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Bowman EML, Sweeney AM, McAuley DF, Cardwell C, Kane J, Badawi N, Jahan N, Iqbal HK, Mitchell C, Ballantyne JA, Cunningham EL. Assessment and report of individual symptoms in studies of delirium in postoperative populations: a systematic review. Age Ageing 2024; 53:afae077. [PMID: 38640126 PMCID: PMC11028403 DOI: 10.1093/ageing/afae077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 03/06/2024] [Indexed: 04/21/2024] Open
Abstract
OBJECTIVES Delirium is most often reported as present or absent. Patients with symptoms falling short of the diagnostic criteria for delirium fall into 'no delirium' or 'control' groups. This binary classification neglects individual symptoms and may be hindering identification of the pathophysiology underlying delirium. This systematic review investigates which individual symptoms of delirium are reported by studies of postoperative delirium in adults. METHODS Medline, EMBASE and Web of Science databases were searched on 03 June 2021 and 06 April 2023. Two reviewers independently examined titles and abstracts. Each paper was screened in duplicate and conflicting decisions settled by consensus discussion. Data were extracted, qualitatively synthesised and narratively reported. All included studies were quality assessed. RESULTS These searches yielded 4,367 results. After title and abstract screening, 694 full-text studies were reviewed, and 62 deemed eligible for inclusion. This review details 11,377 patients including 2,049 patients with delirium. In total, 78 differently described delirium symptoms were reported. The most reported symptoms were inattention (N = 29), disorientation (N = 27), psychomotor agitation/retardation (N = 22), hallucination (N = 22) and memory impairment (N = 18). Notably, psychomotor agitation and hallucinations are not listed in the current Diagnostic and Statistical Manual for Mental Disorders-5-Text Revision delirium definition. CONCLUSIONS The 78 symptoms reported in this systematic review cover domains of attention, awareness, disorientation and other cognitive changes. There is a lack of standardisation of terms, and many recorded symptoms are synonyms of each other. This systematic review provides a library of individual delirium symptoms, which may be used to inform future reporting.
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Affiliation(s)
- Emily M L Bowman
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
- Centre for Experimental Medicine, Queen’s University Belfast, Wellcome-Wolfson Institute for Experimental Medicine, 97 Lisburn Road, Belfast BT9 7BL, Northern Ireland
| | - Aoife M Sweeney
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Danny F McAuley
- Centre for Experimental Medicine, Queen’s University Belfast, Wellcome-Wolfson Institute for Experimental Medicine, 97 Lisburn Road, Belfast BT9 7BL, Northern Ireland
| | - Chris Cardwell
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Joseph Kane
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Nadine Badawi
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Nusrat Jahan
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Halla Kiyan Iqbal
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Callum Mitchell
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Jessica A Ballantyne
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
| | - Emma L Cunningham
- Centre for Public Health, Queen’s University Belfast, Block B, Institute of Clinical Sciences, Royal Victoria Hospital site, Grosvenor Road, Belfast BT12 6BA, Northern Ireland
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Leah V, Ngwu L. Identifying the relationship between delirium and falls. Nurs Older People 2023; 35:22-27. [PMID: 36810921 DOI: 10.7748/nop.2023.e1418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2022] [Indexed: 02/24/2023]
Abstract
Delirium, which may present as acute fluctuation in arousal and attention and changes in a person's behaviours, can increase the risk of falls, while a fall can increase the risk of developing delirium. There is, therefore, a fundamental relationship between delirium and falls. This article describes the main types of delirium and the challenges associated with recognition of the condition and discusses the relationship between delirium and falls. The article also describes some of the validated tools used to screen patients for delirium and includes two brief case studies to illustrate this in practice.
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Affiliation(s)
- Vicki Leah
- University of East London, London, England
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3
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Sabbe K, Aerts N, van der Mast R, Van Rompaey B. Certified Nursing Assistants' Perspectives on Delirium Care. J Gerontol Nurs 2023; 49:43-51. [PMID: 36719657 DOI: 10.3928/00989134-20230106-07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The current descriptive qualitative study provides an in-depth understanding of the perspectives of certified nursing assistants (CNAs, N = 7) regarding delirium. Data were collected through interviews with seven CNAs working in a long-term care facility. Five themes emerged: Knowledge About Delirium, Caring for Residents With Delirium, Delirium Education, Psychological Burden, and Quality of Care. CNAs' care of residents with delirium was based on prior experiences and gut feelings, indicating a high need for delirium training. [Journal of Gerontological Nursing, 49(2), 43-51.].
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Recall of delirium and related distress in elderly hospitalized patients: A prospective study. Porto Biomed J 2022; 7:e196. [PMID: 37152084 PMCID: PMC10158885 DOI: 10.1097/j.pbj.0000000000000196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 10/17/2022] [Accepted: 10/17/2022] [Indexed: 12/23/2022] Open
Abstract
Background: Delirium is a very common neuropsychiatric disorder in the elderly, with a significant physical and psychological burden. Much is still unknown about its psychological effects. This study aims to identify the proportion of patients who recall delirium and to analyze the distress caused by it. In addition, this study aims to analyze the association between delirium recall and related distress and global psychological distress regarding hospitalization. Methods: This is a prospective study with elderly hospitalized patients in level-2 units of intensive care medicine department of a university hospital. Exclusion criteria were a Glasgow Coma Scale total ≤11, brain injury, blindness, deafness, or inability to communicate. Delirium was daily assessed with the Confusion Assessment Method. Delirium recall and related distress in patients were measured using the Delirium Experience Questionnaire. Global psychological distress was assessed with the Kessler Psychological Distress Scale. Results: From 105 patients, 38 (36.2%) developed delirium. Most patients did not remember the delirium episode (64.7%). Among those who remembered (35.3%), most described delirium as a distressing experience (75%). Delirium recall was associated with high global psychological distress (P = .029). Conclusions: Distress related to delirium is high, namely in patients who recall the episode. Global psychological distress during hospitalization is associated with delirium recall. This study highlights the need to assess the experience of delirium in these patients, as well as the importance of providing support and psychological interventions to minimize the associated distress.
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Cohen CL, Atkins KJ, Evered LA, Silbert BS, Scott DA. Examining Subjective Psychological Experiences of Postoperative Delirium in Older Cardiac Surgery Patients. Anesth Analg 2022; 136:1174-1181. [PMID: 36201368 DOI: 10.1213/ane.0000000000006226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Postoperative delirium (POD) is an acute syndrome including inattention and impaired cognition that affects approximately 42% of older cardiac surgical patients. POD is linked to adverse outcomes including morbidity, mortality, and further cognitive decline. Less is known about the subjective psychological experience of POD and its ongoing impact on well-being. METHODS We performed a qualitative analysis of the long-term psychological sequelae of older adults who experience POD after cardiac surgery. We sampled 30 patients aged 60 years and older who experienced at least 2 episodes of POD during a prior hospital admission. We administered semistructured interviews with participants via telephone 3 to 5 years postoperatively. Interviews were transcribed and thematically analyzed. Data were interpreted in accordance with the naturalist paradigm. RESULTS Three overarching themes emerged in our qualitative analysis. The first reflected the multifaceted presentation of POD, including distortion of time and reality; feelings of isolation; and a loss of self, identity, and control. The second theme reflected the psychological challenges associated with functional decline after surgery. Common examples of functional decline included cognitive difficulties, excessive fatigue, and a perceived loss of independence. The final theme captured the emotional sequelae of acute illness, which included low mood, reduced motivation, and social comparisons. CONCLUSIONS Our findings emphasize the multidimensional experience of POD and long-term effects on psychological wellbeing. Our research highlights the beneficial role multidisciplinary clinicians play in managing POD including strategies that may be embedded into clinical practice and helps anesthesiologists understand why patients who have experienced POD in the past may present with specific concerns should they require subsequent surgery.
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Affiliation(s)
- Caitlin L Cohen
- From the School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia.,Department of Anaesthesia, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Kelly J Atkins
- From the School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia.,Department of Anaesthesia, St Vincent's Hospital, Melbourne, Victoria, Australia.,The University of Melbourne, Melbourne, Victoria, Australia
| | - Lisbeth A Evered
- Department of Anaesthesia, St Vincent's Hospital, Melbourne, Victoria, Australia.,The University of Melbourne, Melbourne, Victoria, Australia.,Weill Cornell Medicine, New York, New York
| | - Brendan S Silbert
- Department of Anaesthesia, St Vincent's Hospital, Melbourne, Victoria, Australia.,The University of Melbourne, Melbourne, Victoria, Australia
| | - David A Scott
- Department of Anaesthesia, St Vincent's Hospital, Melbourne, Victoria, Australia.,The University of Melbourne, Melbourne, Victoria, Australia
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Hermes C, Ottens T, Knitter P, Hauss O, Bellgardt M, von Dossow V. Delir – Beurteilung, Vorbeugung und Behandlung. Med Klin Intensivmed Notfmed 2022; 117:479-488. [DOI: 10.1007/s00063-022-00943-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/02/2022] [Accepted: 06/02/2022] [Indexed: 11/27/2022]
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Abstract
This review provides an overview for health care teams involved in the perioperative care of cardiac surgery patients. The intention is to summarize key determinants of delirium, its impact on short- and long-term outcomes as well as to discuss effective management strategies. The first component of this review examines the prevalence and the factors associated with an increased risk of postoperative delirium. A multitude of predisposing (eg, baseline vulnerability and comorbidities) and precipitating (eg, type of cardiac surgery and postoperative care) factors that contribute to the occurrence of delirium are discussed.
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8
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Zolfi Kashani A, Ranjbar H, Rasoulian M, Shabani A, Ghadirivasfi M, Mohammadsadeghi H. The experience of patients with bipolar disorder from diagnosis disclosure: A qualitative study. Med J Islam Repub Iran 2020; 34:36. [PMID: 32617275 PMCID: PMC7320983 DOI: 10.34171/mjiri.34.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Indexed: 11/05/2022] Open
Abstract
Background: Disclosure of the diagnosis is an essential part of the treatment process and an important part of patient rights. However, it can be a very stressful experience, especially in mental health disorders. Patients with bipolar disorder have a unique experience of receiving and managing their diagnosis. The objective of the current study was to explore the experience of patients with bipolar disorder of diagnosis disclosure. Methods: This was a qualitative study. Participants were recruited from patients who knew their disorder's name using purposive sampling method. The inclusion criteria were being diagnosed by a psychiatrist as having bipolar disorder and the disclosure was conducted by a psychiatrist. Sixteen semi-structured, in-depth interviews were conducted with twelve patients. Data were analyzed using thematic content analysis. Results: Patients received their diagnosis name in three steps including Wandering in Unknowns, Limited Brightness and Reaching to a Relative Insight. Patients believed that disclosure of the diagnosis was not accompanied by enough information. Conclusion: The disclosure of diagnosis in patients with bipolar disorder without providing enough information is stressful and is not helpful in empowering these patients. Based on our results, disclosure of diagnosis to patients with bipolar disorder was not conducted with enough information and patients had problems for understanding their symptoms and treatments.
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Affiliation(s)
| | - Hadi Ranjbar
- Mental Health Research Center, Psychosocial Health Research Institute, Iran University of Medical Science, Tehran, Iran
| | - Maryam Rasoulian
- Mental Health Research Center, Tehran Institute of Psychiatry- School of Behavioral Sciences and Mental Health, Iran University of Medical Sciences, Tehran, Iran
| | - Amir Shabani
- Mental Health Research Center, Mood Disorders Research Group, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Ghadirivasfi
- Mental Health Research Center, Tehran Institute of Psychiatry- School of Behavioral Sciences and Mental Health, Iran University of Medical Sciences, Tehran, Iran
| | - Homa Mohammadsadeghi
- Mental Health Research Center, Tehran Institute of Psychiatry- School of Behavioral Sciences and Mental Health, Iran University of Medical Sciences, Tehran, Iran
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Lee-Steere K, Liddle J, Mudge A, Bennett S, McRae P, Barrimore SE. "You've got to keep moving, keep going": Understanding older patients' experiences and perceptions of delirium and nonpharmacological delirium prevention strategies in the acute hospital setting. J Clin Nurs 2020; 29:2363-2377. [PMID: 32220101 DOI: 10.1111/jocn.15248] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 02/17/2020] [Accepted: 03/12/2020] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To explore older inpatients' experiences and perceptions of delirium and nonpharmacological delirium prevention strategies (NDPS). BACKGROUND Delirium is a distressing and serious complication in hospitalised older adults. NDPS (supporting nutrition, mobility and cognitive participation) have strong supporting evidence. Few studies have explored older inpatients' perspectives of these strategies. This information may assist staff to better support patient participation in NDPS. DESIGN Qualitative study using an interpretive descriptive (ID) methodological approach to explore older patient's experience of delirium and NDPS. METHODS Structured interviews of inpatients aged over 65 years across 6 medical and surgical wards explored patients' experiences and perceptions of delirium and prevention activities related to nutrition, mobility and cognition; and barriers and enablers to participation. Reporting used COREQ. RESULTS Twenty-three participants were included (12 male, 11 reported delirium experience). Participants reported a range of physiological, emotional and psychological responses to delirium, hearing about delirium was different to experiencing it. Most participants were aware of the benefits of maintaining nutrition and hydration, physical activity and cognitive engagement in hospital. Barriers included poor symptom control, inflexible routines and inconsistent communication, whilst enablers included access to equipment, family involvement, staff encouragement and individual goals. These were organised into themes: outlook, feeling well enough, hospital environment, feeling informed and listened to, and support networks. CONCLUSION A more patient-centred approach to delirium prevention requires consideration of older people's values, needs, preferences and fit within the hospital environment and routines. Feeling informed, listened to and receiving support from staff and family carers can improve older inpatients' engagement in NPDS to prevent delirium in hospital. RELEVANCE TO CLINICAL PRACTICE Nurses are ideally placed to improve patient participation in NDPS through holistic assessment and care, addressing symptoms, providing clear information about delirium and delirium prevention, and facilitating family carer support and patient interactions.
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Affiliation(s)
- Karen Lee-Steere
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia.,Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Jacki Liddle
- ARC Centre of Excellence for the Dynamics of Language, School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, QLD, Australia
| | - Alison Mudge
- Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,Queensland University of Technology, Brisbane, QLD, Australia.,School of Clinical Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Sally Bennett
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Prue McRae
- Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Sally E Barrimore
- Nutrition and Dietetics Department, The Prince Charles Hospital, Brisbane, QLD, Australia
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10
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Meilak C, Biswell E, Willis R, Partridge J, Dhesi J. A qualitative exploration of the views of patients and their relatives regarding interventions to minimize the distress related to postoperative delirium. Int J Geriatr Psychiatry 2020; 35:230-249. [PMID: 31762082 DOI: 10.1002/gps.5241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 11/07/2019] [Indexed: 11/05/2022]
Abstract
BACKGROUND Postoperative delirium (POD) is common in older people and can be distressing for patients and their relatives. This study aimed to describe the experience of postoperative delirium and explore the views of patients and relatives in order to inform the codesign of an intervention to minimize distress related to postoperative delirium. METHODS Qualitative study using a thematic analysis of semistructured interviews in patients (n = 11) and relatives (n = 12) who experienced and witnessed POD, respectively. RESULTS Patients and relatives find POD distressing and desire information on the cause and consequences of delirium. This information should be delivered pre-emptively where possible for patients and relatives during the episode for relatives and in post episode follow up for patients and their families. Information should be provided in person by a health care professional who has experience in managing delirium, supplemented by written materials. In addition, participants suggested training to improve staff and public awareness of delirium. CONCLUSIONS This qualitative study showed that patients and relatives find delirium distressing, report the need for an intervention to minimize this distress, and enabled codesign of a pilot intervention. Refinement and evaluation of this intervention should form the next step in this program of work.
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Affiliation(s)
- Catherine Meilak
- Perioperative Medicine for Older People Undergoing Surgery (POPS), East Kent Hospitals University Foundation Trust, Kent, UK
| | - Elizabeth Biswell
- Perioperative Medicine for Older People Undergoing Surgery (POPS), Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Rosalind Willis
- Centre for Research on Ageing, University of Southampton, UK
| | - Judith Partridge
- Perioperative Medicine for Older People Undergoing Surgery (POPS), Guy's and St Thomas' NHS Foundation Trust, London, UK.,Division of Primary Care and Public Health Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Jugdeep Dhesi
- Perioperative Medicine for Older People Undergoing Surgery (POPS), Guy's and St Thomas' NHS Foundation Trust, London, UK.,Division of Primary Care and Public Health Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
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Older people's experiences in acute care settings: Systematic review and synthesis of qualitative studies. Int J Nurs Stud 2020; 102:103469. [DOI: 10.1016/j.ijnurstu.2019.103469] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 10/28/2019] [Indexed: 01/13/2023]
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Klankluang W, Pukrittayakamee P, Atsariyasing W, Siriussawakul A, Chanthong P, Tongsai S, Tayjasanant S. Validity and Reliability of the Memorial Delirium Assessment Scale-Thai Version (MDAS-T) for Assessment of Delirium in Palliative Care Patients. Oncologist 2019; 25:e335-e340. [PMID: 32043769 PMCID: PMC7011635 DOI: 10.1634/theoncologist.2019-0399] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 10/14/2019] [Indexed: 12/03/2022] Open
Abstract
Background Delirium, a neuropsychiatric syndrome that occurs throughout medical illness trajectories, is frequently misdiagnosed. The Memorial Delirium Assessment Scale (MDAS) is a commonly used tool in palliative care (PC) settings. Our objective was to establish and validate the Memorial Delirium Assessment Scale‐Thai version (MDAS‐T) in PC patients. Materials and Methods The MDAS was translated into Thai. Content validity, inter‐rater reliability, and internal consistency were explored. The construct validity of the MDAS‐T was analyzed using exploratory factor analysis. Instrument testing of the MDAS‐T, the Thai version of the Confusion Assessment Method for the Intensive Care Unit (CAM‐ICU‐T), and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition as the gold standard was performed. The receiver operating characteristic (ROC) curve was used to determine the optimal cutoff score. The duration of each assessment was recorded. Results The study enrolled 194 patients. The content validity index was 0.97. The intraclass correlation coefficient and Cronbach's α coefficient were 0.98 and 0.96, respectively. A principal component analysis indicated a homogeneous, one‐factor structure. The area under the ROC curve was 0.96 (95% confidence interval [CI], 0.93–0.99). The best combination of sensitivity and specificity (95% CI) of the MDAS‐T were 0.92 (0.85–0.96) and 0.90 (0.82–0.94), respectively, with a cutoff score of 9, whereas the CAM‐ICU‐T yielded 0.58 (0.48–0.67) and 0.98 (0.93–0.99), respectively. The median MDAS‐T assessment time was 5 minutes. Conclusion This study established and validated the MDAS‐T as a good and feasible tool for delirium screening and severity rating in PC settings. Implications for Practice Delirium is prevalent in palliative care (PC) settings and causes distress to patients and families, thereby making delirium screening necessary. This study found that the MDAS‐T is a highly objective and feasible test for delirium screening and severity monitoring in PC settings and can greatly improve the quality of care for this population. Delirium is often misdiagnosed. This article reports on the value of assessment tools for diagnosis of delirium, in particular the Memorial Delirium Assessment Scale, which was translated into Thai for purposes of this study.
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Affiliation(s)
| | | | | | - Arunotai Siriussawakul
- Department Anesthesiology, Mahidol UniversityBangkokThailand
- Department Integrated Perioperative Geriatric Excellent Research Center, Mahidol UniversityBangkokThailand
| | | | - Sasima Tongsai
- Department Office for Research and Development, Faculty of Medicine, Siriraj Hospital, Mahidol UniversityBangkokThailand
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Weissenberger-Leduc M, Maier N, Iglseder B. What do geriatric patients experience during an episode of delirium in acute care hospitals? : A qualitative study. Z Gerontol Geriatr 2019; 52:557-562. [PMID: 30623226 DOI: 10.1007/s00391-018-01492-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Predispositions and triggers for delirium, such as noxious agents are known and behavior can be monitored; however, there is little to no information available regarding the experience of patients during delirium episodes. Not much is known about a person's world of experiences, which therefore mostly remains as a sort of black box. OBJECTIVE This study was motivated by the following question: "What do (Austrian) geriatric patients experience during an episode of delirium in an acute care hospital?" The main objective of this article is to present little snippets from the experiences and to allow geriatric patients to speak for themselves. PATIENTS AND METHODS From 2013 to 2016 interviews were carried out within the framework of a qualitative investigation. For data collection narrative interviews according to Fritz Schütze were employed and 10 interviews were conducted in a hospital setting with German-speaking Austrian patients aged between 75 and 90 years (mean age 80.2 years; 7 female and 3 male). The individual interviews lasted between 60 and 120 min. Primary data in the form of individual interpretation and interpretation groups from interview transcripts were marked and coded according to Mayring. RESULTS All patients who participated in the interviews subjectively recognized delirium as a negative experience. The data analysis led to three main categories with subcategories: changes in sensory perception, extraordinarily strong emotions and memories. It is important to differentiate between two very different types of memories: firstly, personal fate or life changes and secondly, those regarding experiences of war. CONCLUSION Scandinavian and Anglo-American literature describe different categories, such as a change in reality, strong emotions and dramatic episodes in the experience of delirium, which can be transferred to Austria. Others consider the biography of each individual patient in context with the sociocultural history of Austria, especially following developments after 1940.
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Affiliation(s)
| | - Nicola Maier
- NÖGUS - NÖ Gesundheits- und Sozialfonds, St. Pölten, A-3100, Austria
| | - Bernhard Iglseder
- Universitätsklinik für Geriatrie der PMU, Uniklinikum Salzburg Christian-Doppler-Klinik, Ignaz-Harrer-Str. 79, 5020, Salzburg, Austria
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Boucher V, Lamontagne ME, Nadeau A, Carmichael PH, Yadav K, Voyer P, Pelletier M, Gouin É, Daoust R, Berthelot S, Morin M, Lemire S, Minh Vu TT, Lee J, Émond M. Unrecognized Incident Delirium in Older Emergency Department Patients. J Emerg Med 2019; 57:535-542. [DOI: 10.1016/j.jemermed.2019.05.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 04/30/2019] [Accepted: 05/06/2019] [Indexed: 10/26/2022]
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Schmitt EM, Gallagher J, Albuquerque A, Tabloski P, Lee HJ, Gleason L, Weiner LS, Marcantonio ER, Jones RN, Inouye SK, Schulman-Green D. Perspectives on the Delirium Experience and Its Burden: Common Themes Among Older Patients, Their Family Caregivers, and Nurses. THE GERONTOLOGIST 2019; 59:327-337. [PMID: 30870568 DOI: 10.1093/geront/gnx153] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 09/01/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND OBJECTIVES While there are qualitative studies examining the delirium-related experiences of patients, family caregivers, and nurses separately, little is known about common aspects of delirium burden among all three groups. We describe common delirium burdens from the perspectives of patients, family caregivers, and nurses. RESEARCH DESIGN AND METHODS We conducted semistructured qualitative interviews about delirium burden with 18 patients who had recently experienced a delirium episode, with 16 family caregivers, and with 15 nurses who routinely cared for patients with delirium. We recruited participants from a large, urban teaching hospital in Boston, Massachusetts. Interviews were recorded and transcribed. We used interpretive description as the approach to data analysis. RESULTS We identified three common burden themes of the delirium experience: Symptom Burden (Disorientation, Hallucinations/Delusions, Impaired Communication, Memory Problems, Personality Changes, Sleep Disturbances); Emotional Burden (Anger/Frustration, Emotional Distress, Fear, Guilt, Helplessness); and Situational Burden (Loss of Control, Lack of Attention, Lack of Knowledge, Lack of Resources, Safety Concerns, Unpredictability, Unpreparedness). These burdens arise from different sources among patients, family caregivers, and nurses, with markedly differing perspectives on the burden experience. DISCUSSION AND IMPLICATIONS Our findings advance the understanding of common burdens of the delirium experience for all groups and offer structure for instrument development and distinct interventions to address the burden of delirium as an individual or group experience. Our work reinforces that no one group experiences delirium in isolation. Delirium is a shared experience that will respond best to systemwide approaches to reduce associated burden.
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Affiliation(s)
- Eva M Schmitt
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Jacqueline Gallagher
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Asha Albuquerque
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Patricia Tabloski
- Boston College, William F Connell School of Nursing, Chestnut Hill, Massachusetts
| | - Hyo Jung Lee
- School of Aging Studies, University of South Florida, Tampa
| | - Lauren Gleason
- Department of Medicine, Section of Geriatrics and Palliative Medicine, University of Chicago, Illinois
| | - Lauren S Weiner
- Department of Family Medicine and Public Health, University of California, San Diego
| | - Edward R Marcantonio
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Richard N Jones
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Sharon K Inouye
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Dena Schulman-Green
- Division of Acute Care and Health Systems, Yale School of Nursing, West Haven, Connecticut
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Gaete Ortega D, Papathanassoglou E, Norris CM. The lived experience of delirium in intensive care unit patients: A meta-ethnography. Aust Crit Care 2019; 33:193-202. [PMID: 30871853 DOI: 10.1016/j.aucc.2019.01.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 12/17/2018] [Accepted: 01/07/2019] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES The objectives were to interpretatively synthesise qualitative findings on patients' lived experience of delirium in the intensive care unit (ICU) and to identify meanings and potential existential issues that affect them during and after their experience. Patients may face existential challenges when they are vulnerable in their confusion, all while confronting the reality of their mortality in the critically ill state. REVIEW METHODS The study involved meta-ethnographic synthesis of published qualitative studies addressing the lived experience of delirium for patients in ICU based on a systematic literature search. DATA SOURCES MEDLINE, PsycINFO, Embase, Scopus, CINAHL, ProQuest, and Cochrane were the sources. Studies were selected based on the predefined inclusion/exclusion criteria. The identified studies were subjected to a quality appraisal based on a Critical Appraisal Skills Programme tool. RESULTS Based on the eligibility criteria, nine qualitative studies were included, of overall medium to high quality. One core theme, "a perturbing altered reality" and four main themes were identified: "disturbed sense of time", "omnipresent feeling of fear", "impact of human connection", and "perceiving surreal events". These four themes illustrate how the three salient existential issues of uncertainty, self-perceived helplessness, and death that are present in delirium make it a highly distressing experience for patients in ICU. CONCLUSIONS Critically ill patients who experience delirium appear to face intense existential issues, which may not be identified by care providers and may remain unaddressed during their ICU stay and after discharge. Patients report that addressing the memories of these issues would be therapeutic. Future research needs to explore care approaches to meet the unique psychosocial needs of critically ill patients with delirium.
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Affiliation(s)
| | | | - Colleen M Norris
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada; Heart Health and Stroke Strategic Clinical Network-AHS, Canada; Division of Cardiac Surgery, Faculty of Medicine, Canada.
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Green S, Reivonen S, Rutter LM, Nouzova E, Duncan N, Clarke C, MacLullich AMJ, Tieges Z. Investigating speech and language impairments in delirium: A preliminary case-control study. PLoS One 2018; 13:e0207527. [PMID: 30475831 PMCID: PMC6261049 DOI: 10.1371/journal.pone.0207527] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 11/01/2018] [Indexed: 02/02/2023] Open
Abstract
Introduction Language impairment is recognized as as part of the delirium syndrome, yet there is little neuropsychological research on the nature of this dysfunction. Here we hypothesized that patients with delirium show impairments in language formation, coherence and comprehension. Methods This was a case-control study in 45 hospitalized patients (aged 65–97 years) with delirium, dementia without delirium, or no cognitive impairment (N = 15 per group). DSM-5 criteria were used for delirium. Speech was elicited during (1) structured conversational questioning, and (2) the "Cookie Theft" picture description task. Language comprehension was assessed through standardized verbal and written commands. Interviews were audio-recorded and transcribed. Results Delirium and dementia groups scored lower on the conversational assessment than the control group (p<0.01, moderate effect sizes (r) of 0.48 and 0.51, resp.). In the Cookie Theft task, the average length of utterances (i.e. unit of speech), indicating language productivity and fluency, distinguished patients with delirium from those with dementia (p<0.01, r = 0.50) and no cognitive impairment (p<0.01, r = 0.55). Patients with delirium performed worse on written comprehension tests compared to cognitively unimpaired patients (p<0.01, r = 0.63), but not compared to the dementia group. Conclusions Production of spontaneous speech, word quantity, speech content and verbal and written language comprehension are impaired in delirious patients compared to cognitively unimpaired patients. Additionally, patients with delirium produced significantly less fluent speech than those with dementia. These findings have implications for how speech and language are evaluated in delirium assessments, and also for communication with patients with delirium. A study limitation was that the delirium group included patients with co-morbid dementia, which precludes drawing conclusions about the specific language profile of delirium.
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Affiliation(s)
- Samantha Green
- Department of Psychology, University of Edinburgh, Edinburgh, Scotland, United Kingdom
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Satu Reivonen
- Department of Psychology, University of Edinburgh, Edinburgh, Scotland, United Kingdom
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Lisa-Marie Rutter
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Eva Nouzova
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Nikki Duncan
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Caoimhe Clarke
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Alasdair M. J. MacLullich
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Zoë Tieges
- Edinburgh Delirium Research Group, University of Edinburgh, Edinburgh, Scotland, United Kingdom
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland, United Kingdom
- * E-mail:
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Malik AT, Quatman CE, Phieffer LS, Ly TV, Khan SN. Incidence, risk factors and clinical impact of postoperative delirium following open reduction and internal fixation (ORIF) for hip fractures: an analysis of 7859 patients from the ACS-NSQIP hip fracture procedure targeted database. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 29:435-446. [PMID: 30229446 DOI: 10.1007/s00590-018-2308-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 08/29/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Delirium is one of the most common acute psychiatric disturbances taking place in patients, particularly elderly, following hip fractures. Using a validated national surgical database, we sought to define the incidence, risk factors and clinical impact associated with the occurrence of delirium following open reduction and internal fixation (ORIF) for hip fracture. METHODS The 2016 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) Hip Fracture Targeted Procedure file-was retrieved and merged with the ACS-NSQIP 2016 file. A total of 7859 patients were finally included in the study. RESULTS A total of 2177 (27.7%) patients experienced an episode of delirium following the procedure. Adjusted analysis showed an increasing age ≥ 65 years (p < 0.001), partially dependent functional health status prior to surgery (p = 0.001), bleeding disorder (p = 0.012), preoperative dementia (p < 0.001), preoperative delirium (p < 0.001), being bed-ridden postoperatively (p < 0.001), no weight bearing as tolerated on first postoperative day (p < 0.001), an ASA grade > II (p < 0.001), non-emergency case (p = 0.010) and a prolonged length of stay > 3 days (p < 0.001). In addition, Black or African-American ethnicity had a lower odds of developing postoperative delirium (p = 0.020) as compared to Whites. Moreover, postoperative delirium was significantly associated with non-home discharge disposition (p < 0.001), higher odds of 30-day readmissions (p < 0.001) and 30-day mortality (p < 0.001). CONCLUSION This study identifies several risk factors associated with the occurrence of postoperative delirium in patients undergoing ORIF for hip fracture. Surgeons can utilize these data to risk stratify and consequently tailor an appropriate preoperative and postoperative care protocol to prevent the occurrence of delirium.
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Affiliation(s)
| | - Carmen E Quatman
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Laura S Phieffer
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Thuan V Ly
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Safdar N Khan
- The Ohio State University Wexner Medical Center, Columbus, OH, USA.
- The Benjamin R. and Helen Slack Wiltberger Endowed Chair in Orthopaedic Spine Surgery, Wexner Medical Center at The Ohio State University, Columbus, OH, USA.
- Division of Spine Surgery, Department of Orthopaedic Surgery, Wexner Medical Center at The Ohio State University, Columbus, OH, USA.
- Department of Integrated Systems Engineering, Clinical Faculty, Spine Research Institute, Wexner Medical Center at The Ohio State University, Columbus, OH, USA.
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Godfrey M, Young J, Shannon R, Skingley A, Woolley R, Arrojo F, Brooker D, Manley K, Surr C. The Person, Interactions and Environment Programme to improve care of people with dementia in hospital: a multisite study. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06230] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Improving the care of people with dementia on acute hospital wards is a policy priority. Person-centred care is a marker of care quality; delivering such care is a goal of service improvement.
Objectives
The Person, Interactions and Environment (PIE) Programme comprises an observation tool and a systematic approach to implement and embed a person-centred approach in routine care for hospitalised patients with dementia. The study aims were to evaluate PIE as a method to improve the care of older people with dementia on acute hospital wards, and develop insight into what person-centred care might look like in practice in this setting.
Methods
We performed a longitudinal comparative case study design in 10 purposively selected wards in five trusts in three English regions, alongside an embedded process evaluation. Data were collected from multiple sources: staff, patients, relatives, organisational aggregate information and documents. Mixed methods were employed: ethnographic observation; interviews and questionnaires; patient case studies (patient observation and conversations ‘in the moment’, interviews with relatives and case records); and patient and ward aggregate data. Data were synthesised to create individual case studies of PIE implementation and outcomes in context of ward structure, organisation, patient profile and process of care delivery. A cross-case comparison facilitated a descriptive and explanatory account of PIE implementation in context, the pattern of variation, what shaped it and the consequences flowing from it. Quantitative data were analysed using simple descriptive statistics. A qualitative data analysis employed grounded theory methods.
Results
The study furthered the understanding of the dimensions of care quality for older people with dementia on acute hospital wards and the environmental, organisational and cultural factors that shaped delivery. Only two wards fully implemented PIE, sustaining and embedding change over 18 months. The remaining wards either did not install PIE (‘non-implementers’) or were ‘partial implementers’. The interaction between micro-level contextual factors [aspects of leadership (drivers, facilitators, team, networks), fit with strategic initiatives and salience with valued goals] and meso- and macro-level organisational factors were the main barriers to PIE adoption. Evidence suggests that the programme, where implemented, directly affected improvements in ward practice, with a positive impact on the experiences of patients and caregivers, although the heterogeneity of need and severity of impairment meant that some of the more visible changes did not affect everyone equally.
Limitations
Although PIE has the potential to improve the care of people with dementia when implemented, findings are indicative only: data on clinical outcomes were not systematically collected, and PIE was not adopted on most study wards.
Research implications
Further research is required to identify more precisely the skill mix and resources necessary to provide person-focused care to hospitalised people with dementia, across the spectrum of need, including those with moderate and severe impairment. Implementing innovations to change practices in complex organisations requires a more in-depth understanding of the contextual factors that have an impact on the capacity of organisations to absorb and embed new practices.
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Mary Godfrey
- Academic Unit of Elderly Care and Rehabilitation, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - John Young
- Academic Unit of Elderly Care and Rehabilitation, Faculty of Medicine and Health, University of Leeds, Leeds, UK
- Bradford Institute for Health Research (BIHR), Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Rosemary Shannon
- Bradford Institute for Health Research (BIHR), Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Ann Skingley
- Sidney de Haan Research Centre for Arts and Health, Faculty of Health and Wellbeing, Canterbury Christ Church University, Canterbury, UK
- East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - Rosemary Woolley
- Bradford Institute for Health Research (BIHR), Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Frank Arrojo
- Patient and public involvement representative, Alzheimer’s Society Research Network
| | - Dawn Brooker
- Association for Dementia Studies, Institute of Health and Society, University of Worcester, Worcester, UK
| | - Kim Manley
- East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
- England Centre for Practice Development, Faculty of Health and Wellbeing, Canterbury Christ Church University, Canterbury, UK
| | - Claire Surr
- School of Health and Community Studies, Leeds Beckett University, Leeds, UK
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20
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Olofsson B, Persson M, Bellelli G, Morandi A, Gustafson Y, Stenvall M. Development of dementia in patients with femoral neck fracture who experience postoperative delirium-A three-year follow-up study. Int J Geriatr Psychiatry 2018; 33:623-632. [PMID: 29292537 DOI: 10.1002/gps.4832] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 11/02/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVES It remains unclear to what extent postoperative delirium (POD) affects the incidence of dementia in hip fracture patients, and the methods used to detect delirium and dementia require validation. The aim of this study was to investigate the development of dementia within 3 years of femoral neck fracture repair surgery, with a focus on POD as a potential predictive factor. METHODS Patients were assessed for cognition, delirium, depression, psychological well-being, and nutritional status during their hospitalization as well as 4, 12, and 36 months after the operation. Logistic regression models were used to analyse factors associated with POD and factors associated with the development of dementia. RESULTS The study sample consisted of 135 patients without a history of dementia, of whom 20 (14.8%) were delirious preoperatively and 75 (55.5%) postoperatively. Three years after their operations, 43/135 patients (31.8%) were diagnosed with dementia. A greater portion of patients diagnosed with dementia (39/43, 90.6%) than patients with no dementia (36/92, 39.1%) were included among the 75 patients who had experienced POD (P < 0.001). In a logistic regression model, after adjustment for covariates (age, sex, diabetes, delirium pre-and postoperatively, hyperactive delirium, days with delirium, urinary tract infection, and Mini Nutritional Assessment score), POD emerged an independent predictor for the development of new dementia (odds ratio, 15.6; 95% confidence interval, 2.6-91.6) within 3 years after the operation. CONCLUSION Geriatric hip fracture patients who exhibit POD should be monitored closely for the development of dementia.
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Affiliation(s)
- B Olofsson
- Department of Nursing, Umeå University, Umeå, Sweden.,Department of Surgical and Perioperative Science, Orthopaedics, Umeå University, Umeå, Sweden
| | - M Persson
- Department of Nursing, Umeå University, Umeå, Sweden
| | - G Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - A Morandi
- Department of Rehabilitation, Ancelle Hospital Cremona, Italy
| | - Y Gustafson
- Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, Umeå, Sweden
| | - M Stenvall
- Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, Umeå, Sweden
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Svenningsen H, Egerod I, Dreyer P. Strange and scary memories of the intensive care unit: a qualitative, longitudinal study inspired by Ricoeur's interpretation theory. J Clin Nurs 2016; 25:2807-15. [DOI: 10.1111/jocn.13318] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2016] [Indexed: 12/01/2022]
Affiliation(s)
- Helle Svenningsen
- Department of Nursing; Faculty of Health Sciences; VIA University College; Aarhus N Denmark
| | - Ingrid Egerod
- University of Copenhagen Health & Medical Sciences Rigshospitalet; Trauma Center HOC 3193; Copenhagen Denmark
| | - Pia Dreyer
- Department of Anaesthesiology and Intensive Care; Aarhus University Hospital; Aarhus C Denmark
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22
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Finucane AM, Lugton J, Kennedy C, Spiller JA. The experiences of caregivers of patients with delirium, and their role in its management in palliative care settings: an integrative literature review. Psychooncology 2016; 26:291-300. [PMID: 27132588 PMCID: PMC5363350 DOI: 10.1002/pon.4140] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 03/07/2016] [Accepted: 03/25/2016] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To explore the experiences of caregivers of terminally ill patients with delirium, to determine the potential role of caregivers in the management of delirium at the end of life, to identify the support required to improve caregiver experience and to help the caregiver support the patient. METHODS Four electronic databases were searched-PsychInfo, Medline, Cinahl and Scopus from January 2000 to July 2015 using the terms 'delirium', 'terminal restlessness' or 'agitated restlessness' combined with 'carer' or 'caregiver' or 'family' or 'families'. Thirty-three papers met the inclusion criteria and remained in the final review. RESULTS Papers focused on (i) caregiver experience-distress, deteriorating relationships, balancing the need to relieve suffering with desire to communicate and helplessness versus control; (ii) the caregiver role-detection and prevention of delirium, symptom monitoring and acting as a patient advocate; and (iii) caregiver support-information needs, advice on how to respond to the patient, interventions to improve caregiver outcomes and interventions delivered by caregivers to improve patient outcomes. CONCLUSION High levels of distress are experienced by caregivers of patients with delirium. Distress is heightened because of the potential irreversibility of delirium in palliative care settings and uncertainty around whether the caregiver-patient relationship can be re-established before death. Caregivers can contribute to the management of patient delirium. Additional intervention studies with informational, emotional and behavioural components are required to improve support for caregivers and to help the caregiver support the patient. Reducing caregiver distress should be a goal of any future intervention.© 2016 The Authors. Psycho-Oncology Published by John Wiley & Sons Ltd.
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Affiliation(s)
| | - Jean Lugton
- Marie Curie Hospice Edinburgh, Edinburgh, UK
| | - Catriona Kennedy
- School of Nursing and Midwifery, Robert Gordon University, Aberdeen, UK
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Yeung J, Patel V, Champaneria R, Dretzke J. Regional versus general anaesthesia in elderly patients undergoing surgery for hip fracture: protocol for a systematic review. Syst Rev 2016; 5:66. [PMID: 27098125 PMCID: PMC4839155 DOI: 10.1186/s13643-016-0246-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 04/13/2016] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND With an ageing population, the incidence of hip fractures requiring surgery is increasing. Post-operative delirium is common following hip fracture surgery. Delirium is associated with high mortality and morbidity, poor long-term functional outcomes and institutionalisation. There is some evidence to suggest that perioperative intervention, specifically the anaesthetic technique employed, may reduce the incidence of delirium in this population. The aim of this systematic review is to investigate the impact of anaesthesia type on post-operative delirium. METHOD We will conduct a systematic literature review using Embase, MEDLINE, CINAHL and the Cochrane Library (CENTRAL) bibliographic databases and the ZETOC and Web of Science websites. Authors of these trials will be invited to contribute unpublished data. PROSPERO register and clinical trial registers will also be searched to identify any ongoing reviews and trials. Eligible studies will assess the incidence of post-operative delirium in patients having regional or general anaesthesia for hip fracture surgery. The primary outcome of interest will be post-operative delirium; secondary outcomes will include mortality, measures of functional outcome, quality of life, length of hospital stay, discharge location and adverse events. Two reviewers will independently screen references identified by electronic literature searches. Two independent reviewers will extract data from studies fulfilling our inclusion criteria using a piloted data extraction form. Methodological quality and bias of included randomised controlled trials will be assessed using the 'Cochrane Collaborations tool for assessing risk of bias'; for non-randomised studies, this will be assessed using the Newcastle-Ottawa scale. Data on similar outcomes will be pooled when possible. Where possible, meta-analysis will be undertaken using Review Manager (RevMan version 5.3) software. DISCUSSION This systematic review will provide an updated evidence base with which to guide clinical practice and research for this group of challenging patients. If the anaesthetic technique employed is shown to reduce the incidence of post-operative cognition dysfunction, then this may lead to a change in evidence-based practice, influence future guidelines and support further randomised controlled trial research. There is no known effective treatment for delirium, creating the urgent need for research into delirium prevention. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015020166.
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Affiliation(s)
- Joyce Yeung
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
| | - Vanisha Patel
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Rita Champaneria
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Janine Dretzke
- Institute of Applied Health Research Public Health, Epidemiology and Biostatistics, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
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Affiliation(s)
- Valerie Fuller
- Department of Surgery; Maine Medical Center; Portland ME 04102
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25
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Van Rompaey B, Van Hoof A, van Bogaert P, Timmermans O, Dilles T. The patient's perception of a delirium: A qualitative research in a Belgian intensive care unit. Intensive Crit Care Nurs 2016; 32:66-74. [DOI: 10.1016/j.iccn.2015.03.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 02/27/2015] [Accepted: 03/13/2015] [Indexed: 11/26/2022]
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Delirium superimposed on dementia: A quantitative and qualitative evaluation of patient experience. J Psychosom Res 2015; 79:281-7. [PMID: 26282373 PMCID: PMC4686231 DOI: 10.1016/j.jpsychores.2015.07.010] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 07/21/2015] [Accepted: 07/24/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Delirium superimposed on dementia is common and is associated with adverse outcomes. Yet little is known about the patients' personal delirium experiences. We used quantitative and qualitative methods to assess the delirium superimposed on dementia experience among older patients. METHODS We conducted a prospective cohort study among patients with delirium superimposed on dementia who were admitted to a rehabilitation ward. Delirium was diagnosed using DSM-IV-TR criteria. Delirium severity and symptoms were evaluated with the Delirium-O-Meter (D-O-M). The experience of delirium was assessed after delirium resolution (T0) and one month later (T1) with a standardized questionnaire and a qualitative interview. Level of distress was measured with the Delirium Experience Questionnaire. RESULTS Of the 30 patients included in the study, 50% had mild dementia; 33% and 17% had moderate and severe dementia. Half of the patients had evidence of the full range of D-O-M delirium symptoms. We evaluated 30 patients at T0 and 20 at T1. At T0, half of the patients remembered being confused as part of the delirium episode, and reported an overall moderate level of related distress. Patients reported high distress related to memories of anxiety/fear, delusions, restlessness, hypokinesia, and impaired orientation. Qualitative interviews revealed six main aspects of patient delirium experiences: Emotions; Cognitive Impairment; Psychosis; Memories; Awareness of Change; and Physical Symptoms. CONCLUSIONS The study provides novel information on the delirium experience in patients with dementia. These findings are the key for health care providers to improve the everyday care of this important group of frail older patients.
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Delirium superimposed on dementia: A quantitative and qualitative evaluation of informal caregivers and health care staff experience. J Psychosom Res 2015; 79:272-80. [PMID: 26286892 PMCID: PMC4688906 DOI: 10.1016/j.jpsychores.2015.06.012] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 06/16/2015] [Accepted: 06/22/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Delirium superimposed on dementia is common and potentially distressing for patients, caregivers, and health care staff. We quantitatively and qualitatively assessed the experience of informal caregiver and staff (staff nurses, nurse aides, physical therapists) caring for patients with delirium superimposed on dementia. METHODS Caregivers' and staff experience was evaluated three days after delirium superimposed on dementia resolution (T0) with a standardized questionnaire (quantitative interview) and open-ended questions (qualitative interview); caregivers were also evaluated at 1-month follow-up (T1). RESULTS A total of 74 subjects were included; 33 caregivers and 41 health care staff (8 staff nurses, 20 physical therapists, 13 staff nurse aides/health care assistants). Overall, at both T0 and T1, the distress level was moderate among caregivers and mild among health care staff. Caregivers reported, at both T0 and T1, higher distress related to deficits of sustained attention and orientation, hypokinesia/psychomotor retardation, incoherence and delusions. The distress of health care staff related to each specific item of the Delirium-O-Meter was relatively low except for the physical therapists who reported higher level of distress on deficits of sustained/shifting attention and orientation, apathy, hypokinesia/psychomotor retardation, incoherence, delusion, hallucinations, and anxiety/fear. The qualitative evaluation identified important categories of caregivers' and staff feelings related to the delirium experience. CONCLUSIONS This study provides information on the implication of the experience of delirium on caregivers and staff. The distress related to delirium superimposed on dementia underlines the importance of providing continuous training, support and experience for both the caregivers and health care staff to improve the care of patients with delirium superimposed on dementia.
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Hasemann W, Tolson D, Godwin J, Spirig R, Frei IA, Kressig RW. A before and after study of a nurse led comprehensive delirium management programme (DemDel) for older acute care inpatients with cognitive impairment. Int J Nurs Stud 2015; 53:27-38. [PMID: 26323529 DOI: 10.1016/j.ijnurstu.2015.08.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Revised: 08/03/2015] [Accepted: 08/04/2015] [Indexed: 01/20/2023]
Abstract
BACKGROUND Studies estimate that approximately one-third of episodes of delirium are preventable and that delirium prevention and management are often suboptimal in practice. While there is no doubt that prevention is desirable, the evidence of the benefits of early intervention and treatment for older hospitalised patients with dementia is unclear. AIM To determine the effects of DemDel, a comprehensive delirium management programme, in inpatient acute care elders with cognitive impairment. DESIGN AND METHODS This paper reports the quantitative part of a mixed methods study, comparing an intervention with treatment as usual using validated outcome measures. After training, ward nurses and physicians administered the intervention based on the DemDel algorithm that focused on delirium prevention, including an intensive systematic screening schedule for cognitive impairment and delirium, as well as comprehensive delirium management. The delirium management regimen included timely administration of pro re nata medication. SETTINGS The study was conducted within four medical wards of an acute care university hospital in urban Switzerland. PARTICIPANTS A total of 268 patients with cognitive impairment participated in the pre/post comparison study. The intervention and treatment as usual groups consisted of 138 and 130 patients, respectively. RESULTS Eighty-seven (32.5%) out of 268 patients developed delirium, of whom 51 (58.6%) were of mixed, 10 (11.5%) hyperactive and 26 (29.9%) hypoactive delirium subtypes. Delirium appeared within the first five days after admission in 81.6% of cases. The 44 (31.9%) patients with delirium in the intervention group with systematic delirium management had less severe episodes of delirium and required medication for management than the 43 (33.1%) delirious patients in the control group. Intervention compliance was good on three of the four units. CONCLUSIONS The DemDel programme was effective with regard to improvement of outcomes associated with delirium in patients with cognitive impairment. The intervention was feasible and possible to be embedded within routine practice on four busy general medical wards.
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Affiliation(s)
| | - D Tolson
- University of West of Scotland, Scotland, UK.
| | - J Godwin
- Glasgow Caledonian University, Scotland, UK.
| | - R Spirig
- University Hospital Zürich, Switzerland; Institute of Nursing Science, University Basel, Switzerland.
| | - I A Frei
- University Hospital Basel, Switzerland; Institute of Nursing Science, University Basel, Switzerland.
| | - R W Kressig
- Felix Platter Hospital Basel, University Center for Medicine of Aging, Basel, Switzerland.
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Pollard C, Fitzgerald M, Ford K. Delirium: the lived experience of older people who are delirious post-orthopaedic surgery. Int J Ment Health Nurs 2015; 24:213-21. [PMID: 25976839 DOI: 10.1111/inm.12132] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Delirium is a common, potentially preventable and reversible cause of postoperative functional disability, morbidity, and mortality. It can lead to increased health-care use and also poses a substantial challenge for nurses caring for patients who experience delirium after surgery. Predominantly, the published work concentrates on diagnosis, reduction of the modifiable risk factors, and treatments. Compared with this body of published work, the experience of delirium from a patient's perspective has been largely ignored except for a limited number of qualitative research reports. The importance of researching the lived experience of delirium is that a better understanding may lead to more empathic, therapeutic nursing care and help other sufferers to know they are not alone. The aims of the study were to explore and clarify the lived experience of delirium. Eleven patients were recruited to the study following discharge post-surgery from an orthopaedic ward of a major tertiary hospital. The study used a qualitative descriptive approach and incorporated grounded theory data analysis processes. The findings of this study provide an insight into the incomprehensible emotional pain suffered by patients while they were delirious and the disparate feelings of remorse, guilt, and shame they experienced after the episode of delirium. Following this study, recommendations for nursing practice include formal follow-up support for patients with post-delirium episodes and more research into the long-term impact of the experience of delirium.
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Affiliation(s)
- Cecily Pollard
- Mental Health and Statewide Services, Tasmania Health Organisation South, Hobart, Tasmania
| | - Mary Fitzgerald
- Faculty of Science, Charles Sturt University, Wagga Wagga, New South Wales, Australia
| | - Karen Ford
- Practice Development Unit, Royal Hobart Hospital, Hobart, Tasmania
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Frühwald T, Weissenberger-Leduc M, Jagsch C, Singler K, Gurlit S, Hofmann W, Böhmdorfer B, Iglseder B. [Delirium: an interdisciplinary challenge]. Z Gerontol Geriatr 2015; 47:425-38; quiz 439-40. [PMID: 24609425 DOI: 10.1007/s00391-014-0613-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Delirium, the acute deterioration of cognitive function and attention, is the most frequent mental disorder in elderly. Its correct diagnosis and adequate management are of crucial importance for the patient's health and functional outcome. First of all, one has to be aware of the possibilities of preventing this complex, potentially life-threatening problem, which means recognizing the patient at risk, avoiding environmental stress and causal factors (i.e., anticholinergic medication) in cognitively impaired patients, and timely reaction to prodromal symptoms. Causal therapy (i.e., treatment of the causal condition and/or eliminating the precipitating situation) is imperative. It must be accompanied by nursing and environmental measures and, if necessary, by antipsychotic and/or sedating symptomatic treatment.
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Affiliation(s)
- T Frühwald
- Abteilung für Akutgeriatrie, Krankenhaus Hietzing mit Neurologischem Zentrum Rosenhügel, Wolkersbergenstr. 1, 1130, Wien, Österreich,
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Claesson Lingehall H, Smulter N, Olofsson B, Lindahl E. Experiences of undergoing cardiac surgery among older people diagnosed with postoperative delirium: one year follow-up. BMC Nurs 2015; 14:17. [PMID: 25866476 PMCID: PMC4392811 DOI: 10.1186/s12912-015-0069-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 03/18/2015] [Indexed: 01/07/2023] Open
Abstract
Background Cardiovascular disease is common among old people and many undergo cardiac surgery. Scientific knowledge is available on cardiac surgery from several perspectives. However, we found few studies focusing on older patients’ experiences of cardiac surgery. The aim of this study was to illuminate experiences of undergoing cardiac surgery among older people diagnosed with postoperative delirium, a one year follow-up. Methods Qualitative interviews were conducted with 49 participants (aged ≥70 years) diagnosed with delirium after cardiac surgery. Data were collected in Sweden during 2010 through individual, semi-structured interviews in participants’ homes one year after surgery. The interviews were analyzed using qualitative content analysis. Results Four themes with sub-themes were formulated: Feeling drained of viability includes having a body under attack, losing strength and being close to death. Feeling trapped in a weird world describes participants having hallucinations, being in a nightmare and being remorseful for their behavior. Being met with disrespect includes feeling disappointed, being forced, and feeling like cargo. On the other hand, Feeling safe, including being in supportive hands and feeling grateful, points to participants’ experiences of good care and the gift of getting a second chance in life. Conclusions Even one year after cardiac surgery, participants described in detail feelings of extreme vulnerability and frailty. They also had felt completely in the hands of the health care professionals. Participants described experiences of hallucinations and nightmares during hospitalization. Cardiac surgery was a unique, fearful, traumatic and unpleasant experience yet could also include pleasant or rewarding aspects. It seems that health care professionals need deeper knowledge on postoperative delirium in order to prevent, detect and treat delirium to avoid and relieve the suffering these experiences might cause.
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Affiliation(s)
- Helena Claesson Lingehall
- Department of Nursing, Umeå University, Umeå, SE-901 87 Sweden ; Department of Surgical and Perioperative Science, Cardiothoracic Surgery Division, Umeå, SE-901 85 Sweden
| | - Nina Smulter
- Department of Nursing, Umeå University, Umeå, SE-901 87 Sweden ; Department of Surgical and Perioperative Science, Cardiothoracic Surgery Division, Umeå, SE-901 85 Sweden
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Lawlor PG, Bush SH. Delirium in patients with cancer: assessment, impact, mechanisms and management. Nat Rev Clin Oncol 2014; 12:77-92. [DOI: 10.1038/nrclinonc.2014.147] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Wright DK, Brajtman S, Macdonald ME. A relational ethical approach to end-of-life delirium. J Pain Symptom Manage 2014; 48:191-8. [PMID: 24417807 DOI: 10.1016/j.jpainsymman.2013.08.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Revised: 08/17/2013] [Accepted: 08/28/2013] [Indexed: 11/29/2022]
Abstract
Delirium is a condition of acute onset and fluctuating course in which a person's level of consciousness and cognition become disturbed. Delirium is a common and distressing phenomenon in end-of-life care, yet it is underrecognized and undertreated. In this article, we review qualitative descriptions of the delirium experience in end-of-life care, found through a systematic search of academic databases, to generate insight into the intersubjective nature of the delirium experience. Our analysis of retrieved studies advances an understanding of the relational ethical dimensions of this phenomenon, that is, how delirium is lived by patients, families, and health care providers and how it affects the relationships and values at stake. We propose three themes that explain the distressing nature of delirium in palliative care: 1) experiences of relational tension; 2) challenges in recognizing the delirious person; and 3) struggles to interpret the meaning of delirious behaviors. By approaching end-of-life delirium from a perspective of relational ethics, attention is focused on the implications for the therapeutic relationship with patients and families when delirium becomes part of the dying trajectory.
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Affiliation(s)
- David Kenneth Wright
- Department of Biomedical Ethics, McGill University, Montreal, Quebec, Canada; Department of Palliative Care, Jewish General Hospital, Montreal, Quebec, Canada.
| | - Susan Brajtman
- School of Nursing, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Mary Ellen Macdonald
- Faculty of Dentistry, McGill University, Montreal, Quebec, Canada; Pediatric Palliative Care Research, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
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Terzaghi M, Sartori I, Rustioni V, Manni R. Sleep disorders and acute nocturnal delirium in the elderly: a comorbidity not to be overlooked. Eur J Intern Med 2014; 25:350-5. [PMID: 24636782 DOI: 10.1016/j.ejim.2014.02.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 02/07/2014] [Accepted: 02/20/2014] [Indexed: 01/08/2023]
Abstract
Delirium is a disturbance of consciousness and cognition that results in a confusional state. It tends to fluctuate in intensity and is often observed in older patients. Sleep is a window of vulnerability for the occurrence of delirium and sleep disorders can play a role in its appearance. In particular, delirious episodes have been associated with obstructive sleep apnoea syndrome, which is reported to be frequent in the elderly. Hereby, we present a case-report documenting the sudden onset of a confusional state triggered by obstructive sleep apnoea-induced arousal, together with a review of the literature on the topic. We emphasise that, among the many pathogenic factors implicated in delirium, it is worth considering the possible link between nocturnal delirium and the occurrence of impaired arousals. Indeed, the complex confusional manifestations of delirium could be due, in part, to persistence of dysfunctional sleep activity resulting in an inability to sustain full arousal during behavioural wakefulness. Arousals can be triggered by sleep disturbances or other medical conditions. Clinicians should be aware that older patients may present disordered sleep patterns, and make investigation of sleep patterns and disorders potentially affecting sleep continuity a key part of their clinical workup, especially in the presence of cognitive comorbidities. Correct diagnosis and optimal treatment of sleep disorders and disrupted sleep can have a significant impact in the elderly, improving sleep quality and reducing the occurrence of abnormal sleep-related behaviours.
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Affiliation(s)
- Michele Terzaghi
- Sleep Medicine and Epilepsy Unit, C. Mondino National Neurological Institute, IRCCS, Pavia, Italy.
| | - Ivana Sartori
- Epilepsy Surgery Centre "C. Munari", Sleep Disorders Centre, Niguarda Hospital, Milan, Italy
| | - Valter Rustioni
- Sleep Medicine and Epilepsy Unit, C. Mondino National Neurological Institute, IRCCS, Pavia, Italy
| | - Raffaele Manni
- Sleep Medicine and Epilepsy Unit, C. Mondino National Neurological Institute, IRCCS, Pavia, Italy
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Lingehall HC, Smulter N, Engström KG, Gustafson Y, Olofsson B. Validation of the Swedish version of the Nursing Delirium Screening Scale used in patients 70 years and older undergoing cardiac surgery. J Clin Nurs 2013; 22:2858-66. [DOI: 10.1111/j.1365-2702.2012.04102.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Godfrey M, Smith J, Green J, Cheater F, Inouye SK, Young JB. Developing and implementing an integrated delirium prevention system of care: a theory driven, participatory research study. BMC Health Serv Res 2013; 13:341. [PMID: 24004917 PMCID: PMC3766659 DOI: 10.1186/1472-6963-13-341] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 08/26/2013] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Delirium is a common complication for older people in hospital. Evidence suggests that delirium incidence in hospital may be reduced by about a third through a multi-component intervention targeted at known modifiable risk factors. We describe the research design and conceptual framework underpinning it that informed the development of a novel delirium prevention system of care for acute hospital wards. Particular focus of the study was on developing an implementation process aimed at embedding practice change within routine care delivery. METHODS We adopted a participatory action research approach involving staff, volunteers, and patient and carer representatives in three northern NHS Trusts in England. We employed Normalization Process Theory to explore knowledge and ward practices on delirium and delirium prevention. We established a Development Team in each Trust comprising senior and frontline staff from selected wards, and others with a potential role or interest in delirium prevention. Data collection included facilitated workshops, relevant documents/records, qualitative one-to-one interviews and focus groups with multiple stakeholders and observation of ward practices. We used grounded theory strategies in analysing and synthesising data. RESULTS Awareness of delirium was variable among staff with no attention on delirium prevention at any level; delirium prevention was typically neither understood nor perceived as meaningful. The busy, chaotic and challenging ward life rhythm focused primarily on diagnostics, clinical observations and treatment. Ward practices pertinent to delirium prevention were undertaken inconsistently. Staff welcomed the possibility of volunteers being engaged in delirium prevention work, but existing systems for volunteer support were viewed as a barrier. Our evolving conception of an integrated model of delirium prevention presented major implementation challenges flowing from minimal understanding of delirium prevention and securing engagement of volunteers alongside practice change. The resulting Prevention of Delirium (POD) Programme combines a multi-component delirium prevention and implementation process, incorporating systems and mechanisms to introduce and embed delirium prevention into routine ward practices. CONCLUSIONS Although our substantive interest was in delirium prevention, the conceptual and methodological strategies pursued have implications for implementing and sustaining practice and service improvements more broadly. STUDY REGISTRATION ISRCTN65924234.
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Affiliation(s)
- Mary Godfrey
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford Institute for Health Research, Bradford Royal Infirmary, Duckworth Lane, Bradford, West Yorkshire BD9 6RJ, UK
| | - Jane Smith
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford Institute for Health Research, Bradford Royal Infirmary, Duckworth Lane, Bradford, West Yorkshire BD9 6RJ, UK
| | - John Green
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford Institute for Health Research, Bradford Royal Infirmary, Duckworth Lane, Bradford, West Yorkshire BD9 6RJ, UK
| | - Francine Cheater
- School of Nursing Sciences, Faculty of Medicine and Health Sciences, Edith Cavell Building, University of East Anglia, Norwich Research Park, Norwich, Norfolk NR4 7TJ, UK
| | - Sharon K Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School and Institute for Aging Research, Hebrew SeniorLife, 1200 Centre Street, Roslindale, MA 02131, USA
| | - John B Young
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford Institute for Health Research, Bradford Royal Infirmary, Duckworth Lane, Bradford, West Yorkshire BD9 6RJ, UK
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Yeager JJ. Delirium superimposed on Charles Bonnet syndrome: a case study. Geriatr Nurs 2013; 34:453-6. [PMID: 23972541 DOI: 10.1016/j.gerinurse.2013.07.001] [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: 08/28/2012] [Revised: 07/10/2013] [Accepted: 07/14/2013] [Indexed: 10/26/2022]
Abstract
Older adults with visual impairment may experience visual hallucinations in the setting of normal cognition and absence of psychiatric illness. This phenomenon is referred to as Charles Bonnet syndrome. Information concerning Charles Bonnet syndrome predominantly comes from case studies. Reassuring the person experiencing the hallucinations they are not suffering from psychosis constitutes the mainstay of treatment. What follows is the case of a vision impaired, older adult male with known Charles Bonnet syndrome, who, following emergency surgery and associated delirium while in the intensive care unit, experiences an aggressive change in hallucinations. Nurses need to understand the pathology and characteristics of Charles Bonnet syndrome in order to distinguish it from other pathologies underlying hallucinations. This knowledge is necessary to provide safe, patient-centered care for older adults.
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Affiliation(s)
- Jennifer J Yeager
- Tarleton State University, Department of Nursing, Box T-0500, Stephenville, TX 76402, USA.
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Partridge JSL, Martin FC, Harari D, Dhesi JK. The delirium experience: what is the effect on patients, relatives and staff and what can be done to modify this? Int J Geriatr Psychiatry 2013; 28:804-12. [PMID: 23112139 DOI: 10.1002/gps.3900] [Citation(s) in RCA: 126] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Accepted: 10/10/2012] [Indexed: 12/26/2022]
Abstract
BACKGROUND Delirium is a common clinical syndrome with significant associated mortality, morbidity and financial cost. Less is understood about the experience of delirium for the patient, their family and staff involved in their care. OBJECTIVE This synthesis draws on qualitative and quantitative literature examining different populations (patients, relatives and staff) in different clinical settings (intensive care units, surgery and hospice care) to provide a clinical summary of the delirium experience from the perspective of patients, relatives and staff. DESIGN A literature search was conducted in Ovid, MEDLINE, Embase, PsychINFO, British Nursing Index and Archive and PubMed between 1980 and 2011 using the terms 'delirium' combined with 'distress', 'recall', 'anxiety', 'depression', 'PTSD', 'experience' and 'patient education'. Articles were restricted to English language only. RESULTS Evidence suggests that some patients recall delirium and that recollections are generally distressing. Distress may be greater in relatives witnessing delirium and is also reported in professional staff. This distress may result in longer-term psychological sequelae. Remedial action, such as explanatory information to patients and their families, may reduce distress and psychological morbidity. CONCLUSIONS A better understanding of the experience and psychological consequences of delirium will inform the development of appropriate methods of providing support and information to those at risk of delirium and their families or carers.
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Jeffs KJ, Berlowitz DJ, Grant S, Lawlor V, Graco M, de Morton NA, Savige JA, Lim WK. An enhanced exercise and cognitive programme does not appear to reduce incident delirium in hospitalised patients: a randomised controlled trial. BMJ Open 2013; 3:bmjopen-2013-002569. [PMID: 23794558 PMCID: PMC3686162 DOI: 10.1136/bmjopen-2013-002569] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE To determine if a programme of progressive resistance exercise, mobilisation and orientation, in addition to usual care, was superior to usual care alone in the prevention of incident delirium in older hospitalised patients. DESIGN A randomised controlled trial. SETTING The study was performed at a secondary referral hospital in Melbourne, Australia between May 2005 and December 2007. PARTICIPANTS 648 consecutive medical inpatients aged 65 years or older who had been in hospital for less than 48 h and who did not have delirium. INTERVENTION Participants were randomly allocated to a twice-daily programme of progressive resistance exercise tailored to individual ability, mobilisation and orientation in addition to usual care or to usual care alone. MEASUREMENTS Delirium was measured using the Confusion Assessment Method at baseline and every 48 h until discharge. Secondary outcome measures were severity and duration of delirium, discharge destination and length of stay. RESULTS Delirium occurred in 4.9% (95% CI 2.3% to 7.3%) of the intervention group (15/305) and in 5.9% (20/339; 95% CI 3.8% to 9.2%) of the group receiving usual care. No difference was observed between groups (χ(2); p=0.5). The intervention had no effect on delirium duration, severity, discharge destination or length of stay. CONCLUSION A programme of progressive resistance exercise and orientation was not effective in reducing incident delirium in hospitalised elderly patients.
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Fjerstad E, Lang N. ["Dante's Inferno" - psychological first aid for postoperative delirium]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2013; 133:1084-6. [PMID: 23712174 DOI: 10.4045/tidsskr.13.0202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Affiliation(s)
- Elin Fjerstad
- Prosjekt klinisk helsepsykologi/Nasjonal behandlingstjeneste for revmatologisk rehabilitering, NBRR/Nasjonal kompetansetjeneste for revmatologisk rehabilitering, Diakonhjemmet sykehus, Norway.
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Devlin JW, Al-Qadhee NS, Skrobik Y. Pharmacologic prevention and treatment of delirium in critically ill and non-critically ill hospitalised patients: a review of data from prospective, randomised studies. Best Pract Res Clin Anaesthesiol 2013; 26:289-309. [PMID: 23040282 DOI: 10.1016/j.bpa.2012.07.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Accepted: 07/25/2012] [Indexed: 12/13/2022]
Abstract
Delirium occurs commonly in acutely ill hospitalised patients, particularly in the elderly or in cardiac or orthopaedic surgery patients, or those in intensive care units (ICUs). Delirium worsens outcome. Pharmaceutical agents such as antipsychotics and, in the critically ill, dexmedetomidine, are considered therapeutic despite uncertainty regarding their efficacy and safety. Using MEDLINE, we reviewed randomised controlled trials (RCTs) published between 1977 and April 2012 evaluating a pharmacologic intervention to prevent or treat delirium in critically ill and non-critically ill hospitalised patients. The number of prospective RCTs remains limited. Any conclusions about pharmacologic efficacy are limited by the small size of many studies, the inconsistency by which non-pharmacologic delirium prevention strategies were incorporated, the lack of a true placebo arm and a failure to incorporate ICU and non-ICU clinical outcomes. A research framework for future evaluation of the use of medications in both ICU and non-ICU is proposed.
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Affiliation(s)
- John W Devlin
- Northeastern University School of Pharmacy, Boston, MA 02118, USA.
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Verloo H, Goulet C, Morin D, von Gunten A. Delirium among Home-Dwelling Elderly after a Recent Hospitalization: An Urgent Need for Effective Nursing Interventions. Dement Geriatr Cogn Dis Extra 2012; 2:187-9. [PMID: 22719744 PMCID: PMC3379730 DOI: 10.1159/000338229] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Affiliation(s)
- Henk Verloo
- Institut Universitaire de Formation et de Recherche en Soins, Faculté de Médecine et Biologie, Université de Lausanne, Lausanne, Switzerland
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Sörensen Duppils G, Johansson I. Predictive value and validation of the NEECHAM Confusion Scale using DSM-IV criteria for delirium as gold standard. Int J Older People Nurs 2011; 6:133-42. [PMID: 21539718 DOI: 10.1111/j.1748-3743.2010.00232.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Delirium is common among older people in hospital and various instruments have been developed for detecting delirium. One of these, the NEECHAM Confusion Scale, is easy for nurses to administrate but needs to be tested further. AIMS AND OBJECTIVES The aim of the present study was to assess the validity and predictive value of the NEECHAM Confusion Scale. METHODS The study was conducted among 149 patients aged ≥ 65, who had undergone surgery for a hip fracture. The patients were observed daily using DSM-IV criteria for delirium. The NEECHAM Confusion Scale was performed upon admission and prior to discharge. RESULTS The incidence of DSM-IV related delirium was 24%. Patients who scored below 25 points on the NEECHAM scale had a 12 times higher risk of developing DSM-IV related delirium. During admission, the sensitivity of NEECHAM was zero because all patients with DSM-IV delirium were excluded, the specificity was 75%. On discharge, it was 100% and 91% respectively. CONCLUSIONS This study adds to the body of knowledge that NEECHAM discriminates for delirium. It is a valid and reliable screening instrument for predicting delirium. The instrument can be used for clinical practice to identify patients who are at risk of contracting delirium and when considering prevention measures.
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Bélanger L, Ducharme F. Patients' and nurses' experiences of delirium: a review of qualitative studies. Nurs Crit Care 2011; 16:303-15. [DOI: 10.1111/j.1478-5153.2011.00454.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Sleep paralysis in narcolepsy: more than just a motor dissociative phenomenon? Neurol Sci 2011; 33:169-72. [DOI: 10.1007/s10072-011-0644-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Accepted: 05/23/2011] [Indexed: 10/18/2022]
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The effects of exercise therapy on delirium in cancer patients: a retrospective study. Support Care Cancer 2010; 19:765-70. [DOI: 10.1007/s00520-010-0874-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Accepted: 03/29/2010] [Indexed: 11/25/2022]
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Bridges J, Flatley M, Meyer J. Older people's and relatives' experiences in acute care settings: systematic review and synthesis of qualitative studies. Int J Nurs Stud 2009; 47:89-107. [PMID: 19854441 DOI: 10.1016/j.ijnurstu.2009.09.009] [Citation(s) in RCA: 179] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2009] [Revised: 09/11/2009] [Accepted: 09/20/2009] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To explore older people's and their relatives' views on and experiences of acute health care. DESIGN Systematic procedures were used for study selection and data extraction and analysis. A comparative thematic approach to synthesis was taken with a number of features adopted from the literature on meta-ethnography. DATA SOURCES Worldwide grey and published literature written in English between January 1999 and June 2008 identified from databases: CINAHL, Medline, British Nursing Index, EMBASE Psychiatry, International Bibliography of the Social Sciences, PsychINFO, and AgeInfo. REVIEW METHODS We conducted a systematic review and synthesis of qualitative studies describing older patients' and/or their relatives' experiences of care in acute hospital settings. 42 primary studies and 1 systematic review met the inclusion criteria. RESULTS A number of themes emerged. The quality of technical care is often taken for granted by older patients, and good or bad experiences are described more in terms of relational aspects of care. Older patients in hospital may feel worthless, fearful or not in control of what happens, especially if they have impaired cognition, or communication difficulties. Three key features of care consistently mediated these negative feelings and were linked to more positive experiences: "creating communities: connect with me", "maintaining identity: see who I am" and "sharing decision-making: include me". CONCLUSION These findings highlight the perspectives of older people and their relatives on the delivery of personalized and dignified care in acute settings. They lend support to previous calls for relationship-centred approaches to care and provide a useful experience-based framework for practice for those involved in care for older people.
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Affiliation(s)
- Jackie Bridges
- City University London, School of Community and Health Sciences, Philpot Street, Whitechapel London E1 2EA, UK.
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Bruera E, Bush SH, Willey J, Paraskevopoulos T, Li Z, Palmer JL, Cohen MZ, Sivesind D, Elsayem A. Impact of delirium and recall on the level of distress in patients with advanced cancer and their family caregivers. Cancer 2009; 115:2004-12. [PMID: 19241420 DOI: 10.1002/cncr.24215] [Citation(s) in RCA: 183] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND : Delirium has been the most frequent neuropsychiatric complication in patients with advanced cancer. This exploratory study aimed to determine the proportion of patients who were able to recall their experience of delirium and the level of distress experienced by patients, family caregivers, and healthcare professionals. METHODS : Patients with advanced cancer who had completely recovered from an acute delirium episode, had Memorial Delirium Assessment Scale score <13, and had a family caregiver present during the delirium were studied. Patients were given the Delirium Experience Questionnaire. Patients' and family caregivers' demographics, and the frequency and distress associated with different delirium symptoms were also collected. Bedside nurses and palliative care specialists reported the frequency of recalled delirium symptoms and their distress score. RESULTS : A total of 99 patient/family caregiver dyads participated in the study. The main identified causes for delirium were opioids, infection, brain metastases, hypercalcemia, and dehydration. There were 73 patients (74%) who remembered the episode of being delirious, with 59 of 73 patients (81%) reporting the experience as distressing (median distress level of 3). The median overall delirium distress score was higher in family caregivers (median, 3; 25%-75% quartile, 2-4) than in patients (median, 2; 25%-75% quartile, 0-3) (P = .0004). Bedside nurses and palliative care specialists expressed low median overall delirium distress scores (median, 0; 25%-75% quartile 0-1). CONCLUSIONS : The majority of patients with advanced cancer recalled their experience of delirium, causing moderate to severe distress in both patients and family caregivers. Appropriate interventions to reduce this distress are needed. Cancer 2009. (c) 2009 American Cancer Society.
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Affiliation(s)
- Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA.
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