Delirium Prevention, Identification and Management in the Oncology Setting: A Unique Partnership with Patients and Their Family Caregivers

Significance & Background: Delirium affects a significant number of hospitalized adults each year resulting in negative patient outcomes and family caregiver distress. Clinical identification of delirium by nurses and use of family caregivers as part of a multicomponent delirium prevention strategy are not consistently implemented in the practice setting despite being best practice.Purpose: An interdisciplinary team in this 800 bed level one trauma center has been created to create and implement this best practice delirium protocol. The purpose of this initiative was to incorporate the family caregiver into this existing multicomponent delirium prevention, detection and management protocol. Interventions: Consistent implementation of basic care interventions and personalized care for at risk patients can help to prevent delirium in the acute care setting. The team has focused on staff education on the use of the CAM (confusion assessment method) as a consistent delirium-screening tool as well as early implementation of the protocol. Use of non-pharmacological interventions can be effective in the prevention of delirium as well as in reduction of the episode if it does occur. Family caregivers can be educated and engaged by the nurse to help create a personalized plan of care. Evaluation: Evaluation of the protocol has been measured by hospital safety and quality metrics such as falls, length of stay, mortality rates as well as patient experience scores.Discussion: Oncology patients are at high risk for delirium and require a team approach to identify this medical emergency early and to begin evidenced based interventions. Cancer care is most often done in the out patient setting making partnerships with family caregivers even more critical. Non-pharmacological interventions are simple and easily taught to family caregivers. These interventions include encouragement of food and drink, ambulation, cognitive stimulation/orienting strategies and protected rest. This opportunity of partnership is missed by nurses and contributes to poor outcomes.Innovative: The identification and treatment of delirium is becoming an international priority as its negative impact to quality of life and the bottom line become undeniable. This medical emergency requires a team approach that includes the family caregiver and a personalized plan of care. The oncology nurse is poised to be an important team member to create positive outcomes

Using Simulated Family Presence to Decrease Agitation in Older Hospitalized Delirious Patients: A Randomized Controlled Trial

Background: Simulated family presence has been shown to be an effective nonpharmacological intervention to reduce agitation in persons with dementia in nursing homes. Hyperactive or mixed delirium is a common and serious complication experienced by hospitalized patients, a key feature of which is agitation. Effective nonpharmacological interventions to manage delirium are needed. Objectives: To examine the effect of simulated family presence through pre-recorded video messages on the agitation level of hospitalized, delirious, acutely agitated patients. Design: Single site randomized control trial, 3 groups x 4 time points mixed factorial design conducted from July 2015 to March 2016. Setting: Acute care level one trauma center in an inner city of the state of Connecticut, USA. Participants: Hospitalized patients experiencing hyperactive or mixed delirium and receiving continuous observation were consecutively enrolled (n = 126), with 111 participants completing the study. Most were older, male, Caucasian, spouseless, with a pre-existing dementia. Methods: Participants were randomized to one of the following study arms: view a one minute family video message, view a one minute nature video, or usual care. Participants in experimental groups also received usual care. The Agitated Behavior Scale was used to measure the level of agitation prior to, during, immediately following, and 30 minutes following the intervention. Results: Both the family video and nature video groups displayed a significant change in median agitation scores over the four time periods (p \u3c .001), whereas the control group did not. The family video group had significantly lower median agitation scores during the intervention period (p \u3c .001) and a significantly greater proportion (94%) of participants experiencing a reduction in agitation from the pre-intervention to during intervention (p \u3c .001) than those viewing the nature video (70%) or those in usual care only (30%). The median agitation scores for the three groups were not significantly different at either of the post intervention time measurements. When comparing the proportion of participants experiencing a reduction in agitation from baseline to post intervention, there remained a statistically significant difference (p = .001) between family video(60%) and usual care (35.1%) immediately following the intervention Conclusion: This work provides preliminary support for the use of family video messaging as a nonpharmacological intervention that may decrease agitation in selected hospitalized delirious patients. Further studies are necessary to determine the efficacy of the intervention as part of a multi-component intervention as well as among younger delirious patients without baseline dementia

Using positive images to manage resistance-to-care and combative behaviors in nursing home residents with dementia: A pilot study.

This pilot study attempted to reduce resistance-to-care (RTC) and combative behaviors in nursing home residents with dementia by eliciting their positive affect. Four female residents with dementia were recruited from a nursing facility. Each resident was involved in one intervention trial and one control trial. The response of the residents was assessed by the Agitated Behavior Scale and the Observational Measurement of Engagement Tool. The distress level of the certified nursing assistants (CNAs) delivering the care was reported through the Distress Thermometer. Results showed that the residents displayed fewer behavioral symptoms in the intervention trial than in the control trial. The CNAs reported less distress in the intervention trial than in the control trial. These preliminary findings suggest that it might be feasible to use positive images to reduce residents' behavioral symptoms and decrease the distress of CNAs

Delirium: assessment and treatment of patients with cancer PART 2

Delirium at the end of life may present significant ethical dilemmas in clinical practice: whether to simply treat it in order to maximise symptom relief, with the resulting side effect being palliative sedation, or to attempt to reverse delirium and risk prolonging suffering. Determining whether the delirium can be reversed involves comprehensive assessment using established tools, which may or may not provide the answer to the question posed. This article examines the evidence surrounding several assessment tools that have been suggested as effective in identifying delirium, and the consequences of various approaches to the management of delirium in a patient with a cancer diagnosis. It also considers the impact delirium may have on the health professional and those close to the patient.N/

Incidence and correlates of delirium in a West African mental health clinic

Objective: <br/> <br/> To determine the incidence of delirium in those patients presenting to a psychiatric clinic in Nigeria and to examine if any demographic or clinical variables were correlated with this diagnosis. <br/> <br/> Method <br/> <br/> A prospective survey design; 264 consecutive new referrals to a psychiatric clinic in Nigeria were assessed for the presence of delirium using a standardised diagnostic scale. Data was analysed for normality and appropriate statistical test employed to examine the relationships between the presence of delirium and demographic and clinical variables. <br/> <br/> Results <br/> <br/> Of individuals presenting to the mental health clinics, 18.2% had delirium. No demographic variable was significant regarding the presence or absence of delirium. With regard to clinical variables duration of current symptoms, referral source and the presence of comorbid physical illness were significantly associated with the presence of delirium. Most delirium was due to infections. Nearly all patients with delirium were prescribed psychotropic medication (95.2%), and most attributed their symptoms to a spiritual cause.Conclusion(s) Delirium presents more commonly to psychiatry services in the less developed world compared to the West. Development efforts should focus on recognition and management of delirium to improve outcomes and maximise resource

The DSM-5 criteria, level of arousal and delirium diagnosis: Inclusiveness is safer

© 2014 European Delirium Association et al.; licensee BioMed Central Ltd. Background: Delirium is a common and serious problem among acutely unwell persons. Alhough linked to higher rates of mortality, institutionalisation and dementia, it remains underdiagnosed. Careful consideration of its phenomenology is warranted to improve detection and therefore mitigate some of its clinical impact. The publication of the fifth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-5) provides an opportunity to examine the constructs underlying delirium as a clinical entity.Discussion: Altered consciousness has been regarded as a core feature of delirium; the fact that consciousness itself should be physiologically disrupted due to acute illness attests to its clinical urgency. DSM-5 now operationalises 'consciousness' as 'changes in attention'. It should be recognised that attention relates to content of consciousness, but arousal corresponds to level of consciousness. Reduced arousal is also associated with adverse outcomes. Attention and arousal are hierarchically related; level of arousal must be sufficient before attention can be reasonably tested.Summary: Our conceptualisation of delirium must extend beyond what can be assessed through cognitive testing (attention) and accept that altered arousal is fundamental. Understanding the DSM-5 criteria explicitly in this way offers the most inclusive and clinically safe interpretation

Berührbarkeit : Krisen der Distanznahme bei Hans Blumenberg und Jacob Burckhardt

Der Artikel schlägt vor, die Frage nach dem Berühren indirekt, d.h. ausgehend von einer Unhaltbarkeit der Unbetroffenheit aufzugreifen. In 'Schiffbruch mit Zuschauer' diskutiert Hans Blumenberg den Verlust der Zuschauerposition als einen rezeptionsgeschichtlichen Umschlagpunkt. Entscheidend hierfür sind die von Jacob Burckhardt beschriebenen Aporien der Geschichtsschreibung im "Revolutionszeitalter". Ein Blick auf Burckhardts Metaphernkonstellationen kann zeigen, dass die beschriebene "Krisis" die Logik der großen historischen Instanzen gerade unberührt lässt. Demgegenüber lässt sich mit Blumenbergs bereits 1979 angekündigter 'Theorie der Unbegrifflichkeit' eine Variante möglichen Distanzverlusts erschließen, die sich keinem hintergründigen Spiel historisch wirksamer Kräfte, sondern der immanenten – und darin keineswegs ahistorischen – Destruktion der Leistung des Begriffs verdankt. Unter dem Titel der Berührbarkeit wird die Wiederkehr des Sinnlichen zunächst als eine Krise methodischer Sicherungen reformulierbar

Using Simulated Family Presence to Decrease Agitation in Hospitalized Delirious Patients

Purpose/Objectives: To examine the effect of family video messages on the agitation level of hospitalized, delirious, acutely agitated patients. To describe the patient and family responses to videos. Design Randomized control trial, three-group repeated measures. Method: Eligible patients and their family members were randomly assigned to the intervention (family video), attention control (nature video) or placebo group (usual care). The principal investigator (PI) made videos of family members of patients in the family video group and used a commercial nature video. The PI was notified when the patient was agitated at which time the PI inconspicuously videotaped the patient for a minute prior to initiating the intervention (family video, nature video or usual care) and for one minute during, immediately following, and 30 minutes after the intervention. An outcome assessor blinded to group assignment watched each patient\u27s four recordings that were presented in random order and scored the patient\u27s behavior using the Agitated Behavioral Scale (ABS). The PI observed the patient and family response to the video and documented these responses in a ledger. A research assistant watched the family videos and assigned the content as positive, neutral or negative