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Huang C, Wu B, Chen H, Tao H, Wei Z, Su L, Wang L. Delirium in psychiatric settings: risk factors and assessment tools in patients with psychiatric illness: a scoping review. BMC Nurs 2024; 23:464. [PMID: 38977984 PMCID: PMC11229275 DOI: 10.1186/s12912-024-02121-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 06/24/2024] [Indexed: 07/10/2024] Open
Abstract
BACKGROUND Delirium is a common disorder affecting patients' psychiatric illness, characterized by a high rate of underdiagnosis, misdiagnosis, and high risks. However, previous studies frequently excluded patients with psychiatric illness, leading to limited knowledge about risk factors and optimal assessment tools for delirium in psychiatric settings. OBJECTIVES The scoping review was carried out to (1) identify the risk factors associated with delirium in patients with psychiatric illness; (2) synthesize the performance of assessment tools for detecting delirium in patients with psychiatric illness in psychiatric settings. DESIGN Scoping review. DATA SOURCES PubMed, Web of Science, and Embase were searched to identify primary studies on delirium in psychiatric settings from inception to Dec 2023 inclusive. Two independent reviewers screened eligible studies against inclusion criteria. A narrative synthesis of the included studies was conducted. RESULTS A final set of 36 articles meeting the inclusion criteria, two main themes were extracted: risk factors associated with delirium in patients with psychiatric illness and assessment tools for detecting delirium in psychiatric settings. The risk factors associated with delirium primarily included advanced age, physical comorbid, types of psychiatric illness, antipsychotics, anticholinergic drug, Electroconvulsive therapy, and the combination of lithium and Electroconvulsive therapy. Delirium Rating Scale-Revised-98, Memorial Delirium Assessment Scale, and Delirium Diagnostic Tool-Provisional might be valuable for delirium assessment in patients with psychiatric illness in psychiatric settings. CONCLUSIONS Delirium diagnosis in psychiatric settings is complex due to the overlapping clinical manifestations between psychiatric illness and delirium, as well as their potential co-occurrence. It is imperative to understand the risk factors and assessment methods related to delirium in this population to address diagnostic delays, establish effective prevention and screening strategies. Future research should focus on designing, implementing, and evaluating interventions that target modifiable risk factors, to prevent and manage delirium in patients with psychiatric illness.
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Affiliation(s)
- Cheng Huang
- School of Medicine, Huzhou University, 759 Second Ring Road East, Huzhou, Zhejiang, 313000, China
- Health Management Center, Deyang People's Hospital, Deyang, Sichua, 618000, China
| | - Bei Wu
- Rory Meyers College of Nursing, New York University, New York, NY, USA
| | - Haiqin Chen
- Nursing Department, Huzhou Third People's Hospital, Huzhou, Zhejiang, 313000, China
| | - Hong Tao
- AdventHealth Whole-Person Research, Orlando, FL, USA
| | - Zhuqin Wei
- School of Medicine, Huzhou University, 759 Second Ring Road East, Huzhou, Zhejiang, 313000, China
| | - Liming Su
- School of Medicine, Huzhou University, 759 Second Ring Road East, Huzhou, Zhejiang, 313000, China
| | - Lina Wang
- School of Medicine, Huzhou University, 759 Second Ring Road East, Huzhou, Zhejiang, 313000, China.
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Zhang GB, Li HY, Yu WJ, Ying YZ, Zheng D, Zhang XK, Wang YG, Shi GZ, Huang HW. Occurrence and risk factors for post-stroke delirium: A systematic review and meta-analysis. Asian J Psychiatr 2024; 99:104132. [PMID: 38981150 DOI: 10.1016/j.ajp.2024.104132] [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] [Received: 01/01/2024] [Revised: 05/15/2024] [Accepted: 06/13/2024] [Indexed: 07/11/2024]
Abstract
OBJECTIVES Delirium is a significant health concern in acute stroke patients. We aim to systematically summarize existing evidence to conduct a meta-analysis to quantify the occurrence and risk factors for delirium after acute stroke. METHOD PubMed, EMBASE and MEDLINE were searched from inception to Feb. 2023 for prospective observational studies that reported the incidence or prevalence of post-stroke delirium and/or evaluated potential risk factors. The search strategy was created using controlled vocabulary terms and text words for stroke and delirium. We performed a meta-analysis of the estimates for occurrence and risk factors using random-effects models. Meta-regression and subgroup meta-analyses were conducted to explore the sources of heterogeneity. Study quality and quality of evidence were assessed using the customized Newcastle-Ottawa Scale and GRADE, respectively. RESULTS Forty-nine studies that enrolled 12383 patients were included. The pooled occurrence rate of post-stroke delirium was 24.4 % (95 %CI, 20.4 %-28.9 %, I2=96.2 %). The pooled occurrence of hyperactive, hypoactive, and mixed delirium was 8.5 %, 5.7 % and 5.0 %, respectively. Study location, delirium assessment method and stroke type independently affected the heterogeneity of the pooled estimate of delirium. Statistically significant risk factors were older age, low education level, cigarette smoking, alcohol drinking, atrial fibrillation, lower ADL level, higher pre-stroke mRS score, premorbid cognitive impairment or dementia, aphasia, total anterior circulation impairment, higher National Institute of Health Stroke Scale score and infection. CONCLUSIONS Delirium affected 1 in 4 acute stroke patients, although reported rates may depend on assessment method and stroke type. Timely prevention, recognition and intervention require prioritizing patients with dominant risk factors.
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Affiliation(s)
- Guo-Bin Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; National Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders and Beijing Key Laboratory of Brain Tumor, Beijing, China
| | - Hao-Yi Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; National Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders and Beijing Key Laboratory of Brain Tumor, Beijing, China
| | - Wei-Jie Yu
- Department of Neurosurgery, The School of Clinical Medicine, Fujian Medical University, Fuzhou, China
| | - Yu-Zhe Ying
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; National Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders and Beijing Key Laboratory of Brain Tumor, Beijing, China
| | - Dao Zheng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; National Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders and Beijing Key Laboratory of Brain Tumor, Beijing, China
| | - Xiao-Kang Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; National Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders and Beijing Key Laboratory of Brain Tumor, Beijing, China
| | - Yong-Gang Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; National Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders and Beijing Key Laboratory of Brain Tumor, Beijing, China
| | - Guang-Zhi Shi
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| | - Hua-Wei Huang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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Badrfam R, Zandifar A. Status dissociatus and movement disorders in anti N-methyl-d-aspartate receptor (anti NMDAR) encephalitis; diagnostic challenges ahead. Gen Hosp Psychiatry 2024; 88:75-76. [PMID: 38278744 DOI: 10.1016/j.genhosppsych.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 01/20/2024] [Accepted: 01/21/2024] [Indexed: 01/28/2024]
Affiliation(s)
- Rahim Badrfam
- Department of Psychiatry, Imam Hossein Hospital, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Atefeh Zandifar
- Department of Psychiatry, Imam Hossein Hospital, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran; Social Determinants of Health Research Center, Alborz University of Medical Sciences, Karaj, Iran.
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Glynn K, McKenna F, Lally K, Grover S, Chakrabarti S, Mattoo SK, Avasthi A, Sharma A, Adamis D, Awan F, Dunne CP, McFarland J, Jabbar F, O’Connell H, Leonard M, Meagher DJ. Does the Etiology, Phenomenology and Motor Subtype of Delirium Differ When It Occurs in Patients With An Underlying Dementia?: A Multi-Site, International Study. J Geriatr Psychiatry Neurol 2024; 37:125-133. [PMID: 37566435 PMCID: PMC10802083 DOI: 10.1177/08919887231195232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
OBJECTIVES To compare the etiology, phenomenology and motor subtype of delirium in patients with and without an underlying dementia. METHODS A combined dataset (n = 992) was collated from two databases of older adults (>65 years) from liaison psychiatry and palliative care populations in Ireland and India. Phenomenology and severity of delirium were analysed using the Delirium Symptom Rating Scale Revised (DRS-R98) and contributory etiologies for the delirium groups were ascertained using the Delirium Etiology Checklist (DEC). Delirium motor subtype was documented using the abbreviated version of the Delirium Motor Subtype Scale (DMSS4). RESULTS Delirium superimposed on dementia (DSD) showed greater impairment in short term memory, long term memory and visuospatial ability than the delirium group but showed significantly less perceptual disturbance, temporal onset and fluctuation. Systemic infection, cerebrovascular and other Central nervous system etiology were associated with DSD while metabolic disturbance, organ insufficiency and intracranial neoplasm were associated with the delirium only group. CONCLUSION The etiology and phenomenology of delirium differs when it occurs in the patient with an underlying dementia. We discuss the implications in terms of identification and management of this complex condition.
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Affiliation(s)
- Kevin Glynn
- Department of Psychiatry, University Hospital Limerick, Dooradoyle, Ireland
| | - Frank McKenna
- Department of Psychiatry, University Hospital Limerick, Dooradoyle, Ireland
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
| | - Kevin Lally
- Department of Psychiatry, University Hospital Limerick, Dooradoyle, Ireland
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
| | - Sandeep Grover
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Subho Chakrabarti
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Surendra K. Mattoo
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajita Avasthi
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Akhilesh Sharma
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Dimitrios Adamis
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
- Sligo Mental Health Services, Sligo, Ireland
| | - Fahad Awan
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
| | - Colum P. Dunne
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
| | - John McFarland
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
| | - Faiza Jabbar
- Psychiatry for Later Life Service, University College Hospital, Galway, Ireland
| | - Henry O’Connell
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
| | - Maeve Leonard
- Department of Psychiatry, University Hospital Limerick, Dooradoyle, Ireland
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
| | - David J. Meagher
- Department of Psychiatry, University Hospital Limerick, Dooradoyle, Ireland
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Dooradoyle, Ireland
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Yang L, Do Q, Zhu X, Leung JM, Sands LP. Assessing patterns of delirium symptoms reveals a novel subtype among elective surgical patients with postoperative delirium. Int J Geriatr Psychiatry 2024; 39:e6049. [PMID: 38168022 DOI: 10.1002/gps.6049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 12/14/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVES Prior studies reported incidence of hypoactive and hyperactive subtypes of postoperative delirium, but did not consider cognitive symptoms of delirium which are highlighted in the DSM-5 criteria for delirium. This study aims to address this gap in the literature by classifying cases of delirium according to their constellation of cognitive and motoric symptoms of delirium using a statistical technique called Latent Class Analysis (LCA). METHODS Data were from five independent study cohorts (N = 1968) of patients who underwent elective spine, knee/hip, or elective gastrointestinal and thoracic procedures, between 2001 and 2017. Assessments of delirium symptoms were conducted using the long form of the Confusion Assessment Method (CAM) pre- and post-surgery. Latent class analyses of CAM data from the first 2 days after surgery were conducted to determine subtypes of delirium based on patterns of cognitive and motoric symptoms of delirium. We also determined perioperative patient characteristics associated with each latent class of delirium and assessed whether the length of delirium for each of the patterns of delirium symptoms identified by the latent class analysis. RESULTS The latent class model from postoperative day 1 revealed three distinct patterns of delirium symptoms. One pattern of symptoms, denoted as the Hyperalert class, included patients whose predominant symptoms were being hyperalert or overly sensitive to environmental stimuli and having a low level of motor activity. Another pattern of symptoms, denoted as the Hypoalert class, included patients whose predominant symptom was being hypoalert (lethargic or drowsy). A third pattern of symptoms, denoted as the Cognitive Changes class, included patients who experienced new onset of disorganized thinking, memory impairment, and disorientation. Among 352 patients who met CAM criteria for delirium on postoperative day 1, 34% had symptoms that fit within the Hyperalert latent class, 39% had symptoms that fit within the Hypoalert latent class, and 27% had symptoms that fit within the Cognitive Changes latent class. Similar findings were found when latent class analysis was applied to those who met CAM criteria for delirium on postoperative day 2. Multinomial regression analyses revealed that ASA class, surgery type, and preoperative cognitive status as measured by the Telephone Interview for Cognitive Status (TICS) scores were associated with class membership. Length of delirium differed between the latent classes with the Cognitive Changes latent class having a longer duration compared to the other two classes. CONCLUSIONS Older elective surgery patients who did not have acute events or illnesses or a diagnosis of dementia prior to surgery displayed varying symptoms of delirium after surgery. Compared to prior studies that described hypoactive and hyperactive subtypes of delirium, we identified a novel subtype of delirium that reflects cognitive symptoms of delirium. The three subtypes of delirium reveal distinct patterns of delirium symptoms which provide insight into varying risks and care needs of patients with delirium, indicating the necessity of future research on reducing risk for cognitive symptoms of delirium.
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Affiliation(s)
- Leon Yang
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Quyen Do
- Department of Statistics, Virginia Tech, Blacksburg, Virginia, USA
| | - Xiaofan Zhu
- Department of Statistics, Virginia Tech, Blacksburg, Virginia, USA
| | - Jacqueline M Leung
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, California, USA
| | - Laura P Sands
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
- Department of Statistics, Virginia Tech, Blacksburg, Virginia, USA
- Center for Gerontology, Virginia Tech, Blacksburg, Virginia, US
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Zhou W, Bai X, Yang Y, Huang M, Zheng Q, Wu J, Wang R, Gan X. Revelations of delirium subtype research: A bibliometric analysis of publications in the past twenty years in the field. Asian J Psychiatr 2023; 83:103561. [PMID: 36989982 DOI: 10.1016/j.ajp.2023.103561] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 03/05/2023] [Accepted: 03/17/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Delirium is an acute confusion state that is common and costly. According to different clinical manifestations, delirium can be divided into three subtypes: hyperactive, hypoactive and mixed. Subtype research has become a necessary branch. However, it is difficult to record all the changes in subtype research. METHODS Publications on delirium subtypes in the Web of Science Core Collection (WOSCC) were identified and analyzed by visualization software VOSviewer and CiteSpace. RESULTS A total of 247 articles published from 1999 to 2022 were identified in the WOSCC, and the largest number of articles was published in 2021 (n = 33). The top three countries that contributed publications were the USA (n = 75), Ireland (n = 26), and the United Kingdom (n = 25), which communicated more often and focused on delirium subtypes earlier. Critical Care Medicine published the most articles regarding delirium subtypes, with 11 publications. Three instrument validation studies were cited most frequently. Six clusters were summarized, including descriptions of delirium among elderly people, delirium research, postoperative delirium, delirium motor subtype validation, critical delirium, and motor characteristics. The "postoperative delirium", "intensive care unit", and "cardiac surgery" keywords were seen in recent years. CONCLUSION Based on this bibliometric analysis of the publications in the last twenty years, a comprehensive analysis of the literature clarified the contributions, changes, and evolution regarding delirium subtypes. This research can provide medical staff and researchers with revelations into future directions of delirium subtype advancements.
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Affiliation(s)
- Wen Zhou
- Department of Nursing, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China; The Second Department of Nursing School, Chongqing Medical University, Chongqing, China
| | - Xue Bai
- Department of Nursing, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yun Yang
- Department of Geriatrics, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China; The Second Department of Nursing School, Chongqing Medical University, Chongqing, China
| | - Miao Huang
- Department of Nursing, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China; The Second Department of Nursing School, Chongqing Medical University, Chongqing, China
| | - Qiulan Zheng
- Department of Nursing, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China; The Second Department of Nursing School, Chongqing Medical University, Chongqing, China
| | - Jiaqian Wu
- Department of Nursing, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China; The Second Department of Nursing School, Chongqing Medical University, Chongqing, China
| | - Rui Wang
- The Second Department of Nursing School, Chongqing Medical University, Chongqing, China; Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiuni Gan
- Department of Nursing, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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Zhou W, Zheng Q, Huang M, Zhang C, Zhang H, Yang L, Wu T, Gan X. Knowledge, attitude, and practice toward delirium and subtype assessment among Chinese clinical nurses and determinant factors: A multicentre cross-section study. Front Psychiatry 2022; 13:1017283. [PMID: 36819944 PMCID: PMC9929153 DOI: 10.3389/fpsyt.2022.1017283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 12/23/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Delirium, a confused transient state of consciousness, can be divided into hyperactive, hypoactive, mixed, and no motor subtypes, according to different clinical manifestations. Several studies have investigated delirium subtypes in the knowledge dimension, but few studies have investigated delirium subtype in the attitude and practice dimensions. The barriers, knowledge sources, and practice details regarding subtype assessment are unclear. OBJECTIVES This study had three objectives. First, we planned to investigate the KAP status regarding delirium and subtypes for nurses. Second, we wanted to identify factors affecting clinical nurses' KAP scores. Third, this study expected to explore more details regarding delirium and subtypes assessment, including assessment barriers, assessment instruments, and knowledge sources. METHODS This multicentre cross-section study was conducted in 10 tertiary hospitals in three provinces, China, from January to April 2022. We investigated 477 nurses from six departments with a high prevalence. The self-developed KAP questionnaire regarding delirium and subtypes assessment had four parts: knowledge, attitude, practice, and source. Its reliability and validity were verified effectively by 2-round Delphi expert consultation. RESULTS A total of 477 nurses from the general intensive care unit (ICU), specialty ICU, orthopedics, thoracic surgery, operating room, and geriatrics were 28.3, 22.4, 22.2, 10.5, and 5.2%, respectively. The total KAP score regarding delirium and subtypes assessment was 60.01 ± 6.98, and the scoring rate was 73.18%. The scoring rate for knowledge, attitude, and practice was 58.55, 83.94, and 51.70%, respectively. More than half (54.1%) were unaware of the delirium subtypes assessment instruments. A total of 451 (94.6%) participants recognized the importance of nursing work for delirium prevention. A total of 250 (52.4%) nurses occasionally or sometimes assessed delirium subtypes, and 143 (30.0%) never assessed for delirium subtypes. We found that age, department, technical title, familiarity with delirium, familiarity with delirium subtypes, delirium training, and subtype training affected the total KAP scores. ICU nurses achieved the highest scores. CONCLUSION Chinese nurses' KAP status regarding delirium and subtypes assessment were barely acceptable, and the attitude score was positive, but knowledge and practice needed improvement. Meanwhile, the department was one of the significant KAP factors, and ICU nurses did better in delirium and subtype assessment in knowledge and practice dimension than other departments. Systematic and scientific training processes including subtype content and assessment tools are required. Experience still drives nurses' assessments of delirium and subtype. Adding the delirium assessment into routine tasks should be considered.
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Affiliation(s)
- Wen Zhou
- The Second Department of Nursing School, Chongqing Medical University, Chongqing, China.,Department of Nursing, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Qiulan Zheng
- The Second Department of Nursing School, Chongqing Medical University, Chongqing, China.,Department of Nursing, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Miao Huang
- The Second Department of Nursing School, Chongqing Medical University, Chongqing, China.,Department of Nursing, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Chuanlai Zhang
- The Second Department of Nursing School, Chongqing Medical University, Chongqing, China.,Department of Intensive Care Unit, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Huan Zhang
- The Second Department of Nursing School, Chongqing Medical University, Chongqing, China.,Department of Nursing, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Li Yang
- The Second Department of Nursing School, Chongqing Medical University, Chongqing, China.,Department of Nursing, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Taiqin Wu
- The Second Department of Nursing School, Chongqing Medical University, Chongqing, China.,Department of Nursing, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Xiuni Gan
- The Second Department of Nursing School, Chongqing Medical University, Chongqing, China.,Department of Nursing, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
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