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Molitor V, Busse TS, Giehl C, Lauer R, Otte IC, Vollmar HC, Thürmann P, Holle B, Palm R. Educational interventions aimed at improving knowledge of delirium among nursing home staff-a realist review. BMC Geriatr 2024; 24:633. [PMID: 39054433 PMCID: PMC11274774 DOI: 10.1186/s12877-024-05213-9] [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: 04/05/2024] [Accepted: 07/10/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Delirium is a neuropathological syndrome that is characterised by fluctuating impairments in attention, cognitive performance, and consciousness. Since delirium represents a medical emergency, it can be associated with adverse clinical and economic outcomes. Although nursing home residents face a high risk of developing delirium, health care professionals in this field appear to have limited knowledge of delirium despite the critical role they play in the prevention, diagnosis, and treatment of delirium in nursing homes. OBJECTIVE The purpose of this realist review is to develop an initial programme theory with the goal of understanding how, why, and under what circumstances educational interventions can improve the delirium-specific knowledge of health care professionals in nursing homes. METHODS This realist review was conducted in accordance with the RAMESES (Realist And Meta-narrative Evidence Synthesis: and Evolving Standards) guidelines and includes the following steps: (1) search strategy and literature review; (2) study selection and assessment; (3) data extraction; (4) data synthesis; and (5) development of an initial programme theory. It also included stakeholder discussions with health care professionals recruited from nursing home care, which focused on their experiences with delirium. RESULTS From a set of 1703 initially identified publications, ten publications were included in this realist review. Based on these publications, context-mechanism-outcome configurations were developed; these configurations pertained to (1) management support, (2) cognitive impairments among residents, (3) familiarity with residents, (4) participatory intervention development, (5) practical application, (6) case scenarios, (7) support from experts and (8) relevance of communication. CONCLUSIONS Educational interventions aimed at improving the delirium-specific knowledge of health care professionals should feature methodological diversity if they are to enhance health care professionals' interest in delirium and highlight the fundamental contributions they make to the prevention, diagnosis, and treatment of delirium. Educational interventions should also take into account the multidimensional contextual factors that can have massive impacts on the relevant mode of action as well as the responses of health care professionals in nursing homes. The identification of delirium in residents is a fundamental responsibility for nursing home staff. TRIAL REGISTRATION This review has been registered at Open Science Framework https://doi.org/10.17605/OSF.IO/6ZKM3.
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Affiliation(s)
- Vincent Molitor
- Faculty of Health, School of Nursing Science, Witten Herdecke University, Witten, Germany.
- School VI -School of Medicine and Health Sciences, Carl von Ossietzky Universität, Oldenburg, Germany.
| | - Theresa Sophie Busse
- Institute of General Practice and Family Medicine (AM RUB), Medical Faculty, Ruhr University Bochum, Bochum, Germany
| | - Chantal Giehl
- Institute of General Practice and Family Medicine (AM RUB), Medical Faculty, Ruhr University Bochum, Bochum, Germany
- Department of Geriatric Medicine, Marien Hospital Herne, Ruhr University Bochum, Herne, Germany
| | - Romy Lauer
- Institute of General Practice and Family Medicine (AM RUB), Medical Faculty, Ruhr University Bochum, Bochum, Germany
| | - Ina Carola Otte
- Institute of General Practice and Family Medicine (AM RUB), Medical Faculty, Ruhr University Bochum, Bochum, Germany
| | - Horst Christian Vollmar
- Institute of General Practice and Family Medicine (AM RUB), Medical Faculty, Ruhr University Bochum, Bochum, Germany
| | - Petra Thürmann
- Faculty of Health, School of Medicine, Chair of Clinical Pharmacology, Witten Herdecke University, Witten, Germany
- Philipp Klee-Institute of Clinical Pharmacology, Helios University Hospital Wuppertal, Wuppertal, Germany
| | - Bernhard Holle
- Faculty of Health, School of Nursing Science, Witten Herdecke University, Witten, Germany
- German Center for, Deutsches Zentrum fur Neurodegenerative Erkrankungen (DZNE) Standort Witten, Witten, Germany
| | - Rebecca Palm
- Faculty of Health, School of Nursing Science, Witten Herdecke University, Witten, Germany
- School VI -School of Medicine and Health Sciences, Carl von Ossietzky Universität, Oldenburg, Germany
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Savino T, Vergara FH, Ramos MD, Warzecha D. Bringing Delirium to Light: Impact of CAM-ICU Tool to Improve Care Coordination. Prof Case Manag 2024; 29:149-157. [PMID: 38421724 DOI: 10.1097/ncm.0000000000000715] [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: 03/02/2024]
Abstract
BACKGROUND Delirium is a serious complication in patients in the critical care unit (CCU) that may lead to prolonged hospitalization if left undetected. The CCU at our hospital does not have a framework for determining delirium that could affect patient outcomes and discharge planning. PRIMARY PRACTICE SETTING CCU in a community hospital. METHOD A posttest-only design was used for this study. We established a framework for the early assessment of delirium, educated and trained nurses to detect delirium, collaborated with the informatics department, intensivist, nursing, respiratory therapy and worked with case management to deploy the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). We used a one-tailed independent t test to determine the impact of CAM-ICU on length of stay (LOS). Cross-tabulation and chi-square tests were used to examine the impact of CAM-ICU tool on home care utilization between the intervention and comparison groups. RESULTS There was a 3.12% reduction in LOS after implementing the CAM-ICU tool. Also, a reduction in home care service utilization demonstrated statistical significance ( p = .001) between the intervention group (62.5%; n = 177) and the comparison group (37.5%; n = 106). IMPLICATIONS FOR CASE MANAGEMENT PRACTICE Case managers are essential in improving care transitions. Case managers need to become competent in understanding the implications of the CAM-ICU tool because of their relevant role in the multidisciplinary rounds as advocates to improve care transitions across the continuum of care. Case managers need to have an understanding on how to escalate when changes in the Richmond Agitation-Sedation Scale scores occur during the multidisciplinary rounds because it can affect care coordination throughout the hospital. CONCLUSIONS Implementing the CAM-ICU decreased LOS, and reduced health care utilization. The early identification of patients with delirium can affect the outcomes of critically ill patients and entails multidisciplinary collaboration.
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Affiliation(s)
- Theresa Savino
- Theresa Savino, DNP, RN, CPHQ, CPXP, FNAHQ, is Director of Service Excellence and Patient Experience at Middlesex Health, Middletown, Connecticut. She is also an adjunct nursing faculty member at the University of Connecticut
- Franz H. Vergara, PhD, DNP, MAS, RN, CENP, CCM, ONC, is Senior Director of Nursing Operations and Patient Care Services at MedStar Harbor Hospital, Baltimore, Maryland. He served as the school capstone chairman and supervising faculty of Dr. Savino
- Mary Dioise Ramos, PhD, RN, CNE, is Associate Professor and Interim Director of Graduate Programs, Wellstar College of Health and Human Services, Kennesaw State University, Georgia
- Deborah Warzecha, DNP, RN, NEA-BC, CEN, is Director of Nursing at Middlesex Health, Middletown, Connecticut. She served as the preceptor for Dr. Savino during her doctorate program
| | - Franz H Vergara
- Theresa Savino, DNP, RN, CPHQ, CPXP, FNAHQ, is Director of Service Excellence and Patient Experience at Middlesex Health, Middletown, Connecticut. She is also an adjunct nursing faculty member at the University of Connecticut
- Franz H. Vergara, PhD, DNP, MAS, RN, CENP, CCM, ONC, is Senior Director of Nursing Operations and Patient Care Services at MedStar Harbor Hospital, Baltimore, Maryland. He served as the school capstone chairman and supervising faculty of Dr. Savino
- Mary Dioise Ramos, PhD, RN, CNE, is Associate Professor and Interim Director of Graduate Programs, Wellstar College of Health and Human Services, Kennesaw State University, Georgia
- Deborah Warzecha, DNP, RN, NEA-BC, CEN, is Director of Nursing at Middlesex Health, Middletown, Connecticut. She served as the preceptor for Dr. Savino during her doctorate program
| | - Mary Dioise Ramos
- Theresa Savino, DNP, RN, CPHQ, CPXP, FNAHQ, is Director of Service Excellence and Patient Experience at Middlesex Health, Middletown, Connecticut. She is also an adjunct nursing faculty member at the University of Connecticut
- Franz H. Vergara, PhD, DNP, MAS, RN, CENP, CCM, ONC, is Senior Director of Nursing Operations and Patient Care Services at MedStar Harbor Hospital, Baltimore, Maryland. He served as the school capstone chairman and supervising faculty of Dr. Savino
- Mary Dioise Ramos, PhD, RN, CNE, is Associate Professor and Interim Director of Graduate Programs, Wellstar College of Health and Human Services, Kennesaw State University, Georgia
- Deborah Warzecha, DNP, RN, NEA-BC, CEN, is Director of Nursing at Middlesex Health, Middletown, Connecticut. She served as the preceptor for Dr. Savino during her doctorate program
| | - Deborah Warzecha
- Theresa Savino, DNP, RN, CPHQ, CPXP, FNAHQ, is Director of Service Excellence and Patient Experience at Middlesex Health, Middletown, Connecticut. She is also an adjunct nursing faculty member at the University of Connecticut
- Franz H. Vergara, PhD, DNP, MAS, RN, CENP, CCM, ONC, is Senior Director of Nursing Operations and Patient Care Services at MedStar Harbor Hospital, Baltimore, Maryland. He served as the school capstone chairman and supervising faculty of Dr. Savino
- Mary Dioise Ramos, PhD, RN, CNE, is Associate Professor and Interim Director of Graduate Programs, Wellstar College of Health and Human Services, Kennesaw State University, Georgia
- Deborah Warzecha, DNP, RN, NEA-BC, CEN, is Director of Nursing at Middlesex Health, Middletown, Connecticut. She served as the preceptor for Dr. Savino during her doctorate program
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Marcomini I, Pisoni L, Mellino A, Labaran R, Milani L. Evaluation of Delirium Among Elders in the Emergency Department: A Cross-Sectional Study. Dimens Crit Care Nurs 2024; 43:130-135. [PMID: 38564455 DOI: 10.1097/dcc.0000000000000636] [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: 04/04/2024] Open
Abstract
BACKGROUND Health care professionals underestimate the recognition of delirium in emergency departments (EDs). In these settings, between 57% and 83% of cases of delirium go undetected. When delirium occurs, it causes an increase in the length of hospitalization, readmissions within 30 days, and mortality. No studies were carried out in Italy to assess the prevalence of delirium among elders in EDs. OBJECTIVES The primary goal of the study was to evaluate the prevalence of the risk of delirium in people 65 years and older hospitalized in the ED for a minimum of 8 hours. The study's secondary goal was to identify the variables that influenced the risk of delirium. METHOD A multicenter cross-sectional study was conducted in 2 EDs. The risk of delirium was assessed using the delirium screening tool 4 A's test. One hundred patients were enrolled. Data collection took place from June 28 to August 31, 2022. RESULTS The risk of delirium was detected in 29% of the sample, whereas the risk of cognitive impairment was 13%. The use of psychotropic drugs increased the risk of delirium by 11.8 times (odds ratio [OR], 11.80; P = .003). Bed confinement increased the risk by 4.3 times (OR, 4.31; P = .009). Being dehydrated increased the risk of onset by 4.6 times (OR, 4.62; P = .010). Having dementia increased the risk of delirium manifestation by 4.4 times (OR, 4.35; P = .021). DISCUSSION The risk of delirium was detected in a considerable portion of the sample. The results of this study can be used by health care professionals to implement preventive measures as well as support clinical judgment and establish priorities of care for patients at risk of developing delirium.
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Xin Y, Lin FC, Huang C, He B, Yan YL, Wang S, Zhang GM, Li R. Nurse anesthetists' perceptions and experiences of managing emergence delirium: A qualitative study. World J Psychiatry 2024; 14:553-562. [PMID: 38659604 PMCID: PMC11036462 DOI: 10.5498/wjp.v14.i4.553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 02/02/2024] [Accepted: 03/19/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND This study employs a descriptive phenomenological approach to investigate the challenges anesthesia nurses face in managing emergence delirium (ED), a common and complex postoperative complication in the post-anesthesia care unit. The role of nurses in managing ED is critical, yet research on their understanding and management strategies for ED is lacking. AIM To investigate anesthetic nurses' cognition and management experiences of ED in hopes of developing a standardized management protocol. METHODS This study employed a descriptive phenomenological approach from qualitative research methodologies. Purposeful sampling was utilized to select 12 anesthetic nurses from a tertiary hospital in Shanghai as research subjects. Semi-structured interviews were conducted, and the data were organized and analyzed using Colaizzi's seven-step analysis method, from which the final themes were extracted. RESULTS After analyzing the interview content, four main themes and eight subthemes were distilled: Inefficient cognition hinders the identification of ED (conceptual ambiguity, empirical identification), managing diversity and challenges (patient-centered safe care, low level of medical-nursing collaboration), work responsibilities and pressure coexist (heavy work responsibilities, occupational risks and stress), demand for high-quality management (expecting the construction of predictive assessment tools and prevention strategies, and pursuing standardized management processes to enhance management effectiveness). CONCLUSION Nursing managers should prioritize the needs and suggestions of nurses in order to enhance their nursing capabilities and provide guidance for standardized management processes.
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Affiliation(s)
- Yi Xin
- Wuxi Medical College, Jiangnan University, Wuxi 214122, Jiangsu Province, China
| | - Fu-Cai Lin
- Wuxi Medical College, Jiangnan University, Wuxi 214122, Jiangsu Province, China
| | - Chen Huang
- Department of Anesthesiology, Tongren Hospital Shanghai Jiao Tong University School of Medicine, Shanghai 200335, China
| | - Bin He
- Wuxi Medical College, Jiangnan University, Wuxi 214122, Jiangsu Province, China
| | - Ya-Ling Yan
- Wuxi Medical College, Jiangnan University, Wuxi 214122, Jiangsu Province, China
| | - Shuo Wang
- Department of Anesthesiology, Tongren Hospital Shanghai Jiao Tong University School of Medicine, Shanghai 200335, China
| | - Guang-Ming Zhang
- Department of Anesthesiology, Tongren Hospital Shanghai Jiao Tong University School of Medicine, Shanghai 200335, China
| | - Rui Li
- Department of Nursing, Tongren Hospital Shanghai Jiao Tong University School of Medicine, Shanghai 200335, China
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Jackson GP, Jackson CE, Boland JW, Featherstone I, Huang C, Ogden M, Sartain K, Siddiqi N, Twiddy M, Pearson M, Johnson MJ. Improving the Detection, Assessment, Management and Prevention of Delirium in Hospices (the DAMPen-D study): Feasibility study of a flexible and scalable implementation strategy to deliver guideline-adherent delirium care. Palliat Med 2024; 38:447-456. [PMID: 38634231 PMCID: PMC11025298 DOI: 10.1177/02692163241236325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
BACKGROUND Delirium is a complex condition, stressful for all involved. Although highly prevalent in palliative care settings, it remains underdiagnosed and associated with poor outcomes. Guideline-adherent delirium care may improve its detection, assessment and management. AIM To inform a future definitive study that tests whether an implementation strategy designed to improve guideline-adherent delirium care in palliative care settings improves patient outcomes (reduced proportion of in-patient days with delirium). DESIGN With Patient Involvement members, we conducted a feasibility study to assess the acceptability of and engagement with the implementation strategy by hospice staff (intervention), and whether clinical record data collection of process (e.g. guideline-adherent delirium care) and clinical outcomes (evidence of delirium using a validated chart-based instrument;) pre- and 12-weeks post-implementation of the intervention would be possible. SETTING/PARTICIPANTS In-patient admissions in three English hospices. RESULTS Between June 2021 and December 2022, clinical record data were extracted from 300 consecutive admissions. Despite data collection during COVID-19, target clinical record data collection (n = 300) was achieved. Approximately two-thirds of patients had a delirium episode during in-patient stay at both timepoints. A 6% absolute reduction in proportion of delirium days in those with a delirium episode was observed. Post-implementation improvements in guideline-adherent metrics include: clinical delirium diagnosis 15%-28%; delirium risk assessment 0%-16%; screening on admission 7%-35%. CONCLUSIONS Collection of data on delirium outcomes and guideline-adherence from clinical records is feasible. The signal of patient benefit supports formal evaluation in a large-scale study.
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Affiliation(s)
- Gillian P Jackson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Catriona E Jackson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
- Leeds Teaching Hospitals NHS Trust, St James’s University Hospital, Leeds, UK
| | - Jason W Boland
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | | | - Chao Huang
- Institute of Clinical & Applied Health Research, Hull York Medical School, University of Hull, Hull, UK
| | | | - Kathryn Sartain
- York and Scarborough Teaching Hospitals NHS Foundation Trust, York Hospital, York, UK
| | - Najma Siddiqi
- Department of Health Sciences, University of York, York, UK
| | - Maureen Twiddy
- Institute of Clinical & Applied Health Research, Hull York Medical School, University of Hull, Hull, UK
| | - Mark Pearson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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Featherstone I, Siddiqi N, Jones L, Coppo E, Sheldon T, Hosie A, Wolkowski A, Bush SH, Taylor J, Teodorczuk A, Johnson MJ. 'It's tough. It is hard': A qualitative interview study of staff and volunteers caring for hospice in-patients with delirium. Palliat Med 2023:2692163231170655. [PMID: 37129262 DOI: 10.1177/02692163231170655] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
BACKGROUND Delirium is a distressing condition often experienced by hospice in-patients. Increased understanding of current multidisciplinary care of delirium is needed to develop interventions in this setting. AIM(S) To explore hospice staff and volunteers' practice, its influences and what may need to change to improve hospice delirium care. DESIGN Qualitative interview study using behaviour change theory from a critical realist stance. SETTING/PARTICIPANTS Thirty-seven staff, including different professional groups and roles, and volunteers were purposively sampled from two in-patient hospices. RESULTS We found that participants' practice focus was on managing hyperactive symptoms of delirium, through medication use and non-pharmacological strategies. Delirium prevention, early recognition and hypoactive delirium received less attention. Our theoretically-informed analysis identified this focus was influenced by staff and volunteers' emotional responses to the distress associated with hyperactive symptoms of delirium as well as understanding of delirium prevention, recognition and care, which varied between staff groups. Non-pharmacological delirium management was supported by adequate staffing levels, supportive team working and a culture of person-centred and family-centred care, although behaviours that disrupted the calm hospice environment challenged this. CONCLUSIONS Our findings can inform hospice-tailored behaviour change interventions that develop a shared team understanding and engage staff's emotional responses to improve delirium care. Reflective learning opportunities are needed that increase understanding of the potential to reduce patient distress through prevention and early recognition of delirium, as well as person-centred management. Organisational support for adequate, flexible staffing levels and supportive team working is required to support person-centred delirium care.
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Affiliation(s)
| | - Najma Siddiqi
- Department of Health Sciences, University of York, York, UK
- Hull York Medical School, University of Hull, Hull, UK
| | - Lesley Jones
- Hull York Medical School, University of Hull, Hull, UK
| | - Eleonora Coppo
- Cardinal Massaia Hospital of Asti, Asti, Piemonte, Italy
| | - Trevor Sheldon
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University, London, UK
| | - Annmarie Hosie
- School of Nursing, The University of Notre Dame Australia, Sydney, NSW, Australia
- The Cunningham Centre for Palliative Care, St Vincent's Health Network, Sydney, NSW, Australia
- IMPAACT, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | | | - Shirley H Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada
- Bruyere Research Institute, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Johanna Taylor
- Department of Health Sciences, University of York, York, UK
| | - Andrew Teodorczuk
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- The Prince Charles Hospital, Metro North Mental Health, Brisbane, QLD, Australia
- School of Medicine and Dentistry, Griffith University, Southport, QLD, Australia
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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Byrnes T, Woodward J. Implementing a Delirium Risk Stratification Tool and Rounds to Identify and Prevent Delirium in Hospitalized Older Adults. J Nurs Care Qual 2023; 38:158-163. [PMID: 36322042 DOI: 10.1097/ncq.0000000000000676] [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: 02/23/2023]
Abstract
BACKGROUND Up to 40% of delirium cases are preventable, and early identification is key to improve patient outcomes. PURPOSE To implement and evaluate a multidisciplinary delirium intervention program. INTERVENTION The delirium intervention program targeted patients at high risk for delirium and included patient and nurse education, risk stratification, multidisciplinary rounds, a nonpharmacological intervention bundle, and a treatment order set. RESULTS After implementation, there was a reduction in length of stay of 6.3 days ( P = .01), a 24% decrease in disposition to a skilled nursing facility ( P = .05), and increased detection of delirium by nurses. CONCLUSION Positive patient outcomes were achieved by employing a multifactorial approach for delirium identification, prevention, and management. The components of this quality improvement project provide guidance to hospitals seeking to develop a delirium intervention program.
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Affiliation(s)
- Tru Byrnes
- Carolinas Medical Center, Charlotte, North Carolina (Dr Byrnes); and Geriatric Medicine CHS Senior Care, Charlotte, North Carolina (Dr Woodward)
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Pozzi C, Tatzer VC, Strasser-Gugerell C, Cavalli S, Morandi A, Bellelli G. Innovative Non-Pharmacological Management of Delirium in Persons with Dementia: New Frontiers for Physiotherapy and Occupational Therapy? Geriatrics (Basel) 2023; 8:geriatrics8020028. [PMID: 36960983 PMCID: PMC10037565 DOI: 10.3390/geriatrics8020028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 02/02/2023] [Accepted: 02/20/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Delirium and dementia are two of the most common geriatric syndromes, which requires innovative rehabilitation approaches. AIM We aimed at determining which occupational therapy and physiotherapy interventions are applied with older people with delirium and dementia in different care settings. We also identified the assessment tools that were used. MATERIALS AND METHODS We conducted a literature search for scientific articles published from 2012 to 2022 (PubMed, MEDLINE, AMED and CINAHL) with adults aged >65 years including experimental study designs with randomized or non-randomized intervention, exploratory studies, pilot studies, quasi-experimental studies, case series and/or clinical cases. Studies that did not use interventions that could be classified as occupational therapy or physiotherapy were excluded. RESULTS After applying the exclusion criteria, 9 articles were selected. The most widely used assessment to define dementia was the MMSE (N = 5; 55.5%), whereas the CAM (N = 2; 22.2%), CAM-ICU (N = 2; 22.2%) and RASS (N = 3; 33.3%) were the most widely used to define delirium. The rehabilitation interventions that were most frequently performed were early mobilization, inclusion of the caregiver during treatment, modification of the environment to encourage orientation and autonomy, the interprofessional systemic approach and engaging persons in meaningful activities. CONCLUSIONS Despite the growing evidence on its effectiveness, the role of physiotherapy and occupational therapy interventions in the prevention and treatment of people with dementia and delirium is still emerging. More research is needed to investigate if effective occupational therapy programs known to reduce the behavioral and psychological symptoms in people with dementia are also useful for treating delirium and specifically delirium superimposed on dementia. Regarding physiotherapy, it is crucial to know about the amount and timing of intervention required. Further studies are needed including older adults with delirium superimposed on dementia to define the role of the interprofessional geriatric rehabilitation team.
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Affiliation(s)
- Christian Pozzi
- Centre of Competence on Ageing, University of Applied Sciences and Arts of Southern Switzerland SUPSI, 6928 Manno, Switzerland
- Public Health, University of Milano-Bicocca, 20126 Milano, Italy
| | - Verena C Tatzer
- Department of Occupational Therapy, University of Applied Sciences Wiener Neustadt, 2700 Wiener Neustadt, Austria
| | - Cornelia Strasser-Gugerell
- Department of Occupational Therapy, University of Applied Sciences Wiener Neustadt, 2700 Wiener Neustadt, Austria
| | - Stefano Cavalli
- Centre of Competence on Ageing, University of Applied Sciences and Arts of Southern Switzerland SUPSI, 6928 Manno, Switzerland
| | - Alessandro Morandi
- Azienda Speciale "Cremona Solidale", 26100 Cremona, Italy
- Parc Sanitari Pere Virgili, Vall d'Hebrón Institute of Research, 08016 Barcelona, Spain
| | - Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milano, Italy
- Acute Geriatric Unit, San Gerardo Hospital, ASST-Monza, 20900 Monza, Italy
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Hoch J, Bauer JM, Bizer M, Arnold C, Benzinger P. Nurses’ competence in recognition and management of delirium in older patients: development and piloting of a self-assessment tool. BMC Geriatr 2022; 22:879. [PMCID: PMC9675220 DOI: 10.1186/s12877-022-03573-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 10/31/2022] [Indexed: 11/21/2022] Open
Abstract
Background Delirium is a common condition in elderly inpatients. Health care professionals play a crucial role in recognizing delirium, initiating preventive measures and implementing a multicomponent treatment strategy. Yet, delirium often goes unrecognized in clinical routine. Nurses take an important role in preventing and managing delirium. This study assesses clinical reasoning of nurses using case vignettes to explore their competences in recognizing, preventing and managing delirium. Methods The study was conducted as an online survey. The questionnaire was based on five case vignettes presenting cases of acutely ill older patients with different subtypes of delirium or diseases with overlapping symptoms. In a first step, case vignettes were developed and validated through a multidisciplinary expert panel. Scoring of response options were summed up to a Geriatric Delirium Competence Questionnaire (GDCQ) score including recognition and management tasks The questionnaire was made available online. Descriptive analyses and group comparisons explores differences between nurses from different settings. Factors explaining variance in participants’ score were evaluated using correlations and linear regression models. Results The questionnaire demonstrated good content validity and high reliability (kappa = 0.79). The final sample consisted of 115 nurses. Five hundred seventy-five case vignettes with an accuracy of 0.71 for the correct recognition of delirium presence or absence were solved. Nurses recognized delirium best in cases describing hyperactive delirium (79%) while hypoactive delirium was recognized least (44%). Nurses from geriatric and internal medicine departments had significantly higher GDCQ-score than the other subgroups. Management tasks were correctly identified by most participants. Conclusions Overall, nurses’ competence regarding hypoactive delirium should be strengthened. The online questionnaire might facilitate targeting training opportunities to nurses’ competence. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03573-8.
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Affiliation(s)
- Jonas Hoch
- grid.5253.10000 0001 0328 4908Center for Geriatric Medicine, Heidelberg University Hospital, AGAPLESION Bethanien Hospital Heidelberg, Rohrbacher Strasse 149, 69126 Heidelberg, Germany ,grid.5253.10000 0001 0328 4908Department of General Practice and Health Services Research, Heidelberg University Hospital, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Jürgen M. Bauer
- grid.5253.10000 0001 0328 4908Center for Geriatric Medicine, Heidelberg University Hospital, AGAPLESION Bethanien Hospital Heidelberg, Rohrbacher Strasse 149, 69126 Heidelberg, Germany ,grid.7700.00000 0001 2190 4373Network Aging Research (NAR), Heidelberg University, Bergheimer Strasse 20, 69115 Heidelberg, Germany
| | - Martin Bizer
- grid.5253.10000 0001 0328 4908Department of Internal Medicine, Heidelberg University Hospital, Im Neuenheimer Feld 672, 69120 Heidelberg, Germany
| | - Christine Arnold
- grid.5253.10000 0001 0328 4908Department of General Practice and Health Services Research, Heidelberg University Hospital, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Petra Benzinger
- grid.5253.10000 0001 0328 4908Center for Geriatric Medicine, Heidelberg University Hospital, AGAPLESION Bethanien Hospital Heidelberg, Rohrbacher Strasse 149, 69126 Heidelberg, Germany ,grid.200773.10000 0000 9807 4884Institute of Health and Generations, University of Applied Sciences Kempten, Bahnhofstrasse 61, 87435 Kempten, Germany
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Tan TH, Yang TY, Chen YM, Chung SY, Liu HH, Yang PC, Kao PH, Peng AC, Shu YM, Chu YS, Tsai KT, Hsu CC, Ho CH, Lin HJ, Huang CC. Computerized tool and interdisciplinary care for older patients with delirium in the emergency department: a novel model in Taiwan. Aging Clin Exp Res 2022; 34:3137-3144. [PMID: 36071315 DOI: 10.1007/s40520-022-02240-7] [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: 03/24/2022] [Accepted: 08/24/2022] [Indexed: 11/29/2022]
Abstract
AIMS A computerized tool and interdisciplinary care were implemented to develop a novel model for older patients with delirium in the emergency department (ED). METHODS We developed a computerized tool using a delirium triage screen and brief confusion assessment in the hospital information system, performed education for the healthcare providers, and developed a continuous care protocol. Comparisons for outcomes between pre- and post-intervention periods were performed. RESULTS Compared with the pre-intervention period, patients in the post-intervention period had shorter hospitalization stay, lower expenditure of hospitalization, more likely to return home, lower ED revisits of ≤ 3 days, re-hospitalization of ≤ 14 days, and mortality of ≤ 1 month. All mentioned differences were not statistically significant. CONCLUSIONS A novel model was successfully developed for delirium management in older patients in the ED. Outcome differences were not significant; however, the result is promising, which gives us an important reference in the future.
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Affiliation(s)
- Tian-Hoe Tan
- Department of Emergency Medicine, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan City, 710, Taiwan.,Department of Senior Services, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Ting-Ya Yang
- Department of Nursing, Chi Mei Medical Center, Tainan, Taiwan
| | - Yao-Mei Chen
- Department of Nursing, Chi Mei Medical Center, Tainan, Taiwan
| | - Shiu-Yuan Chung
- Department of Nursing, Chi Mei Medical Center, Tainan, Taiwan
| | - Hsiao-Hua Liu
- Center for Integrative Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Pei-Chi Yang
- Department of Emergency Medicine, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan City, 710, Taiwan
| | - Pei-Hsin Kao
- Department of Psychiatry, Chi Mei Medical Center, Tainan, Taiwan
| | - An-Chi Peng
- Department of Nursing, Chi Mei Medical Center, Tainan, Taiwan
| | - Yi-Min Shu
- Department of Nursing, Chi Mei Medical Center, Tainan, Taiwan
| | - Yu-Sheng Chu
- Department of Pharmacy, Chi Mei Medical Center, Tainan, Taiwan
| | - Kang-Ting Tsai
- Department of Senior Services, Southern Taiwan University of Science and Technology, Tainan, Taiwan.,Center for Integrative Medicine, Chi Mei Medical Center, Tainan, Taiwan.,Division of Geriatrics and Gerontology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Chien-Chin Hsu
- Department of Emergency Medicine, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan City, 710, Taiwan
| | - Chung-Han Ho
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan.,Department of Information Management, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Hung-Jung Lin
- Department of Emergency Medicine, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan City, 710, Taiwan.,Department of Emergency Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chien-Cheng Huang
- Department of Emergency Medicine, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan City, 710, Taiwan. .,Department of Emergency Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan. .,Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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11
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Kotfis K, van Diem-Zaal I, Williams Roberson S, Sietnicki M, van den Boogaard M, Shehabi Y, Ely EW. The future of intensive care: delirium should no longer be an issue. Crit Care 2022; 26:200. [PMID: 35790979 PMCID: PMC9254432 DOI: 10.1186/s13054-022-04077-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 06/30/2022] [Indexed: 01/02/2023] Open
Abstract
In the ideal intensive care unit (ICU) of the future, all patients are free from delirium, a syndrome of brain dysfunction frequently observed in critical illness and associated with worse ICU-related outcomes and long-term cognitive impairment. Although screening for delirium requires limited time and effort, this devastating disorder remains underestimated during routine ICU care. The COVID-19 pandemic brought a catastrophic reduction in delirium monitoring, prevention, and patient care due to organizational issues, lack of personnel, increased use of benzodiazepines and restricted family visitation. These limitations led to increases in delirium incidence, a situation that should never be repeated. Good sedation practices should be complemented by novel ICU design and connectivity, which will facilitate non-pharmacological sedation, anxiolysis and comfort that can be supplemented by balanced pharmacological interventions when necessary. Improvements in the ICU sound, light control, floor planning, and room arrangement can facilitate a healing environment that minimizes stressors and aids delirium prevention and management. The fundamental prerequisite to realize the delirium-free ICU, is an awake non-sedated, pain-free comfortable patient whose management follows the A to F (A-F) bundle. Moreover, the bundle should be expanded with three additional letters, incorporating humanitarian care: gaining (G) insight into patient needs, delivering holistic care with a 'home-like' (H) environment, and redefining ICU architectural design (I). Above all, the delirium-free world relies upon people, with personal challenges for critical care teams to optimize design, environmental factors, management, time spent with the patient and family and to humanize ICU care.
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Affiliation(s)
- Katarzyna Kotfis
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, Szczecin, Poland.
| | - Irene van Diem-Zaal
- Department of Intensive Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Shawniqua Williams Roberson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Center for Health Services Research, Nashville, TN, USA.,Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA
| | - Marek Sietnicki
- Department of Architecture, West Pomeranian University of Technology in Szczecin, Szczecin, Poland
| | - Mark van den Boogaard
- Department of Intensive Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Yahya Shehabi
- Monash Health School of Clinical Sciences, Monash University, Melbourne, VIC, Australia.,School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Center for Health Services Research, Nashville, TN, USA.,Division of Allergy, Department of Medicine, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Geriatric Research, Education and Clinical Center (GRECC) Service, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
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12
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13
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Richardson S, Murray J, Davis D, Stephan BCM, Robinson L, Brayne C, Barnes L, Parker S, Sayer AA, Dodds RM, Allan L. Delirium and Delirium Severity Predict the Trajectory of the Hierarchical Assessment of Balance and Mobility in Hospitalized Older People: Findings From the DECIDE Study. J Gerontol A Biol Sci Med Sci 2022; 77:531-535. [PMID: 35239950 PMCID: PMC8893191 DOI: 10.1093/gerona/glab081] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Delirium is common, distressing, and associated with poor outcomes. Despite this, delirium remains poorly recognized, resulting in worse outcomes. There is an urgent need for methods to objectively assess for delirium. Physical function has been proposed as a potential surrogate marker, but few studies have monitored physical function in the context of delirium. We examined if trajectories of physical function are affected by the presence and severity of delirium in a representative sample of hospitalized participants older than 65 years. METHOD During hospital admissions in 2016, we assessed participants from the Delirium and Cognitive Impact in Dementia study daily for delirium and physical function, using the Hierarchical Assessment of Balance and Mobility (HABAM). We used linear mixed models to assess the effect of delirium and delirium severity during admission on HABAM trajectory. RESULTS Of 178 participants, 58 experienced delirium during admission. Median HABAM scores in those with delirium were significantly higher (indicating worse mobility) than those without delirium. Modeling HABAM trajectories, HABAM scores at first assessment were worse in those with delirium than those without, by 0.76 (95% CI: 0.49-1.04) points. Participants with severe delirium experienced a much greater perturbance in their physical function, with an even lower value at first assessment and slower subsequent improvement. CONCLUSIONS Physical function was worse in those with delirium compared to without. This supports the assertion that motor disturbances are a core feature of delirium and monitoring physical function, using a tool such as the HABAM, may have clinical utility as a surrogate marker for delirium and its resolution.
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Affiliation(s)
- Sarah Richardson
- AGE Research Group, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle University and Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - James Murray
- AGE Research Group, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle University and Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | - Blossom C M Stephan
- Institute of Mental Health, Division of Psychiatry and Applied Psychology, School of Medicine, Nottingham University, UK
| | - Louise Robinson
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Carol Brayne
- Cambridge Public Health, University of Cambridge, UK
| | - Linda Barnes
- Cambridge Public Health, University of Cambridge, UK
| | - Stuart Parker
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Avan A Sayer
- AGE Research Group, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle University and Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - Richard M Dodds
- AGE Research Group, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle University and Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - Louise Allan
- Centre for Research in Ageing and Cognitive Health, University of Exeter, UK
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14
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Vasunilashorn SM, Fong TG, Helfand BKI, Hshieh TT, Marcantonio ER, Metzger ED, Schmitt EM, Tabloski PA, Travison TG, Gou Y, Jones RN, Inouye SK. Psychometric Properties of a Delirium Severity Score for Older Adults and Association With Hospital and Posthospital Outcomes. JAMA Netw Open 2022; 5:e226129. [PMID: 35357447 PMCID: PMC8972033 DOI: 10.1001/jamanetworkopen.2022.6129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
IMPORTANCE The ability to rate delirium severity is key to providing optimal care for older adults, and such ratings would allow clinicians to target patients with severe delirium and monitor response to treatment, recovery time, and prognosis; assess nursing burden and staffing needs; and, ultimately, provide more appropriate patient-centered care. Current delirium severity measures have been limited in their content, gradations, and measurement characteristics. OBJECTIVE To examine the internal consistency, reliability, and validity for clinical outcomes of the DEL-S delirium severity score, a measure of delirium severity that was developed using advanced psychometric approaches, analogous to those of the Patient-Reported Outcomes Measurement Information System initiative. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study was conducted at a large academic medical center in Boston, Massachusetts. Adults aged 70 years or older who were admitted or transferred to medical or surgical services as either emergency or elective admissions were enrolled between October 20, 2015, and March 15, 2017, and were monitored for 1 year. Data analysis was performed from June 2020 to August 2021. EXPOSURES Delirium severity, measured by scores on the delirium severity score short-form (SF; 6 items, scored 0-13, with higher scores indicating more severe delirium) and long-form (LF; 17 items, scored 0-21), considered continuously and grouped into 5 categories. MAIN OUTCOMES AND MEASURES The primary outcomes were in-hospital outcomes, including length of stay and hospital costs, and posthospital (30, 90, and 365 days) outcomes, including death, health care costs, and rehospitalization. RESULTS The 352 participants had a median (IQR) age of 79.7 (74.6-85.5) years, 204 (58.0%) were women, and they were highly educated (median [IQR] duration of education, 14 [7-20] years). Patients in the highest delirium severity score SF group (scores 6-9) had a longer length of stay (13.3 vs 6.9 days; P for trend < .001), greater in-hospital costs ($57 700 vs $34 200), greater cumulative health care costs ($168 700 vs $106 500; P for trend = .01), and increased mortality at 1 year (50% vs 17%; P for trend = .02) compared with patients in the lowest delirium severity score SF group (score 0). Similar trends and significant findings were demonstrated for the delirium severity score LF. CONCLUSIONS AND RELEVANCE These findings suggest that the delirium severity score provides an approach for measuring delirium severity that is associated with adverse clinical outcomes in a direct exposure-response association and that the delirium severity score may help advance patient-centered care for delirium.
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Affiliation(s)
- Sarinnapha M. Vasunilashorn
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Tamara G. Fong
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Tammy T. Hshieh
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Edward R. Marcantonio
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Eran D. Metzger
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Eva M. Schmitt
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Patricia A. Tabloski
- Department of Nursing, William F. Connell School of Nursing at Boston College, Boston, Massachusetts
| | - Thomas G. Travison
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Yun Gou
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Richard N. Jones
- Department of Psychiatry and Human Behavior, Brown University Warren Alpert Medical School, Providence, Rhode Island
- Department of Neurology, Brown University Warren Alpert Medical School, Providence, Rhode Island
| | - Sharon K. Inouye
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Associate Editor, JAMA Network Open
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15
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Rood PJ, Zegers M, Ramnarain D, Koopmans M, Klarenbeek T, Ewalds E, van der Steen MS, Oldenbeuving AW, Kuiper MA, Teerenstra S, Adang E, van Loon LM, Wassenaar A, Vermeulen H, Pickkers P, van den Boogaard M. The Impact of Nursing Delirium Preventive Interventions in the Intensive Care Unit: A Multicenter Cluster Randomized Controlled Trial. Am J Respir Crit Care Med 2021; 204:682-691. [PMID: 34170798 DOI: 10.1164/rccm.202101-0082oc] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale Delirium is common in critically ill patients and associated with deleterious outcomes. Non-pharmacologic interventions are recommended in current delirium guidelines, but their effects have not been unequivocally established. Objective To determine the effects of a multicomponent nursing intervention program on delirium in the Intensive Care Unit. Methods Stepped wedge cluster randomized controlled trial, conducted in Intensive care units of 10 centers. Adult critically ill surgical, medical or trauma patients at high risk to develop delirium were included. A multicomponent nursing intervention program focusing on modifiable risk factors was implemented as standard of care. Primary outcome was the number of delirium-free and coma-free days alive in 28 days after Intensive Care Unit admission. Measurements and main results A total of 1749 patients were included. Time spent per 8 hours shift on interventions was median [IQR] 38 [14-116] in the intervention period and median 32 [13-73] minutes in the control period (p=0.44). Patients in the intervention period had median 23 [4-27] delirium-free and coma-free days alive, compared to median 23 [5-27] days for patients in the control group (mean difference -1.21 days, 95%CI -2.84 to 0.42 days; p=0.15). Also, the number of delirium days was similar: median 2 [1-4] days (ratio of medians 0.90, 95%CI 0.75 to 1.09; p=0.27). Conclusion In this large randomized controlled trial in adult ICU patients, a limited increase was achieved of the use of nursing interventions, and no change in the number of delirium-free and coma-free days alive in 28 days could be determined. Clinical trial registration available at www.clinicaltrials.gov, ID: NCT03002701.
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Affiliation(s)
- Paul Jt Rood
- Radboudumc, 6034, Department of Intensive Care Medicine, Nijmegen, Netherlands.,Radboudumc, 6034, Radboud Institute for Health Sciences, Nijmegen, Netherlands
| | | | | | - Matty Koopmans
- Medical Centre Leeuwarden, 4480, Department of Intensive Care Medicine, Leeuwarden, Netherlands
| | - Toine Klarenbeek
- Maxima Medical Centre Location Veldhoven, 89569, Department of Intensive Care Medicine, Veldhoven, Netherlands
| | - Esther Ewalds
- Bernhoven Hospital Location Uden, 97772, Uden, Netherlands
| | | | | | - Michael A Kuiper
- Medical Centre Leeuwarden, 4480, Department of Intensive Care Medicine, Leeuwarden, Netherlands
| | - Steven Teerenstra
- Radboudumc, 6034, Department for Health Evidence, Nijmegen, Netherlands
| | - Eddy Adang
- Radboudumc, 6034, Department for Health Evidence, Nijmegen, Netherlands
| | - Lex M van Loon
- University of Twente, 3230, Cardiovascular and Respiratory Physiology Group, Technical Medical Centre, Enschede, Netherlands
| | - Annelies Wassenaar
- Radboudumc, 6034, Department of Intensive Care Medicine, Nijmegen, Netherlands
| | | | - Peter Pickkers
- Radboudumc, 6034, Department of Intensive Care Medicine, Nijmegen, Netherlands
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Caetano GM, Niyama BT, Almeida MHMD, Batista MPP, Ratier APP. Intervenção não farmacológica no manejo de delirium: uma revisão bibliográfica integrativa. CADERNOS BRASILEIROS DE TERAPIA OCUPACIONAL 2021. [DOI: 10.1590/2526-8910.ctoar2198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Resumo Introdução O delirium é um quadro clínico complexo caracterizado por uma expressão neuropsiquiátrica de doença orgânica, em que o indivíduo apresenta súbita alteração da capacidade cognitiva, possíveis flutuações do sono, consciência e atenção. O tratamento do delirium deve ser realizado por meio de uma abordagem multicomponente e interdisciplinar. Objetivo Conhecer as intervenções não farmacológicas para o manejo de delirium por equipe multiprofissional e aquelas conduzidas especificamente pelo terapeuta ocupacional. Método Revisão bibliográfica integrativa da literatura indexada nas bases Lilacs, Pubmed, Scopus e Web of Science e SciELO sem recorte temporal. Resultados As intervenções visavam o empoderamento e a participação de todos os agentes envolvidos no tratamento do paciente com delirium. Destacaram-se estratégias voltadas para: o aumento da autonomia e da independência do paciente; adequação das condições ambientais, de modo a promover segurança, conforto, familiaridade e orientação temporal-espacial; adaptação da rotina para favorecer o ciclo sono-vigília; estimulação física, cognitiva e sensorial; melhora do desempenho ocupacional e estímulo à realização de atividades significativas; prescrição de recursos de tecnologia assistiva e terapias complementares, quando indicado; avaliação e monitoramento constante do paciente; controle da dor, de sintomas emocionais e de condições clínicas que predispõem ao delirium; melhora da comunicação do paciente e sua vinculação com a equipe e com a rede de apoio; e educação em saúde. Conclusão As intervenções visam à integralidade do cuidado e devem, portanto, ser realizadas pelos diferentes profissionais que componham a equipe, destacando-se o papel que os terapeutas ocupacionais exercem no gerenciamento do delirium.
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Buijs-Spanjers KR, Harmsen A, Hegge HH, Spook JE, de Rooij SE, Jaarsma DADC. The influence of a serious game's narrative on students' attitudes and learning experiences regarding delirium: an interview study. BMC MEDICAL EDUCATION 2020; 20:289. [PMID: 32873285 PMCID: PMC7465326 DOI: 10.1186/s12909-020-02210-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 08/25/2020] [Indexed: 05/15/2023]
Abstract
BACKGROUND Delirium is a neuropsychiatric syndrome that affects patients' attention and awareness as a result of a physical condition. In recent years, persistent gaps in delirium education have led to suboptimal delirium care. Still, little is known about what are the most important aspects of effective delirium education. Serious games are both entertainment and an interactive, safe learning environment where players can experiment and create new knowledge. They have the potential to contribute to improved delirium education. We used a video-based serious games' narrative to explore aspects essential to enhance students' attitudes and learning experiences regarding delirium. METHODS We created a semi-structured interview guide and interviewed seven nursing and nine medical students about their attitudes and learning experiences, after they had played the game. A qualitative descriptive design and inductive content analysis with constant comparison were used. RESULTS The patient's and nurse's perspective, interactivity to experiment, realistic views on care options, and feedback on care actions were important for enhancing students' attitudes and learning experiences regarding delirium. Students felt these aspects encouraged them to get actively involved in and experiment with the study material, which in turn led to enhanced reflection on delirium care and education. Our findings highlight the importance of a more patient-oriented focus to delirium education to drive attitudinal change. Students' learning experiences were further enhanced through their affective responses provoked by the perspectives, interactivity, realism, and feedback. CONCLUSIONS Students considered the characters' perspectives, interactivity, realism, and feedback important aspects of the game to enhance their attitudes towards delirious patients and enrich their learning experiences. A patient-oriented narrative provides a clinically relevant experience in which reflection plays an important role. The serious game also serves as medium to actively experiment with care solutions to create better understanding of how healthcare professionals can influence a delirious patient's experience.
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Affiliation(s)
- Kiki R Buijs-Spanjers
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, PO Box 30001, HPC: AA43, Groningen, 9700 RB, The Netherlands.
- Center for Education Development and Research in Health Professions, LEARN, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Anne Harmsen
- Strategic Communication Group, Wageningen University, Wageningen, The Netherlands
| | - Harianne H Hegge
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, PO Box 30001, HPC: AA43, Groningen, 9700 RB, The Netherlands
- Center for Education Development and Research in Health Professions, LEARN, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jorinde E Spook
- Strategic Communication Group, Wageningen University, Wageningen, The Netherlands
| | - Sophia E de Rooij
- Department of Geriatric Medicine, University of Groningen, University Medical Center Groningen, PO Box 30001, HPC: AA43, Groningen, 9700 RB, The Netherlands
- Medical School Twente, Medical Spectrum Twente, Enschede, The Netherlands
| | - Debbie A D C Jaarsma
- Center for Education Development and Research in Health Professions, LEARN, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Lauretani F, Bellelli G, Pelà G, Morganti S, Tagliaferri S, Maggio M. Treatment of Delirium in Older Persons: What We Should Not Do! Int J Mol Sci 2020; 21:ijms21072397. [PMID: 32244301 PMCID: PMC7177924 DOI: 10.3390/ijms21072397] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/19/2020] [Accepted: 03/27/2020] [Indexed: 12/13/2022] Open
Abstract
The presentation of common acute diseases in older age is often referred to as “atypical”. Frequently, the symptoms are neither single nor tissue related. In most cases, the onset of symptoms and diseases is the expression of a diminished reserve with a failure of the body system and imbalance of brain function. Delirium is one of the main devastating and prevalent atypical symptoms and could be considered as a geriatric syndrome. It encompasses an array of neuropsychiatric symptoms and represents a disarrangement of the cerebral function in response to one or more stressors. The most recent definition, reported in the DSM-V, depicts delirium as a clear disturbance in attention and awareness. The deficit is to be developed in a relatively short time period (usually hours or days). The attention disorder must be associated with another cognitive impairment in memory, orientation, language, visual-spatial or perception abilities. For the treatment, it is imperative to remove the potential causes of delirium before prescribing drugs. Even a non-pharmacological approach to reducing the precipitating causes should be identified and planned. When we are forced to approach the pharmacological treatment of hyperactive delirium in older persons, we should select highly cost-effective drugs. High attention should be devoted to the correct balance between improvement of psychiatric symptoms and occurrence of side effects. Clinicians should be guided in the correct choice of drugs following cluster symptoms presentation, excluding drugs that could potentially produce complications rather than advantages. In this brief point-of-view, we propose a novel pharmacological flow-chart of treatment in relation to the basic clusters of diseases of an older patient acutely admitted to the hospital and, in particular, we emphasize “What We Should Not Do!”, with the intention of avoiding possible side effects of drugs used.
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Affiliation(s)
- Fulvio Lauretani
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (G.P.); (S.T.); (M.M.)
- Geriatric Clinic, Medicine-Geriatric-Rehabilitation Department, University of Parma, and University Hospital, 43126 Parma, Italy, Italy;
- Correspondence:
| | - Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy;
- Geriatric Unit, S. Gerardo Hospital, 20900 Monza, Italy
| | - Giovanna Pelà
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (G.P.); (S.T.); (M.M.)
| | - Simonetta Morganti
- Geriatric Clinic, Medicine-Geriatric-Rehabilitation Department, University of Parma, and University Hospital, 43126 Parma, Italy, Italy;
| | - Sara Tagliaferri
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (G.P.); (S.T.); (M.M.)
| | - Marcello Maggio
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (G.P.); (S.T.); (M.M.)
- Geriatric Clinic, Medicine-Geriatric-Rehabilitation Department, University of Parma, and University Hospital, 43126 Parma, Italy, Italy;
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Pozzi C, Tatzer VC, Álvarez EA, Lanzoni A, Graff MJL. The applicability and feasibility of occupational therapy in delirium care. Eur Geriatr Med 2020; 11:209-216. [DOI: 10.1007/s41999-020-00308-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 03/07/2020] [Indexed: 01/20/2023]
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Vasunilashorn SM, Schulman-Green D, Tommet D, Fong TG, Hshieh TT, Marcantonio ER, Metzger ED, Schmitt EM, Tabloski PA, Travison TG, Gou Y, Helfand B, Inouye SK, Jones RN. New Delirium Severity Indicators: Generation and Internal Validation in the Better Assessment of Illness (BASIL) Study. Dement Geriatr Cogn Disord 2020; 49:77-90. [PMID: 32554974 PMCID: PMC7484102 DOI: 10.1159/000506700] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 02/20/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Delirium is a common and preventable geriatric syndrome. Moving beyond the binary classification of delirium present/absent, delirium severity represents a potentially important outcome for evaluating preventive and treatment interventions and tracking the course of patients. Although several delirium severity assessment tools currently exist, most have been developed in the absence of advanced measurement methodology and have not been evaluated with rigorous validation studies. OBJECTIVE We aimed to report our development of new delirium severity items and the results of item reduction and selection activities guided by psychometric analysis of data derived from a field study. METHODS Building on our literature review of delirium instruments and expert panel process to identify domains of delirium severity, we adapted items from existing delirium severity instruments and generated new items. We then fielded these items among a sample of 352 older hospitalized patients. RESULTS We used an expert panel process and psychometric data analysis techniques to narrow a set of 303 potential items to 17 items for use in a new delirium severity instrument. The 17-item set demonstrated good internal validity and favorable psychometric characteristics relative to comparator instruments, including the Confusion Assessment Method - Severity (CAM-S) score, the Delirium Rating Scale Revised 98, and the Memorial Delirium Assessment Scale. CONCLUSION We more fully conceptualized delirium severity and identified characteristics of an ideal delirium severity instrument. These characteristics include an instrument that is relatively quick to administer, is easy to use by raters with minimal training, and provides a severity rating with good content validity, high internal consistency reliability, and broad domain coverage across delirium symptoms. We anticipate these characteristics to be represented in the subsequent development of our final delirium severity instrument.
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Affiliation(s)
- Sarinnapha M. Vasunilashorn
- Harvard Medical School, Boston, MA, USA,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA,Department of Epidemiology, Harvard T.H. Chan School of Public Health, USA
| | | | - Douglas Tommet
- Department of Psychiatry and Human Behavior, Brown University Warren Alpert Medical School, Providence, RI
| | - Tamara G. Fong
- Harvard Medical School, Boston, MA, USA,Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA;,Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Tammy T. Hshieh
- Harvard Medical School, Boston, MA, USA,Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Edward R. Marcantonio
- Harvard Medical School, Boston, MA, USA,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA,Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Eran D. Metzger
- Harvard Medical School, Boston, MA, USA,Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, MA
| | - Eva M. Schmitt
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | | | - Thomas G. Travison
- Harvard Medical School, Boston, MA, USA,Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Yun Gou
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | | | - Sharon K. Inouye
- Harvard Medical School, Boston, MA, USA,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA,Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Richard N. Jones
- Department of Psychiatry and Human Behavior, Brown University Warren Alpert Medical School, Providence, RI;,Department of Neurology, Brown University Warren Alpert Medical School, Providence, RI
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Mossello E, Lucchini F, Tesi F, Rasero L. Family and healthcare staff’s perception of delirium. Eur Geriatr Med 2020; 11:95-103. [DOI: 10.1007/s41999-019-00284-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 12/15/2019] [Indexed: 12/14/2022]
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Abstract
PURPOSE Delirium superimposed on dementia (DSD) is a frequent and growing emerging clinical challenge, given the increasing prevalence of dementia. METHODS This narrative review focuses on and discusses the current knowledge on epidemiology, pathogenesis, diagnosis and management of DSD. RESULTS There is a close interaction between delirium and dementia since dementia is a risk factor for delirium and delirium is a known risk factor for newly developed dementia or worsening of dementia. The occurrence of DSD causes adverse clinical outcomes. However, DSD is often under-recognized or is frequently considered as the regular course of dementia. Indeed, especially in the advance stages of dementia, DSD diagnosis is challenging since a clear distinction between symptoms attributable to delirium and to dementia is difficult. Given the importance of DSD, it is essential to educate health care providers on the best approach for delirium management and treatment. It is now well recognized that delirium can be prevented using multicomponent interventions carried out by a multidisciplinary team targeting predisposing and precipitating risk factors for delirium. On the contrary, antipsychotics should only be used in patients with severe distressing symptoms and whose behavior means their safety or the safety of those around them is compromised, given the harmful of these medications in patients with pre-existing dementia. CONCLUSIONS It is essential to improve health care providers knowledge on DSD to improve the quality of care for an epidemiologically relevant though understudied population.
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