Delirium: challenges for clinical governance

Nurses’ Experience of Caring for Patients with Delirium: Systematic Review and Qualitative Evidence Synthesis

Delirium is an acute deterioration in attention, conscious state, perception, and cognition of a person. While nurses possess the theoretical understanding of the condition, they lack insight into its early recognition and management. This systematic review aims to understand what factors influence nurses as they care for patients with delirium, and to identify best practices to improve overall clinical care. The Qualitative Evidence Synthesis (QES), as a strategy process to identify gaps in research, formulate new models or strategies for care, underpinned the review. In addition to specific inclusion and exclusion criteria, a methodological assessment, data were analysed using QES, as informed by the Joanna Briggs Institute Review process. Ten studies were identified and synthesised to generate four key themes. The themes included (1) nurse’s knowledge deficit; (2) increased workload and stress; (3) safety concerns among nurse when caring for patients with delirium; and (4) strategies used when caring for patients with delirium. Overall, the review has highlighted the need for increased delirium education and coping strategies among nurses to effectively care for patients with delirium. This may be augmented through regular education sessions to provide nurses with the confidence and competence to care for the acutely confused person.

Volunteer Programs Supporting People With Dementia/Delirium in Hospital: Systematic Review and Meta-Analysis

Background and Objectives

Volunteer-delivered programs to assist people with dementia and/or delirium in-hospital can provide person-centered one-on-one support in addition to usual care. These programs could mitigate hospital resource demands; however, their effectiveness is unknown. This review evaluated literature of volunteer programs in acute hospital settings for people living with dementia and/or delirium.

Research Design and Methods

Four databases were searched. Studies that reported patient or program outcomes were included (i.e., delirium incidence, length of stay, number of falls, satisfaction). Risk of bias was completed. Meta-analysis was performed where 2 or more studies measured the same outcome. Narrative synthesis was performed on the qualitative results.

Results

Eleven studies were included in the review, with varied design, participant groups and outcomes measured. Risk of bias averaged 71%. Volunteer-delivered programs addressed delirium risk factors, for example, hydration/nutrition, mobility, use of sensory aids. Eight patients and 6 program outcomes were captured, but only 3 patient outcomes could be pooled. Meta-analyses demonstrated a reduction in delirium incidence (rate ratio = 0.65; 95% confidence interval [CI] 0.47, 0.90) but no reduction in length of stay (mean difference −1.09; 95% CI −0.58, 2.77) or number of falls (rate ratio = 0.67; 95% CI 0.19, 2.35). Narrative synthesis identified benefits to patients (e.g., less loneliness), volunteers (sense of meaning), and staff (timesaving, safety).

Discussion and Implications

Volunteer-delivered programs for inpatients with dementia and/or delirium may provide benefits for patients, volunteers, and staff. However, studies conducted with more robust designs are required to determine overall effectiveness on program outcomes. Further high-quality research appropriate for this vulnerable population is required to identify volunteer program effectiveness.

Clinicians' perceptions and recognition of practice improvement strategies to prevent harms to older people in acute care hospitals

AIMS AND OBJECTIVES

Explore clinicians' perceptions of practice improvement strategies used to prevent harms to older people during acute hospitalisation.

BACKGROUND

Older people are vulnerable to many interrelated preventable harms during acute care hospitalisation. Improvement strategies recommend standardisation of practices to assist healthcare staff to mitigate risk; however, older people continue to suffer preventable harms in acute hospitals.

METHODS

A qualitative exploratory descriptive design was used to collect data using focus groups and individual interviews from a purposive sample of 33 participants. Participants represented a wide range of clinicians from four diverse healthcare organisations. Qualitative content analysis used a framework informed by common preventable harms derived from key literature and policy documents.

RESULTS

Participants' perceptions of practice improvement strategies varied depending on their role within their organisational hierarchy. Recognition of preventable harms was guided by standard risk assessment and management tools used in their organisations. Preventable harms relating to skin integrity and falls were universally recognised across all sites and roles. Alternatively, there was variability in participant recognition of preventable harms related to nutrition, continence, medications and cognition; pain was consistently overlooked as a contributor to preventable harms.

CONCLUSIONS

Hospital staff perceived standard clinical risk assessment and management tools as the main practice improvement strategy to prevent harms. These tools prompted staff recognition of preventable harms to older people during acute hospitalisation. Variability in the recognition of some preventable harms was attributed to variable use of standard assessment tools. Pain was unlikely to be recognised as contributing to preventable harms.

RELEVANCE TO CLINICAL PRACTICE

Clinical Risk Management tools may assist clinicians in recognising and responding to preventable harms to older people during hospitalisation. These tools provide critical resources for consistent and timely assessment and evaluation of risk for preventable harms.

Prolonged delirium misdiagnosed as a mood disorder

Delirium can be conceptualized as an acute decline in cognitive function that typically lasts from hours to a few days. Prolonged delirium can also affect patients with multiple predisposing and/or precipitating factors. In clinical practice, prolonged delirium is often unrecognized, and can be misdiagnosed as other psychiatric disorders. We describe a case of a 59-year-old male presenting with behavioral and cognitive symptoms that was first misdiagnosed as a mood disorder in a general hospital setting. After prolonged delirium due to multiple factors was confirmed, the patient was treated accordingly with symptomatic management. He evolved with progressive improvement of his clinical status. Early diagnosis and management of prolonged delirium are important to improve patient prognosis and avoid iatrogenic measures.

Delirium: the lived experience of older people who are delirious post-orthopaedic surgery

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.

Improving delirium care through early intervention: from bench to bedside to boardroom

Delirium is a complex neuropsychiatric syndrome that impacts adversely upon patient outcomes and healthcare outcomes. Delirium occurs in approximately one in five hospitalised patients and is especially common in the elderly and patients who are highly morbid and/or have pre-existing cognitive impairment. However, efforts to improve management of delirium are hindered by gaps in our knowledge and issues that reflect a disparity between existing knowledge and real-world practice. This review focuses on evidence that can assist in prevention, earlier detection and more timely and effective pharmacological and non-pharmacological management of emergent cases and their aftermath. It points towards a new approach to delirium care, encompassing laboratory and clinical aspects and health services realignment supported by health managers prioritising delirium on the healthcare change agenda. Key areas for future research and service organisation are outlined in a plan for improved delirium care across the range of healthcare settings and patient populations in which it occurs.

[Delirium risk assessment in elderly hospitalized patients]

Delirium is a major geriatric syndrome that affects a significant percentage of elderly hospitalized patients. It involves major negative consequences for users and professionals and can be prevented. The aim of this paper is to identify and describe the tools for predicting delirium in hospitalized patients. Lastly, the work analyzes the sources of heterogeneity and the scarcity of such instruments, as well as the reasons why their use is not widespread in clinical practice.