Management of delirium in critically ill older adults

Identification and Best Practice Management of Comorbid Geri-Psych Conditions in Critical Care

Mental illnesses among critically ill patients are approximately 2.5 times that of the general population. Although older adults with physical-mental multimorbidity represent more than 50% of critical care admissions, health-care professionals caring for geriatric patients are not adequately educated to effectively recognize and treat serious mental illness. Additionally, critical care nurses feel vulnerable, unsupported, and unable to provide the best and safest possible patient-centered care for patients with mental illness. Hospitals can reduce these burdens by creating critical care policies and practices that are inclusive of geriatric and mental health concepts, care, and continuing education to those providing care.

Development of a scale measuring the difficulties faced by nurses who care for patients with delirium in intensive care units

BACKGROUND

Delirium in patients in the intensive care unit is associated with adverse outcomes. Nurses experience many difficulties in caring for those with delirium, which can lead to nurse burnout, prevent effective care for patients, and negatively impact the patient. The identification of factors creating challenges for nurses is, therefore, important to enable intervention.

OBJECTIVES

The aim of this study was to develop a new scale to assess the difficulties faced by nurses caring for patients with delirium in the intensive care unit and to examine its reliability and validity.

METHODS

We based our draft scale items on literature reviews and interviews. Four experts evaluated the collected items. After a pilot study, 211 nurses working in intensive care units in Japan completed the questionnaire. Subsequent statistical analysis of results included factor validity, construct validity, known-group validity, internal consistency, and test-retest reliability.

RESULTS

Exploratory factor analysis extracted a scale of 33 items with eight factors and an additional scale of four items with one factor. The analysis of construct validity suggested a possible association with the Strain of Care for Delirium Index. In the known-group validity, a comparison with two groups based on experience in the intensive care unit found significant differences among the five factors. Internal consistency (Cronbach's α = 0.68-.87) and test-retest reliability (intraclass correlation coefficients = .46-.62) were confirmed.

CONCLUSION

We developed a difficulty scale for nurses caring for patients with delirium in the intensive care unit and confirmed its reliability and validity. The difficulty factors were developed with the intention to identify educational interventions for nurses and the introduction of new organisational resources, such as manpower and providing emotional support and feedback to nurses.

Views of wheelchair users and caregivers regarding a passive safety monitoring system for electric powered wheelchair operators with cognitive impairment

The opinions of cognitively intact current wheelchair users and their professional caregivers were solicited to explore acceptability of the concept of a passive electric wheelchair-mounted movement monitor to track driving safety and cognitive impairment. Two focus groups of electric wheelchair users (N = 9), and two focus groups of staff caregivers (N = 8) were conducted at a congregate care facility. Participants also completed a questionnaire examining their perceptions of the concept. The results indicated most wheelchair users and staff caregivers were receptive to the idea of a passive safety monitoring system for wheelchairs to detect cognitive impairment. Three main and interrelated themes emerged regarding how the device could promote safety, how such a system might infringe upon the users' autonomy, and how and to whom the cognitive state information should be communicated. Legal, training, and marketing issues reflected similar concerns over balancing autonomy with safety issues. If successfully addressed, it appears there would be support for the device's use not only for older adults in institutional settings, but perhaps also among community living younger and older adults. A passive safety monitoring system for wheelchairs is acceptable to wheelchair users and can be successfully marketed if developers balance autonomy and safety concerns.

The association of post-operative delirium with patient-reported outcomes and mortality after lung transplantation

Post-operative delirium after lung transplantation is common. Its associations with health-related quality of life (HRQL), depression, and mortality remains unknown. In 236 lung transplant recipients, HRQL and depressive symptoms were assessed as part of a structured survey battery before and after transplantation. Surveys included the Geriatric Depressive Scale (GDS) and Short Form 12 (SF12). Delirium was assessed throughout the post-operative intensive care unit (ICU) stay with Confusion Assessment Method for ICU. Delirium and mortality data were extracted from electronic medical records. We examined associations between delirium and changes in depressive symptoms and HRQL using linear mixed effects models and association between delirium and mortality with Cox-proportional hazard models. Post-operative delirium occurred in 34 participants (14%). Delirium was associated with attenuated improvements in SF12-PCS (difference ₋4.0; 95%CI: -7.4, -0.7) but not SF12-MCS (difference 2.2; 95%CI: -0.7,5.7) or GDS (difference ₋0.4; 95%CI: -1.5,0.7). Thirty-two participants died during the study period. Delirium was associated with increased adjusted hazard risk of mortality (HR 17.9, 95%CI: 4.4,72.5). Delirium after lung transplantation identifies a group at increased risk for poorer HRQL and death within the first post-operative year. Further studies should investigate potential causal links between delirium, and poorer HRQL and mortality risk after lung transplantation.

Assessing delirium with nursing care instruments: Evaluation of the cognitive and associated domains

OBJECTIVE

Nursing instruments have the potential for daily screening of delirium; however, they have not yet been evaluated. Therefore, after assessing the functional domains of the electronic Patient Assessment - Acute Care (ePA-AC), this study evaluates the cognitive and associated domains.

METHODS

In this prospective cohort study in the intensive care unit, 277 patients were assessed and 118 patients were delirious. The impacts of delirium on the cognitive domains, consciousness and cognition, communication and interaction, in addition to respiration, pain, and wounds were determined with simple logistic regressions and their respective odds ratios (ORs).

RESULTS

Delirium was associated with substantial impairment throughout the evaluated domains. Delirious patients were somnolent (OR 6), their orientation (OR 8.2-10.6) and ability to acquire knowledge (OR 5.5-11.6) were substantially impaired, they lost the competence to manage daily routines (OR 8.2-22.4), and their attention was compromised (OR 12.8). In addition, these patients received psychotropics (OR 3.8), were visually impaired (OR 1.8), unable to communicate their needs (OR 5.6-7.6), displayed reduced self-initiated activities (OR 6.5-6.9) and challenging behaviors (OR 6.2), as well as sleep-wake disturbances (OR 2.2-5), Furthermore, delirium was associated with mechanical ventilation, abdominal/thoracic injuries or operations (OR 4.2-4.4), and sensory perception impairment (OR 3.9-5.8).

SIGNIFICANCE OF RESULTS

Delirium caused substantial impairment in cognitive and associated domains. In addition to the previously described functional impairments, these findings will aid the implementation of nursing instruments in delirium screening.

Pharmacologic Management of Delirium in the ICU: A Review of the Literature

Purpose:

Conflicting data exists on the pharmacologic management of intensive care unit (ICU) delirium. This review appraises the current evidence of pharmacologic management of ICU delirium.

Materials and Methods:

A systematic literature search of MEDLINE and Embase was conducted to answer the population, intervention, comparison, and outcome (PICO) question of: “Does the use of a pharmacologic agent compared to standard of care or placebo improve ICU delirium in a critically ill patient population?”

Results:

After application of the PICO question and the inclusion and exclusion criteria, 13 articles were included. Of these articles, 7 were prospective randomized controlled trials, 1 was a prospective nonrandomized controlled trial, and 5 were retrospective investigations. The included articles differed in the agents evaluated, primary outcome, and method of identifying delirium.

Conclusion:

The variability of outcomes illustrates the need for a large-scale investigation to further evaluate the role of pharmacologic management of ICU delirium.

Assessment of Delirium in Intensive Care Unit Patients: Educational Strategies

BACKGROUND

Delirium is an acute brain dysfunction associated with poor outcomes in intensive care unit (ICU) patients. Critical care nurses play an important role in the prevention, detection, and management of delirium, but they must be able to accurately assess for it. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) instrument is a reliable and valid method to assess for delirium, but research reveals most nurses need practice to use it proficiently.

METHOD

A pretest-posttest design was used to evaluate the success of a multimodal educational strategy (i.e., online learning module coupled with standardized patient simulation experience) on critical care nurses' knowledge and confidence to assess and manage delirium using the CAM-ICU.

RESULTS

Participants (N = 34) showed a significant increase (p < .001) in confidence in their ability to assess and manage delirium following the multimodal education. No statistical change in knowledge of delirium existed following the education.

CONCLUSION

A multimodal educational strategy, which included simulation, significantly added confidence in critical care nurses' performance using the CAM-ICU. J Contin Nurs Educ. 2017;48(5):239-244.

Intensive Care Unit Nurses' Beliefs About Delirium Assessment and Management

Delirium, the most frequent complication of hospitalized older adults, particularly in intensive care units (ICUs), can result in increased mortality rates and length of stay. Nurses are neither consistently identifying nor managing delirium in these patients. The purpose of this study was to explore ICU nurses' identification of delirium, actions they would take for patients with signs or symptoms of delirium, and beliefs about delirium assessment and management. In this cross-sectional study using qualitative descriptive methods guided by the theory of planned behavior, 30 ICU nurses' responses to patient vignettes depicting different delirium subtypes were explored. Descriptive and content analyses revealed that nurses did not consistently identify delirium; their actions varied in different vignettes. Nurses believed that they needed adequate staffing, balanced workload, interprofessional collaboration, and established policy and protocols to identify and manage delirium successfully. Research is needed to determine if implementing these changes increases recognition and decreases consequences of delirium.

Incidence and factors related to delirium in an intensive care unit

OBJECTIVES

To identify the incidence of delirium, compare the demographic and clinical characteristics of patients with and without delirium, and verify factors related to delirium in critical care patients.

METHOD

Prospective cohort with a sample made up of patients hospitalized in the Intensive Care Unit (ICU) of a university hospital. Demographic, clinical variables and evaluation with the Confusion Assessment Method for Intensive Care Unit to identify delirium were processed to the univariate analysis and logistic regression to identify factors related to the occurrence of delirium.

RESULTS

Of the total 149 patients in the sample, 69 (46.3%) presented delirium during ICU stay, whose mean age, severity of illness and length of ICU stay were statistically higher. The factors related to delirium were: age, midazolam, morphine and propofol.

CONCLUSION

Results showed high incidence of ICU delirium associated with older age, use of sedatives and analgesics, emphasizing the need for relevant nursing care to prevent and identify early, patients presenting these characteristics.

OBJETIVOS

Identificar a incidência de delirium, comparar as características demográficas e clínicas dos pacientes com e sem delirium e verificar os fatores relacionados ao delirium em pacientes internados em Unidade de Terapia Intensiva (UTI).

MÉTODO

Coorte prospectiva, cuja amostra foi constituída de pacientes internados em UTI de um hospital universitário. Variáveis demográficas, clínicas e da avaliação com o Confusion Assessment Method for Intensive Care Unit para identificação de delirium foram processadas para análise univariada, e regressão logística para identificar fatores relacionados à ocorrência do delirium.

RESULTADOS

Do total de 149 pacientes da amostra, 69 (46,3%) apresentaram delirium durante a internação na UTI, observando-se que a média da idade, o índice de gravidade e o tempo de permanência nas UTI foram estatisticamente maiores. Os fatores relacionados ao delirium foram: idade, midazolam, morfina e propofol.

CONCLUSÃO

Os resultados mostraram elevada incidência de delirium na UTI e sua ocorrência associada às idades mais avançadas e o uso de sedativos e analgésicos, ressaltando-se a importância da atuação do enfermeiro na prevenção e identificação precoce do quadro nos pacientes com essas características.

Nonpharmacological interventions to prevent delirium: an evidence-based systematic review

Development of delirium in critical care patients is associated with increased length of stay, hospital costs, and mortality. Delirium occurs across all inpatient settings, although critically ill patients who require mechanical ventilation are at the highest risk. Overall, evidence to support the use of antipsychotics to either prevent or treat delirium is lacking, and these medications can have adverse effects. The pain, agitation, and delirium guidelines of the American College of Critical Care Medicine provide the strongest level of recommendation for the use of nonpharmacological approaches to prevent delirium, but questions remain about which nonpharmacological interventions are beneficial.

Best Practices for Managing Pain, Sedation, and Delirium in the Mechanically Ventilated Patient

Nursing management of pain, agitation, and delirium in mechanically ventilated patients is a challenge in critical care. Oversedation can lead to delayed extubation, prolonged ventilator days, unnecessary neurologic testing, and complications such as weakness and delirium. Undersedation can lead to self-extubation, invasive line removal, unnecessary patient distress, and injury to self or others. Acquiring an optimal level of sedation requires the bedside nurse to be more vigilant than ever with patient assessment and medication titration. This article provides a historical perspective of the management of pain, agitation, and delirium, and disseminates information contained in revised Society for Critical Care Medicine Clinical Practice Guidelines (January 2013) to promote their implementation in day-to-day nursing care.

The 3 Ds, and newly acquired cognitive impairment: issues for the ICU nurse

As the United States population ages, patients in intensive care units (ICUs) bring with them the challenges of an aging population. One challenge is the different types of confusions seen in the geriatric patient. Intensive care unit nurses must be knowledgeable about the different types of confusions, be able to differentiate among them, and know the appropriate prevention and management strategies for each type. Failure to do so results in consequences that impact the patient long after the ICU stay had ended. The purpose of this article was to differentiate between the 3 most common confusions among older adults--delirium, dementia, and depression. In addition, this article discusses confusion seen postoperatively and post-ICU stay.

Clinical nurse specialist as change agent: delirium prevention and assessment project

PURPOSE/OBJECTIVES

The objective of this article is to address the role of the clinical nurse specialist (CNS) as a change agent in the implementation of a quality improvement program designed to prevent and assess delirium in ventilated patients at a community hospital.

BACKGROUND

Delirium is both a common condition that is not well recognized among patients in the intensive care unit (ICU) setting and a challenging problem to manage. Patients remain ventilated in ICU settings longer, and often, physical/occupational therapy is not started until after the patient is extubated; thus, the risk for delirium is high.

RATIONALE

The quality improvement program was implemented to recognize and decrease delirium in the critically ill patient. An understanding of the role of the CNS as the change agent provides a reference for other CNSs. The CNS's roles of communication, collaboration, and education in fulfilling the core competencies across the spheres of patient, nurse, and system are crucial when implementing lasting change.

DESCRIPTION

A review of the literature supports the use of the ABCDE Bundle to better manage pain, sedation, and delirium. The CNS uses Kurt Lewin's 3-step model of change to implement the quality improvement program.

OUTCOME

A CNS successfully implemented the ABCDE Bundle in a community hospital to improve the prevention and assessment of delirium in the ICU patient.

CONCLUSION

This project demonstrates the CNS's ability to implement a program to aid in the prevention and assessment of delirium in critically ill patients in the ICU.

IMPLICATIONS

The CNS's involvement as the change agent to implement the ABCDE Bundle is effective in the prevention and assessment of delirium in ventilated patients. The goal of the ABCDE Bundle is to extubate patients sooner and transfer them out of the ICU faster.

Potentially inappropriate medication use is associated with clinical outcomes in critically ill elderly patients with neurological injury

BACKGROUND

Limited data suggest that potentially inappropriate medications (PIMs) impact outcomes in critically ill elderly patients. No data are available on the association between PIM use as well as drug burden index (DBI), which is a measure of PIM use, and clinical outcomes in neurocritical care elderly patients. This study evaluates whether PIM use and a higher DBI are associated with poor clinical outcomes in neurocritical care elderly patients.

METHODS

PIMs were retrospectively identified in critically ill elderly patients admitted to the neuroscience intensive care unit (NSICU) from March to July 2011. DBI was calculated based on PIM doses. Relationships with clinical outcomes were evaluated.

RESULTS

PIMs were prescribed to a majority (81.3 %) of the 112 patients. Opioids were most commonly associated with a decrease in Richmond Agitation Sedation Scale (RASS) scores (56 % of PIM doses). Time to recovery was significantly longer in patients with a higher PIM burden (≤2 PIMs: 8 h, >2 PIMs: 29 h; p = 0.02). There was a significantly longer NSICU and hospital length of stay (9 vs 2; 15 vs 5 days; p < 0.0001) as well as a lower Glasgow Coma Scale score upon discharge (14 vs 15, p = 0.02) in patients with a higher DBI after 72 h of hospitalization. There was no difference in mortality.

CONCLUSIONS

PIM use and higher DBI scores were associated with poor clinical outcomes and longer lengths of stay. Further studies are needed to determine the impact of PIMs and DBI on mortality in neurocritical care elderly patients.

Incidence and prevention of delirium in critical care patients

Delirium in the intensive care unit is prevalent and a topic of high interest. Although it has been studied a great deal, screening, prevention, and management remain difficult. There are many causes of delirium and equally as many approaches to prevention and treatment. Two case studies sharing the challenges and successes of education, prevention, and treatment of delirium are presented in the context of complex adaptive systems.

Cornell Assessment of Pediatric Delirium: a valid, rapid, observational tool for screening delirium in the PICU*

OBJECTIVE

To determine validity and reliability of the Cornell Assessment of Pediatric Delirium, a rapid observational screening tool.

DESIGN

Double-blinded assessments were performed with the Cornell Assessment of Pediatric Delirium completed by nursing staff in the PICU. These ratings were compared with an assessment by consultation liaison child psychiatrist using the Diagnostic and Statistical Manual IV criteria as the "gold standard" for diagnosis of delirium. An initial series of duplicate Cornell Assessment of Pediatric Delirium assessments were performed in blinded fashion to assess interrater reliability. Nurses recorded the time required to complete the Cornell Assessment of Pediatric Delirium screen.

SETTING

Twenty-bed general PICU in a major urban academic medical center over a 10-week period, March-May 2012.

PATIENTS

One hundred eleven patients stratified over ages ranging from 0 to 21 years and across developmental levels.

INTERVENTION

Two hundred forty-eight paired assessments completed.

MEASUREMENTS AND MAIN RESULTS

The Cornell Assessment of Pediatric Delirium had an overall sensitivity of 94.1% (95% CI, 83.8-98.8%) and specificity of 79.2% (95% CI, 73.5-84.9%). Overall Cronbach's α of 0.90 was observed, with a range of 0.87-0.90 for each of the eight items, indicating good internal consistency. A scoring cut point of 9 demonstrated good interrater reliability of the Cornell Assessment of Pediatric Delirium when comparing results of the screen between nurses (overall κ = 0.94; item range κ = 0.68-0.78). In patients without significant developmental delay, sensitivity was 92.0% (95% CI, 85.7-98.3%) and specificity was 86.5% (95% CI, 75.4-97.6%). In developmentally delayed children, the Cornell Assessment of Pediatric Delirium showed decreased specificity of 51.2% (95% CI, 24.7-77.8%) but sensitivity remained high at 96.2% (95% CI, 86.5-100%). The Cornell Assessment of Pediatric Delirium takes less than 2 minutes to complete.

CONCLUSIONS

With an overall prevalence rate of 20.6% in our study population, delirium is a common problem in pediatric critical care. The Cornell Assessment of Pediatric Delirium is a valid, rapid, observational nursing screen that is urgently needed for the detection of delirium in PICU settings.

The psychogeriatric patient in the emergency room: focus on management and disposition

Background. The growing geriatric population in the United States (US) has prompted better understanding of treatment of the elderly in the hospital and emergency room (ER) settings. This study examines factors influencing the disposition of psychogeriatric patients after their initial presentation in the ER. Methods. Data was collected on patients 65 years of age or older arriving at the ER of a large urban hospital in the USA (January 2009–December 2010). Results. Of the total subjects (n = 95) included in the study, majority were females (66.3%) with an average age of 75.5 years. The chief complaint for psychogeriatric patients coming to the ER was delirium (61.6%). Caucasians were significantly more likely than African-American patients to get a psychiatric consult (33% versus 9%). Patients with delirium were less likely than patients with other psychiatric complaints to get a psychiatric consult in the ER (1.2% versus 47.2%) and less likely to be referred to a psychiatric inpatient unit compared to patients with other psychiatric complaints (2.4% versus 16.7%). Conclusion. Even though delirium is the most common reason for ER visits among psychogeriatric patients, very few delirium patients got a psychiatric consultation in the ER. A well-equipped geriatric psychiatry unit can manage delirium and associated causes.

A family approach to delirium: a review of the literature

OBJECTIVES

The literature was reviewed to gather original research on a family approach to delirium and determine its applicability to current practice. The review had the following objectives: (1) evaluate the current state of research into delirium management (prevention, identification, or treatment of delirium) with family approaches or involvement, (2) identify gaps and areas that require investigation, and (3) determine a future course of research.

METHOD

A comprehensive search of original research was conducted in six major databases using seven keywords in 2012.

RESULTS

The literature search yielded a total of 2160 articles. Criteria for eligibility were met by a total of 11 articles. The articles were evaluated in regards to purpose, sample, research design, level of evidence, variables, and results.

CONCLUSION

The literature review revealed that this topic is emergent and requires substantial additional research. The aspects of delirium care that researchers investigated were diverse and included bedside interventions (n = 3), screening strategies (n = 4), family education (n = 2), and care that employed multiple components (n = 2). Delirium outcomes improved significantly in two high-quality studies: one multi-component intervention and one bedside intervention program. Other noteworthy findings of lower quality studies warrant further examination. The review of the articles did not determine if the involvement of families in delirium management improves patient outcomes; however, the review revealed potential for program development and future courses of research.

Becoming part of the plan to help conquer Alzheimer's disease: the national Alzheimer's project act

Alzheimer's disease presents one of the largest challenges facing the aging population. The National Alzheimer's Project Act (NAPA) led to a national plan to engage health care team members in addressing this challenge. As nurse clinicians, educators, and researchers review the NAPA and resultant national plan, they can gain further direction in enhancing or expanding their roles to help stem the devastation of Alzheimer's disease.

Extending the ABCDE bundle to the post-intensive care unit setting

A recently proposed interprofessional, evidence-based, multicomponent approach to mitigating the effects of intensive care unit (ICU)-acquired delirium and weakness has the potential to radically transform the way care is delivered to older adults requiring sedation, mechanical ventilation, or both. The Awakening and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility (ABCDE) bundle empowers members of the interdisciplinary ICU team to implement the best available evidence regarding mechanical ventilation, sedation, weakness, and delirium in a safe, effective, and patient-centered manner. Considering that critically ill older adults are cared for in a number of different settings during the course of hospitalization and recovery, the purpose of this article is to explore the rationale and possible benefits of extending the ABCDE bundle into the post-ICU setting. We provide a case study that illustrates how ABCDE bundle adoption could be the key to improving the quality of care provided to seriously ill older adults in the ICU and beyond.