Prevention, diagnosis and treatment of delirium: staff educational approaches

Geriatric fracture centre vs usual care after proximal femur fracture in older patients: what are the benefits? Results of a large international prospective multicentre study

OBJECTIVE

The aim of this study was to determine the effect of treatment in geriatric fracture centres (GFC) on the incidence of major adverse events (MAEs) in patients with hip fractures compared with usual care centres (UCC). Secondary objectives included hospital-workflow and mobility-related outcomes.

DESIGN

Cohort study recruiting patients between June 2015 and January 2017. Follow-up was 1 year.

SETTING

International (six countries, three continents) multicentre study.

PARTICIPANTS

281 patients aged ≥70 with operatively treated proximal femur fractures.

INTERVENTIONS

Treatment in UCCs (n=139) or GFCs (n=142), that is, interdisciplinary treatment including regular geriatric consultation and daily physiotherapy.

OUTCOME MEASURES

Primary outcome was occurrence of prespecified MAEs, including delirium. Secondary outcomes included any other adverse events, time to surgery, time in acute ward, 1-year mortality, mobility, and quality of life.

RESULTS

Patients treated in GFCs (n=142) had a mean age of 81.9 (SD, 6.6) years versus 83.9 (SD 6.9) years in patients (n=139) treated in UCCs (p=0.013) and a higher mean Charlson Comorbidity Index of 2.0 (SD, 2.1) versus 1.2 (SD, 1.5) in UCCs (p=0.001). More patients in GFCs (28.2%) experienced an MAE during the first year after surgery compared with UCCs (7.9%) with an OR of 4.56 (95% CI 2.23 to 9.34, p<0.001). Analysing individual MAEs, this was significant for pneumonia (GFC: 9.2%; UCC: 2.9%; OR, 3.40 (95% CI 1.08 to 10.70), p=0.027) and delirium (GFC: 11.3%; UCC: 2.2%, OR, 5.76 (95% CI 1.64 to 20.23), p=0.002).

CONCLUSIONS

Contrary to our study hypothesis, the rate of MAEs was higher in GFCs than in UCCs. Delirium was revealed as a main contributor. Most likely, this was based on improved detection rather than a truly elevated incidence, which we interpret as positive effect of geriatric comanagement.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT02297581.

Reconceptualizing models of delirium education: findings of a Grounded Theory study

BACKGROUND

Effectiveness of educational interventions targeted at improving delirium care is limited by implementation barriers. Studying factors which shape learning needs can overcome these knowledge transfer barriers. This in-depth qualitative study explores learning needs of hospital staff relating to care needs of the confused older patients.

METHODS

Fifteen research participants from across the healthcare spectrum working within an acute care setting were interviewed. Five focus groups were undertaken with patients, carers, and mental health specialists. A Grounded Theory methodology was adopted and data were analyzed thematically in parallel to collection until theoretical saturation was reached.

RESULTS

Eight categories of practice gap emerged: ownership of the confused patient, negative attitudes, lack of understanding of how frightened the patient is in hospital, carer partnerships, person-centered care, communication, recognition of cognitive impairment and specific clinical needs (e.g. capacity assessments). Conceptually, the learning needs were found to be hierarchically related. Moreover, a vicious circle relating to the core learning needs of ownership, attitudes and patient's fear emerged. A patient with delirium may be frightened in an alien environment and then negatively labeled by staff who subsequently wish for their removal, thereby worsening the patient's fear.

DISCUSSION

These findings reconceptualize delirium education approaches suggesting a need to focus interventions on core level practice gaps. This fresh perspective on education, away from disease-based delirium knowledge toward work-based patient, team and practice knowledge, could lead to more effective educational strategies to improve delirium care.

Delirium: underrecognized and undertreated

Delirium is a complex neuropsychiatric syndrome presenting primarily with disturbances of cognition, perception and sensorium, alertness, sleep/wake cycle, and psychomotor behavior in the context of a medical etiology. The presentation can be quite variable among patients and even within a given patient because of its waxing and waning course. This variability and overlap with other psychiatric syndromes has led to substantial underrecognition and undertreatment in clinical settings. Considering the significant morbidity and mortality associated with delirium and its tremendous economic burden, the failure to diagnose, refer, and treat such patients represents a critically important public health care issue. Clinicians should be systematically educated about delirium symptoms. Also, caregivers and family members of medically compromised patients should be educated about recognizing delirium. The use of structured diagnostic instruments and scales to follow the severity of symptoms has been an improvement in the field. However, much more research is needed into the use of such instruments and how they can be applied to clinical situations to improve the detection and treatment of delirium. Similarly, research is warranted that focuses on preventing delirium, potentially by identifying susceptible patients and intervening early. It is particularly challenging to devise cost-effective interventions for preventing and identifying delirium early in its course, given the rapid pace and resource limitations in inpatient and intensive care settings, and current data do not clearly indicate that such systems have proven benefit. Still, the indisputable health and financial costs of delirium indicate that prevention and identification should be a high priority.

Assessment of Delirium in the Intensive Care Unit: Nursing Practices And Perceptions

Background Despite practice guidelines promoting delirium assessment in intensive care, few data exist regarding current delirium assessment practices among nurses and how these practices compare with those for sedation assessment.

Objectives To identify current practices and perceptions of intensive care nurses regarding delirium assessment and to compare practices for assessing delirium with practices for assessing sedation.

Methods A paper/Web-based survey was administered to 601 staff nurses working in 16 intensive care units at 5 acute care hospitals with sedation guidelines specifying delirium assessment in the Boston, Massachusetts area.

Results Overall, 331 nurses (55%) responded. Only 3% ranked delirium as the most important condition to evaluate, compared with altered level of consciousness (44%), presence of pain (23%), or improper placement of an invasive device (21%). Delirium assessment was less common than sedation assessment (47% vs 98%, P &lt; .001) and was more common among nurses who worked in medical intensive care units (55% vs 40%, P = .03) and at academic centers (53% vs 13%, P &lt; .001). Preferred methods for assessing delirium included assessing ability to follow commands (78%), checking for agitation-related events (71%), the Confusion Assessment Method for the Intensive Care Unit (36%), the Intensive Care Delirium Screening Checklist (11%), and psychiatric consultation (9%). Barriers to assessment included intubation (38%), complexity of the tool for assessing delirium (34%), and sedation level (13%).

Conclusions Practice and perceptions of delirium assessment vary widely among critical care nurses despite the presence of institutional sedation guidelines that promote delirium assessment.

Delirium: where do we stand?

Clinicians are likely to encounter delirium frequently, particularly in inpatient and intensive care settings. However, delirium is underrecognized and undertreated because of its heterogeneous and fluctuating presentation and due to the limitations in resources and training in contemporary clinical settings. Translation of current knowledge about delirium into clinical practice may improve patient care and benefit public health economics. Hence, this review comprehensively discusses the phenomenology and pathophysiology of delirium and its presenting features, risk factors, differential diagnoses, assessment, prognosis, and treatment with antipsychotics; the goal is to facilitate better prevention, recognition, and treatment of delirium. Available research is reviewed, limitations of the research are discussed, and future directions for further delirium research are identified.