Existential Absence: The Lived Experience of Family Members During Their Older Loved One's Delirium

Experiences of relatives of patients with delirium due to an acute health event - A systematic review of qualitative studies

OBJECTIVE

Evaluate relatives' experience of delirium due to an acute health event in a loved person and to compile practical suggestions for health care professionals from these synthesized results.

BACKGROUND

Delirium resulting from an acute health event places patients at increased risk for prolonged hospitalization and mortality. A delirium episode also affects family members who may assist in the diagnosis and recovery from this condition.

INCLUSION CRITERIA

Qualitative studies of family members or other caregivers who witnessed patient delirium in a clinical setting were included if they had appropriate verbatim evidence. Studies dealing exclusively with delirium in the context of dementia, cancer, palliative care, or drug dependence were excluded, and if quotes could not be clearly allocated to relatives.

METHODS

A systematic review of qualitative studies adapted from the Joanna Briggs Institute meta-aggregation approach. A systematic literature search was conducted in CINAHL complete®, MEDLINE®, and several dissertation databases in September 2022.

RESULTS

Eight qualitative studies based on semi-structured interviews were included. In total 75 findings from 105 relatives were aggregated into 13 categories. Finally, three synthesized findings reveal suggestions for health care professionals: providing information adequately, communication and integration during health care and understanding relatives' perspective on delirium experience.

CONCLUSION

The identified burdens and needs of relatives should be considered by health care professionals to enhance the delirium experience for them, thus improving patient care by involving relatives with a better understanding.

Diagnostic yield of CT head in delirium and altered mental status-A systematic review and meta-analysis

BACKGROUND

CT head is commonly performed in the setting of delirium and altered mental status (AMS), with variable yield. We aimed to evaluate the yield of CT head in hospitalized patients with delirium and/or AMS across a variety of clinical settings and identify factors associated with abnormal imaging.

METHODS

We included studies in adult hospitalized patients, admitted to the emergency department (ED) and inpatient medical unit (grouped together) or the intensive care unit (ICU). Patients had a diagnosis of delirium/AMS and underwent a CT head that was classified as abnormal or not. We searched Medline, Embase and other databases (informed by PRISMA guidelines) from inception until November 11, 2021. Studies that were exclusively performed in patients with trauma or a fall were excluded. A meta-analysis of proportions was performed; the pooled proportion of abnormal CTs was estimated using a random effects model. Heterogeneity was determined via the I² statistic. Factors associated with an abnormal CT head were summarized qualitatively.

RESULTS

Forty-six studies were included for analysis. The overall yield of CT head in the inpatient/ED was 13% (95% CI: 10.2%-15.9%) and in ICU was 17.4% (95% CI: 10%-26.3%), with considerable heterogeneity (I² 96% and 98% respectively). Heterogeneity was partly explained after accounting for study region, publication year, and representativeness of the target population. Yield of CT head diminished after year 2000 (19.8% vs. 11.1%) and varied widely depending on geographical region (8.4%-25.9%). The presence of focal neurological deficits was a consistent factor that increased yield.

CONCLUSION

Use of CT head to diagnose the etiology of delirium and AMS varied widely and yield has declined. Guidelines and clinical decision support tools could increase the appropriate use of CT head in the diagnostic etiology of delirium/AMS.

Identifying the relationship between delirium and falls

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.

Building collaborative relationships with family caregivers of hospitalized older persons with delirium superimposed on dementia: A qualitative study

AIMS

To explore experiences of family caregivers providing support to older persons with delirium superimposed on dementia in acute care hospitals, their role in detection and management of this condition, and support they require.

DESIGN

This study has an exploratory-descriptive design using interpretive description methodology.

METHODS

Semi-structured interviews were conducted with nine caregivers from January to April 2020. Interview transcripts underwent thematic analysis.

FINDINGS

Three themes were identified: (1) family caregivers found delirium superimposed on dementia to be an overwhelming experience, (2) family caregivers can play an important role in the detection and management of delirium superimposed on dementia and (3) family caregivers' experiences were influenced by the nature of their relationship with the health care team. Family caregivers found the experience distressing and felt unprepared to face the condition. Family caregivers also possessed knowledge helpful in detecting acute changes and caring for the older person. Family caregivers' relationships with the health care team varied: some felt supported by the team, while others experienced a power imbalance, characterized by lack of communication and opportunities to participate in care.

CONCLUSIONS

Family caregivers were distressed to see family members hospitalized with delirium superimposed on dementia. Family caregivers are also ideally positioned to detect the condition and participate in care. However, power imbalances remain, leaving family caregivers feeling disempowered and believing the health care team had more control over the older person's care.

IMPACT

Findings highlight the need for strategies to address the distress and disempowerment experienced by family caregivers of hospitalized older persons with delirium superimposed on dementia. By building collaborative relationships, nurses and other health care team members can help family caregivers navigate the complex experience with delirium superimposed on dementia and reduce distress, with the ultimate goal of facilitating family caregivers' ability to care for older persons in the community.

NO PATIENT OR PUBLIC CONTRIBUTION

While the study participants are members of the public, this population was not involved in the study design and analysis. This method aligns with interpretive description, where researchers are not just a medium through which participants speak, but also interpretive instruments who discern insights not accessible to persons who may be familiar with only a single case.

Patients' and Relatives' Experiences of Delirium in the Intensive Care Unit-A Qualitative Study

(1) Introduction: Delirium is a cognitive disorder that affects up to 80% of ICU patients and has many negative consequences. The occurrence of delirium in an ICU patient also negatively affects the relatives caring for these patients. The aim of this study was to explore patients' and their families' experiences of delirium during their ICU stay. (2) Method: The study used a qualitative design based on phenomenology as a research method. A semi-structured interview method was used to achieve the aim. The responses of patients and their families were recorded and transcribed, and the data were coded and analyzed. (3) Results: Eight interviews were conducted with past ICU patients who developed delirium during hospitalization and their family members. The mean age of the participants was 71 years. Of the eight patients, 2 (25%) were female and 6 (75%) were male. The relationships of the 8 carers with the patients were wife (in 4 cases), daughter (in 2 cases), and son (in 2 cases). The average length of time a patient stayed in the ICU was 24 days. The following themes were extracted from the interviews: education, feelings before the delirium, pain, thirst, the day after, talking to the family/patient, and return home. (4) Conclusions: Post-delirium patients and their families feel that more emphasis should be placed on information about delirium. Most patients feel embarrassed and ashamed about events during a delirium episode. Patients fear the reaction of their families when delirium occurs. Patients' families are not concerned about their relatives returning home and believe that the home environment will allow them to forget the delirium events more quickly during hospitalization.

Identifying and Responding to Delirium in Acute Stroke: Clinical Team Members' Understandings

Delirium is associated with increased mortality, morbidity, and length of hospital stay. In the acute stroke setting, delirium identification is challenging due to the complexity of cognitive screening in this patient group. The aim of this study was to explore how members of interprofessional stroke-unit teams identified and responded to a potential delirium in a patient. Online focus groups and interviews utilizing case vignettes were conducted with 15 participants: nurses, occupational therapists, speech and language therapists, and physiotherapists working in acute stroke services. Participants' understandings of delirium varied, most participants did not identify the symptoms of a possible hypoactive delirium, and nearly all participants discussed delirium symptoms in tentative terms. Aspects of interprofessional working were discussed through the expression of distinct roles around delirium identification. Although participants demonstrated an ethos of person-focused care, there are ongoing challenges involved in early identification and management of delirium in stroke survivors.

Family caregiver's experience of caring for an older adult with delirium: A systematic review

AIM

To enhance understanding of how family caregivers perceive the experience of caring for an older adult with delirium across care settings and to identify the challenges in recognising and managing delirium to inform future research and best practices.

METHOD

A systematic literature review was conducted in five databases per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. Primary or secondary peer-reviewed articles published between 1987 and October 2018 describing the experiences of family caregivers caring for older adults with delirium or delirium superimposed on dementia were included in the review. Mixed Method Appraisal Tool (MMAT) was used to evaluate the methodological quality. A thematic synthesis of results was conducted to extract relevant data as per the aims of the study.

RESULTS

Eighteen articles met the eligibility criteria, which were reviewed and analysed in regard to purpose, sample, research design, variables and results. Seven themes emerged in the process. The current challenges and gaps in our knowledge of this phenomenon have also been highlighted, which should be helpful to inform best practices, and finally, an agenda for future research is proposed.

CONCLUSION

Family caregivers are an important partner in the detection and management of delirium. The impact of caring for an older adult with delirium on the family caregivers should not be overlooked. This paper highlights the dearth of research on family caregiver's experience of caring for older adults with delirium and even less in the context of delirium superimposed on dementia. More research is required to further understand the family caregiver's experience and their challenges in order to support them in their caregiving role and to determine their needs and preferences of being involved in the plan of care.

IMPLICATIONS FOR PRACTICE

These findings suggest that family caregivers are a valuable resource in the recognition and management of delirium and should be included as care partners in the health care team, while also catering to their health and well-being in the process.

The Caregiver Burden of Delirium in Older Adults With Alzheimer Disease and Related Disorders

OBJECTIVES

To measure the burden of delirium in older adults with or without Alzheimer disease or related disorders (ADRDs).

DESIGN

Prospective, observational cohort.

SETTING

Inpatient hospital and study participants' homes.

PARTICIPANTS

A subset (n = 267) of older medical and surgical patients and their caregivers enrolled in the Better Assessment of Illness study.

MEASUREMENTS

Delirium burden was measured using the DEL-B instrument (range = 0-40, with higher scores indicating greater burden) in caregivers (DEL-B-C) and patients 1 month after hospitalization. Severity of cognitive impairment (Montreal Cognitive Assessment [MoCA]), delirium presence (Confusion Assessment Method [CAM]), and delirium severity (CAM-Severity [CAM-S]) were measured during hospitalization and at 1-month follow-up. ADRD diagnosis was determined by a clinical consensus process.

RESULTS

For patients with (n = 56) and without (n = 211) ADRD, both DEL-B instruments had good internal consistency. DEL-B-C scores had a median (interquartile range) among caregivers of patients with and without ADRD of 9 (5-15) and 5 (1-11), respectively (P < .05). If the patient developed delirium, caregivers experienced greater burden (β[delirium × ADRD] = -.29; P = .42), regardless of ADRD status. Further, caregiver burden was modestly correlated with patient MoCA scores (Spearman correlation coefficient, ρ = -0.18; P = .01). Patients with ADRD who developed delirium self-reported less burden than those without ADRD (β[delirium × ADRD] = -.67; P = .044). As with caregivers, delirium burden was modestly correlated with patient MoCA score (ρ = -0.18; P = .005) and correlated with the CAM-S in patients without ADRD (ρ = 0.38; P < .001) but not for patients with ADRD (ρ = -0.07; P = .61).

CONCLUSIONS

Delirium resulted in the same degree of increased caregiver burden regardless of whether a patient had ADRD, signifying delirium is equally stressful to caregivers, even among those with experience caring for someone with a chronic cognitive disorder. Delirium burden is only modestly associated with degree of cognitive impairment, suggesting that other aspects of delirium contribute to burden. J Am Geriatr Soc 67:2587-2592, 2019.

Perspectives on the Delirium Experience and Its Burden: Common Themes Among Older Patients, Their Family Caregivers, and Nurses

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.

Do health care professionals worry about delirium? Relatives' experience of delirium in the intensive care unit: A qualitative interview study

OBJECTIVES

In intensive care units, there is a high incidence of delirium, which relates to the risk of complications. Engagement of relatives is an acknowledged part of handling delirium, but knowledge of relatives' perspectives is lacking.

AIM

To explore relatives' experiences of delirium in the critically ill patient admitted to an intensive care unit.

RESEARCH DESIGN

A qualitative design with a phenomenological approach. Semi-structured interviews with eleven relatives of critically ill patients who had delirium during admission to the intensive care unit.

SETTING

An intensive care unit in Denmark.

FINDINGS

Three categories emerged: 'Delirium is not the main concern', 'Communication with health-care professionals is crucial', and 'Delirium impacts on relatives'. Relatives had a lack of knowledge of delirium. Symptoms of delirium were thought of as a natural consequence of critical illness and seemed to be a secondary problem. Health-care professionals did not talk about delirium and information was requested. Delirium and the manifestation of it was experienced in different ways and brought different ways of coping.

CONCLUSION

Findings give a new insight into relatives' experience of delirium in the intensive care unit. Relatives need more information to better understand delirium. Future research must investigate the potential in helping relatives to cope with delirium, to the benefit of both patient and relatives.

Silent voices: Transition experiences of family members caring for relatives with dementia

Worldwide 46.8 million persons are living with dementia and many are requiring assistance with performing daily living or instrumental functions. It is often the task of family members to provide care for their relatives with dementia. However, they are often the silent, unseen and unacknowledged figures in the lives of people living with dementia. In 2015, we used a phenomenological design utilising visual participatory methods in the form of collages and interviews to explore and describe the transition experiences of eight family members (seven females and one male) living in a South African city regarding how they became caregivers of their relatives with dementia. They often entered their caregiving roles unexpectedly, often not having much choice regarding whether or not to take on the caregiving role. Family members caring for relatives with dementia have unique support needs as they transition into the caregiving role.

‘I hope you get normal again’: an explorative study on how delirious octogenarian patients experience their interactions with healthcare professionals and relatives after aortic valve therapy

Background:

Delirium affects nearly half of octogenarian patients after aortic valve replacement, resulting in impaired cognition, reduced awareness and hallucinations. Although healthcare professionals and relatives are often present during episodes, the nature of interactions with them is scarcely studied, and little is known about their long-term experiences.

Purpose:

The purpose of this study was to explore and describe how octogenarian patients with post-aortic valve replacement delirium experience interactions with healthcare professionals and relatives within the first year and four years later.

Method:

An explorative design with qualitative content analysis was used. Delirium was assessed for five consecutive days after aortic valve replacement using the Confusion Assessment Method. Delirious patients ( n=10) were interviewed 6–12 months post-discharge and four years later ( n=5). We used an inductive approach to identify themes in transcribed interviews.

Findings:

An overarching theme emerged: ‘ Healthcare professionals’ and relatives’ responses made a considerable impact on the delirium experience postoperatively and in a long-term’. Three sub-themes described the patients’ experiences: ‘ the need for close supportive care’, ‘ disrespectful behaviour created a barrier’ and ‘ insensitive comments made lasting impressions’. Having healthcare professionals and relatives nearby made the patients feel secure, while lack of attention elevated patients’ emotional distress. Four years later, patients clearly recalled negative comments and unsupportive actions in their delirious state.

Conclusions:

Healthcare professionals and relatives have an essential role in the aortic valve replacement recovery process. Inconsiderate behaviour directed at older patients in delirium elevates distress and has long-term implications. Supportive care focused on maintaining the patients’ dignity and integrity is vital.

What effect does delirium have on family and nurses of older adult patients?

OBJECTIVES

This study aims to analyse the level of distress caused by delirium in patients' family and their nurses, and to identify factors associated with psychological distress in families of older adult inpatients in Intermediate Care Units/IMCUs regarding their global experience during hospitalization.

METHOD

A prospective pilot study was carried out with families and nurses of older adult patients (≥65 y.o.) consecutively recruited from two IMCUs in Intensive Care Medicine Service in a University Hospital. Patients with Glasgow Coma Scale ≤11, brain injury, blindness/deafness and inability to communicate were excluded. Delirium was daily assessed with Confusion Assessment Method/CAM. The distress level regarding this episode in family and nurses was measured with Delirium Experience Questionnaire/DEQ. Family psychological distress of all recruited patients was assessed with Kessler Psychological Distress Scale/K10.

RESULTS

This study included 42 inpatients (mean age/MA = 78 y.o., 50% women), 32 families (68.8% sons/daughters, MA = 50.6 y.o., 81.3% women) and 12 nurses caring for delirium patients (MA = 33 y.o., all women). A total of 12 (28.6%) patients had delirium. Distress related to this episode were higher for families than for nurses (M = 3 vs. M = 2), but differences did not reach statistical significance (Z = -1.535, p = 0.125). The hierarchical regression model explained 44.3% of variability in family psychological distress. Higher levels of psychological distress were associated with living with the patient (p = 0.029), presence of previous cognitive decline (p = 0.048) and development of delirium (p = 0.010).

CONCLUSION

These preliminary results show that family psychological distress is higher, when older adult patients developed delirium during hospitalization. Particular attention to these family carers should be given in future development of psychological support and psychoeducational interventions.

Mum's absence(s): conceptual insights into absence as loss during a loved one's delirium

AIMS AND OBJECTIVES

To examine qualitative research findings about family experiences of absence or loss during older person delirium, and provide a critical discussion of the similarities and differences in these experiences with conceptual understandings of absence and loss.

BACKGROUND

Families who care for older people with chronic illnesses experience many losses. However, the nondeath loss experiences of family during an older loved one's delirium, an acute condition accompanied by marked changes in demeanour, have received little consideration.

DESIGN

Discursive position paper.

METHODS

The findings from two qualitative research studies about family experiences during an older loved one's delirium are discussed in relation to the concepts of absence and nondeath loss.

RESULTS

The uncharacteristic behaviours and cognitive changes that accompany delirium may estrange family who, despite the older person's corporeal presence, sense the profound absence or loss of their loved one. Although the notion of absence, a nondeath loss, is similar to the experiences of family of people with chronic conditions, there are differences that distinguish these encounters. The similarities and differences between absence during delirium and the concepts of psychological absence, nonfinite loss and psychosocial death are discussed. Psychosocial death, reversibility/irreversibility and partial marked change, are suggested as conceptual descriptions for the absence families experience during an older loved one's delirium.

CONCLUSIONS

The sense of absence or loss that family may experience during their older loved one's delirium needs to be recognised, understood and addressed by healthcare staff. Understanding or appreciating conceptualisations of absence, as a nondeath loss, may enhance understandings of family member needs during delirium and enable better support strategies.

RELEVANCE TO CLINICAL PRACTICE

Conceptualisations of absence enhance understandings of family distress and needs during their older loved one's delirium. The potential for family members to experience their loved one's absence during delirium, a nondeath loss, needs to be considered by healthcare staff. Family experiences of absence during delirium need to be recognised by healthcare staff, acknowledged as a potential source of distress, and considered when involving family in the older person's care. Nurses are ideally placed to respond compassionately and provide appropriate family member re-assurance, support and information during delirium. Information should include possible impacts on family and coping strategies.

The experiences of caregivers of patients with delirium, and their role in its management in palliative care settings: an integrative literature review

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.

Reflexivity and exploring the meaning of delirium through media depictions: Methodological insights from a phenomenological study

In the course of a phenomenological study that explored the experiences of family members during their older loved one's delirium, a range of delirium experiences depicted in artistic, creative, and linguistic media were reviewed. The search for, and compilation of, media sources for reflection during data analysis is described in this paper. In doing so, the researcher reveals how attentiveness and openness to varied depictions of lived experiences, as well as a valuing attitude toward challenging subjective perspectives, can enhance researcher reflexivity and appreciation of interpretive meanings. Turning to media depictions of delirium offered alternative perspectives on the experience. It challenged the researcher's assumptions, enhanced phenomenological reflection, promoted critique of evolving interpretations, and suggested meanings that might not have otherwise been realized. The approach used is a potent, although often overlooked, way to differentiate the nature of phenomena shared through lived experience data. Media-based methods and their use in phenomenology continue to be explored. Illustrations of how to integrate media sources, as well as discussion about the benefits and alternatives to more common uses, are needed.