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Kresevic DM, Miller D, Fuseck CW, Wade M, Whitney L, Conley M, Rimac J, Jacono F, O'Leary-Wilson HL, Burant CJ. Assessment and Management of Delirium in Critically Ill Veterans. Crit Care Nurse 2021; 40:42-52. [PMID: 32737489 DOI: 10.4037/ccn2020137] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Delirium is a complex syndrome prevalent in the intensive care unit. It has been associated with significant morbidity including distress, longer hospital stays, prolonged cognitive impairment, and increased mortality. OBJECTIVE To describe a nurse-led interdisciplinary quality improvement initiative to increase nurses' knowledge of delirium, documentation of delirium assessment, and patient mobility. METHODS Sixty-seven nurses in medical and surgical intensive care units were required to attend an interactive education program on delirium assessment and management. Scores on tests taken before and after the education program were used to evaluate knowledge. Medical records and bedside rounds were used to validate Confusion Assessment Method for the Intensive Care Unit documentation and interventions. Descriptive statistics were used to describe changes over time. A delirium resource team composed of nurses, physicians, and therapists provided didactic education paired with simulation training and bedside coaching. Mobility screening tests and computer templates guided assessments and interventions. RESULTS Documentation of the Confusion Assessment Method improved from less than 50% to consistently 99%. Mobilization in the surgical intensive care unit increased from 90% to 98% after intervention. Days of delirium significantly decreased from 51% before intervention to 31% after intervention (χ12=7.01, P = .008). CONCLUSIONS The success of this quality improvement project to enhance recognition of delirium and increase mobility (critical components of the pain assessment, breathing, sedation choice, delirium, early mobility, and family education bundle) was contingent on nursing leaders hip, interdisciplinary team collaboration, and interactive education.
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Affiliation(s)
- Denise M Kresevic
- Denise M. Kresevic is a US Department of Veterans Affairs nurse researcher and advanced practice nurse at VA Northeast Ohio Healthcare System, Cleveland, Ohio, and University Hospitals of Cleveland
| | - Donna Miller
- Donna Miller is a clinical nurse specialist and professional nursing practice program manager, Carole W. Fuseck is a clinical nurse specialist, Mia Wade and Laura Whitney are collaborative care case managers, Mary Conley is a licensed physical therapist, Joanne Rimac is a nurse informaticist, and Heather L. O'Leary-Wilson is a registered nurse, VA Northeast Ohio Healthcare System
| | - Carole W Fuseck
- Donna Miller is a clinical nurse specialist and professional nursing practice program manager, Carole W. Fuseck is a clinical nurse specialist, Mia Wade and Laura Whitney are collaborative care case managers, Mary Conley is a licensed physical therapist, Joanne Rimac is a nurse informaticist, and Heather L. O'Leary-Wilson is a registered nurse, VA Northeast Ohio Healthcare System
| | - Mia Wade
- Donna Miller is a clinical nurse specialist and professional nursing practice program manager, Carole W. Fuseck is a clinical nurse specialist, Mia Wade and Laura Whitney are collaborative care case managers, Mary Conley is a licensed physical therapist, Joanne Rimac is a nurse informaticist, and Heather L. O'Leary-Wilson is a registered nurse, VA Northeast Ohio Healthcare System
| | - Laura Whitney
- Donna Miller is a clinical nurse specialist and professional nursing practice program manager, Carole W. Fuseck is a clinical nurse specialist, Mia Wade and Laura Whitney are collaborative care case managers, Mary Conley is a licensed physical therapist, Joanne Rimac is a nurse informaticist, and Heather L. O'Leary-Wilson is a registered nurse, VA Northeast Ohio Healthcare System
| | - Mary Conley
- Donna Miller is a clinical nurse specialist and professional nursing practice program manager, Carole W. Fuseck is a clinical nurse specialist, Mia Wade and Laura Whitney are collaborative care case managers, Mary Conley is a licensed physical therapist, Joanne Rimac is a nurse informaticist, and Heather L. O'Leary-Wilson is a registered nurse, VA Northeast Ohio Healthcare System
| | - Joanne Rimac
- Donna Miller is a clinical nurse specialist and professional nursing practice program manager, Carole W. Fuseck is a clinical nurse specialist, Mia Wade and Laura Whitney are collaborative care case managers, Mary Conley is a licensed physical therapist, Joanne Rimac is a nurse informaticist, and Heather L. O'Leary-Wilson is a registered nurse, VA Northeast Ohio Healthcare System
| | - Frank Jacono
- Frank Jacono is an intensive care unit attending physician at VA Northeast Ohio Healthcare System and University Hospitals of Cleveland
| | - Heather L O'Leary-Wilson
- Donna Miller is a clinical nurse specialist and professional nursing practice program manager, Carole W. Fuseck is a clinical nurse specialist, Mia Wade and Laura Whitney are collaborative care case managers, Mary Conley is a licensed physical therapist, Joanne Rimac is a nurse informaticist, and Heather L. O'Leary-Wilson is a registered nurse, VA Northeast Ohio Healthcare System
| | - Christopher J Burant
- Christopher J. Burant is the director of the Geriatric Research Education Clinical Center, VA Northeast Ohio Healthcare System, and an associate professor at the Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio
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Feast AR, White N, Lord K, Kupeli N, Vickerstaff V, Sampson EL. Pain and delirium in people with dementia in the acute general hospital setting. Age Ageing 2018; 47:841-846. [PMID: 30165420 PMCID: PMC6201828 DOI: 10.1093/ageing/afy112] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 06/06/2018] [Accepted: 07/16/2018] [Indexed: 12/30/2022] Open
Abstract
Background Pain and delirium are common in people with dementia admitted to hospitals. These are often under-diagnosed and under-treated. Pain is implicated as a cause of delirium but this association has not been investigated in this setting. Objective To investigate the relationship between pain and delirium in people with dementia, on admission and throughout a hospital admission. Design Exploratory secondary analysis of observational prospective longitudinal cohort data. Setting Two acute hospitals in the UK. Methodology Two-hundred and thirty participants aged ≥70 years were assessed for dementia severity, delirium ((Confusion Assessment Method (CAM), pain (Pain Assessment in Advanced Dementia (PAINAD)) scale and prescription of analgesics. Logistic and linear regressions explored the relationship between pain and delirium using cross-sectional data. Results Pain at rest developed in 49%, and pain during activity for 26% of participants during their inpatient stay. Incident delirium developed in 15%, of participants, and 42% remained delirious for at least two assessments. Of the 35% of participants who were delirious and unable to self-report pain, 33% of these participants experienced pain at rest, and 56 experienced pain during activity. The odds of being delirious were 3.26 times higher in participants experiencing pain at rest (95% Confidence Interval 1.03-10.25, P = 0.044). Conclusion An association between pain at rest and delirium was found, suggesting pain may be a risk factor for delirium. Since pain and delirium were found to persist and develop during an inpatient stay, regular pain and delirium assessments are required to manage pain and delirium effectively.
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Affiliation(s)
- Alexandra R Feast
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Nicola White
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Kathryn Lord
- Faculty of Health Studies, Centre for Applied Dementia Studies, University of Bradford, Bradford, UK
| | - Nuriye Kupeli
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- The Research Department of Primary Care and Population Health, University College London, London, UK
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Barnet Enfield and Haringey Mental Health Trust Liaison Psychiatry Team, North Middlesex University Hospital, London, UK
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El Hussein M, Hirst S, Osuji J. Professional Socialization: A Grounded Theory of the Clinical Reasoning Processes That RNs and LPNs Use to Recognize Delirium. Clin Nurs Res 2017; 28:321-339. [PMID: 28817952 DOI: 10.1177/1054773817724961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Delirium is an acute disorder of attention and cognition. It affects half of older adults in acute care settings and is a cause of increasing mortality and costs. Registered nurses (RNs) and licensed practical nurses (LPNs) frequently fail to recognize delirium. The goals of this research were to identify the reasoning processes that RNs and LPNs use to recognize delirium, to compare their reasoning processes, and to generate a theory that explains their clinical reasoning processes. Theoretical sampling was employed to elicit data from 28 participants using grounded theory methodology. Theoretical coding culminated in the emergence of Professional Socialization as the substantive theory. Professional Socialization emerged from participants' responses and was based on two social processes, specifically reasoning to uncover and reasoning to report. Professional Socialization makes explicit the similarities and variations in the clinical reasoning processes between RNs and LPNs and highlights their main concerns when interacting with delirious patients.
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Affiliation(s)
| | | | - Joseph Osuji
- Mount Royal University, Calgary, Alberta, Canada
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Cacchione PZ, Culp K, Dyck MJ, Laing J. Risk for Acute Confusion in Sensory-Impaired, Rural, Long-Term-Care Elders. Clin Nurs Res 2016; 12:340-55. [PMID: 14620691 DOI: 10.1177/1054773803253917] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Acute confusion is a common geriatric syndrome in long-term care (LTC) elders with prevalence rates of 10% to 39%. Sensory impairment, specifically vision and hearing impairment, is even more common in LTC, with prevalence rates of 40% to 90%. The purpose of this study was to investigate the risk relationship between sensory impairment and the development of acute confusion in LTC elders. Each resident (N = 114) underwent sensory screening and then was followed for 28 days to monitor for the onset of acute confusion. Twenty residents (17.5%) developed acute confusion, 60 residents (52.6%) were found to be visually impaired, 49 (44.1%) were hearing impaired, and 28 (24.6%) were found to be dually impaired. Significant relationships between vision impairment, odds ratio (OR) = 3.67, confidence interval (CI) (1.13, 11.92), and dual sensory impairment, OR = 2.88, CI (1.04, 8.26), with the development of acute confusion were identified.
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Wakefield BJ, Holman JE. Functional Trajectories Associated With Hospitalization in Older Adults. West J Nurs Res 2016; 29:161-77; discussion 178-82. [PMID: 17337620 DOI: 10.1177/0193945906293809] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
For older adults, acute-care hospital stays can result in functional decline that leads to increased risk of hospitalization, nursing home admission, or mortality. This study describes functional trajectories in hospitalized older adults and identifies risk factors associated with those trajectories. Respondents ( N = 45) exhibited five of six possible functional trajectory patterns. The largest change in functional status was a decline in activities of daily living (ADL) from baseline at 2 weeks before admission to the time of admission; ADL did not return to baseline during the first 4 days in the hospital. Depression scores were significantly higher in respondents who reported experiencing ADL decline before admission. Respondents whose ADL scores declined during hospitalization (regardless of baseline status) were more likely than others to die within 3 months of discharge. Functional trajectory in hospitalized elderly patients is an important and underappreciated prognostic concept requiring further attention.
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Affiliation(s)
- Bonnie J Wakefield
- Harry S. Truman Memorial Veterans Hospital, Health Services Research and Development, Columbia, USA
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Cull E, Kent B, Phillips NM, Mistarz R. Risk factors for incident delirium in acute medical in-patients: a systematic review. ACTA ACUST UNITED AC 2013. [DOI: 10.11124/01938924-201311050-00003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Matarese M, Generoso S, Ivziku D, Pedone C, De Marinis MG. Delirium in older patients: a diagnostic study of NEECHAM Confusion Scale in surgical intensive care unit. J Clin Nurs 2012; 22:2849-57. [DOI: 10.1111/j.1365-2702.2012.04300.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2012] [Indexed: 01/13/2023]
Affiliation(s)
- Maria Matarese
- School of Nursing; Campus Bio-Medico of Rome University; Rome
| | - Stefano Generoso
- Surgical Intensive Care Unit; Azienda Ospedaliera San Camillo-Forlanini; Rome
| | | | - Claudio Pedone
- Geriatrics Department; Campus Bio-Medico of Rome University Hospital; Rome
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Schreier AM. Nursing care, delirium, and pain management for the hospitalized older adult. Pain Manag Nurs 2010; 11:177-85. [PMID: 20728067 DOI: 10.1016/j.pmn.2009.07.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2009] [Revised: 07/29/2009] [Accepted: 07/30/2009] [Indexed: 02/07/2023]
Abstract
Delirium is a reversible cognitive disorder that has a rapid onset. Delirium risk factors include older age, severity of illness, poorer baseline functional status, comorbid medical conditions, and dementia. There are adverse consequences of delirium, including increased length of stay and increased mortality. Therefore, it is important for nurses to identify clients at risk and prevent and manage delirium in the hospitalized older client. Once high-risk clients are identified, prevention strategies may be used to reduce the incidence. Examples of prevention strategies include providing glasses and working hearing aids and effective pain management. This article discusses various assessment instruments that detect the presence of delirium. With this information, nurses are better equipped to evaluate the best assessment options for their work setting. Early detection is crucial to reduce the adverse consequences of delirium. Once a client is found to be experiencing delirium, a treatment plan can be established using both nonpharmacologic and pharmacologic interventions. In addition, the identification and the correction of etiologies of delirium can shorten the course of delirium.
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Affiliation(s)
- Ann M Schreier
- East Carolina University College of Nursing, Greenville, NC, USA.
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Boustani M, Baker MS, Campbell N, Munger S, Hui SL, Castelluccio P, Farber M, Guzman O, Ademuyiwa A, Miller D, Callahan C. Impact and recognition of cognitive impairment among hospitalized elders. J Hosp Med 2010; 5:69-75. [PMID: 20104623 PMCID: PMC2814975 DOI: 10.1002/jhm.589] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Older adults are predisposed to developing cognitive deficits. This increases their vulnerability for adverse health outcomes when hospitalized. OBJECTIVE To determine the prevalence and impact of cognitive impairment (CI) among hospitalized elders based on recognition by lCD-coding versus screening done on admission. DESIGN Observational cohort study. SETTING Urban public hospital in Indianapolis. PATIENTS 997 patients age 65 and older admitted to medical services between July 2006 and March 2008. MEASUREMENTS Impact of CI in terms of length of stay, survival, quality of care and prescribing practices. Cognition was assessed by the Short Portable Mental Status Questionnaire (SPMSQ). RESULTS 424 patients (43%) were cognitively impaired. Of those 424 patients with CI, 61% had not been recognized by ICD-9 coding. Those unrecognized were younger (mean age 76.1 vs. 79.1, P <0.001); had more comorbidity (mean Charlson index of 2.3 vs.1.9, P = 0.03), had less cognitive deficit (mean SPMSQ 6.3 vs. 3.4, P < 0.001). Among elders with CI, 163 (38%) had at least one day of delirium during their hospital course. Patients with delirium stayed longer in the hospital (9.2 days vs. 5.9, P < 0.001); were more likely to be discharged into institutional settings (75% vs. 31%, P < 0.001) and more likely to receive tethers during their care (89% vs. 69%, P < 0.001), and had higher mortality (9% vs. 4%, P = 0.09). CONCLUSION Cognitive impairment, while common in hospitalized elders, is under-recognized, impacts care, and increases risk for adverse health outcomes.
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Affiliation(s)
- Malaz Boustani
- Indiana University Center for Aging Research, Indiana University, Indianapolis, Indiana, USA.
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10
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Holroyd A, Dahlke S, Fehr C, Jung P, Hunter A. Attitudes Toward Aging: Implications for a Caring Profession. J Nurs Educ 2009; 48:374-80. [DOI: 10.3928/01484834-20090615-04] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Wakefield BJ, Mentes J, Holman JE, Culp K. Risk factors and outcomes associated with hospital admission for dehydration. Rehabil Nurs 2009; 33:233-41. [PMID: 19024237 DOI: 10.1002/j.2048-7940.2008.tb00234.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The hospital admission rate for dehydration is one of the Agency for Healthcare Research and Quality Prevention's Quality Indicators, which are considered screening tools for potential quality issues. Thus, admission for dehydration may reflect the quality of care provided in community settings. Using a case-control design, this study estimated the incidence, risk factors, and outcomes of dehydration in adults admitted to the hospital. The overall prevalence rate for three International Classification of Diseases codes for dehydration at admission was 0.55%. Cases and controls differed significantly on a number of clinical variables at admission, including weight, body mass index, pulse, blood pressure, use of bulk-forming laxatives, serum sodium and chloride, and presence of generalized weakness or hemiplegia, edema, diarrhea, vomiting, and having nothing by mouth before admission. Mortality rates at 30 and 180 days after discharge were not significantly different between the two groups. Dehydration in community-dwelling adults may delay rehabilitation or result in hospital admission. Prevention, monitoring, and management are critical to preventing dehydration-associated problems.
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Abstract
This evidence-based project was undertaken to implement research-based preventive protocols to decrease the negative outcomes associated with delirium/acute confusion. After implementation, the medical-surgical unit experienced a 62% reduction in falls and a 100% decrease in sitter usage the first year. The use of medications known to cause acute confusion was decreased by more than 50%. Since implementation, the fall rate as well as the use of restraints has decreased by 25%.
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13
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Dahlke S, Phinney A. Caring for hospitalized older adults at risk for delirium: the silent, unspoken piece of nursing practice. J Gerontol Nurs 2008; 34:41-7. [PMID: 18561562 DOI: 10.3928/00989134-20080601-03] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
More than half of hospitalized older adults will experience delirium, which--if left untreated--can lead to detrimental outcomes. Despite the prevalence and severity of delirium, nurses recognize less than one third of cases. Because little is known about how nurses manage this problem, a qualitative study was conducted to explore how nurses care for hospitalized older adults at risk for delirium. The data revealed that nurses care for older adults byTaking a Quick Look, Keeping an Eye on Them, and Controlling the Situation. The context in which nurses choose their priorities and interventions was reflected in the themes of the Care Environment and Negative Beliefs and Attitudes about older adults. Nurses are caring for an older population whose care requirements are different than those of younger people and in a context where this challenging work is rarely addressed. To improve care, the older population must be acknowledged, and nurses must possess the knowledge and resources needed to meet this population's unique needs.
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Affiliation(s)
- Sherry Dahlke
- School of Nursing, University of British Columbia, Vancouver, Canada.
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14
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Nutritional status and delirium in long-term care elderly individuals. Appl Nurs Res 2008; 21:66-74. [PMID: 18457745 DOI: 10.1016/j.apnr.2006.09.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2006] [Revised: 09/14/2006] [Accepted: 09/21/2006] [Indexed: 11/21/2022]
Abstract
Delirium is physiologically plausible in elderly individuals with a poor nutritional status. We explored body composition, serum protein levels, and delirium in a multicenter long-term care study using bioelectrical impedance analysis (BIA). Estimates from the BIA procedure included the body cell mass and fat-free mass (FFM) of nursing home elderly residents (N = 312). Increased delirium was identified in men and women who were leaner and had lower FFM. Clinical surveillance for delirium in frail elderly individuals with low serum albumin levels and polypharmacy is recommended because of their increased likelihood of having drug toxicities for medications with protein-binding properties.
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Delirium in the Long-Term Care Setting: Clinical and Research Challenges. J Am Med Dir Assoc 2008; 9:157-61. [DOI: 10.1016/j.jamda.2007.12.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2007] [Accepted: 12/05/2007] [Indexed: 11/17/2022]
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Voyer P, McCusker J, Cole MG, St-Jacques S, Khomenko L. Factors associated with delirium severity among older patients. J Clin Nurs 2007; 16:819-31. [PMID: 17462033 DOI: 10.1111/j.1365-2702.2006.01808.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM The goal of this study was to determine whether the factors associated with delirium varied according to the severity of the delirium experienced by the older patients. BACKGROUND Delirium among older patients is prevalent and leads to numerous detrimental effects. The negative consequences of delirium are worse among older adults with severe delirium compared with patients with mild delirium. There has been no study identifying those factors associated with delirium severity among long-term care older patients newly admitted to an acute care hospital. DESIGN This is a descriptive study. METHODS This is a secondary analysis study of institutionalized older patients newly admitted to an acute care hospital (n = 104). Upon admission, patients were screened for delirium with the Confusion Assessment Method and severity of delirium symptoms were determined by using the Delirium Index. RESULTS Of the 71 delirious older patients, 32 (45.1%) had moderate-severe delirium while 39 (54.9%) presented mild delirium. In univariate analyses, a significant positive relationship was observed between the level of prior cognitive impairment and the severity of delirium (p = 0.0058). Low mini-mental state examination (MMSE) scores (p < 0.0001), the presence of severe illness at the time of hospitalization (p = 0.0016) and low functional autonomy (BI: p = 0.0017; instrumental activities of daily living: p = 0.0003) were significantly associated with moderate-severe delirium. Older patients suffering from mild delirium used significantly more drugs (p = 0.0056), notably narcotics (p = 0.0017), than those with moderate-severe delirium. Results from the stepwise regression indicated that MMSE score at admission and narcotic medication use are the factors most strongly associated with the severity of delirium symptoms. CONCLUSIONS This present study indicates that factors associated with moderate-severe delirium are different from those associated with mild delirium. Given the result concerning the role of narcotics, future studies should evaluate the role of pain management in the context of delirium severity. RELEVANCE TO CLINICAL PRACTICE As moderate-severe delirium is associated with poorer outcomes than is mild delirium, early risk factor identification for moderate-severe delirium by nurses may prove to be of value in preventing further deterioration of those older patients afflicted with delirium.
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Affiliation(s)
- Philippe Voyer
- Faculty of Nursing Sciences, Laval University, Québec, QC, Canada.
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Balas MC, Deutschman CS, Sullivan-Marx EM, Strumpf NE, Alston RP, Richmond TS. Delirium in Older Patients in Surgical Intensive Care Units. J Nurs Scholarsh 2007; 39:147-54. [PMID: 17535315 DOI: 10.1111/j.1547-5069.2007.00160.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE To examine the frequency and course of delirium in older adults admitted to a surgical intensive care unit (SICU). DESIGN AND METHODS Prospective, observational cohort study of 114 English-speaking participants and their surrogates, aged 65 and older, admitted to an SICU, and managed by a surgical critical care service. Chart reviews and surrogate interviews were conducted within 24 hours of SICU admission to collect information regarding evidence of dementia using the short form of the Informant Questionnaire on Cognitive Decline in the Elderly. Participants were also screened for delirium daily throughout their hospitalization with either the Confusion Assessment Method-ICU (CAM-ICU) while in the SICU or the CAM while on medical/surgical units. RESULTS In this population of older adults, 18.4% had evidence of dementia on admission to the SICU. Few older adults (2.6%) were admitted to the hospital with evidence of preexisting delirium, but 28.3% developed delirium in the SICU and 22.7% during the post-SICU period. A total of 52 of 114 (45.6%) participants were delirious sometime during their hospital stay or 24 hours before hospital admission. Episodes of deep sedation and nonarousal were uncommon, occurring in only 9.7% of the sample. CONCLUSIONS Older adults admitted to SICUs were at high risk for developing delirium during hospitalization. Further research is needed to elucidate the risk factors for, and outcomes of, delirium in this uniquely vulnerable population.
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Affiliation(s)
- Michele C Balas
- University of Pennsylvania, School of Nursing, Philadelphia, PA, USA.
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Abstract
This review demonstrates essential issues to consider when caring for older trauma patients, including baseline physical status, mental health, comorbidities, and risk factors for sequelae and future injuries. The impact of a traumatic injury on older adults is complex. Issues of normal aging, functional status, chronic health conditions, and response to treatment affect health care and related decisions. Studies that have examined outcomes for older trauma patients to date have been mainly descriptive or confined to a single institution, limiting our ability to generalize. Other studies, using large data sets, have provided some information regarding possible primary prevention strategies, yet have limitations in the individual level detail collected. Nevertheless, this review also demonstrates the dearth of available evidence-based recommendations that provides support to treatment protocols in this complex and diverse patient population. The lack of an evidence base to use in the management of older trauma patients demonstrates the critical need for research in this rapidly growing population. An example of one such area includes the use of pulmonary artery catheters in older trauma patients. Although evidence to date suggests that pulmonary artery catheters are of benefit in the management of patients with physiologic compromise, it is unclear whether using these published cardiac output management recommendations leads to improved outcomes. In light of newly published data suggesting equivocal benefit from use of pulmonary artery catheters, with increased side effects, this controversy is an important area for future research. Critical care nurses, with their emphasis on multidisciplinary, holistic practice, can expand their influence as essential members of the interdisciplinary team caring for older trauma patients by cultivating geriatric specialty knowledge. Older trauma patients would benefit greatly from this type of specialty nursing care during all phases of the recovery trajectory, particularly in terms of adequate symptom management and prevention of sequelae, as well as with timely and appropriate initiation of consultative services. Using the intersection of primary and secondary prevention as the overall guide for practice, critical care nurses and other health care providers who possess an understanding of aging processes and comorbid conditions can significantly improve outcomes for older adults with traumatic injuries.
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Affiliation(s)
- Hilaire J Thompson
- Biobehavioral Nursing and Health Systems, University of Washington, Box 357266, Seattle, WA 98195-7266, USA.
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Stierle LJ, Mezey M, Schumann MJ, Esterson J, Smolenski MC, Horsley KD, Rotunda N, Brenner BR, Paulson D, Huba GJ, Gould E. The Nurse Competence in Aging Initiative. Am J Nurs 2006; 106:93-6. [PMID: 16954777 DOI: 10.1097/00000446-200609000-00040] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Affiliation(s)
- Jeng Wang
- Department of Nursing, Chang-Gung Institution of Technology, Tao Yuan, Taiwan
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Amella EJ. Presentation of illness in older adults. If you think you know what you're looking for, think again. AORN J 2006; 83:372-4, 377-82, 385-9. [PMID: 16544857 DOI: 10.1016/s0001-2092(06)60168-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
ALTHOUGH PEOPLE AGE at different rates, changes to the composition of the human body are a hallmark of aging. As a result of such changes, disease can present differently in a person over 65 years old than it would in a younger adult or child. THIS ARTICLE IDENTIFIES the critical indicators of underlying conditions, including changes in mental status, loss of function, decrease in appetite, dehydration, falls, pain, dizziness, and incontinence. It also describes the presentation of diseases common to older adults, including depression, infection, cardiac disease, gastrointestinal disorders, thyroid disease, and type 2 diabetes.
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Affiliation(s)
- Elaine J Amella
- Medical University of South Carolina College of Nursing, Charleston, USA
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Abstract
Delirium is a mental disorder of acute onset and fluctuating course, characterized by disturbances in consciousness, orientation, memory, thought, perception, and behavior. It occurs in up to 50% of elderly hospital inpatients, many with preexisting dementia, and is associated with significant increases in functional disability, length of hospital stay, rates of death, and health care costs. Despite its clinical importance, delirium often remains undetected or misdiagnosed as dementia or other psychiatric illness. Awareness of the etiologies and risk factors of delirium should enable nurses to focus on patients at risk and to recognize delirium symptoms early. Knowledge of pharmacological and nonpharmacological treatments for delirium will provide the nurse with an arsenal of potential interventions in the care of the delirious hospitalized elder.
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Affiliation(s)
- Ted S Rigney
- The Nurse Practitioner Program at College of Nursing University of Arizona, USA
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Abstract
Delirium is a classic geriatric syndrome that occurs commonly among the frail elders who make up many of the residents in postacute and long-term care facilities. The prevalence of the disorder in these settings may be increasing as a result of the pressure to reduce hospital length of stay. Clinicians often do not recognize when patients in their care are delirious, but simple and practical means exist to allow its diagnosis. Those who practice in long-term care must be knowledgeable about the risk factors for the disorder, as well as how to recognize, diagnose, prevent, and treat it.
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Affiliation(s)
- William L Lyons
- Section of Geriatrics and Gerontology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE 68198-1320, USA.
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Voyer P, Cole MG, McCusker J, Belzile É. Characteristics of institutionalized older patients with delirium newly admitted to an acute care hospital. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/j.cein.2005.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Abstract
Although people age at different rates, changes to the composition of the human body are a hallmark of aging. As a result of such changes, disease can present differently in a person over 65 years old than it would in a younger adult or child. This article identifies the critical indicators of underlying conditions, including changes in mental status, loss of function, decrease in appetite, dehydration, falls, pain, dizziness, and incontinence. It also describes the presentation of diseases common to older adults, including depression, infection, cardiac disease, gastrointestinal disorders, thyroid disease, and type 2 diabetes.
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Affiliation(s)
- Elaine J Amella
- Medical University of South Carolina College of Nursing, Charleston, SC, USA.
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Affiliation(s)
- Michele C. Balas
- Michele C. Balas, a recent recipient of the John A. Hartford Foundation Building Academic Geriatric Nursing Capacity Scholarship, is pursuing a doctorate in nursing at the University of Pennsylvania School of Nursing, Philadelphia, Pa. The focus of her investigation is variables that influence disparate outcomes of critically ill older adults
| | - Melissa Gale
- Melissa Gale practices as a clinical faculty member, specializing in nursing care of older adults, at the University of Pennsylvania School of Nursing
| | - Sarah H. Kagan
- Sarah H. Kagan is an associate professor of gerontological nursing at the University of Pennsylvania School of Nursing. She teaches nursing of older adults and practices as gerontological clinical nurse specialist at the Hospital of the University of Pennsylvania in Philadelphia. She holds a secondary faculty appointment in the Department of Otorhinolaryngology: Head and Neck Surgery in the School of Medicine and collaborates with the University of Pennsylvania Cancer Center
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Affiliation(s)
- Carol A Miller
- Care & Counseling, Miller/Wetzler Associates, Cleveland, Ohio USA
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Lou MF, Yu PJ, Huang GS, Dai YT. Predicting post-surgical cognitive disturbance in older Taiwanese patients. Int J Nurs Stud 2004; 41:29-41. [PMID: 14670392 DOI: 10.1016/s0020-7489(03)00112-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The purpose of this study was to test a theoretical model to understand the influences of six predicting variables in post-surgical cognitive disturbance in older Taiwanese patients after elective surgery. The data were collected in a medical center in Taipei, Taiwan. Ninety-three patients were included in the final analysis. The findings showed that cognitive function at admission (beta=0.50, p<0.001), physical function at admission (beta=-0.34, p<0.001), and physiological stability (beta=-0.21, p<0.01) had direct effects on post-surgical cognitive disturbance. Physical function and cognitive function at admission also affected post-surgical cognitive disturbance indirectly through physiological stability. These variables accounted for 67% of the total variance of post-surgical cognitive disturbance. The findings from this study suggest that a careful and systematic assessment of the patient's condition at the time of admission is important. It is necessary to monitor and correct these variables at admission or before surgery to prevent or reduce the impact of post-operative delirium. It is also necessary to monitor these variables during the hospital stay to help nurses to distinguish the etiology of delirium. In each case, knowing when confusion is more likely to occur can assist in focusing more appropriate and effective efforts at detection, thereby reducing the consequences associated with confusion.
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Affiliation(s)
- Meei-Fang Lou
- School of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan, ROC.
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McCarthy MC. Detecting acute confusion in older adults: Comparing clinical reasoning of nurses working in acute, long-term, and community health care environments. Res Nurs Health 2003; 26:203-12. [PMID: 12754728 DOI: 10.1002/nur.10081] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In an article on a previous study involving hospitalized older adults (McCarthy, 2003), it was argued that the theory of situated clinical reasoning explains why nurses often fail to recognize acute confusion. Further, the theory illuminates how nurses' perspectives toward health in aging affect the ways they regard and ultimately deal with older people in this particular clinical situation. The purpose of the current study was to challenge and refine the theory by exploring the influence of different care environments on clinical reasoning related to acute confusion. Following a period of participant observation, a purposive sample of 30 nurses, 10 each from a teaching hospital, a long-term facility, and a home care agency, participated in semistructured interviews. Dimensional analysis provided the methodological framework for data collection and interpretation. The results reinforce prior findings that the ability of nurses to recognize acute confusion and to distinguish it from dementia can be attributed to their personal philosophies about aging. Care environment was identified as a factor that influenced clinical reasoning in limited ways under certain conditions and within certain contexts.
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Affiliation(s)
- Marianne C McCarthy
- Arizona State University, College of Nursing, Tempe, Arizona 85287-2602, USA
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Andersson EM, Hallberg IR, Edberg AK. Nurses' experiences of the encounter with elderly patients in acute confusional state in orthopaedic care. Int J Nurs Stud 2003; 40:437-48. [PMID: 12667520 DOI: 10.1016/s0020-7489(02)00109-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The aim of this study was to illuminate nurses' experiences of the encounter with elderly patients who developed acute confusional state (ACS) in orthopaedic care. Forty-eight nurses with professional background as registered (n=26) or licensed practical nurses (n=22) who took part in the nursing care of acute confused patients were involved. Open-ended unstructured interviews were conducted with regard to the course of events, experiences and interpretation of what had happened during the ACS as well as the nurses' actions and encounter with the confused patient. The texts were analysed using manifest and latent content analysis, revealing that the nurses had difficulties in reaching the patients and their reality, and thus in understanding their experiences. Interpretation of the nurses' experiences showed that the nurses found it difficult to reach the patients' reality because the patients were in a divided and/or different world. They interpreted the patients as seeking solitude or company, keeping a distance or being suspicious of the nurses. The findings indicated that the interaction in the encounter between the acutely confused patients and the nurses indicated insufficient and/or broken reciprocity. The nurses used various strategies to meet the patients, being a companion and/or being a surrogate. They acted in the encounter based on their view of the patient and their ability to enter into and understand the patients' situation. The strategies were more or less successful, sometimes resulting in contact and calming the patients and in other cases increasing the patients' irritation and anger. The results were more successful when the strategies were derived from the nurses' interpretation of the patients' situation and the nurses paid attention to the patients and confirmed them.
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Affiliation(s)
- Edith M Andersson
- Department of Nursing, University of Lund, P.O. Box 157, SE-221 00 Lund, Sweden.
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Cacchione PZ, Culp K, Laing J, Tripp-Reimer T. Clinical profile of acute confusion in the long-term care setting. Clin Nurs Res 2003; 12:145-58. [PMID: 12741667 DOI: 10.1177/1054773803012002003] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Aspects of acute confusion (AC) including risk factors, behavior patterns, and outcomes are not well documented in long-term care (LTC) residents. The purpose of this prospective study was to describe the clinical profile of AC in LTC including risk factors, behavior patterns, etiologies, and 3-month outcomes. Seventy-four elderly LTC residents were assessed for AC, depression, and global cognitive impairment. Risk factors associated with AC included hearing deficits, depression, pulmonary disorders, and abnormal serum sodium or potassium levels. Behavior patterns of acutely confused residents included hyperactive (n = 9, 31%), hypoactive (n = 8, 28%), and mixed (n = 7, 24%). In the majority of the AC cases, the etiology was multIfactorial infections and dehydration were the most common causes. Residents with AC had very poor 3-month outcomes. Thirty-four percent (n = 10) of the residents with AC died within 3 months of the evaluation. This study highlights the complexity and serious nature of AC in this frail population.
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Culp K, Mentes J, Wakefield B. Hydration and acute confusion in long-term care residents. West J Nurs Res 2003; 25:251-66; discussion 267-73. [PMID: 12705111 DOI: 10.1177/0193945902250409] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Although it is generally appropriate for a healthy adult to consume 2000 to 2500 ml per day, the literature does not address evaluating any standard. The objective here was to develop a weight-based hydration management intervention and evaluate the impact of this on the incidence of acute confusion (AC) using an N = 98. The intervention consisted of a fluid intake goal based on 100 ml per kg for the first 10 kg, 50 ml/kg for the next 10 kg, and 15 ml for the remaining body weight. The treatment group received instruction and assistance on the fluid goal and the control group received routine care. Measurements included serum electrolytes, bioimpedance analysis, urinalysis, Mini-Mental State Exam, and the NEECHAM. There was no difference in the incidence of AC between treatment and controls, but those individuals with > or = 90% compliance demonstrated higher ECF volumes and also lower urine leukocyte counts.
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McCarthy M. Situated clinical reasoning: distinguishing acute confusion from dementia in hospitalized older adults. Res Nurs Health 2003; 26:90-101. [PMID: 12652606 DOI: 10.1002/nur.10079] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
In this study a dimensional analysis approach was used to explore the clinical reasoning of nurses who care for hospitalized older adults to identify factors that might explain their failure to detect acute confusion and to distinguish it from dementia in this patient population. Data analysis yielded a grounded theory of situated clinical reasoning, which proposes that the ability of nurses to identify acute confusion varies widely. This variation can be attributed to the differences in nurses' philosophical perspectives on aging. According to this theory, three distinct perspectives are unwittingly embraced by nurses who care for older patients. These perspectives influence how nurses characterize aging and the aged and condition the ways in which they judge and ultimately deal with older adults in clinical situations.
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Affiliation(s)
- Marianne McCarthy
- Arizona State University, College of Nursing, Main Campus, P.O. Box 872602, Tempe, AZ 85287-2602, USA
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O'Brien D. Acute postoperative delirium: definitions, incidence, recognition, and interventions. J Perianesth Nurs 2002; 17:384-92. [PMID: 12476404 DOI: 10.1053/jpan.2002.36783] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Emergence excitement or delirium is a common postanesthesia complication. Often, the emergence excitement resolves quickly, and the patient's continued recovery is uneventful. Although the initial period of excitement may be short lived and resolve without long-term sequela, some patients may experience acute postoperative delirium, a phenomenon that is more difficult to assess and of potentially longer duration. Although patients are spending less time in the hospital after surgical procedures, concern over the potential development of acute postoperative delirium remains. Patients at risk present in ambulatory surgery centers and inpatient perianesthesia settings daily. Identification of at-risk patients is crucial to avoiding the development of delirium in the acute postanesthesia care setting. The purpose of this selective review is to define acute postoperative delirium and its incidence, discuss assessment and recognition, describe interventions, and identify future considerations related to this phenomenon.
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Affiliation(s)
- Denise O'Brien
- University of Michigan Health System, Ann Arbor, MI, USA.
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Affiliation(s)
- Keela Herr
- Adult and Gerontological Nursing, University of Iowa College of Nursing, Iowa City, IA, USA
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Experiences of orthopaedic nurses caring for elderly patients with acute confusion. ACTA ACUST UNITED AC 2002. [DOI: 10.1054/joon.2001.0210] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Hart BD, Birkas J, Lachmann M, Saunders L. Promoting positive outcomes for elderly persons in the hospital: prevention and risk factor modification. AACN CLINICAL ISSUES 2002; 13:22-33. [PMID: 11852720 DOI: 10.1097/00044067-200202000-00004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The hospitalized elderly are at an increased risk for poor outcomes such as increased length of stay, readmissions, functional decline, and iatrogenic complications, as compared with other age groups. Research related to the hospitalized elderly has identified factors associated with poor outcomes. Nurses and other healthcare team members may be able to identify elderly patients at risk for poor outcomes and target modifiable factors to minimize their negative impact. Clinical experience and research validate the conclusion that multidimensional, preventive risk factor modification balanced with acute illness treatment can result in positive outcomes for elderly patients.
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Affiliation(s)
- Brian D Hart
- Southeastern Regional Geriatric Program, Providence Continuing Care Centre, 340 Union Street, Kingston, Ontario K7L 5A2.
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