portugal
- Department of Intensive Care, Hospital de São Francisco Xavier, CHLO, 1500-650 Lisbon, Portugal
| | - Heidi Lindroth
- Division of Nursing Research, Department of Nursing, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
- Center for Aging Research, Regenstrief Institute, School of Medicine, Indiana University, 1101 W 10th St, Indianapolis, IN 46202, USA
| | - Rebecca von Haken
- Department of Anesthesiology, University Hospital Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
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Tomlinson EJ, Schnitker LM, Casey PA. Exploring Antipsychotic Use for Delirium Management in Adults in Hospital, Sub-Acute Rehabilitation and Aged Care Settings: A Systematic Literature Review. Drugs Aging 2024; 41:455-486. [PMID: 38856874 PMCID: PMC11193698 DOI: 10.1007/s40266-024-01122-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2024] [Indexed: 06/11/2024]
Abstract
BACKGROUND International guidelines discourage antipsychotic use for delirium; however, concerns persist about their continued use in clinical practice. OBJECTIVES We aimed to describe the prevalence and patterns of antipsychotic use in delirium management with regard to best-practice recommendations. Primary outcomes investigated were prevalence of use, antipsychotic type, dosage and clinical indication. METHODS Eligibility criteria: studies of any design that examined antipsychotic use to manage delirium in adults in critical care, acute care, palliative care, rehabilitation, and aged care were included. Studies of patients in acute psychiatric care, with psychiatric illness or pre-existing antipsychotic use were excluded. INFORMATION SOURCES we searched five health databases on 16 August, 2023 (PubMed, CINAHL, Embase, APA PsycInfo, ProQuest Health and Medical Collection) using MeSH terms and relevant keywords, including 'delirium' and 'antipsychotic'. Risk of bias: as no included studies were randomised controlled trials, all studies were assessed for methodological quality using the Mixed Methods Appraisal Tool. SYNTHESIS OF RESULTS descriptive data were extracted in Covidence and synthesised in Microsoft Excel. RESULTS Included studies: 39 studies published between March 2004 and August 2023 from 13 countries (n = 1,359,519 patients). Most study designs were retrospective medical record audits (n = 16). SYNTHESIS OF RESULTS in 18 studies, participants' mean age was ≥65 years (77.79, ±5.20). Palliative care had the highest average proportion of patients with delirium managed with antipsychotics (70.87%, ±33.81%); it was lower and varied little between intensive care unit (53.53%, ±19.73%) and non-intensive care unit settings [medical, surgical and any acute care wards] (56.93%, ±26.44%) and was lowest in in-patient rehabilitation (17.8%). Seventeen different antipsychotics were reported on. In patients aged ≥65 years, haloperidol was the most frequently used and at higher than recommended mean daily doses (2.75 mg, ±2.21 mg). Other antipsychotics commonly administered were olanzapine (mean 11 mg, ±8.54 mg), quetiapine (mean 64.23 mg, ±43.20 mg) and risperidone (mean 0.97 mg, ±0.64 mg). CONCLUSIONS The use of antipsychotics to manage delirium is strongly discouraged in international guidelines. Antipsychotic use in delirium care is a risk for adverse health outcomes and a longer duration of delirium, especially in older people. However, this study has provided evidence that clinicians continue to use antipsychotics for delirium management, the dose, frequency and duration of which are often outside evidence-based guideline recommendations. Clinicians continue to choose antipsychotics to manage delirium symptoms to settle agitation and maintain patient and staff safety, particularly in situations where workload pressures are high. Sustained efforts are needed at the individual, team and organisational levels to educate, train and support clinicians to prioritise non-pharmacological interventions early before deciding to use antipsychotics. This could prevent delirium and avert escalation in behavioural symptoms that often lead to antipsychotic use.
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Affiliation(s)
- Emily J Tomlinson
- Deakin University, Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Geelong, Victoria, Australia.
- Deakin University, School of Nursing and Midwifery, Geelong, Victoria, Australia.
| | - Linda M Schnitker
- School of Nursing, Queensland University of Technology, Kelvin Grove, Brisbane, QLD, Australia
- Bolton Clarke Research Institute, Kelvin Grove, Brisbane, QLD, Australia
| | - Penelope A Casey
- Deakin University, School of Nursing and Midwifery, Geelong, Victoria, Australia
- Deakin University, Centre for Quality and Patient Safety Research-Eastern Health Partnership, Geelong, Victoria, Australia
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Lozano-Vicario L, Robles-Raya MJ, Del Val-Lafaja A, Cancio-Trujillo JM, Sánchez-García E, García-Meana J, Ferrara MC, Bellelli G, Gual N. [Multicenter cross-sectional study on the prevalence of delirium in orthogeriatric units: «DELFRA 24 study» protocol]. Rev Esp Geriatr Gerontol 2024; 59:101431. [PMID: 37918323 DOI: 10.1016/j.regg.2023.101431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/30/2023] [Accepted: 10/03/2023] [Indexed: 11/04/2023]
Abstract
INTRODUCTION Delirium is the most common perioperative complication in older adults with hip fracture (HF), leading to a catastrophic impact on their functional recovery and cognitive status. Currently, the true prevalence of this syndrome is unknown as its detection and management are not standardized in clinical practice. METHODS A multicenter observational cross-sectional study will be conducted nationwide, involving different orthogeriatric units in Spain. The prevalence of delirium will be assessed using the 4AT scale, along with its characteristics and its relationship with other geriatric syndromes, sociodemographic variables, surgical characteristics, and laboratory parameters. RESULTS Data collection is scheduled to take place on World Delirium Day (Wednesday, March 13, 2024), and therefore, the results are expected during the second or third quarter of 2024. CONCLUSIONS Understanding the real prevalence and characteristics of delirium in older adults with HF could contribute to the development of strategies for its detection and management, reducing the impact of its consequences.
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Affiliation(s)
- Lucía Lozano-Vicario
- Grupo de trabajo de Delirium de la Sociedad Española de Geriatría y Gerontología (SEGG); Servicio de Geriatría, Hospital Universitario de Navarra, Pamplona, Navarra, España.
| | - María José Robles-Raya
- Grupo de trabajo de Delirium de la Sociedad Española de Geriatría y Gerontología (SEGG); Servicio de Geriatría, Parc de Salut Mar, Barcelona, España
| | - Alodia Del Val-Lafaja
- Grupo de trabajo de Delirium de la Sociedad Española de Geriatría y Gerontología (SEGG); Servicio de Geriatría, Hospital Universitario Miguel Servet, Zaragoza, España
| | - José Manuel Cancio-Trujillo
- Grupo de trabajo de Delirium de la Sociedad Española de Geriatría y Gerontología (SEGG); Servicio de Geriatría y Cuidados Paliativos, Centro de Salud El Carme Badalona Servicios Asistenciales, Badalona, Barcelona, España
| | - Elisabet Sánchez-García
- Grupo de trabajo de Delirium de la Sociedad Española de Geriatría y Gerontología (SEGG); Servicio de Geriatría, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Javier García-Meana
- Grupo de trabajo de Delirium de la Sociedad Española de Geriatría y Gerontología (SEGG); Unidad del Paciente Crónico Complejo, Hospital General Universitario Santa María del Rosell, Cartagena, Murcia, España
| | | | | | - Neus Gual
- Grupo de trabajo de Delirium de la Sociedad Española de Geriatría y Gerontología (SEGG); Parc Sanitari Pere Virgili, Barcelona, España; Universidad Autónoma de Barcelona, Barcelona, España
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Zilezinski M, Lohrmann R, Hauß A, Bergjan M. [Development and content validity of a questionnaire to assess knowledge about delirium]. Z Gerontol Geriatr 2023; 56:132-138. [PMID: 35080647 PMCID: PMC8791090 DOI: 10.1007/s00391-022-02015-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 12/21/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Delirium is a neuropsychiatric syndrome that can have serious consequences and is often overlooked by healthcare professionals. The level of knowledge about delirium is often insufficient among nursing and medical staff. At the current time there is no suitable questionnaire to record the level of knowledge in German-speaking countries. AIM Development of a questionnaire and evaluation of content validity. METHODS Following a literature search to identify current best practice, several questionnaires were identified. An already published questionnaire with the dimensions of basic knowledge of delirium and risk factors has been translated, adapted and extended by the dimension of nonpharmacological delirium prevention. Delirium experts assessed the relevance of the questionnaire items in two rounds of reviews. Content validity was calculated using the Content Validity Index (CVI) at item (I-CVI) and scale (S-CVI) level. Additionally, the modified Kappa (k*) was calculated using a lower 95% confidence interval (CI). RESULTS The original 30-item questionnaire was expanded to include 18 delirium prevention items. After the first round of scoring 30 out of 48 items showed good to excellent I‑CVI scores. Considering the comments, 6 items were discarded and 12 were adapted in terms of language and content. In the final version of the questionnaire 41 items with excellent scores remained. The total scale score increased from 0.88 in the first version to 1.0 in the final version. Nurses were identified as the target group, potentially also therapists and medical personnel. CONCLUSION The delirium knowledge questionnaire is content-valid.
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Affiliation(s)
- Max Zilezinski
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Geschäftsbereich Pflegedirektion - Pflegewissenschaft, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.,Universitätsmedizin Halle (Saale), AG Versorgungsforschung
- Pflege im Krankenhaus, Department für Innere Medizin, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Deutschland.,Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, Dorothea Erxleben Lernzentrum Halle (DELH), Projekt FORMAT, Magdeburger Straße 12, 06112, Halle (Saale), Deutschland
| | - Renée Lohrmann
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Geschäftsbereich Pflegedirektion - Pflegewissenschaft, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
| | - Armin Hauß
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Geschäftsbereich Pflegedirektion - Pflegewissenschaft, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
| | - Manuela Bergjan
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Geschäftsbereich Pflegedirektion - Pflegewissenschaft, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
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Noble E, McCartney H, MacLullich AM, Shenkin SD, Muniz-Terrera G, Evans JJ, Davis D, Sandeman D, Tieges Z. Assessing Recovery from Delirium: An International Survey of Healthcare Professionals Involved in Delirium Care. DELIRIUM COMMUNICATIONS 2022; 1:56675. [PMID: 36968519 PMCID: PMC7614362 DOI: 10.56392/001c.56675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
Background A crucial part of delirium care is determining if the delirium episode has resolved. Yet, there is no clear evidence or consensus on which assessments clinicians should use to assess for delirium recovery. Objective To evaluate current opinions from delirium specialists on assessment of delirium recovery. Design Online questionnaire-based survey distributed internationally to healthcare professionals involved in delirium care. Methods The survey covered methods for assessing recovery, the importance of different symptom domains for capturing recovery, and local guidance or pathways that recommend monitoring for delirium recovery. Results Responses from 199 clinicians were collected. Respondents were from the UK (51%), US (13%), Australia (9%), Canada (7%), Ireland (7%) and 16 other countries. Most respondents were doctors (52%) and nurses (27%). Clinicians worked mostly in geriatrics (52%), ICUs (21%) and acute assessment units (17%). Ninety-four percent of respondents indicated that they conduct repeat delirium assessments (i.e., on ≥2 occasions) to monitor delirium recovery. The symptom domains considered most important for capturing recovery were: arousal (92%), inattention (84%), motor disturbance (84%), and hallucinations and delusions (83%). The most used tool for assessing recovery was the 4 ’A’s Test (4AT, 51%), followed by the Confusion Assessment Method (CAM, 26%), the CAM for the ICU (CAM-ICU, 17%) and the Single Question in Delirium (SQiD, 11%). Twenty-eight percent used clinical features only. Less than half (45%) of clinicians reported having local guidance that recommends monitoring for delirium recovery. Conclusions The survey results suggest a lack of standardisation regarding tools and methods used for repeat delirium assessment, despite consensus surrounding the key domains for capturing delirium recovery. These findings emphasise the need for further research to establish best practice for assessing delirium recovery.
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Montgomery A, Baird L, Traynor V, Chang H, Smerdely P. Teaching delirium to undergraduate medical students: Exploring the effects of a cross‐professional group objective structured clinical examination compared to standard education. Australas J Ageing 2022; 42:118-126. [PMID: 36300802 DOI: 10.1111/ajag.13144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 09/20/2022] [Accepted: 09/26/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To compare a cross-professional facilitated delirium group objective structured clinical examination (GOSCE) educational intervention with standard delirium education for medical students during clinical placement, and explore the differences in the examiner's written feedback between the two groups. METHODS A non-randomised clustered controlled designed study at a single metropolitan university across several campuses in Sydney, Australia. A convenience sample of third-year medical students was recruited. Students' knowledge, communication, and clinical reasoning skills were assessed using a delirium case mock OSCE at the end of the academic year. The OSCE marks and the examiner's feedback for the intervention and control group were compared. RESULTS The intervention group (n = 41) had a higher total mean OSCE mark compared to the control group (n = 29) (36.5, SD 2.9 vs. 33.7, SD 2.9, p < 0.001). Content analysis of the examiner's feedback showed the intervention group had a greater understanding of the need for forward planning and future cognitive assessments, and the roles of the interdisciplinary team in delirium care. CONCLUSIONS The innovative cross-professional facilitated delirium GOSCE education was effective in increasing delirium knowledge, communication, and clinical reasoning skills compared to conventional education for medical students during clinical placement. Further studies are needed to investigate how this is translated into practice.
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Affiliation(s)
- Amy Montgomery
- School of Nursing University of Wollongong Wollongong New South Wales Australia
- Illawarra Health and Medical Research Institute University of Wollongong Wollongong New South Wales Australia
| | - Louise Baird
- Department of Aged Care St. George Hospital Kogarah New South Wales Australia
- St. George and Sutherland Clinical School University of New South Wales Sydney New South Wales Australia
| | - Victoria Traynor
- School of Nursing University of Wollongong Wollongong New South Wales Australia
- Illawarra Health and Medical Research Institute University of Wollongong Wollongong New South Wales Australia
| | - Hui‐Chen (Rita) Chang
- School of Nursing University of Wollongong Wollongong New South Wales Australia
- Illawarra Health and Medical Research Institute University of Wollongong Wollongong New South Wales Australia
| | - Peter Smerdely
- School of Nursing University of Wollongong Wollongong New South Wales Australia
- Department of Aged Care St. George Hospital Kogarah New South Wales Australia
- School of Public Health and Community Medicine University of New South Wales Sydney New South Wales Australia
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Vreeswijk R, Maier AB, Kalisvaart KJ. Recipe for primary prevention of delirium in hospitalized older patients. Aging Clin Exp Res 2022; 34:2927-2944. [PMID: 36131074 DOI: 10.1007/s40520-022-02249-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 09/03/2022] [Indexed: 11/29/2022]
Abstract
Delirium is an acute fluctuating syndrome characterized by a change in consciousness, perception, orientation, cognition, sleep-wake rhythm, psychomotor skills, and the mood and feelings of a patient. Delirium and delirium prevention remain a challenge for healthcare professionals, especially nurses who form the basis of patient care. It also causes distress for patients, their caregivers and healthcare professionals. However, delirium is preventable in 30-40% of cases. The aim of this article is to summarize the delirium risk models, delirium screening tools, and (non-pharmacological) delirium prevention strategies. A literature search of review articles supplemented by original articles published in PubMed, Cinahl, and Cochrane between 1 January 2000 and 31 December 2020 was carried out. Among the older patients, delirium is a common condition with major consequences in terms of mortality and morbidity, but prevention is possible. Despite the fact that delirium risk models, delirium screening scales and non-pharmacological prevention are available for the development of a hospital delirium prevention programme, such a programme is still not commonly used on a daily basis.
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Affiliation(s)
- Ralph Vreeswijk
- Department of Geriatric Medicine, Spaarne Gasthuis Haarlem, Boerhavelaan 22, 2035 RC, Haarlem, The Netherlands.
| | - Andrea B Maier
- Department of Human Movement Sciences, @AgeAmsterdam, Faculty of Behavioral and Movement Sciences, Amsterdam Movement Sciences, Vrije Universiteit, Amsterdam, The Netherlands.,Healthy Longevity Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Centre for Healthy Longevity, @AgeSingapore, National University Health System, Singapore, Singapore
| | - Kees J Kalisvaart
- Department of Geriatric Medicine, Spaarne Gasthuis Haarlem, Boerhavelaan 22, 2035 RC, Haarlem, The Netherlands
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Proposing a Scientific and Technological Approach to the Summaries of Clinical Issues of Inpatient Elderly with Delirium: A Viewpoint. Healthcare (Basel) 2022; 10:healthcare10081534. [PMID: 36011191 PMCID: PMC9408148 DOI: 10.3390/healthcare10081534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 07/13/2022] [Accepted: 08/08/2022] [Indexed: 12/02/2022] Open
Abstract
Background/rationale: Despite mounting evidence about delirium, this complex geriatric syndrome is still not well managed in clinical contexts. The aging population creates a very demanding area for innovation and technology in healthcare. For instance, an outline of an aging-friendly healthcare environment and clear guidance for technology-supported improvements for people at delirium risk are lacking. Objective: We aimed to foster debate about the importance of technical support in optimizing healthcare professional practice and improving the outcomes for inpatients’ at delirium risk. We focused on critical clinical points in the field of delirium worthy of being addressed by a multidisciplinary approach. Methods: Starting from a consensus workshop sponsored by the Management Perfectioning Course based at the Marco Biagi Foundation (Modena, Italy) about clinical issues related to delirium management still not addressed in our healthcare organizations, we developed a requirements’ analysis among the representatives of different disciplines and tried to formulate how technology could support the summaries of the clinical issues. We analyzed the national and international panorama by a PubMed consultation of articles with the following keywords in advanced research: “delirium”, “delirium management”, “technology in healthcare”, and “elderly population”. Results: Despite international recommendations, delirium remains underdiagnosed, underdetected, underreported, and mismanaged in the acute hospital, increasing healthcare costs, healthcare professionals’ job distress, and poor clinical outcomes. Discussion: Although all healthcare professionals recognize delirium as a severe and potentially preventable source of morbidity and mortality for hospitalized older people, it receives insufficient attention in resource allocation and multidisciplinary research. We synthesized how tech-based tools could offer potential solutions to the critical clinical points in delirium management.
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10
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Leslie DL, Fick DM, Moore A, Inouye SK, Jung Y, Ngo LH, Boltz M, Husser E, Shrestha P, Boustani M, Marcantonio ER. Comparative salary-related costs of a brief app-directed delirium identification protocol by hospitalists, nurses, and nursing assistants. J Am Geriatr Soc 2022; 70:2371-2378. [PMID: 35441698 PMCID: PMC9378349 DOI: 10.1111/jgs.17789] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 03/12/2022] [Accepted: 03/22/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Systematic screening can improve delirium identification among hospitalized older adults. Prior studies have shown clinicians and health system leaders may believe they do not have the time and resources for assessment. We conducted a comparative salary-related cost analysis of an adaptive delirium identification protocol directed by an iPad app. METHODS We recruited 527 older adult medicine patients from an urban academic medical center (n = 269) and a rural community hospital (n = 258). Physicians and nurses completed the two-step Ultra-brief Confusion Assessment Method (UB-CAM) protocol (with or without a skip pattern), while certified nursing assistants completed only the UB-2 ultra-brief screen. The sample included 527 patients (average age 80, 57% women, 35% with dementia). Time required to administer the protocol was collected automatically by the iPad app. Salary-related costs of screening were determined by multiplying the time required by the hourly wage for the three disciplines, as obtained from national and regional published healthcare salary cost data. Cost estimates for entire hospital implementation were also calculated. RESULTS Participants were screened on 924 hospital days by 399 clinicians (53 physicians, 236 nurses, 110 CNAs). For the UB-2, CNAs cost per screen was lower than the other clinician types ($0.37 per screen vs. $0.73 for nurses and $2.39 for hospitalists). For the UB-CAM with skip (UB-CAM), costs per protocol were $1.10 for nurses vs. $3.61 for physicians. The annual salary-related costs of hospital-wide implementation of a nurse-based UB-CAM protocol in a medium-sized (300-bed) hospital was $63,015 plus $4356 for initial and annual training. CONCLUSIONS CNAs and nurses had the lowest salary-associated costs for app-directed CAM-based delirium screening and identification, respectively. Salary-related annual hospital costs for the most efficient protocols in a medium-sized hospital were less than the annual cost of hiring 1 FTE of the discipline performing the protocols.
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Affiliation(s)
- Douglas L Leslie
- College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Donna M Fick
- College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA.,The Ross and Carol Nese College of Nursing, The Pennsylvania State University, University Park, Pennsylvania, USA
| | - Amber Moore
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Divisions of General Medicine and Gerontology, Harvard Medical School, Boston, Massachusetts, USA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sharon K Inouye
- Divisions of General Medicine and Gerontology, Harvard Medical School, Boston, Massachusetts, USA.,Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA.,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Yoojin Jung
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Long H Ngo
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Divisions of General Medicine and Gerontology, Harvard Medical School, Boston, Massachusetts, USA
| | - Marie Boltz
- The Ross and Carol Nese College of Nursing, The Pennsylvania State University, University Park, Pennsylvania, USA
| | - Erica Husser
- The Ross and Carol Nese College of Nursing, The Pennsylvania State University, University Park, Pennsylvania, USA
| | - Priyanka Shrestha
- The Ross and Carol Nese College of Nursing, The Pennsylvania State University, University Park, Pennsylvania, USA
| | - Malaz Boustani
- Division of Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Edward R Marcantonio
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Divisions of General Medicine and Gerontology, Harvard Medical School, Boston, Massachusetts, USA.,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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11
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Nydahl P, Baumgarte F, Berg D, Bergjan M, Borzikowsky C, Franke C, Green D, Hannig A, Hansen HC, Hauss A, Hansen U, Istel R, Krämer N, Krause K, Lohrmann R, Mohammadzadeh-Vazifeh M, Osterbrink J, Palm F, Petersen T, Schöller B, Stolze H, Zilezinski M, Meyne J, Margraf NG. Delirium on stroke units: a prospective, multicentric quality-improvement project. J Neurol 2022; 269:3735-3744. [PMID: 35157137 PMCID: PMC9217833 DOI: 10.1007/s00415-022-11000-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/25/2022] [Accepted: 01/28/2022] [Indexed: 11/24/2022]
Abstract
Background Post-stroke delirium (POD) in patients on stroke units (SU) is associated with an increased risk for complications and poorer clinical outcome. The objective was to reduce the severity of POD by implementing an interprofessional delirium-management. Methods Multicentric quality-improvement project on five SU implementing a delirium-management with pre/post-comparison. Primary outcome was severity of POD, assessed with the Nursing Delirium Screening Scale (Nu-DESC). Secondary outcome parameters were POD incidence, duration, modified Rankin Scale (mRS), length of stay in SU and hospital, mortality, and others. Results Out of a total of 799 patients, 59.4% (n = 475) could be included with 9.5% (n = 45) being delirious. Implementation of a delirium-management led to reduced POD severity; Nu-DESC median: pre: 3.5 (interquartile range 2.6–4.7) vs. post 3.0 (2.2–4.0), albeit not significant (p = 0.154). Other outcome parameters were not meaningful different. In the post-period, delirium-management could be delivered to 75% (n = 18) of delirious patients, and only 24 (53.3%) of delirious patients required pharmacological treatments. Patients with a more severe stroke and POD remained on their disability levels, compared to similar affected, non-delirious patients who improved. Conclusions Implementation of delirium-management on SU is feasible and can be delivered to most patients, but with limited effects. Nursing interventions as first choice could be delivered to the majority of patients, and only the half required pharmacological treatments. Delirium-management may lead to reduced severity of POD but had only partial effects on duration of POD or length of stay. POD hampers rehabilitation, especially in patients with more severe stroke. Registry DRKS, DRKS00021436. Registered 04/17/2020, www.drks.de/DRKS00021436. Supplementary Information The online version contains supplementary material available at 10.1007/s00415-022-11000-6.
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Affiliation(s)
- Peter Nydahl
- Nursing Science and development, Department of Anesthesiology and Intensive Care Medicine, University Hospital of Schleswig-Holstein, Kiel, Germany
| | | | - Daniela Berg
- Department of Neurology, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Manuela Bergjan
- Business Division Nursing Directorate, Nursing Science, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Christoph Borzikowsky
- Institute of Medical Informatics und Statistics, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Christiana Franke
- Department of Neurology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Diana Green
- Christian Albrechts University Kiel, Kiel, Germany
| | - Anisa Hannig
- Department of Neurology, Friedrich-Ebert-Krankenhaus, Neumünster, Germany
| | | | - Armin Hauss
- Business Division Nursing Directorate, Nursing Science, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Uta Hansen
- Department of Neurology, Diako Flensburg, Flensburg, Germany
| | - Rahel Istel
- Christian Albrechts University Kiel, Kiel, Germany
| | - Norma Krämer
- Department of Neurology, Friedrich-Ebert-Krankenhaus, Neumünster, Germany
| | | | - Renée Lohrmann
- Business Division Nursing Directorate, Nursing Science, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | | | - Jürgen Osterbrink
- Institut für Pflegewissenschaft und-praxis, Paracelsus Medizinische Privatuniversität, Salzburg, Austria
- Brooks College of Health, University of North Florida, Jacksonville, USA
| | - Frederick Palm
- Department of Neurology, Heliosklinikum Schleswig, Schleswig, Germany
| | | | - Bernd Schöller
- Department of Neurology, Heliosklinikum Schleswig, Schleswig, Germany
| | - Henning Stolze
- Department of Neurology, Diako Flensburg, Flensburg, Germany
| | - Max Zilezinski
- Business Division Nursing Directorate, Nursing Science, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
- University Medicine Halle (Saale), Health Service Research Working Group | Acute Care, Department of Internal Medicine, Faculty of Medicine, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Johannes Meyne
- Department of Neurology, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Nils G. Margraf
- Department of Neurology, University Hospital of Schleswig-Holstein, Kiel, Germany
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12
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Johansson YA, Tsevis T, Nasic S, Gillsjö C, Johansson L, Bogdanovic N, Kenne Sarenmalm E. Diagnostic accuracy and clinical applicability of the Swedish version of the 4AT assessment test for delirium detection, in a mixed patient population and setting. BMC Geriatr 2021; 21:568. [PMID: 34663229 PMCID: PMC8522056 DOI: 10.1186/s12877-021-02493-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 09/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Delirium is common in older hospitalized patients. It has serious consequences e.g., poor health outcomes, mortality and increased costs. Despite that, many cases are undetected. Early detection of delirium is important in improving outcomes and use of assessment tools improves detection rates. The 4AT is a brief screening tool for delirium detection, which has not previously been translated into Swedish. The study aim was to evaluate diagnostic accuracy and clinical applicability of a Swedish version of the screening tool 4AT for delirium detection. METHOD This diagnostic test accuracy study used a quantitative and a qualitative approach and evaluated the patients' and the health care professionals' experiences of the tool. Study included 200 patients ≥65 years from a university hospital and a county hospital in two Swedish regions. Medical specialties were geriatric stroke/neurology, geriatric multimorbidity, severe cognitive impairment, orthopaedic, and urology. The translated 4AT was tested against the reference standard DSM-IV-TR criteria, based on the Organic Brain Syndrome scale and patient records. The 4AT was assessed simultaneously and independently by two assessors. Additionally, data was collected through patient record reviews, and questions about applicability to the patients (n = 200) and the assessors (n = 37). Statistical analyses, and qualitative content analyses were conducted. RESULTS By reference standard 18% had delirium, and by 4AT 19%. The overall percent agreement was 88%, AUROC 0.808, sensitivity 0.70 (95% CI 0.51-0.84) and specificity 0.92 (95% CI 0.87-0.96). In the ward for severe cognitive impairment (n = 63) the 4AT was less sensitive and less specific. In the other wards (n = 132) sensitivity was 0.77 (95% CI 0.50-0.93), specificity 0.93 (95% CI 0.87-0.97), and AUROC 0.848. Interrater reliability (Kappa) was 0.918, p = < 0.001 (n = 144). The 4AT was well tolerated by patients, easy to use for health care professionals, and took a few minutes to conduct. CONCLUSION The Swedish version of 4AT is an accurate and applicable tool to use in clinical practice for detecting delirium in hospitalized patients across different medical specialities, and to use by different professionals and levels of seniority. To improve patient outcomes, we recommend the 4AT to be incorporated in clinical practice in health care settings in Sweden.
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Affiliation(s)
- Yvonne A Johansson
- Skaraborg Hospital, Skövde, Sweden. .,The Research School of Health and Welfare, Aging Research Network-Jönköping (ARN-J), Jönköping University, Jönköping, Sweden.
| | - Theofanis Tsevis
- Theme Inflammation and Aging, Karolinska University Hospital, Stockholm, Sweden.,Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Salmir Nasic
- Skaraborg Hospital, Skövde, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Catharina Gillsjö
- School of Health Sciences, University of Skövde, Skövde, Sweden.,College of Nursing, University of Rhode Island, Kingston, RI, USA
| | - Linda Johansson
- Institute of Gerontology, Aging Research Network-Jönköping (ARN-J), School of Health and Welfare, Jönköping University, Jönköping, Sweden
| | - Nenad Bogdanovic
- Theme Inflammation and Aging, Karolinska University Hospital, Stockholm, Sweden.,Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Elisabeth Kenne Sarenmalm
- Skaraborg Hospital, Skövde, Sweden.,School of Health Sciences, University of Skövde, Skövde, Sweden.,Institute of Health and Care Science, Sahlgrenska Academy, Centre for Person-Centred Care Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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13
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Jenraumjit R, Somboon J, Chainan S, Chuenchom P, Wongpakaran N, Wongpakaran T. Drug-related problems of antipsychotics in treating delirium among elderly patients: A real-world observational study. J Clin Pharm Ther 2021; 46:1274-1280. [PMID: 33768628 DOI: 10.1111/jcpt.13423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 03/01/2021] [Accepted: 03/12/2021] [Indexed: 11/29/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Delirium is more common and life-threatening among the elderly. Currently, no other medications, including antipsychotics, have been approved for delirium. The number of practice guidelines recommends antipsychotics to be the first option among selected patients. This study aimed to identify the type of drug-related problems (DRPs) concerning antipsychotics use among elderly patients with delirium. METHODS A retrospective observational study was conducted by collecting data from 2013 to 2016 in Maharaj Nakorn Chiang Mai Hospital, Thailand. Inpatients who were 60 years and over, diagnosed with delirium by ICD-10 diseases coding F05.X and treated with antipsychotics for delirium were included. A modified version of the American Society of Hospital Pharmacists classification criteria (mASHP-delirium) was used. RESULTS AND DISCUSSION A total of 379 patients were enrolled. Mean daily dose of haloperidol (oral) was 1.06 ± 1.33 mg, haloperidol (intramuscular) 2.71 ± 1.88 mg, haloperidol (intravenous; IV) 3.42 ± 1.97 mg, risperidone was 0.71 ± 0.52 mg, and quetiapine was 19.26 ± 15.63 mg. Among all, 427 events were classified as DRPs. The most common DRPs included inappropriate duration, dose, route of administration or dosage form accounting for the 416 events (97.4%), followed by actual adverse drug reactions (extrapyramidal symptoms; EPS), 6 events (1.4%) and potential drug-drug interactions for 5 events (1.2%). Of those 416 events, 200 events (48.1%) antipsychotics were continued after discharge and continued for more than 10 days. Dosage exceeding initial dose or maximum daily dose accounted for 179 events (43.0%). Other DRPs such as inappropriate route haloperidol IV and receiving the extended-release dosage form of quetiapine involve 26 (6.3%) and 11 (2.6%) events, respectively. WHAT IS NEW AND CONCLUSION To the best of our knowledge, this is the first study using mASHP-delirium to identify DRPs of antipsychotics in treating delirium among elderly patients. Several DRPs were found that might lead to severe adverse drug reactions, particularly EPS and QTc interval prolongation. However, all DRPs could be prevented by developing antipsychotic setting protocols and specialty consulting systems to communicate among healthcare providers caring for vulnerable groups of patients. In addition, a prospective pharmacist intervention is required.
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Affiliation(s)
- Rewadee Jenraumjit
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Jinjuta Somboon
- Department of Pharmacy, Phayamengrai Hospital, Chiang Rai, Thailand
| | | | - Pao Chuenchom
- Department of Pharmacy, Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand
| | - Nahathai Wongpakaran
- Geriatric Psychiatry Unit, Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Tinakon Wongpakaran
- Geriatric Psychiatry Unit, Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Husser EK, Fick DM, Boltz M, Shrestha P, Siuta J, Malloy S, Overstreet A, Leslie DL, Ngo L, Jung Y, Inouye SK, Marcantonio ER. Implementing a Rapid, Two-Step Delirium Screening Protocol in Acute Care: Barriers and Facilitators. J Am Geriatr Soc 2021; 69:1349-1356. [PMID: 33474729 DOI: 10.1111/jgs.17026] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/14/2020] [Accepted: 12/17/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND/OBJECTIVES An effective and efficient protocol for delirium identification is needed to improve health outcomes for older adults and reduce healthcare costs. This study describes the barriers and facilitators related to the implementation of the ultra-brief confusion assessment method (UB-CAM), a rapid two-step delirium identification protocol (ultra-brief screen, followed by CAM in positives), field tested with hospitalized older adults (70+). DESIGN A qualitative descriptive design using observational data collection and brief semi-structured interviews. SETTINGS An urban academic medical center and a community teaching hospital. PARTICIPANTS Participants included 50 physician hospitalists, 189 registered nurses, and 83 nursing assistants (NAs). MEASUREMENTS Field researchers guided by a modified multi-level implementation framework, collected observational data as participants administered the UB-CAM (n = 767). Thematic analysis was conducted on five observational categories: structural, organizational, patient, clinician, and innovation. Field notes and brief semi-structured interviews (n = 231) with clinicians, explored the utility, acceptability, and feasibility of the protocol, and supplemented the observations. RESULTS The UB-CAM was generally positively received by all three clinician types. Six themes describe barriers and/or facilitators to implementing the UB-CAM: (1) physical setting and milieu; (2) practice environment; (3) integrating into role; (4) adaptive techniques; (5) patient responses; and (6) systematic assessment. The composition and interaction of the six themes determined if the theme was expressed as a barrier or facilitator, affirming the importance of context when implementing system-level delirium screening. CONCLUSION This is one of the first studies to test a two-step process for delirium identification, and to involve NAs in screening, and the findings demonstrate overall support from clinicians for delirium identification, and describe the need for a multifaceted, contextualized, and systemic approach to implementation and evaluation of delirium screening.
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Affiliation(s)
- Erica K Husser
- The Pennsylvania State University, College of Nursing, University Park, Pennsylvania, USA
| | - Donna M Fick
- The Pennsylvania State University, College of Nursing, University Park, Pennsylvania, USA
| | - Marie Boltz
- The Pennsylvania State University, College of Nursing, University Park, Pennsylvania, USA
| | - Priyanka Shrestha
- The Pennsylvania State University, College of Nursing, University Park, Pennsylvania, USA
| | - Jonathan Siuta
- Mount Nittany Physician Group, Mount Nittany Medical Center, State College, Pennsylvania, USA
| | - Shannon Malloy
- Beth Israel Deaconess Medical Center, Department of General Medicine, Boston, Massachusetts, USA
| | - Abigail Overstreet
- Beth Israel Deaconess Medical Center, Department of General Medicine, Boston, Massachusetts, USA
| | - Douglas L Leslie
- The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA
| | - Long Ngo
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Yoojin Jung
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Sharon K Inouye
- Hebrew SeniorLife, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Edward R Marcantonio
- Divisions of General Medicine and Gerontology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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15
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Egberts A, Alan H, Ziere G, Mattace-Raso FUS. Antipsychotics and Lorazepam During Delirium: Are We Harming Older Patients? A Real-Life Data Study. Drugs Aging 2021; 38:53-62. [PMID: 33164161 PMCID: PMC7838136 DOI: 10.1007/s40266-020-00813-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Delirium affects approximately one out of three older hospitalized patients and is associated with poor clinical outcomes. Approaches used to manage delirium consist of non-pharmacological and pharmacological interventions. Antipsychotics and lorazepam are commonly used to treat symptoms of delirium, but conflicting data exist on the effect of these drugs on the outcomes of delirium. OBJECTIVE The aim of this study was to investigate whether the use of antipsychotics, with or without lorazepam, increases the risk of prolonged hospital stay, post-discharge institutionalization, and in-hospital mortality in older patients with delirium. METHODS In this retrospective chart review study, we included acutely ill patients aged ≥ 65 years who were admitted to a geriatric ward and diagnosed with delirium. Patients were stratified into three groups based on whether or not they received antipsychotics and lorazepam to manage delirium: (0) no antipsychotics; (1) antipsychotics only; and (2) antipsychotics plus lorazepam. Length of hospital stay (LOS) and frequencies of post-discharge institutionalization and in-hospital mortality were compared. RESULTS In total, 212 patients with delirium were included (mean age 81.9 ± 5.6 years); 40 did not receive antipsychotics (18.9%), 123 received antipsychotics only (58.0%) and 49 received antipsychotics and lorazepam (23.1%). There was a trend to a longer LOS in patients who received both antipsychotics and lorazepam (median LOS group 0 = 8.0 days, group 1 = 10.0 days, and group 2 = 12.0 days). Furthermore, trends to a higher incidence of post-discharge institutionalization and in-hospital mortality were observed in patients who received both treatments (institutionalization group 0 = 45.0%, group 1 = 59.3%, group 2 = 81.6%; and in-hospital mortality group 0 = 7.5%, group 1 = 10.6%, group 2 = 16.3%). CONCLUSION The use of antipsychotics, with or without lorazepam, during delirium is associated with increased risks of poor outcomes. These findings suggest that clinicians should be cautious about routine prescribing of these drugs to older patients with delirium. Further investigation is needed to clarify this association.
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Affiliation(s)
- Angelique Egberts
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC University Medical Center, Room Rg-527, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.
- Department of Hospital Pharmacy, Franciscus Gasthuis and Vlietland, Rotterdam and Schiedam, The Netherlands.
| | - Hava Alan
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC University Medical Center, Room Rg-527, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Gijsbertus Ziere
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC University Medical Center, Room Rg-527, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Francesco U S Mattace-Raso
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC University Medical Center, Room Rg-527, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
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MacLullich AM, Shenkin SD, Goodacre S, Godfrey M, Hanley J, Stíobhairt A, Lavender E, Boyd J, Stephen J, Weir C, MacRaild A, Steven J, Black P, Diernberger K, Hall P, Tieges Z, Fox C, Anand A, Young J, Siddiqi N, Gray A. The 4 'A's test for detecting delirium in acute medical patients: a diagnostic accuracy study. Health Technol Assess 2020; 23:1-194. [PMID: 31397263 DOI: 10.3310/hta23400] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Delirium is a common and serious neuropsychiatric syndrome, usually triggered by illness or drugs. It remains underdetected. One reason for this is a lack of brief, pragmatic assessment tools. The 4 'A's test (Arousal, Attention, Abbreviated Mental Test - 4, Acute change) (4AT) is a screening tool designed for routine use. This project evaluated its usability, diagnostic accuracy and cost. METHODS Phase 1 - the usability of the 4AT in routine practice was measured with two surveys and two qualitative studies of health-care professionals, and a review of current clinical use of the 4AT as well as its presence in guidelines and reports. Phase 2 - the 4AT's diagnostic accuracy was assessed in newly admitted acute medical patients aged ≥ 70 years. Its performance was compared with that of the Confusion Assessment Method (CAM; a longer screening tool). The performance of individual 4AT test items was related to cognitive status, length of stay, new institutionalisation, mortality at 12 weeks and outcomes. The method used was a prospective, double-blind diagnostic test accuracy study in emergency departments or in acute general medical wards in three UK sites. Each patient underwent a reference standard delirium assessment and was also randomised to receive an assessment with either the 4AT (n = 421) or the CAM (n = 420). A health economics analysis was also conducted. RESULTS Phase 1 found evidence that delirium awareness is increasing, but also that there is a need for education on delirium in general and on the 4AT in particular. Most users reported that the 4AT was useful, and it was in widespread use both in the UK and beyond. No changes to the 4AT were considered necessary. Phase 2 involved 785 individuals who had data for analysis; their mean age was 81.4 (standard deviation 6.4) years, 45% were male, 99% were white and 9% had a known dementia diagnosis. The 4AT (n = 392) had an area under the receiver operating characteristic curve of 0.90. A positive 4AT score (> 3) had a specificity of 95% [95% confidence interval (CI) 92% to 97%] and a sensitivity of 76% (95% CI 61% to 87%) for reference standard delirium. The CAM (n = 382) had a specificity of 100% (95% CI 98% to 100%) and a sensitivity of 40% (95% CI 26% to 57%) in the subset of participants whom it was possible to assess using this. Patients with positive 4AT scores had longer lengths of stay (median 5 days, interquartile range 2.0-14.0 days) than did those with negative 4AT scores (median 2 days, interquartile range 1.0-6.0 days), and they had a higher 12-week mortality rate (16.1% and 9.2%, respectively). The estimated 12-week costs of an initial inpatient stay for patients with delirium were more than double the costs of an inpatient stay for patients without delirium (e.g. in Scotland, £7559, 95% CI £7362 to £7755, vs. £4215, 95% CI £4175 to £4254). The estimated cost of false-positive cases was £4653, of false-negative cases was £8956, and of a missed diagnosis was £2067. LIMITATIONS Patients were aged ≥ 70 years and were assessed soon after they were admitted, limiting generalisability. The treatment of patients in accordance with reference standard diagnosis limited the ability to assess comparative cost-effectiveness. CONCLUSIONS These findings support the use of the 4AT as a rapid delirium assessment instrument. The 4AT has acceptable diagnostic accuracy for acute older patients aged > 70 years. FUTURE WORK Further research should address the real-world implementation of delirium assessment. The 4AT should be tested in other populations. TRIAL REGISTRATION Current Controlled Trials ISRCTN53388093. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 40. See the NIHR Journals Library website for further project information. The funder specified that any new delirium assessment tool should be compared against the CAM, but had no other role in the study design or conduct of the study.
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Affiliation(s)
| | - Susan D Shenkin
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Steve Goodacre
- Emergency Medicine, University of Sheffield, Sheffield, UK
| | - Mary Godfrey
- Health and Social Care, Leeds Institute of Health Sciences, School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Janet Hanley
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Antaine Stíobhairt
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Elizabeth Lavender
- Health and Social Care, Leeds Institute of Health Sciences, School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Julia Boyd
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK.,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Christopher Weir
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK.,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Allan MacRaild
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Jill Steven
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Polly Black
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Katharina Diernberger
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Peter Hall
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Zoë Tieges
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Christopher Fox
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Atul Anand
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - John Young
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK
| | - Najma Siddiqi
- Psychiatry, University of York, York.,Hull York Medical School, York, UK.,Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Alasdair Gray
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
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Lee KY, Tan ECK, Hanrahan JR, Chircop C, Michael F, Ong JA. Effect of Antipsychotics and Non-Pharmacotherapy for the Management of Delirium in People Receiving Palliative Care. J Pain Palliat Care Pharmacother 2020; 34:225-236. [DOI: 10.1080/15360288.2020.1784353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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18
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Buijs-Spanjers KR, Harmsen A, Hegge HH, Spook JE, de Rooij SE, Jaarsma DADC. The influence of a serious game's narrative on students' attitudes and learning experiences regarding delirium: an interview study. BMC MEDICAL EDUCATION 2020; 20:289. [PMID: 32873285 PMCID: PMC7465326 DOI: 10.1186/s12909-020-02210-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 08/25/2020] [Indexed: 05/15/2023]
Abstract
BACKGROUND Delirium is a neuropsychiatric syndrome that affects patients' attention and awareness as a result of a physical condition. In recent years, persistent gaps in delirium education have led to suboptimal delirium care. Still, little is known about what are the most important aspects of effective delirium education. Serious games are both entertainment and an interactive, safe learning environment where players can experiment and create new knowledge. They have the potential to contribute to improved delirium education. We used a video-based serious games' narrative to explore aspects essential to enhance students' attitudes and learning experiences regarding delirium. METHODS We created a semi-structured interview guide and interviewed seven nursing and nine medical students about their attitudes and learning experiences, after they had played the game. A qualitative descriptive design and inductive content analysis with constant comparison were used. RESULTS The patient's and nurse's perspective, interactivity to experiment, realistic views on care options, and feedback on care actions were important for enhancing students' attitudes and learning experiences regarding delirium. Students felt these aspects encouraged them to get actively involved in and experiment with the study material, which in turn led to enhanced reflection on delirium care and education. Our findings highlight the importance of a more patient-oriented focus to delirium education to drive attitudinal change. Students' learning experiences were further enhanced through their affective responses provoked by the perspectives, interactivity, realism, and feedback. CONCLUSIONS Students considered the characters' perspectives, interactivity, realism, and feedback important aspects of the game to enhance their attitudes towards delirious patients and enrich their learning experiences. A patient-oriented narrative provides a clinically relevant experience in which reflection plays an important role. The serious game also serves as medium to actively experiment with care solutions to create better understanding of how healthcare professionals can influence a delirious patient's experience.
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Affiliation(s)
- Kiki R Buijs-Spanjers
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, PO Box 30001, HPC: AA43, Groningen, 9700 RB, The Netherlands.
- Center for Education Development and Research in Health Professions, LEARN, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Anne Harmsen
- Strategic Communication Group, Wageningen University, Wageningen, The Netherlands
| | - Harianne H Hegge
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, PO Box 30001, HPC: AA43, Groningen, 9700 RB, The Netherlands
- Center for Education Development and Research in Health Professions, LEARN, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jorinde E Spook
- Strategic Communication Group, Wageningen University, Wageningen, The Netherlands
| | - Sophia E de Rooij
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, PO Box 30001, HPC: AA43, Groningen, 9700 RB, The Netherlands
- Medical School Twente, Medical Spectrum Twente, Enschede, The Netherlands
| | - Debbie A D C Jaarsma
- Center for Education Development and Research in Health Professions, LEARN, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Buijs-Spanjers KR, Hegge HH, Cnossen F, Jaarsma DA, de Rooij SE. Reasons to Engage in and Learning Experiences From Different Play Strategies in a Web-Based Serious Game on Delirium for Medical Students: Mixed Methods Design. JMIR Serious Games 2020; 8:e18479. [PMID: 32723710 PMCID: PMC7424470 DOI: 10.2196/18479] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/14/2020] [Accepted: 05/20/2020] [Indexed: 12/30/2022] Open
Abstract
Background Although many studies have recently been published on the value of serious games for medical education, little attention has been given to the role of dark play (choosing unacceptable actions in games). Objective This study aimed to investigate potential differences in the characteristics of medical students who have the opportunity to choose normal or dark play in a serious game. This study also aimed to compare their reasons for choosing a play strategy and their perceptions of what they learned from their game play. Methods We asked undergraduate medical students to play a serious game in which they had to take care of a patient with delirium (The Delirium Experience). After getting acquainted with the game, students could opt for normal or dark play. Student characteristics (age, gender, experience with caring for older or delirious patients, and number of completed clerkships) were collected, and the Delirium Attitude Scale and Learning Motivation and Engagement Questionnaire were administered. Reasons for choosing normal or dark play were evaluated with an open-ended question. Information on lessons they had learned from the game was collected using an open-ended question and self-reported knowledge on delirium. Results This study had 160 participants (89 normal play, 71 dark play). Male students (26/160, 56.5%) chose dark play significantly more often than female students (45/160, 39.5%; P=.049). We did not find significant differences in student characteristics or measurement outcomes between play strategies. Participants’ main reason for choosing normal play was to learn how to provide care to delirious patients, and the main reason for dark play was to gain insight into what a delirious patient has to endure during delirious episodes. All participants learned what to do when taking care of a delirious patient and gained insight into how a patient experiences delirium. We found no differences in self-reported knowledge. Conclusions When medical students have the opportunity to choose dark play in a serious game, half of them will probably choose this play strategy. Male students will more likely opt for dark play than female students. Choice of play strategy is not affected by any other student characteristic or measurement outcome. All students learned the same lessons from playing the game, irrespective of their learning strategy.
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Affiliation(s)
- Kiki R Buijs-Spanjers
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, Groningen, Netherlands.,Center for Education Development and Research in Health Professions, LEARN, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Harianne Hm Hegge
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, Groningen, Netherlands.,Center for Education Development and Research in Health Professions, LEARN, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Fokie Cnossen
- Bernoulli Institute of Mathematics, Computer Science and Artificial Intelligence, Department of Artificial Intelligence, University of Groningen, Groningen, Netherlands
| | - Debbie Adc Jaarsma
- Center for Education Development and Research in Health Professions, LEARN, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Sophia E de Rooij
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, Groningen, Netherlands.,Medical Spectrum Twente, Medical School Twente, Enschede, Netherlands
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20
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Canet E, Amjad S, Robbins R, Lewis J, Matalanis M, Jones D, Bellomo R. Differential clinical characteristics, management and outcome of delirium among ward compared with intensive care unit patients. Intern Med J 2020; 49:1496-1504. [PMID: 30887670 DOI: 10.1111/imj.14287] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 02/24/2019] [Accepted: 03/08/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Delirium is common in hospitalised patients but its epidemiology remains poorly characterised. AIMS To test the hypothesis that patient demographics, clinical phenotype, management and outcomes of patient with delirium in hospital ward patients differ from intensive care unit (ICU) patients. METHODS Retrospective cohort of patients admitted to an Australian university-affiliated hospital between March 2013 and April 2017 and coded for delirium at discharge using the International Classification of Diseases System, 10th revision, criteria. RESULTS Among 61 032 hospitalised patients, 2864 (4.7%) were coded for delirium. From these, we studied a random sample of 100 ward patients and 100 ICU patients. Ward patients were older (median age: 84 vs 65 years; P < 0.0001), more likely to have dementia (38% vs 2% for ICU patients; P < 0.0001) and less likely to have had surgery (24% vs 62%; P < 0.0001). Of ward patients, 74% had hypoactive delirium, while 64% of ICU patients had agitated delirium (P < 0.0001). Persistent delirium at hospital discharge was more common among ward patients (66% vs 17%, P < 0.0001). On multivariable analysis, age and dementia predicted persistent delirium, while surgery predicted recovery. CONCLUSIONS Delirium in ward patients is profoundly different from delirium in ICU patients. It has a dominant hypoactive clinical phenotype, is preceded by dementia and is less likely to recover at hospital discharge. Therefore, delirium prevention, detection and goals of care should be adapted to the environment in which it occurs.
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Affiliation(s)
- Emmanuel Canet
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Sobia Amjad
- School of Computing and Information Systems, The University of Melbourne, Melbourne, Victoria, Australia
| | - Raymond Robbins
- Business Intelligence Unit, Austin Hospital, Melbourne, Victoria, Australia
| | - Jane Lewis
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | | | - Daryl Jones
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,School of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, Victoria, Australia
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21
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Vreeswijk R, Kalisvaart I, Maier AB, Kalisvaart KJ. Development and validation of the delirium risk assessment score (DRAS). Eur Geriatr Med 2020; 11:307-314. [PMID: 32297197 DOI: 10.1007/s41999-019-00287-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 12/27/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE Development and validation of a delirium risk assessment score. Predisposing risk factors for delirium were used, which are easily assessed at hospital admission without additional clinical or laboratory testing. METHODS A systematic literature search identified ten risk factors: acute admission, alcohol use > 4 units/day, cognitive impairment, ADL impairment, age > 75 years, earlier delirium, hearing/vision problems, number of medication ≥ 5, number of morbidities > 2 and male. The DRAS was developed in a mixed patient population (N = 842) by the use of univariate and multivariate analyses and -2 log-likelihood calculation to weigh the risk factors. Based on the sensitivity and specificity, a cutoff score was calculated. The validation was performed in 3 cohorts (N = 408, N = 186, N = 365). In cohort 3, the DRAS was compared (AUC, sensitivity and specificity) to 3 instruments (Inouye, Kalisvaart, VMS rules). RESULTS The delirium incidence was 31.8%, 20.3%, 15.6% and 15.1%. All risk factors were independently predictive for delirium, except male. The multivariate analyses excluded morbidities. The final DRAS consists of 8 items; acute admission, cognitive impairment, alcohol use (3 points), ADLimpairment/mobilityproblems (2 points), higher age, earlier delirium, hearing/vision problems, and medication (1 point). The total score is 15 points and at a cut-of score of 5 or higher the patient is at risk of developing a delirium. The cutoff was at 5 or more points, AUC: 0.76 (95% CI 0.72-0.79), sensitivity 0.77, specificity 0.60. Validation cohorts AUC was 0.75 (95% CI 0.96-0.81), 0.76 (95% CI 0.70-0.83) and 0.78 (95% CI 0.70-0.87), sensitivity 0.71, 0.67 and 0.89 and specificity 0.70, 0.72 and 0.60. The comparison revealed the highest AUC for the DRAS. CONCLUSION Based on an admission interview, the delirium risk can be easily evaluated using the DRAS shortlist score of predisposing risk factors for delirium in older inpatients.
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Affiliation(s)
- Ralph Vreeswijk
- Department of Geriatric Medicine, Spaarne Gasthuis Haarlem, Boerhavelaan 22, 2035 RC, Haarlem, The Netherlands.
| | - Imke Kalisvaart
- Health Care Inspectorate (IGJ), Stadsplateau 1, 3521 AZ, Utrecht, The Netherlands
| | - Andrea B Maier
- Department of Human Movement Sciences, @AgeAmsterdam, Faculty of Behavioral and Movement Sciences, Amsterdam Movement Sciences, Vrije Universiteit, Amsterdam, The Netherlands.,Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Kees J Kalisvaart
- Department of Geriatric Medicine, Spaarne Gasthuis Haarlem, Boerhavelaan 22, 2035 RC, Haarlem, The Netherlands
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22
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[Study protocol to improve the quality of delirium management in intensive care]. Med Klin Intensivmed Notfmed 2020; 115:428-436. [PMID: 32248245 DOI: 10.1007/s00063-020-00676-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 12/31/2019] [Accepted: 02/24/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Delirium in cardiac surgery patients is common and is associated with prolonged mechanical ventilation and hospital stay as well as higher mortality. Protocols may improve outcome. In our cardiac surgery intensive care unit (ICU), patients with delirium have not received standardized treatment so far. HYPOTHESIS In cardiac surgery ICU patients, standardized delirium management will lead after a 4‑week introduction, compared to nonstandardized treatment, to a reduction of delirium duration. METHODS Prospective before/after study to evaluate a quality improvement project for delirium management over 12 weeks including 140 patients. INCLUSION CRITERIA (a) ≥18 years, (b) consent for research with their data. EXCLUSION CRITERIA (a) palliative status, (b) present during both the before/after phase, (c) pregnancy, (d) included in a competitive study, or (e) delirium not assessable. The implementation includes the introduction of a protocol with interprofessional training, bedside-teaching, pocket cards, posters, and reminders. The primary outcome is the duration of delirium, assessed four times a day with validated instruments. Secondary outcome measures include delirium incidence, duration of mechanical ventilation, length of stay in ICU and hospital, mortality, nursing/therapeutic interventions, cumulative doses of delirium-related drugs, and complications of delirium for a follow-up of 28 days. Empirical data will be analyzed with descriptive and inferential statistics. OBJECTIVES The purpose of the study is a reduction of the duration and frequency of delirium in cardiac ICU patients and will provide evidence of the effect size of the introduction of a delirium management.
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23
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Finucane AM, Jones L, Leurent B, Sampson EL, Stone P, Tookman A, Candy B. Drug therapy for delirium in terminally ill adults. Cochrane Database Syst Rev 2020; 1:CD004770. [PMID: 31960954 PMCID: PMC6984445 DOI: 10.1002/14651858.cd004770.pub3] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Delirium is a syndrome characterised by an acute disturbance of attention and awareness which develops over a short time period and fluctuates in severity over the course of the day. It is commonly experienced during inpatient admission in the terminal phase of illness. It can cause symptoms such as agitation and hallucinations and is distressing for terminally ill people, their families and staff. Delirium may arise from any number of causes and treatment should aim to address these causes. When this is not possible, or treatment is unsuccessful, drug therapy to manage the symptoms may become necessary. This is the second update of the review first published in 2004. OBJECTIVES To evaluate the effectiveness and safety of drug therapies to manage delirium symptoms in terminally ill adults. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL and PsycINFO from inception to July 2019, reference lists of retrieved papers, and online trial registries. SELECTION CRITERIA We included randomised controlled trials of drug therapies in any dose by any route, compared to another drug therapy, a non-pharmacological approach, placebo, standard care or wait-list control, for the management of delirium symptoms in terminally ill adults (18 years or older). DATA COLLECTION AND ANALYSIS We independently screened citations, extracted data and assessed risk of bias. Primary outcomes were delirium symptoms; agitation score; adverse events. Secondary outcomes were: use of rescue medication; cognitive status; survival. We applied the GRADE approach to assess the overall quality of the evidence for each outcome and we include eight 'Summary of findings' tables. MAIN RESULTS We included four studies (three new to this update), with 399 participants. Most participants had advanced cancer or advanced AIDS, and mild- to moderate-severity delirium. Meta-analysis was not possible because no two studies examined the same comparison. Each study was at high risk of bias for at least one criterion. Most evidence was low to very low quality, downgraded due to very serious study limitations, imprecision or because there were so few data. Most studies reported delirium symptoms; two reported agitation scores; three reported adverse events with data on extrapyramidal effects; and none reported serious adverse events. 1. Haloperidol versus placebo There may be little to no difference between placebo and haloperidol in delirium symptoms within 24 hours (mean difference (MD) 0.34, 95% confidence interval (CI) -0.07 to 0.75; 133 participants). Haloperidol may slightly worsen delirium symptoms compared with placebo at 48 hours (MD 0.49, 95% CI 0.10 to 0.88; 123 participants with mild- to moderate-severity delirium). Haloperidol may reduce agitation slightly compared with placebo between 24 and 48 hours (MD -0.14, 95% -0.28 to -0.00; 123 participants with mild- to moderate-severity delirium). Haloperidol probably increases extrapyramidal adverse effects compared with placebo (MD 0.79, 95% CI 0.17 to 1.41; 123 participants with mild- to moderate-severity delirium). 2. Haloperidol versus risperidone There may be little to no difference in delirium symptoms with haloperidol compared with risperidone within 24 hours (MD -0.42, 95% CI -0.90 to 0.06; 126 participants) or 48 hours (MD -0.36, 95% CI -0.92 to 0.20; 106 participants with mild- to moderate-severity delirium). Agitation scores and adverse events were not reported for this comparison. 3. Haloperidol versus olanzapine We are uncertain whether haloperidol reduces delirium symptoms compared with olanzapine within 24 hours (MD 2.36, 95% CI -0.75 to 5.47; 28 participants) or 48 hours (MD 1.90, 95% CI -1.50 to 5.30, 24 participants). Agitation scores and adverse events were not reported for this comparison. 4. Risperidone versus placebo Risperidone may slightly worsen delirium symptoms compared with placebo within 24 hours (MD 0.76, 95% CI 0.30 to 1.22; 129 participants); and at 48 hours (MD 0.85, 95% CI 0.32 to 1.38; 111 participants with mild- to moderate-severity delirium). There may be little to no difference in agitation with risperidone compared with placebo between 24 and 48 hours (MD -0.05, 95% CI -0.19 to 0.09; 111 participants with mild- to moderate-severity delirium). Risperidone may increase extrapyramidal adverse effects compared with placebo (MD 0.73 95% CI 0.09 to 1.37; 111 participants with mild- to moderate-severity delirium). 5. Lorazepam plus haloperidol versus placebo plus haloperidol We are uncertain whether lorazepam plus haloperidol compared with placebo plus haloperidol improves delirium symptoms within 24 hours (MD 2.10, 95% CI -1.00 to 5.20; 50 participants with moderate to severe delirium), reduces agitation within 24 hours (MD 1.90, 95% CI 0.90 to 2.80; 52 participants), or increases adverse events (RR 0.70, 95% CI -0.19 to 2.63; 31 participants with moderate to severe delirium). 6. Haloperidol versus chlorpromazine We are uncertain whether haloperidol reduces delirium symptoms compared with chlorpromazine at 48 hours (MD 0.37, 95% CI -4.58 to 5.32; 24 participants). Agitation scores were not reported. We are uncertain whether haloperidol increases adverse events compared with chlorpromazine (MD 0.46, 95% CI -4.22 to 5.14; 24 participants). 7. Haloperidol versus lorazepam We are uncertain whether haloperidol reduces delirium symptoms compared with lorazepam at 48 hours (MD -4.88, 95% CI -9.70 to 0.06; 17 participants). Agitation scores were not reported. We are uncertain whether haloperidol increases adverse events compared with lorazepam (MD -6.66, 95% CI -14.85 to 1.53; 17 participants). 8. Lorazepam versus chlorpromazine We are uncertain whether lorazepam reduces delirium symptoms compared with chlorpromazine at 48 hours (MD 5.25, 95% CI 0.38 to 10.12; 19 participants), or increases adverse events (MD 7.12, 95% CI 1.08 to 15.32; 18 participants). Agitation scores were not reported. SECONDARY OUTCOMES use of rescue medication, cognitive impairment, survival There were insufficient data to draw conclusions or assess GRADE. AUTHORS' CONCLUSIONS We found no high-quality evidence to support or refute the use of drug therapy for delirium symptoms in terminally ill adults. We found low-quality evidence that risperidone or haloperidol may slightly worsen delirium symptoms of mild to moderate severity for terminally ill people compared with placebo. We found moderate- to low-quality evidence that haloperidol and risperidone may slightly increase extrapyramidal adverse events for people with mild- to moderate-severity delirium. Given the small number of studies and participants on which current evidence is based, further research is essential.
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Affiliation(s)
- Anne M Finucane
- Marie Curie Hospice Edinburgh45 Frogston Road WestEdinburghUKEH10 7DR
- University of EdinburghUsher InstituteEdinburghUK
| | - Louise Jones
- University College LondonMarie Curie Palliative Care Research Department, Division of PsychiatryLondonUK
| | - Baptiste Leurent
- London School of Hygiene and Tropical MedicineDepartment of Medical StatisticsLondonUK
| | - Elizabeth L Sampson
- University College LondonMarie Curie Palliative Care Research Department, Division of PsychiatryLondonUK
| | - Patrick Stone
- University College LondonMarie Curie Palliative Care Research Department, Division of PsychiatryLondonUK
| | | | - Bridget Candy
- University College LondonMarie Curie Palliative Care Research Department, Division of PsychiatryLondonUK
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Morandi A, Pozzi C, Milisen K, Hobbelen H, Bottomley JM, Lanzoni A, Tatzer VC, Carpena MG, Cherubini A, Ranhoff A, MacLullich AMJ, Teodorczuk A, Bellelli G. An interdisciplinary statement of scientific societies for the advancement of delirium care across Europe (EDA, EANS, EUGMS, COTEC, IPTOP/WCPT). BMC Geriatr 2019; 19:253. [PMID: 31510941 PMCID: PMC6739939 DOI: 10.1186/s12877-019-1264-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 08/29/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Delirium is a geriatric syndrome that presents in 1 out of 5 hospitalized older patients. It is also common in the community, in hospices, and in nursing homes. Delirium prevalence varies according to clinical setting, with rates of under 5% in minor elective surgery but up to 80% in intensive care unit patients. Delirium has severe adverse consequences, but despite this and its high prevalence, it remains undetected in the majority of cases. Optimal delirium care requires an interdisciplinary, multi-dimensional diagnostic and therapeutic approach involving doctors, nurses, physiotherapists, and occupational therapists. However, there are still important gaps in the knowledge and management of this syndrome. MAIN BODY The objective of this paper is to promote the interdisciplinary approach in the prevention and management of delirium as endorsed by a delirium society (European Delirium Association, EDA), a geriatrics society (European Geriatric Medicine Society, EuGMS), a nursing society (European Academy of Nursing Science, EANS), an occupational therapy society (Council of Occupational Therapists for European Countries, COTEC), and a physiotherapy society (International Association of Physical Therapists working with Older People of the World Confederation for Physical Therapy, IPTOP/WCPT). SHORT CONCLUSION In this paper we have strongly promoted and supported interdisciplinary collaboration underlying the necessity of increasing communication among scientific societies. We have also provided suggestions on how to fill the current gaps via improvements in undergraduate and postgraduate delirium education among European Countries.
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Affiliation(s)
- Alessandro Morandi
- Department of Rehabilitation and Aged Care "Fondazione Camplani" Hospital, Cremona, Italy.
- Rehabilitation Hospital Ancelle di Cremona, Via Aselli 14, 26100, Cremona, CR, Italy.
| | - Christian Pozzi
- University of Applied Sciences and Arts of Southern Switzerland (SUPSI), Manno, Switzerland
| | - Koen Milisen
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium
- Division of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Hans Hobbelen
- Healthy Lifestyle, Ageing and Healthcare Research group Healthy Ageing, Allied Health Care and Nursing Centre of Expertise Healthy Ageing Hanze University of Applied Sciences Groningen, Groningen, Netherlands
- International Physical Therapist Working with Older People, Subgroup of World Confederation for Physical Therapy, WCPT, London, UK
| | - Jennifer M Bottomley
- International Physical Therapist Working with Older People, Subgroup of World Confederation for Physical Therapy, WCPT, London, UK
- Simmons College, Boston, MA, USA
| | - Alessandro Lanzoni
- NODAIA Unit, Villa Igea, Modena, Italy
- University of Modena and Reggio Emilia, Modena, Italy
| | - Verena C Tatzer
- University of applied Sciences Wiener Neustadt, Neustadt, Austria
| | | | - Antonio Cherubini
- Geriatria, Accettazione geriatrica e Centro di ricerca per l'invecchiamento, IRCCS INRCA, Ancona, Italy
| | - Anette Ranhoff
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Division of Health Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK
| | - Andrew Teodorczuk
- School of Medicine, Gold Coast Campus, Griffith University, Mount Gravatt, QLD, Australia
| | - Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Geriatric Unit, S. Gerardo Hospital, Monza, Italy
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Hov KR, Neerland BE, Undseth Ø, Wyller VBB, MacLullich AMJ, Qvigstad E, Skovlund E, Wyller TB. The Oslo Study of Clonidine in Elderly Patients with Delirium; LUCID: a randomised placebo-controlled trial. Int J Geriatr Psychiatry 2019; 34:974-981. [PMID: 30901487 DOI: 10.1002/gps.5098] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 03/17/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The aim of this double-blinded randomised placebo-controlled trial was to investigate the efficacy of clonidine for delirium in medical inpatients greater than 65 years. METHODS Acutely admitted medical patients greater than 65 years with delirium or subsyndromal delirium were eligible for inclusion. Included patients were given a loading dose of either placebo or clonidine; 75 μg every third hour up to a maximum of four doses to reach steady state and further 75 μg twice daily until delirium free for 2 days, discharge or a maximum of 7 days of treatment. The primary endpoint was the trajectory of the Memorial Delirium Assessment Scale (MDAS) for the 7 days of treatment. Presence of delirium according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria and severity measured by MDAS were assessed daily until discharge or a maximum of 7 days after end of treatment. RESULTS Because of slower enrolment than anticipated, the study was halted early. Ten patients in each group were studied. The low recruitment rate was mainly due to the presence of multiple patient exclusion criteria for patient safety. There was no significant difference between the treatment group in the primary endpoint comparing the trajectory of MDAS for the 7 days of treatment using mixed linear models with log transformation, (P = .60). The treatment group did not have increased adverse effects. CONCLUSIONS No effect of clonidine for delirium was found, although the study was under powered. Further studies in less frail populations are now required.
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Affiliation(s)
- Karen R Hov
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Bjørn Erik Neerland
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Øystein Undseth
- Department of Acute Medicine, Oslo University Hospital, Oslo, Norway
| | - Vegard Bruun Bratholm Wyller
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Pediatrics, Akershus University Hospital, Lørenskog, Norway
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, University of Edinburgh, Edinburgh, UK
| | - Eirik Qvigstad
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Eva Skovlund
- Department of Public Health and Nursing, NTNU, Trondheim, Norway
| | - Torgeir Bruun Wyller
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Baessler F, Ciprianidis A, Rizvi AZ, Weidlich J, Wagner FL, Klein SB, Baumann TC, Nikendei C, Schultz JH. Delirium: Medical Students' Knowledge and Effectiveness of Different Teaching Methods. Am J Geriatr Psychiatry 2019; 27:737-744. [PMID: 31005497 DOI: 10.1016/j.jagp.2019.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 02/13/2019] [Accepted: 03/05/2019] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Medical schools are often blamed for inadequately training doctors on delirium. This study assesses the knowledge of medical students regarding delirium and evaluates different teaching methods for comparing learning outcomes. METHODS A video, a handout, and a video+handout were used as three different teaching methods. Students were randomly assigned to three groups and pre- and postintervention knowledge gains were compared. Interventions were held between 2015 and 2018 at the University of Heidelberg Medical School in Germany. Seventy-eight (video intervention 33; handout 26; video+handout 19) sixth-year medical students participated. Participants learned about delirium with the help of a video, a handout, and both a video+handout at the start of one-hour lectures dedicated to teaching about delirium. Pre- and postintervention questionnaires, comprising five multiple-choice questions and a self-estimated grade of knowledge about delirium, were used. Variables calculated were objective and subjective knowledge, recall, and accuracy of self-assessment. Microsoft Excel and analysis of covariance were used to analyze data. RESULTS Knowledge gains for all interventions were large (d>0.8) irrespective of gender. Post hoc comparison showed video and video+handout methods were more effective with high recall for video (92.8%). Students rated their knowledge as satisfactory, although they scored 11.4 out of 20. Preintervention knowledge level was correctly estimated by 31% of students, and postintervention by 40.3% students. CONCLUSION Teaching about delirium to medical students with a video resulted in better knowledge transfer and recall. Most medical students, particularly men, overestimated their knowledge about delirium.
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Affiliation(s)
- Franziska Baessler
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany.
| | - Anja Ciprianidis
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Ali Z Rizvi
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Joshua Weidlich
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Fabienne L Wagner
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Sonja B Klein
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Tabea C Baumann
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Christoph Nikendei
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Jobst-Hendrik Schultz
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
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27
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Impact of an educational workshop upon psychiatrists' attitudes towards delirium care. Ir J Psychol Med 2019; 36:89-98. [PMID: 31187719 DOI: 10.1017/ipm.2016.47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Improving knowledge about delirium care is a key target for health care. We describe the implementation of a four-part workshop focusing upon key aspects of delirium care. METHODS Attitudes towards and understanding of delirium diagnosis and management amongst psychiatrists were surveyed before and immediately after an educational workshop. RESULTS There were 62 participants. Pre-workshop, delirium was rated highly relevant to psychiatry. Overall level of confidence in diagnosis was modest, with the behavioural and psychological symptoms of dementia considered the most challenging differential diagnosis. Only nine participants (15%) correctly identified DSM-5 delirium criteria. Preferred assessment of attention varied with six different approaches endorsed. Confidence was higher for managing hyperactive compared with hypoactive delirium (p<0.001). Pharmacotherapy was more frequently endorsed for hyperactive compared with hypoactive presentations, with haloperidol the most popular agent (p<0.001). A total of 41 (66%) participants completed post-workshop assessments. Post-workshop, there were significant increases to the perceived relevance of delirium (p = 0.003), confidence in overall diagnosis (p<0.001) accuracy of awareness of DSM-5 criteria (p<0.001), and confidence in treating different presentations (p<0.001). The Months Backward Test was the preferred bedside test of attention (38/40 respondents). CONCLUSIONS This interactive educational intervention impacted positively upon knowledge and attitudes amongst psychiatrists towards key aspects of delirium care. Further investigation can examine the impact upon longer term knowledge and behaviour.
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Boland JW, Kabir M, Bush SH, Spiller JA, Johnson MJ, Agar M, Lawlor P. Delirium management by palliative medicine specialists: a survey from the association for palliative medicine of Great Britain and Ireland. BMJ Support Palliat Care 2019; 12:73-80. [PMID: 30837278 DOI: 10.1136/bmjspcare-2018-001586] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 11/21/2018] [Accepted: 02/11/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Delirium is common in palliative care settings. Management includes detection, treatment of cause(s), non-pharmacological interventions and family support; strategies which are supported with varying levels of evidence. Emerging evidence suggests that antipsychotic use should be minimised in managing mild to moderate severity delirium, but the integration of this evidence into clinical practice is unknown. METHODS A 21-question online anonymous survey was emailed to Association for Palliative Medicine members in current clinical practice (n=859), asking about delirium assessment, management and research priorities. RESULTS Response rate was 39%: 70% of respondents were palliative medicine consultants. Delirium guidelines were used by some: 42% used local guidelines but 38% used none. On inpatient admission, 59% never use a delirium screening tool. Respondents would use non-pharmacological interventions to manage delirium, either alone (39%) or with an antipsychotic (58%). Most respondents (91%) would prescribe an antipsychotic and 6% a benzodiazepine, for distressing hallucinations unresponsive to non-pharmacological measures. Inpatient (57%) and community teams (60%) do not formally support family carers. Research priorities were delirium prevention, management and prediction of reversibility. CONCLUSION This survey of UK and Irish Palliative Medicine specialists shows that delirium screening at inpatient admission is suboptimal. Most specialists continue to use antipsychotics in combination with non-pharmacological interventions to manage delirium. More support for family carers should be routinely provided by clinical teams. Further rigorously designed clinical trials are urgently needed in view of management variability, emerging evidence and perceived priorities for research.
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Affiliation(s)
- Jason W Boland
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Monisha Kabir
- Division of Palliative Care, Bruyère Research Institute; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Division of Palliative Care, Bruyère Research Institute; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada.,Department of Palliative Care, Bruyère Continuing Care, Ottawa, Ontario, Canada
| | - Juliet Anne Spiller
- Palliative Medicine, Marie Curie Hospice, Edinburgh, UK.,IMPACCT (Improving Palliative, Chronic and Aged Care through Clinical Research and Translation), Faculty of Health, University of Technology, Sydney, Australia
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Meera Agar
- IMPACCT (Improving Palliative, Chronic and Aged Care through Clinical Research and Translation), Faculty of Health, University of Technology, Sydney, Australia
| | - Peter Lawlor
- Division of Palliative Care, Bruyère Research Institute; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada.,Department of Palliative Care, Bruyère Continuing Care, Ottawa, Ontario, Canada
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29
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Bush SH, Tierney S, Lawlor PG. Clinical Assessment and Management of Delirium in the Palliative Care Setting. Drugs 2019; 77:1623-1643. [PMID: 28864877 PMCID: PMC5613058 DOI: 10.1007/s40265-017-0804-3] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Delirium is a neurocognitive syndrome arising from acute global brain dysfunction, and is prevalent in up to 42% of patients admitted to palliative care inpatient units. The symptoms of delirium and its associated communicative impediment invariably generate high levels of patient and family distress. Furthermore, delirium is associated with significant patient morbidity and increased mortality in many patient populations, especially palliative care where refractory delirium is common in the dying phase. As the clinical diagnosis of delirium is frequently missed by the healthcare team, the case for regular screening is arguably very compelling. Depending on its precipitating factors, a delirium episode is often reversible, especially in the earlier stages of a life-threatening illness. Until recently, antipsychotics have played a pivotal role in delirium management, but this role now requires critical re-evaluation in light of recent research that failed to demonstrate their efficacy in mild- to moderate-severity delirium occurring in palliative care patients. Non-pharmacological strategies for the management of delirium play a fundamental role and should be optimized through the collective efforts of the whole interprofessional team. Refractory agitated delirium in the last days or weeks of life may require the use of pharmacological sedation to ameliorate the distress of patients, which is invariably juxtaposed with increasing distress of family members. Further evaluation of multicomponent strategies for delirium prevention and treatment in the palliative care patient population is urgently required.
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Affiliation(s)
- Shirley Harvey Bush
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Bruyère Research Institute (BRI), Ottawa, ON, Canada. .,Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada. .,Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada.
| | - Sallyanne Tierney
- Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada
| | - Peter Gerard Lawlor
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute (BRI), Ottawa, ON, Canada.,Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.,Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada
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30
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Rivière J, van der Mast RC, Vandenberghe J, Van Den Eede F. Efficacy and Tolerability of Atypical Antipsychotics in the Treatment of Delirium: A Systematic Review of the Literature. PSYCHOSOMATICS 2019; 60:18-26. [DOI: 10.1016/j.psym.2018.05.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 05/22/2018] [Accepted: 05/23/2018] [Indexed: 10/14/2022]
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Meagher D, Agar MR, Teodorczuk A. Debate article: Antipsychotic medications are clinically useful for the treatment of delirium. Int J Geriatr Psychiatry 2018; 33:1420-1427. [PMID: 28758323 DOI: 10.1002/gps.4759] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 06/01/2017] [Indexed: 11/05/2022]
Abstract
Prescribing of antipsychotic medications for patients with delirium remains controversial. Concerns exist that these vulnerable and frail patients may be prescribed antipsychotics inappropriately as a substitute for non-pharmacological approaches when identifiable causes are not found or they challenge ward processes. Moreover, recent evidence suggests that antipsychotics may cause more harm than good in the palliative care patient group with delirium. On the other hand, guidelines in the United Kingdom and the Netherlands support prescribing of antipsychotics in certain circumstances, and a large European survey has revealed that antipsychotics tend to be prescribed first line for hyperactive delirium. Never before, therefore, is there a greater need to examine whether indeed these medications are clinically useful for the treatment of delirium. With this in mind, evidence-based arguments for and against prescribing antipsychotics for the treatment of delirium are presented in this debate article. The paper concludes with a moderation piece to help guide clinical practice.
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Affiliation(s)
- David Meagher
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Ireland.,Department of Psychiatry, University Hospital Limerick, Ireland
| | - Meera R Agar
- Faculty of Health, University of Technology Sydney, New South Wales, Australia.,South West Sydney Clinical School, University of New South Wales, New South Wales, Australia.,Ingham Institute of Applied Medical Research, New South Wales, Australia.,Discipline, Palliative and Supportive Services, Flinders University, South Australia, Australia
| | - Andrew Teodorczuk
- School of Medicine, Griffith University, Gold Coast, Australia.,Health Institute for the Development of Education and Scholarship (Health IDEAS), Griffith University, Queensland, Australia
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32
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Teodorczuk A, MacLullich A. New waves of delirium understanding. Int J Geriatr Psychiatry 2018; 33:1417-1419. [PMID: 29314268 DOI: 10.1002/gps.4848] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 11/21/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Andrew Teodorczuk
- School of Medicine, Gold Coast Campus, Griffith University, QLD, Australia.,Health Institute for the Development of Education and Scholarship (Health IDEAS), Gold Coast Campus, Griffith University, QLD, Australia
| | - Alasdair MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, University of Edinburgh, UK
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Buijs-Spanjers KR, Hegge HH, Jansen CJ, Hoogendoorn E, de Rooij SE. A Web-Based Serious Game on Delirium as an Educational Intervention for Medical Students: Randomized Controlled Trial. JMIR Serious Games 2018; 6:e17. [PMID: 30368436 PMCID: PMC6229519 DOI: 10.2196/games.9886] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 04/23/2018] [Accepted: 06/21/2018] [Indexed: 12/14/2022] Open
Abstract
Background Adequate delirium recognition and management are important to reduce the incidence and severity of delirium. To improve delirium recognition and management, training of medical staff and students is needed. Objective In this study, we aimed to gain insight into whether the serious game, Delirium Experience, is suited as an educational intervention. Methods We conducted a three-arm randomized controlled trial. We enrolled 156 students in the third year of their Bachelor of Medical Sciences degree at the University Medical Centre Groningen. The Game group of this study played Delirium Experience. The Control D group watched a video with explanations on delirium and a patient’s experience of delirious episodes. The Control A group watched a video on healthy aging. To investigate students’ skills, we used a video of a delirious patient for which students had to give care recommendations and complete the Delirium Observations Screening Scale and Delirium Rating Scale R-98. Furthermore, students completed the Delirium Attitude Scale, the Learning Motivation and Engagement Questionnaire, and self-reported knowledge on delirium. Results In total, 156 students participated in this study (Game group, n=51; Control D group, n=51; Control A group, n=55). The Game group scored higher with a median (interquartile range) of 6 (4-8) for given recommendations and learning motivation and engagement compared with the Control D (1, 1-4) and A (0, 0-3) groups (P<.001). Furthermore, the Game group scored higher (7, 6-8) on self-reported knowledge compared with the Control A group (6, 5-6; P<.001). We did not find differences between the groups regarding delirium screening (P=.07) and rating (P=.45) skills or attitude toward delirious patients (P=.55). Conclusions The serious game, Delirium Experience, is suitable as an educational intervention to teach delirium care to medical students and has added value in addition to a lecture.
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Affiliation(s)
- Kiki R Buijs-Spanjers
- Department of Geriatric Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Harianne Hm Hegge
- Department of Geriatric Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Carolien J Jansen
- Department of Geriatric Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | | | - Sophia E de Rooij
- Department of Geriatric Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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34
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Hov KR, Neerland BE, Andersen AM, Undseth Ø, Wyller VB, MacLullich AMJ, Skovlund E, Qvigstad E, Wyller TB. The use of clonidine in elderly patients with delirium; pharmacokinetics and hemodynamic responses. BMC Pharmacol Toxicol 2018; 19:29. [PMID: 29884231 PMCID: PMC5994030 DOI: 10.1186/s40360-018-0218-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 05/22/2018] [Indexed: 01/29/2023] Open
Abstract
Background The Oslo Study of Clonidine in Elderly Patients with Delirium (LUCID) is an RCT investigating the effect of clonidine in medical patients > 65 years with delirium. To assess the dosage regimen and safety measures of this study protocol, we measured the plasma concentrations and hemodynamic effects of clonidine in the first 20 patients. Methods Patients were randomised to clonidine (n = 10) or placebo (n = 10). The treatment group was given a loading dose (75μg every 3rd hour up to a maximum of 4 doses) to reach steady state, and further 75μg twice daily until delirium free for 2 days, discharge or a maximum of 7 days. Blood pressure (BP) and heart rate (HR) were measured just before every dose. If the systolic BP was < 100 mmHg or HR < 50 beats per minute the next dose was omitted. Plasma concentrations of clonidine were measured 3 h after each drug intake on day 1, just before intake (day 2 and at steady state day 4–6) and 3 h after intake at steady state (Cmax). Our estimated pre-specified plasma concentration target range was 0.3–0.7μg/L. Results 3 h after the first dose of 75μg clonidine, plasma concentration levels rose to median 0.35 (range 0.24–0.40)μg/L. Median trough concentration (C0) at day 2 was 0.70 (0.47–0.96)μg/L. At steady state, median C0 was 0.47 (0.36–0.76)μg/L, rising to Cmax 0.74 (0.56–0.95)μg/L 3 h post dose. A significant haemodynamic change from baseline was only found at a few time-points during the loading doses within the clonidine group. There was however extensive individual BP and HR variation in both the clonidine and placebo groups, and when comparing the change scores (delta values) between the clonidine and the placebo groups, there were no significant differences. Conclusions The plasma concentration of clonidine was at the higher end of the estimated therapeutic range. Hemodynamic changes during clonidine treatment were as expected, with trends towards lower blood pressure and heart rate in patients treated with clonidine, but with dose adjustments based on SBP this protocol appears safe. Trial registration ClinicalTrials.gov NCT01956604, 09.25.2013. EudraCT Number: 2013–000815-26, 03.18.2013. Enrolment of first participant: 04.24.2014.
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Affiliation(s)
- Karen Roksund Hov
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway. .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Bjørn Erik Neerland
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Øystein Undseth
- Department of Acute Medicine, Oslo University Hospital, Oslo, Norway
| | - Vegard Bruun Wyller
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Paediatrics, Akershus University Hospital, Lørenskog, Norway
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, University of Edinburgh, Edinburgh, UK
| | - Eva Skovlund
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Eirik Qvigstad
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Torgeir Bruun Wyller
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Schrijver EJM, Verstraaten M, van de Ven PM, Bet PM, van Strien AM, de Cock C, Nanayakkara PWB. Low dose oral haloperidol does not prolong QTc interval in older acutely hospitalised adults: a subanalysis of a randomised double-blind placebo-controlled study. J Geriatr Cardiol 2018; 15:401-407. [PMID: 30108611 PMCID: PMC6087514 DOI: 10.11909/j.issn.1671-5411.2018.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 02/26/2018] [Accepted: 03/20/2018] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Haloperidol is the most frequently prescribed antipsychotic for delirium symptoms. The risk of QTc prolongation often raises concerns, although the effect of haloperidol on QTc interval has not yet been investigated in a randomised placebo-controlled fixed-dose study. METHODS A subanalysis of a randomised double-blind placebo-controlled study was conducted to evaluate the effect of prophylactic haloperidol 1 mg or placebo 1 mg orally twice-daily (maximum of 14 doses) on QTc interval in patients aged 70 years and over. Bedside, 12-lead ECGs were recorded before, during and after the one-week intervention period. Automatic QTc measurements were obtained in addition to manual measurements of QT and RR intervals, blinded for treatment status. Manual measurements were corrected (QTc) using Bazett (QTc-B), Framingham (QTc-Fa), Fridericia (QTc-Fi) and Hodges (QTc-H) methods. Mixed model analyses were used to test for differences in longitudinal course of QTc between patients receiving haloperidol and placebo. RESULTS ECG recordings of 72 patients (haloperidol n = 38) were analysed, 45.8% male. Median (range) haloperidol serum concentration on day 4 was 0.71 (0.32-1.82) µg/L (n = 23). Longitudinal course of mean QTc did not significantly differ between treatment arms for any of the automatic or manually derived QTc values. CONCLUSIONS Low dose oral haloperidol did not result in QTc prolongation in older acutely hospitalised patients. Results may not be generalizable to patients with existing ECG abnormalities such as atrial fibrillation.
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Affiliation(s)
- Edmée JM Schrijver
- Department of Internal Medicine, VU University Medical Centre, Amsterdam, the Netherlands
| | - Maaike Verstraaten
- Department of Cardiology, VU University Medical Centre, Amsterdam, the Netherlands
| | - Peter M van de Ven
- Department of Epidemiology and Biostatistics, VU University Medical Centre, the Netherlands
| | - Pierre M Bet
- Department of Clinical Pharmacology and Pharmacy, VU University Medical Centre, the Netherlands
| | - Astrid M van Strien
- Department of Geriatric Medicine, Jeroen Bosch Hospital, ‘s-Hertogenbosch, the Netherlands
| | - Carel de Cock
- Department of Cardiology, VU University Medical Centre, Amsterdam, the Netherlands
| | - Prabath WB Nanayakkara
- Department of Internal Medicine, VU University Medical Centre, Amsterdam, the Netherlands
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Abstract
Delirium is a common, often underdiagnosed, geriatric syndrome characterized by an acute change in attention and consciousness. As a neuropsychiatric disorder with an underlying organic cause, delirium has been considered a diagnosis reserved for the hospital setting. However, delirium is known to occur as both an acute and subacute condition that carries significant morbidity and mortality. Combined with its association with dementia and aging, this makes delirium an important topic for primary care providers to become more familiar with as they are tasked with caring for an aging population.
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Schrijver EJM, de Vries OJ, van de Ven PM, Bet PM, Kamper AM, Diepeveen SHA, van Marum RJ, van Strien AM, Anten S, Lagaay AM, Boelaarts L, Bloemers FW, Kramer MHH, Nanayakkara PWB. Haloperidol versus placebo for delirium prevention in acutely hospitalised older at risk patients: a multi-centre double-blind randomised controlled clinical trial. Age Ageing 2018; 47:48-55. [PMID: 28985255 DOI: 10.1093/ageing/afx124] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 06/22/2017] [Indexed: 11/14/2022] Open
Abstract
Background because the few randomised placebo-controlled trials investigating the potential role for prophylactic haloperidol in delirium prevention have focused on specific surgical populations, we investigated its efficacy and safety in acutely hospitalised older patients. Methods this multi-centre, double-blind, stratified, block randomised, placebo-controlled trial was conducted at six Dutch hospitals. Patients age ≥70 years, acutely admitted through the emergency department for general medicine or surgical specialties and at risk for delirium were randomised (n = 245) to haloperidol or placebo 1 mg orally twice-daily (maximum of 14 doses) on top of standard nonpharmacological prevention strategies. The primary outcome was delirium incidence. Other endpoints included delirium severity and duration, drug safety and clinical outcomes. Results intention-to-treat analysis included 242 participants (calculated sample size n = 390, statistical power of current sample 59%) allocated to haloperidol (n = 118) or placebo (n = 124). In the haloperidol and placebo group, delirium incidence was 19.5 versus 14.5% (OR 1.43, 95% CI 0.72 to 2.78); median (IQR) delirium duration 4 (2, 5) versus 3 (1, 6) days (P = 0.366); maximum DRS-R-98 score 16 (9.8, 19.5) versus 10 (5.5, 22.5) (P = 0.549; 53.7% missing data); hospital LOS 7 (4, 10.3) versus 7 (5, 11.8) days (P = 0.343); 3-month mortality 9.9 versus 12.5% (OR 0.77, 95% CI 0.34 to 1.75), respectively. No treatment-limiting side effects were noted. Conclusions prophylactic low-dose oral haloperidol did not reduce delirium incidence in acutely hospitalised older patients. Therefore, prophylactic use of haloperidol in this population is not recommended.
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Affiliation(s)
- Edmée J M Schrijver
- Department of Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - Oscar J de Vries
- Department of Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
- Department of Internal Medicine, Onze Lieve Vrouwe Gasthuis (OLVG Hospital), Amsterdam, The Netherlands
| | - Peter M van de Ven
- Department of Epidemiology and Biostatistics, VU University Medical Centre, Amsterdam, The Netherlands
| | - Pierre M Bet
- Department of Clinical Pharmacology and Pharmacy, VU University Medical Centre, Amsterdam, The Netherlands
| | - Ad M Kamper
- Department of Internal Medicine, Isala Hospital, Zwolle, The Netherlands
| | | | - Rob J van Marum
- Department of Geriatric Medicine, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
- Department of General Practice and Elderly Care Medicine, VU University Medical Centre, EMGO Institute for Health and Care Research, Amsterdam, The Netherlands
| | - Astrid M van Strien
- Department of Geriatric Medicine, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Sander Anten
- Department of Internal Medicine, Alrijne Hospital, Leiderdorp, The Netherlands
| | - Anne M Lagaay
- Department of Internal Medicine, Spaarne Hospital, Hoofddorp, The Netherlands
- Department of Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - Leo Boelaarts
- Department of Geriatric Medicine, Northwest Clinics, Alkmaar, The Netherlands
| | - Frank W Bloemers
- Department of Trauma Surgery, VU University Medical Centre, Amsterdam, The Netherlands
| | - Mark H H Kramer
- Department of Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
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Eeles E, McCrow J, Teodorczuk A, Caplan GA. Delirium care: Real-world solutions to real-world problems. Australas J Ageing 2017; 36:E64-E69. [DOI: 10.1111/ajag.12461] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Eamonn Eeles
- Prince Charles Hospital Northside Clinical Unit; University of Queensland; Brisbane Queensland Australia
- Queensland Health; The Prince Charles Hospital; Brisbane Queensland Australia
| | - Judy McCrow
- Churches of Christ; Brisbane Queensland Australia
| | | | - Gideon A Caplan
- University of New South Wales; Sydney New South Wales Australia
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39
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Bush SH, Tierney S, Lawlor PG. Clinical Assessment and Management of Delirium in the Palliative Care Setting. Drugs 2017. [PMID: 28864877 DOI: 10.1007/s40265‐017‐0804‐3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Delirium is a neurocognitive syndrome arising from acute global brain dysfunction, and is prevalent in up to 42% of patients admitted to palliative care inpatient units. The symptoms of delirium and its associated communicative impediment invariably generate high levels of patient and family distress. Furthermore, delirium is associated with significant patient morbidity and increased mortality in many patient populations, especially palliative care where refractory delirium is common in the dying phase. As the clinical diagnosis of delirium is frequently missed by the healthcare team, the case for regular screening is arguably very compelling. Depending on its precipitating factors, a delirium episode is often reversible, especially in the earlier stages of a life-threatening illness. Until recently, antipsychotics have played a pivotal role in delirium management, but this role now requires critical re-evaluation in light of recent research that failed to demonstrate their efficacy in mild- to moderate-severity delirium occurring in palliative care patients. Non-pharmacological strategies for the management of delirium play a fundamental role and should be optimized through the collective efforts of the whole interprofessional team. Refractory agitated delirium in the last days or weeks of life may require the use of pharmacological sedation to ameliorate the distress of patients, which is invariably juxtaposed with increasing distress of family members. Further evaluation of multicomponent strategies for delirium prevention and treatment in the palliative care patient population is urgently required.
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Affiliation(s)
- Shirley Harvey Bush
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Bruyère Research Institute (BRI), Ottawa, ON, Canada. .,Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada. .,Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada.
| | - Sallyanne Tierney
- Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada
| | - Peter Gerard Lawlor
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute (BRI), Ottawa, ON, Canada.,Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.,Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada
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40
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Nydahl P, Dewes M, Dubb R, Hermes C, Kaltwasser A, Krotsetis S, von Haken R. Survey among critical care nurses and physicians about delirium management. Nurs Crit Care 2017; 23:23-29. [DOI: 10.1111/nicc.12299] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 04/06/2017] [Accepted: 04/10/2017] [Indexed: 12/13/2022]
Affiliation(s)
- Peter Nydahl
- Department of Nursing Research; University Hospital of Schleswig-Holstein; Campus Kiel, Brunswiker Str. 10, Kiel Germany
| | - Michael Dewes
- Department of Critical Care; Centre Hospitalier Emile Mayrisch; Esch-sur-Alzette Luxembourg
| | - Rolf Dubb
- Nursing Education District Hospital of Reutlingen GmbH; Reutlingen Germany
| | | | - Arnold Kaltwasser
- Nursing Education; District Hospital of Reutlingen GmbH; Reutlingen Germany
| | - Susanne Krotsetis
- Department of Nursing Research; University Hospital of Schleswig-Holstein; Campus Lübeck Germany
| | - Rebecca von Haken
- Department of Anesthesia and Critical Care; University Hospital Heidelberg; Heidelberg Germany
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41
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Oldham MA, Piddoubny W, Peterson R, Lee HB. Detection and Management of Preexisting Cognitive Impairment in the Critical Care Unit. Crit Care Clin 2017; 33:441-459. [PMID: 28601131 DOI: 10.1016/j.ccc.2017.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Older adults account for half of intensive care unit (ICU) admissions and ICU days, and approximately 2 in 5 older adults in the ICU have preexisting cognitive impairment (PCI). PCI identification is important for risk stratification and may influence ICU utilization and decision-making surrogacy. PCI is overlooked in more than half of patients without screening; however, screening instruments can identify PCI in less than 5 minutes. Management of PCI in the ICU involves addressing associated neuropsychiatric symptoms. Nonpharmacological interventions should be considered the mainstay of treatment; psychotropics may be considered, although available data on their efficacy is limited.
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Affiliation(s)
- Mark A Oldham
- Department of Psychiatry, Yale School of Medicine, 20 York Street, Fitkin 615, New Haven, CT 06510, USA.
| | - Walter Piddoubny
- Department of Psychiatry, Yale School of Medicine, 20 York Street, Fitkin 615, New Haven, CT 06510, USA
| | - Ryan Peterson
- Department of Psychiatry, Yale School of Medicine, 20 York Street, Fitkin 615, New Haven, CT 06510, USA
| | - Hochang B Lee
- Department of Psychiatry, Yale School of Medicine, 20 York Street, Fitkin 615, New Haven, CT 06510, USA
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42
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Antipsychotic drug use associated with urinary tract infections in older women. Maturitas 2017; 98:46-50. [DOI: 10.1016/j.maturitas.2017.01.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 01/11/2017] [Accepted: 01/16/2017] [Indexed: 11/17/2022]
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43
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Abstract
Delirium describes a sudden onset change in mental status of fluctuating course. This is a state of altered consciousness characterised chiefly by inattention or lack of arousal, but can also include new impairment of language, perception and behaviour. Certain predisposing factors can make an individual more susceptible to delirium in the face of a stressor. Stressors include direct insults to the brain, insults peripheral to the brain or external changes in the environment of an individual. Delirium is varied in its presentation, and can be categorised by the psychomotor profile as: hyperactive type (overly vigilant, agitated, often wandersome), hypoactive type (sedate or withdrawn) or mixed types.
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Affiliation(s)
- Oliver M Todd
- Bradford Institute for Health Research, Bradford, UK
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44
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[Treatment with psychotropic agents in patients with dementia and delirium : Gap between guideline recommendations and treatment practice]. Z Gerontol Geriatr 2017; 50:106-114. [PMID: 28124100 DOI: 10.1007/s00391-016-1176-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Revised: 12/05/2016] [Accepted: 12/16/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Psychiatric symptoms in dementia and delirium are associated with a substantially reduced quality of life of patients and their families and often challenging for professionals. Pharmacoepidemiological surveys have shown that, in particular, patients living in nursing homes receive prescriptions of psychotropic agents in significant higher frequency than recommended by current guidelines. This article focuses on a critical appraisal of this gap from the point of view of German healthcare services. MATERIAL AND METHODS Narrative review with special reference to the German dementia guideline from 2016 and recently published practice guidelines for delirium in old age in German and English language. RESULTS The indications for use of psychotropic agents, especially antipsychotics, are defined narrowly in the German dementia guideline. According to this guideline for several psychopathological symptoms evidence based recommendations cannot be given, currently. For delirium several practice guidelines related to different treatment settings have been published recently. Comparable to the German dementia guideline they recommend general medical interventions and nonpharmacological treatment as first line measures and the use of psychotropic agents only under certain conditions. These guidelines differ to some extent regarding the strength of recommendation for psychopharmacological treatment. CONCLUSION The guidelines discussed here advocate well-founded a cautious prescription of psychotropic agents in patients with dementia and delirium. This contrasts to everyday practice which is characterized by significantly higher prescription rates. This gap may explained partially by a lack of evidence-based recommendations regarding certain psychopathological symptoms. Most notably, however, epidemiological data disclose an unacceptable rate of hazardous overtreatment with psychotropic agents, especially in long-term care of persons with dementia. In this situation counteractive measures by consequent implementation of the principles of good clinical practice in geriatrics are required urgently.
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45
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Todd OM, Teale EA. Delirium: a guide for the general physician. Clin Med (Lond) 2016. [PMID: 27956448 PMCID: PMC6329570 DOI: 10.7861/clinmedicine.16-6s-s98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Delirium describes a sudden onset change in mental status of fluctuating course. This is a state of altered consciousness characterised chiefly by inattention or lack of arousal, but can also include new impairment of language, perception and behaviour. Certain predisposing factors can make an individual more susceptible to delirium in the face of a stressor. Stressors include direct insults to the brain, insults peripheral to the brain or external changes in the environment of an individual. Delirium is varied in its presentation, and can be categorised by the psychomotor profile as: hyperactive type (overly vigilant, agitated, often wandersome), hypoactive type (sedate or withdrawn) or mixed types.
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Affiliation(s)
- Oliver M Todd
- ABradford Institute for Health Research, Bradford, UK,Address for correspondence: Dr O M Todd, Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford Institute for Health Research, Duckworth Lane, Bradford BD9 6RJ, UK.
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46
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Abstract
Delirium describes a sudden onset change in mental status of fluctuating course. This is a state of altered consciousness characterised chiefly by inattention or lack of arousal, but can also include new impairment of language, perception and behaviour. Certain predisposing factors can make an individual more susceptible to delirium in the face of a stressor. Stressors include direct insults to the brain, insults peripheral to the brain or external changes in the environment of an individual. Delirium is varied in its presentation, and can be categorised by the psychomotor profile as: hyperactive type (overly vigilant, agitated, often wandersome), hypoactive type (sedate or withdrawn) or mixed types.
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Affiliation(s)
- Oliver M Todd
- Bradford Institute for Health Research, Bradford, UK
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47
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Kolanowski A, Fick D, Litaker M, Mulhall P, Clare L, Hill N, Mogle J, Boustani M, Gill D, Yevchak-Sillner A. Effect of Cognitively Stimulating Activities on Symptom Management of Delirium Superimposed on Dementia: A Randomized Controlled Trial. J Am Geriatr Soc 2016; 64:2424-2432. [PMID: 27861718 DOI: 10.1111/jgs.14511] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine whether cognitively stimulating activities would reduce duration and severity of delirium and improve cognitive and physical function to a greater extent than usual care. DESIGN Single-blind randomized clinical trial. SETTING Eight post-acute care (PAC) facilities. PARTICIPANTS Community-dwelling older adults with dementia and delirium (N = 283). INTERVENTION Research staff provided cognitively stimulating activities daily for up to 30 days. MEASUREMENTS Primary outcomes were delirium duration (Confusion Assessment Method) and delirium severity (Delirium Rating Scale). Secondary outcomes were cognitive function (Digits Forward, Montreal Cognitive Assessment, CLOX) and physical function (Barthel Index). RESULTS Mean percentage of delirium-free days (intervention: 64.8%, 95% confidence interval (CI) = 59.6-70.1; control: 68.7%, 95% CI = 63.9-73.6; P = .37, Wilcoxon rank sum test) and delirium severity (range 0-39: intervention: 10.77, 95% CI = 10.10-11.45; control: 11.15, 95% CI = 10.50-11.80; difference 0.37, 95% CI = 0.56-1.31, P = .43) were similar in both groups. Significant differences for secondary outcomes favoring intervention were found (executive function (range 0-15): intervention: 6.58, 95% CI = 6.12-7.04; control: 5.89, 95% CI = 5.45-6.33; difference -0.69, 95% CI = 1.33 to -0.06, P = .03; constructional praxis (range 0-15): intervention: 8.84, 95% CI = 8.83-9.34; control: 7.53, 95% CI = 7.04-8.01; difference -1.31, 95% CI = 2.01 to -0.61, P < .001). After adjusting for baseline constructional praxis, the group comparison was no longer significant. Average length of stay was shorter in the intervention (36.09 days) than the control (53.13 days) group (standard error = 0.15, P = .01, negative binomial regression). CONCLUSION Cognitively stimulating activities did not improve delirium but improved executive function and reduced length of stay. Resolution of delirium may require more-intense nonpharmacological management when the individual has dementia.
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Affiliation(s)
- Ann Kolanowski
- College of Nursing, Pennsylvania State University, University Park, Pennsylvania
| | - Donna Fick
- College of Nursing, Pennsylvania State University, University Park, Pennsylvania
| | - Mark Litaker
- School of Dentistry, University of Alabama, Birmingham, Alabama
| | - Paula Mulhall
- Prevention Research Center, College of Health and Human Development, Pennsylvania State University, University Park, Pennsylvania
| | - Linda Clare
- Centre for Research in Ageing and Cognitive Health, Washington Singer Laboratories, Exeter, United Kingdom
| | - Nikki Hill
- College of Nursing, Pennsylvania State University, University Park, Pennsylvania
| | - Jacqueline Mogle
- College of Nursing, Pennsylvania State University, University Park, Pennsylvania
| | - Malaz Boustani
- School of Medicine and Aging Brain Center, Indiana University, Indianapolis, Indiana
| | - David Gill
- Rochester Regional Health, University of Rochester, Rochester, New York.,Department of Neurology, University of Rochester, Rochester, New York
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48
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Saller T, V Dossow V, Hofmann-Kiefer K. [Knowledge and implementation of the S3 guideline on delirium management in Germany]. Anaesthesist 2016; 65:755-762. [PMID: 27646394 DOI: 10.1007/s00101-016-0218-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 07/18/2016] [Accepted: 08/04/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND Delirium is a common complication in critical care. The syndrome is often underestimated due to its potentially no less dangerous course as a hypoactive delirium. Therefore, current guidelines ask for a structured, regular and routine screening in all intensive care units. If delirium is diagnosed, symptomatic therapy should be initiated promptly. OBJECTIVES The aim of the current study was to evaluate recent German anesthetists' strategies regarding delirium care compared to the German guidelines for sedation and delirium in intensive care. METHODS In an online survey German hospitals' senior anesthetists (n = 922) were interviewed anonymously between May and June 2015 regarding guideline use in delirium management in German intensive care units. In 33 direct questions the anesthetists were invited to answer items regarding the structure of their hospitals, intensive care and delirium therapy in order to review their knowledge of the German delirium guidelines that expired in 2014. RESULTS The 249 senior anesthetists who responded to the survey, can be associated with (or represent) a quarter of German intensive care beds and cases, respectively. In every tenth clinic that runs an intensive care unit the guideline was unknown. In three of four intensive care units physicians specified a preferred delirium score, the CAM-ICU (49.4 %) is used most frequently. With knowledge of the guidelines more often a recommended delirium score is used (p = 0.017). However, only 53.6 % of the respondents ascertain a score every eight hours and 36 % have no facility for standardized documentation in the records. At intensive care rounds, a possible diagnosis of delirium is an inherent part in only 34.9 % of the responders even with guideline knowledge. The particular gold standard for the therapy of delirium (alphaagonists for vegetative symptoms; 89.6 %, benzodiazepines for anxiety, 77.5 %; antipsychotics in 86.7 % for psychotic symptoms) is implemented more often with growing knowledge of the guidelines. The latter applies to the implementation of structured programs for delirium prophylaxis, cognition and therapy. CONCLUSION For the first time, this study documents knowledge and implementation of the German S3 guidelines for delirium in intensive care. Overall, the guidelines for delirium care are less well executed than those for sedation. With growing knowledge of the guidelines, diagnosis and treatment of delirium fits the guidelines more frequently. The facility to document a delirium score in intensive records is insufficient. Especially a nursing-based delirium strategy could possibly improve implementation of the guidelines, claiming an eight-hour screening and documentation. However, the small number of hospitals that have integrated the guidelines into in-house standard operating procedures (40 %) shows urgent need for optimization. A re-evaluation involving all relevant caretakers could probably improve the implementation of guidelines in intensive care and perioperative medicine.
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Affiliation(s)
- T Saller
- Klinik für Anaesthesiologie, Klinikum der Ludwig-Maximilians-Universität München, Nußbaumstraße 20, 80336, München, Deutschland.
| | - V V Dossow
- Klinik für Anaesthesiologie, Klinikum der Ludwig-Maximilians-Universität München, Nußbaumstraße 20, 80336, München, Deutschland
| | - K Hofmann-Kiefer
- Klinik für Anaesthesiologie, Klinikum der Ludwig-Maximilians-Universität München, Nußbaumstraße 20, 80336, München, Deutschland
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49
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Bellelli G, Morandi A, Di Santo SG, Mazzone A, Cherubini A, Mossello E, Bo M, Bianchetti A, Rozzini R, Zanetti E, Musicco M, Ferrari A, Ferrara N, Trabucchi M. "Delirium Day": a nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool. BMC Med 2016; 14:106. [PMID: 27430902 PMCID: PMC4950237 DOI: 10.1186/s12916-016-0649-8] [Citation(s) in RCA: 155] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 06/23/2016] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND To date, delirium prevalence in adult acute hospital populations has been estimated generally from pooled findings of single-center studies and/or among specific patient populations. Furthermore, the number of participants in these studies has not exceeded a few hundred. To overcome these limitations, we have determined, in a multicenter study, the prevalence of delirium over a single day among a large population of patients admitted to acute and rehabilitation hospital wards in Italy. METHODS This is a point prevalence study (called "Delirium Day") including 1867 older patients (aged 65 years or more) across 108 acute and 12 rehabilitation wards in Italian hospitals. Delirium was assessed on the same day in all patients using the 4AT, a validated and briefly administered tool which does not require training. We also collected data regarding motoric subtypes of delirium, functional and nutritional status, dementia, comorbidity, medications, feeding tubes, peripheral venous and urinary catheters, and physical restraints. RESULTS The mean sample age was 82.0 ± 7.5 years (58 % female). Overall, 429 patients (22.9 %) had delirium. Hypoactive was the commonest subtype (132/344 patients, 38.5 %), followed by mixed, hyperactive, and nonmotoric delirium. The prevalence was highest in Neurology (28.5 %) and Geriatrics (24.7 %), lowest in Rehabilitation (14.0 %), and intermediate in Orthopedic (20.6 %) and Internal Medicine wards (21.4 %). In a multivariable logistic regression, age (odds ratio [OR] 1.03, 95 % confidence interval [CI] 1.01-1.05), Activities of Daily Living dependence (OR 1.19, 95 % CI 1.12-1.27), dementia (OR 3.25, 95 % CI 2.41-4.38), malnutrition (OR 2.01, 95 % CI 1.29-3.14), and use of antipsychotics (OR 2.03, 95 % CI 1.45-2.82), feeding tubes (OR 2.51, 95 % CI 1.11-5.66), peripheral venous catheters (OR 1.41, 95 % CI 1.06-1.87), urinary catheters (OR 1.73, 95 % CI 1.30-2.29), and physical restraints (OR 1.84, 95 % CI 1.40-2.40) were associated with delirium. Admission to Neurology wards was also associated with delirium (OR 2.00, 95 % CI 1.29-3.14), while admission to other settings was not. CONCLUSIONS Delirium occurred in more than one out of five patients in acute and rehabilitation hospital wards. Prevalence was highest in Neurology and lowest in Rehabilitation divisions. The "Delirium Day" project might become a useful method to assess delirium across hospital settings and a benchmarking platform for future surveys.
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Affiliation(s)
- Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy. .,Geriatric Unit, San Gerardo University Hospital, Monza, Italy. .,Geriatric Research Group, Brescia, Italy.
| | - Alessandro Morandi
- Geriatric Research Group, Brescia, Italy.,Department of Rehabilitation and Aged Care "Fondazione Camplani" Hospital, Cremona, Italy
| | - Simona G Di Santo
- Department of Clinical and Behavioral Neurology, Neuropsychiatry Laboratory, IRCCS Foundation S Lucia, Roma, Italy
| | | | | | - Enrico Mossello
- Research Unit of Medicine of Ageing, Department of Experimental and Clinical Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Mario Bo
- Section of Geriatrics, Città della Salute e della Scienza - Molinette, Torino, Italy
| | - Angelo Bianchetti
- Medicine and Rehabilitation Department, Istituto Clinico S. Anna, Brescia, Italy
| | - Renzo Rozzini
- Department of Geriatric and Internal Medicine, Poliambulanza Hospital, Brescia, Italy
| | | | - Massimo Musicco
- Institute of Biomedical Technologies, National Research Council, Segrate (Milan), Italy.,Italian Society of Neurology for Dementia (SINDEM), Siena, Italy
| | - Alberto Ferrari
- Geriatric Unit, Department of Neuromotor Physiology, ASMN Hospital, Reggio Emilia, Italy.,Italian Society of Hospital and Community Geriatrics (SIGOT), Roma, Italy
| | - Nicola Ferrara
- Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy.,Salvatore Maugeri Foundation, IRCCS, Scientific Institute of Telese, Telese Terme (BN), Italy.,Italian Society of Gerontology and Geriatrics (SIGG), Florence, Italy
| | - Marco Trabucchi
- Geriatric Research Group, Brescia, Italy.,Tor Vergata, Rome University, Rome, Italy.,Italian Psychogeriatric Association (AIP), Brescia, Italy
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Jenkin RPL, Al-Attar A, Richardson S, Myint PK, MacLullich AMJ, Davis DHJ. Increasing delirium skills at the front door: results from a repeated survey on delirium knowledge and attitudes. Age Ageing 2016; 45:517-22. [PMID: 27118700 PMCID: PMC4916344 DOI: 10.1093/ageing/afw066] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 01/06/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND delirium is under-recognised in comparison to other common and serious acute disorders. A 2006 survey of UK junior doctors (not undertaking specialist training) identified poor knowledge of the diagnostic criteria and treatment of delirium. We hypothesised that increased prominence accorded to delirium in the form of national initiatives and guidelines may have had an impact on understanding among junior doctors. OBJECTIVE we repeated a multi-centre survey of knowledge of and attitudes to delirium in junior doctors (not undertaking specialist training) assessing unselected acute medical presentations (the 'medical take'). DESIGN questionnaire-based survey in 48 acute hospitals in UK and Ireland. METHODS we used questionnaires designed to test understanding of delirium, including prevalence, knowledge of the DSM-IV diagnostic criteria, use of specific screening tools, association with adverse outcomes and pharmacological management. RESULTS one thousand two hundred and fifteen trainee physicians participated. Compared with the 2006 cohort, improvements were seen in 9 of 17 knowledge-based questions and overall score improved in the 2013 cohort. Nonetheless, significant deficits in knowledge, particularly for the diagnostic criteria for delirium, remained. CONCLUSIONS despite improvements in some aspects of delirium knowledge, the diagnostic criteria for delirium remain poorly understood. Challenges remain in ensuring adequate training for junior doctors in delirium.
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Affiliation(s)
| | - Adam Al-Attar
- Department of Medicine for the Elderly, St Mary's Hospital, London W2 1NY, UK
| | - Sarah Richardson
- Institute of Neuroscience, Newcastle University, Newcastle Upon Tyne, UK
| | - Phyo Kyaw Myint
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen, Scotland AB25 2ZD, UK
| | | | - Daniel H J Davis
- MRC Unit for Lifelong Health and Ageing, University College London, London, UK
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