Developing and implementing an integrated delirium prevention system of care:a theory driven, participatory research study

Background: Delirium is a common complication for older people in hospital. Evidence suggests that delirium incidence in hospital may be reduced by about a third through a multi-component intervention targeted at known modifiable risk factors. We describe the research design and conceptual framework underpinning it that informed the development of a novel delirium prevention system of care for acute hospital wards. Particular focus of the study was on developing an implementation process aimed at embedding practice change within routine care delivery. Methods: We adopted a participatory action research approach involving staff, volunteers, and patient and carer representatives in three northern NHS Trusts in England. We employed Normalization Process Theory to explore knowledge and ward practices on delirium and delirium prevention. We established a Development Team in each Trust comprising senior and frontline staff from selected wards, and others with a potential role or interest in delirium prevention. Data collection included facilitated workshops, relevant documents/records, qualitative one-to-one interviews and focus groups with multiple stakeholders and observation of ward practices. We used grounded theory strategies in analysing and synthesising data. Results: Awareness of delirium was variable among staff with no attention on delirium prevention at any level; delirium prevention was typically neither understood nor perceived as meaningful. The busy, chaotic and challenging ward life rhythm focused primarily on diagnostics, clinical observations and treatment. Ward practices pertinent to delirium prevention were undertaken inconsistently. Staff welcomed the possibility of volunteers being engaged in delirium prevention work, but existing systems for volunteer support were viewed as a barrier. Our evolving conception of an integrated model of delirium prevention presented major implementation challenges flowing from minimal understanding of delirium prevention and securing engagement of volunteers alongside practice change. The resulting Prevention of Delirium (POD) Programme combines a multi-component delirium prevention and implementation process, incorporating systems and mechanisms to introduce and embed delirium prevention into routine ward practices. Conclusions: Although our substantive interest was in delirium prevention, the conceptual and methodological strategies pursued have implications for implementing and sustaining practice and service improvements more broadly

A novel computerized test for detecting and monitoring visual attentional deficits and delirium in the ICU

Objectives: Delirium in the ICU is associated with poor outcomes but is under-detected. Here we evaluated performance of a novel, graded test for objectively detecting inattention in delirium, implemented on a custom-built computerized device (Edinburgh Delirium Test Box–ICU). Design: A pilot study was conducted, followed by a prospective case-control study. Setting: Royal Infirmary of Edinburgh General ICU. Patients: A pilot study was conducted in an opportunistic sample of 20 patients. This was followed by a validation study in 30 selected patients with and without delirium (median age, 63 yr; range, 23–84) who were assessed with the Edinburgh Delirium Test Box–ICU on up to 5 separate days. Presence of delirium was assessed using the Confusion Assessment Method for the ICU. Measurements and Main Results: The Edinburgh Delirium Test Box–ICU involves a behavioral assessment and a computerized test of attention, requiring patients to count slowly presented lights. Thirty patients were assessed a total of 79 times (n = 31, 23, 15, 8, and 2 for subsequent assessments; 38% delirious). Edinburgh Delirium Test Box–ICU scores (range, 0–11) were lower for patients with delirium than those without at the first (median, 0 vs 9.5), second (median, 3.5 vs 9), and third (median, 0 vs 10.5) assessments (all p < 0.001). An Edinburgh Delirium Test Box–ICU score less than or equal to 5 was 100% sensitive and 92% specific to delirium across assessments. Longitudinally, participants’ Edinburgh Delirium Test Box–ICU performance was associated with delirium status. Conclusions: These findings suggest that the Edinburgh Delirium Test Box–ICU has diagnostic utility in detecting ICU delirium in patients with Richmond Agitation and Sedation Scale Score greater than –3. The Edinburgh Delirium Test Box–ICU has potential additional value in longitudinally tracking attentional deficits because it provides a range of scores and is sensitive to change

Educating Family Caregivers for Older Adults About Delirium: A Systematic Review

Background Delirium in older adults is considered a medical emergency; it contributes to a cascade of functional decline and to increased mortality. Early recognition of delirium symptoms is critical to prevent these negative consequences. Family caregivers who are educated about delirium could partner with nurses and other healthcare professionals in early recognition of delirium symptoms. Before implementing such partnership models, it is important to examine the effectiveness of educating family caregivers about delirium. Aims To examine whether providing education on delirium to family caregivers improved their knowledge, emotional state, or response in reducing the incidence of delirium in older adults. Methods For this systematic review, we conducted literature searches in CINAHL, Cochrane Library, Medline, PsycINFO, Web of Science, Social Sciences in ProQuest, Dissertations and Theses, and the Virginia Henderson Global Nursing eRepository for studies published in the English language between January 2000 and June 2015. Criteria for inclusion were: (a) primary focus on educating family caregivers for older adults about delirium; (b) use of experimental, quasi-experimental, or comparative design; (c) measured family caregiver outcomes of delirium knowledge, emotional state, or response in reducing delirium incidence in older adults; and (d) published in the English language. Articles were appraised using Melnyk\u27s rapid critical appraisal guides. Results Seven studies met the review criteria. Four studies found that family caregivers’ delirium knowledge increased; two noted that delirium incidence in older adults declined; and one study reported less distress following receipt of education. Linking Evidence to Action Providing family caregivers with information about delirium can be beneficial for both family caregivers and older adults. However, rigorous evaluation of education programs for family caregivers about delirium is needed

Bright light therapy as part of a multicomponent management program improves sleep and functional outcomes in delirious older hospitalized adults.

ObjectiveDelirium is associated with poor outcomes following acute hospitalization. A specialized delirium management unit, the Geriatric Monitoring Unit (GMU), was established. Evening bright light therapy (2000-3000 lux; 6-10 pm daily) was added as adjunctive treatment, to consolidate circadian activity rhythms and improve sleep. This study examined whether the GMU program improved sleep, cognitive, and functional outcomes in delirious patients.MethodA total of 228 patients (mean age = 84.2 years) were studied. The clinical characteristics, delirium duration, delirium subtype, Delirium Rating Score (DRS), cognitive status (Chinese Mini-Mental State Examination), functional status (modified Barthel Index [MBI]), and chemical restraint use during the initial and predischarge phase of the patient's GMU admission were obtained. Nurses completed hourly 24-hour patient sleep logs, and from these, the mean total sleep time, number of awakenings, and sleep bouts (SB) were computed.ResultsThe mean delirium duration was 6.7 ± 4.6 days. Analysis of the delirium subtypes showed that 18.4% had hypoactive delirium, 30.2% mixed delirium, and 51.3% had hyperactive delirium. There were significant improvements in MBI scores, especially for the hyperactive and mixed delirium subtypes (P < 0.05). Significant improvements were noted on the DRS sleep-wake disturbance subscore, for all delirium-subtypes. The mean total sleep time (7.7 from 6.4 hours) (P < 0.05) and length of first SB (6.0 compared with 5.3 hours) (P < 0.05) improved, with decreased mean number of SBs and awakenings. The sleep improvements were mainly seen in the hyperactive delirium subtype.ConclusionThis study shows initial evidence for the clinical benefits (longer total sleep time, increased first SB length, and functional gains) of incorporating bright light therapy as part of a multicomponent delirium management program. The benefits appear to have occurred mainly in patients with hyperactive delirium, which merits further in-depth, randomized controlled studies

Investigating speech and language impairments in delirium: a preliminary case-control study

<div><p>Introduction</p><p>Language impairment is recognized as as part of the delirium syndrome, yet there is little neuropsychological research on the nature of this dysfunction. Here we hypothesized that patients with delirium show impairments in language formation, coherence and comprehension.</p><p>Methods</p><p>This was a case-control study in 45 hospitalized patients (aged 65–97 years) with delirium, dementia without delirium, or no cognitive impairment (N = 15 per group). DSM-5 criteria were used for delirium. Speech was elicited during (1) structured conversational questioning, and (2) the "Cookie Theft" picture description task. Language comprehension was assessed through standardized verbal and written commands. Interviews were audio-recorded and transcribed.</p><p>Results</p><p>Delirium and dementia groups scored lower on the conversational assessment than the control group (p<0.01, moderate effect sizes (r) of 0.48 and 0.51, resp.). In the Cookie Theft task, the average length of utterances (i.e. unit of speech), indicating language productivity and fluency, distinguished patients with delirium from those with dementia (p<0.01, r = 0.50) and no cognitive impairment (p<0.01, r = 0.55). Patients with delirium performed worse on written comprehension tests compared to cognitively unimpaired patients (p<0.01, r = 0.63), but not compared to the dementia group.</p><p>Conclusions</p><p>Production of spontaneous speech, word quantity, speech content and verbal and written language comprehension are impaired in delirious patients compared to cognitively unimpaired patients. Additionally, patients with delirium produced significantly less fluent speech than those with dementia. These findings have implications for how speech and language are evaluated in delirium assessments, and also for communication with patients with delirium. A study limitation was that the delirium group included patients with co-morbid dementia, which precludes drawing conclusions about the specific language profile of delirium.</p></div

Perioperative Risk Factors for Postoperative Delirium in Patients Undergoing Esophagectomy

Background Postoperative delirium affects up to 50% of patients undergoing esophagectomy and is associated with negative outcomes. The perioperative risk factors for delirium in this population are not well understood. We conducted this study to assess perioperative risk factors for postoperative delirium among esophagectomy patients. Methods We performed a secondary data analysis of patients enrolled in a randomized controlled trial evaluating the efficacy of haloperidol prophylaxis postoperatively in reducing delirium among esophagectomy patients. Postoperative delirium was assessed twice daily using the Confusion Assessment Method for the ICU. Univariate and logistic regression analyses were performed to examine the association between perioperative variables and development of postoperative delirium. Results Of 84 consecutive esophagectomy patients, 27 (32%) developed postoperative delirium. Patients who developed postoperative delirium had higher APACHE II scores [22.1 (6.5) versus 17.4 (6.8); p=0.003], longer mechanical ventilation days [1.7 (1.4) versus 1.0 (1.1); p=0.001], and longer ICU days [5.1 (2.6) versus 2.6 (1.6); p<0.001]. In a logistic regression model, only ICU length of stay was found to have significant association with postoperative delirium [OR 1.65; 95% CI 1.21-2.25]. Conclusions ICU length of stay was significantly associated with postoperative delirium. Other perioperative factors including duration of surgery, blood loss, and hemoglobin levels were not significantly associated with postoperative delirium

Family Caregivers’ Knowledge of Delirium and Preferred Modalities for Receipt of Information

Delirium is a life-threatening, frequently reversible condition that is often a sign of an underlying health problem. In-hospital mortality alone for older adults with delirium ranges from 25% to 33%. Early recognition of delirium is critical because prolonged duration poses a greater risk of poor functional outcomes for older adults. Family caregivers, who are familiar with the older adult’s usual behaviors, are most likely to recognize delirium symptoms but might dismiss them as due to aging. It is important to learn what family caregivers know about delirium to ascertain their need for education. The aims of this study were to describe family caregivers’ knowledge of delirium and preferred modalities for receipt of information about delirium. A cross-sectional design was used for this study and a survey distributed to family caregivers for older adults. Analysis of 134 usable surveys indicated that family caregivers need and want information about delirium. The preferred modalities for receipt of information included Internet, in-person classes, and newsletters

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

Objective: &lt;br/&gt; &lt;br/&gt; 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. &lt;br/&gt; &lt;br/&gt; Method &lt;br/&gt; &lt;br/&gt; 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. &lt;br/&gt; &lt;br/&gt; Results &lt;br/&gt; &lt;br/&gt; 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

Early Delirium Assessment for Hospitalized Older People in Indonesia: a Systematic Review

Background: Due to the increasing risk of getting co-morbidity and frailty, older people tend to be prone to hospitalization. Hospitalization in older people brings many adverse effects. Moreover, when these elderly get delirium, the mortality and morbidity will increase. The risk of getting deterioration and worsening condition because of delirium would also increase. In fact, delirium assessment is not a high priority in taking care older people during hospitalization because the focus of care is treating the disease.Delirium screening as an early recognition of delirium in the hospitalized elderly inIndonesia remains unreported and even do not well evaluated. Therefore, delirium as a preventable problem or causing problems remains unrecognized.Purpose: This paper aims to review the current evidence of early assessment of delirium in hospitalized older people.Methods: A systematic review was conducted from four databases yielding to 4 articles which met the inclusion and exclusion criteria.Results: There are four focuses on the result, namely delirium screening tools, patient characteristics, identified early delirium assessment, and outcomes affected by early delirium assessment. Confusion Assessment Method (CAM) was used as the delirium screening tool in the hospital. Establishing the care team involving many disciplines will give a better way to improve the integrated care and collaborative care.Conclusion: Performing CAM integrated into comprehensive geriatric assessment can be the most important thing to be undertaken when looking after the hospitalized elderly

Evaluation of delirium screening tools in geriatric medical inpatients: a diagnostic test accuracy study

Introduction: screening all unscheduled older adults for delirium is recommended in national guidelines, but there is no consensus on how to perform initial assessment. Aim: to evaluate the test accuracy of five brief cognitive assessment tools for delirium diagnosis in routine clinical practice. Methods: a consecutive cohort of non-elective, elderly care (older than 65 years) hospital inpatients admitted to a geriatric medical assessment unit of an urban teaching hospital. Reference assessments were clinical diagnosis of delirium performed by elderly care physicians. Routine screening tests were: Abbreviated Mental Test (AMT-10, AMT-4), 4 A's Test (4AT), brief Confusion Assessment Method (bCAM), months of the year backwards (MOTYB) and informant Single Question in Delirium (SQiD). Results: we assessed 500 patients, mean age 83 years (range = 66−101). Clinical diagnoses were: 93 of 500 (18.6%) definite delirium, 104 of 500 (20.8%) possible delirium and 277 of 500 (55.4%) no delirium; 266 of 500 (53.2%) were identified as definite or possible dementia. For diagnosis of definite delirium, AMT-4 (cut-point &lt; 3/4) had a sensitivity of 92.7% (95% confidence interval (CI): 84.8–97.3), with a specificity of 53.7% (95% CI: 48.1–59.2); AMT-10 (&lt;4/10), MOTYB (&lt;4/12) and SQiD showed similar performance. bCAM had a sensitivity of 70.3% (95% CI: 58.5–80.3) with a specificity of 91.4% (95% CI: 87.7–94.3). 4AT (&gt;4/12) had a sensitivity of 86.7% (95% CI: 77.5–93.2) and specificity of 69.5% (95% CI: 64.4–74.3). Conclusions: short screening tools such as AMT-4 or MOTYB have good sensitivity for definite delirium, but poor specificity; these tools may be reasonable as a first stage in assessment for delirium. The 4AT is feasible and appears to perform well with good sensitivity and reasonable specificity