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Fenta E, Teshome D, Kibret S, Hunie M, Tiruneh A, Belete A, Molla A, Dessie B, Geta K. Incidence and risk factors of postoperative delirium in elderly surgical patients 2023. Sci Rep 2025; 15:1400. [PMID: 39789093 PMCID: PMC11718272 DOI: 10.1038/s41598-024-84554-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 12/24/2024] [Indexed: 01/12/2025] Open
Abstract
Postoperative delirium has the potential to impact individuals of all age groups, with a significant emphasis on the elderly population. Its presence leads to an increase in surgical morbidity and mortality rates, as well as a notable prolongation of hospital stays. However, there is a lack of research regarding the prevalence, risk factors, and implications of postoperative delirium in developing nations like Ethiopia, which affects both patients and healthcare institutions. An observational study was conducted at hospitals in the South Gondar Zone to diagnose postoperative delirium in the Post-Anesthesia Care Unit (PACU) using the Nursing Delirium Screening Scale. Both bivariable and multivariable logistic regression techniques were employed to analyze the association between independent factors and postoperative delirium. The strength of the association was indicated by the odds ratio with a 95% confidence interval (CI). Any p-values below 0.05 were considered statistically significant. The incidence of postoperative delirium was determined to be 41%. In the multivariate logistic regression analysis, several factors were identified as significantly associated with postoperative delirium. These factors include an age of 75 or older (AOR, 11.24; 95% CI, 4.74-26.65), ASA-PS IV (AOR, 3.25; 95% CI, 1.81-5.85), severe functional impairment of activities of daily living (AOR, 3.29; 95% CI, 1.06-10.20), premedication with benzodiazepine (AOR, 4.61; 95% CI, 2.48-8.57), intraoperative estimated blood loss exceeding 1000 ml (AOR, 2.74; 95% CI, 1.50-4.98), and intraoperative ketamine use (AOR, 3.84; 95% CI, 2.21-6.68). Additionally, postoperative delirium was found to significantly prolong the duration of stay in the post-anesthesia care unit (PACU) and the length of hospital stay (p-value < 0.05). Patients aged 75 or older, ASA-PS IV, experiencing severe functional impairment of ADL, patients premedicated with benzodiazepine, patients with intraoperative estimated blood loss exceeding 1000 ml, and intraoperative ketamine use were identified as risk factors for post-operative delirium.
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Affiliation(s)
- Efrem Fenta
- Department of Anesthesia, College of Health Sciences, Debre Tabor University, PO. Box: 272, Debre Tabor, Ethiopia
| | - Diriba Teshome
- Department of Anesthesia, College of Health Sciences, Debre Tabor University, PO. Box: 272, Debre Tabor, Ethiopia
| | - Simegnew Kibret
- Department of Anesthesia, College of Health Sciences, Debre Tabor University, PO. Box: 272, Debre Tabor, Ethiopia
| | - Metages Hunie
- Department of Anesthesia, College of Health Sciences, Debre Tabor University, PO. Box: 272, Debre Tabor, Ethiopia
| | - Abebe Tiruneh
- Department of Anesthesia, College of Health Sciences, Debre Tabor University, PO. Box: 272, Debre Tabor, Ethiopia
| | - Amsalu Belete
- Department of Psychiatry, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Amsalu Molla
- Department of Surgery, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Belayneh Dessie
- Department of Emergency Medicine, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Kumlachew Geta
- Department of Anesthesia, College of Health Sciences, Debre Tabor University, PO. Box: 272, Debre Tabor, Ethiopia.
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Zhao Q, Liu S, Zhao H, Dong L, Zhu X, Liu J. Non-pharmacological interventions to prevent and treat delirium in older people: An overview of systematic reviews. Int J Nurs Stud 2023; 148:104584. [PMID: 37826889 DOI: 10.1016/j.ijnurstu.2023.104584] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 07/30/2023] [Accepted: 08/02/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND As advanced age is a major risk factor for confusion status, delirium has become prevalent in the older population, contributing to longer hospital stays, cognitive impairment, and higher risks of complications and mortality. Compared with pharmacological methods, non-pharmacological interventions are preferred and are recommended by the National Institute for Health and Care Excellence for the prevention of delirium. Numerous systematic reviews and meta-analyses have been carried out to investigate the effects of non-pharmacological interventions. However, the outcomes were diverse and the quality varied widely, making it challenging to draw firm conclusions from the evidence. OBJECTIVE To summarize the contents and evaluate the effects of non-pharmacological interventions to prevent and treat delirium among older people. DESIGN Overview of systematic reviews. METHODS A comprehensive literature search was conducted in Medline, Cochrane Library, EMBASE, CINAHL, PsycINFO, JBI EBP Database, China's SinoMed, CNKI, and Wangfang databases from inception to 2nd December 2022. Two reviewers performed the study selection, quality appraisal, and data extraction independently. The AMSTAR 2 tool was used to appraise the methodological quality of eligible reviews. The results were presented in narrative synthesis based on types of intervention, including multicomponent and single-component interventions. RESULTS Twenty-four systematic reviews were included in this overview, of which four reviews were of high quality. Multicomponent interventions were the most widely disseminated non-pharmacological strategy, which were effective in preventing delirium with 27 %-54 % reduction in delirium incidence. Additionally, the multicomponent strategy also reduced the incidence of falls and pressure ulcers, and showed trends toward shortening the length of stay and improving cognitive function. Among single-component interventions, physical training, geriatric risk assessment, and reorientation protocol revealed positive effects in delirium prevention. However, the effectiveness of non-pharmacological interventions for treating delirium was limited, and while multicomponent methods had inconsistent impacts on the duration and severity of delirium, single-component methods showed no significant impact. CONCLUSION Non-pharmacological interventions are effective in reducing the incidence of delirium and improving other health outcomes among older patients. However, the effects on the duration and severity of delirium need more evidence to confirm. REGISTRATION NUMBER CRD42022376651 in PROSPERO.
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Affiliation(s)
- Qin Zhao
- Nursing Department, The Third Xiangya Hospital of Central South University, Changsha, China; Xiangya Nursing School, Central South University, Changsha, China
| | - Shan Liu
- College of Nursing and Public Health, Adelphi University 1 South Ave., Garden City, NY, USA
| | - Hongyu Zhao
- Xiangya Nursing School, Central South University, Changsha, China
| | - Lei Dong
- Xiangya Nursing School, Central South University, Changsha, China
| | - Xiao Zhu
- Nursing Department, The Third Xiangya Hospital of Central South University, Changsha, China; Xiangya Nursing School, Central South University, Changsha, China; Research Center of Chinese Health Ministry on Transplantation Medicine Engineering and Technology, Changsha, China
| | - Jia Liu
- Nursing Department, The Third Xiangya Hospital of Central South University, Changsha, China; Xiangya Nursing School, Central South University, Changsha, China; Research Center of Chinese Health Ministry on Transplantation Medicine Engineering and Technology, Changsha, China.
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Matsuda KI, Watanuki S. Correlates of delirium care competency among shift leader nurses in acute medical wards in Japan: A cross-sectional study. Jpn J Nurs Sci 2023; 20:e12551. [PMID: 37402502 DOI: 10.1111/jjns.12551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/12/2023] [Accepted: 06/04/2023] [Indexed: 07/06/2023]
Abstract
AIM This study identified the correlates of delirium care competency among shift leader nurses in acute medical wards in Japan. METHODS A cross-sectional study was conducted from November 2019 to February 2020. We sent request letters to a random sample of 381 general acute care hospitals in Japan. Of these, 68 agreed to participate and distributed 735 self-administered questionnaires to shift leader nurses working in their acute medical wards. The questionnaire included the Self-rated Delirium Care Competency Scale for Shift Leader Nurses in Acute Medical Wards (DCSL-M), developed by the authors. It gathered data on the respondents' demographics and delirium care competency, and investigated a total of 25 variables. We calculated descriptive statistics and examined associations between delirium care competency and the demographics using multiple logistic regression analysis. RESULTS Of the total, 301 (40.9%) questionnaires were returned. Delirium care competency was high among shift leader nurses who: (1) had experience as a clinical practice preceptor for nursing students; (2) had experience attending training related to dementia or delirium care; (3) worked at a hospital/ward that charged additional medical fees for dementia care; and (4) had access to consulting psychiatrists to refer patients with delirium. CONCLUSIONS The results suggest the need for efforts to improve delirium care competency among shift leader nurses who work in hospitals that do not charge additional medical fees for dementia care or that do not have consulting psychiatrists to refer patients with delirium.
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Bilek AJ, Richardson D. Post-stroke delirium and challenges for the rehabilitation setting: A narrative review. J Stroke Cerebrovasc Dis 2023; 32:107149. [PMID: 37245495 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 04/19/2023] [Accepted: 04/20/2023] [Indexed: 05/30/2023] Open
Abstract
INTRODUCTION Post-stroke delirium (PSD) is a common yet underrecognized complication following stroke, with its effect on stroke rehabilitation being the subject of limited attention. The objective of this narrative review is to provide an overview of core issues in PSD including epidemiology, diagnostic challenges, and management considerations, with an emphasis on the rehabilitation phase. METHODS Ovid Medline and Google Scholar were searched through February 2023 using keywords related to delirium, rehabilitation, and the post-stroke period. Only studies conducted on adults (≥18 years) and written in the English language were included. RESULTS PSD affects approximately 25% of stroke patients, and often persists well into the post-acute phase, with a negative impact on rehabilitation outcomes including lengths of stay, function, and cognition. Certain stroke and patient characteristics can help predict risk for PSD. The diagnosis of delirium becomes more challenging when superimposed on stroke deficits (such as attentional impairment or other cognitive, psychiatric, or behavioural disorders), leading to underdiagnosis, overdiagnosis, or misdiagnosis. Particularly in patients with post-stroke language or cognitive disorders, common screening tools are less accurate. The multidisciplinary rehabilitation team should be involved in management of PSD as rehabilitative activities can be beneficial for patients who can participate safely. Addressing barriers to effective delirium care at various levels of the health care system can improve rehabilitation trajectories for these patients. CONCLUSIONS PSD is a disease entity commonly encountered in the rehabilitation setting, but it is challenging to diagnose and manage. New delirium screening tools and management approaches specific for the post-stroke and rehabilitation settings are needed.
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Affiliation(s)
- Aaron Jason Bilek
- Geriatric Rehabilitation Department, Tel Aviv Sourasky Medical Centre, Tel Aviv, Israel.
| | - Denyse Richardson
- Professor, Clinician Educator, and Department Head, Department of Physical Medicine and Rehabilitation, Queen's University and Providence Care Hospital, Kingston, Canada
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Martínez-García M, Sánchez-López E, Fernández-Trinidad M. Managing delirium in acute inpatient units: A cross-sectional study of nursing teams' knowledge and perceived limitations. Nurs Open 2023; 10:2213-2221. [PMID: 36379912 PMCID: PMC10006588 DOI: 10.1002/nop2.1471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 10/05/2022] [Accepted: 10/29/2022] [Indexed: 11/17/2022] Open
Abstract
AIM The aim of the study was to describe nursing teams' theoretical knowledge of delirium and their perceptions of the way in which it is handled in acute inpatient units. DESIGN This is a descriptive cross-sectional study using a questionnaire comprising ten questions on knowledge and seven on perception. METHODS The sample consisted of 216 professionals working at a hospital complex in Madrid, Spain. Descriptive and non-parametric bivariate analyses were performed for a p < .05. RESULTS Fifty-three point two per cent of staff possessed sufficient theoretical knowledge, and this figure rose significantly among professionals with more years of experience. Areas for improvement in theoretical knowledge included the use of therapeutic immobilization, screening scale, subtypes of delirium and precipitating factors. Sixty-eight point five per cent of staff perceived their knowledge as fair, 50% agreed that delirium was underdiagnosed and 48.1% agreed that preventive measures were only occasionally taken. Perceived barriers included lack of training, work overload, ineffective coordination and lack of standardized protocols.
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Affiliation(s)
- Marta Martínez-García
- Hospital Universitario Infanta Leonor, Madrid, Spain.,Facultad de Enfermería Fisioterapia y Podología, Universidad Complutense de Madrid, Madrid, Spain
| | | | - Miriam Fernández-Trinidad
- Hospital Universitario Infanta Leonor, Madrid, Spain.,Facultad de Enfermería Fisioterapia y Podología, Universidad Complutense de Madrid, Madrid, Spain
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[Delirium in the context of intensive care medicine-Part 2: diagnosis, prevention and treatment]. DER NERVENARZT 2023; 94:99-105. [PMID: 36269366 DOI: 10.1007/s00115-022-01399-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/05/2022] [Indexed: 02/04/2023]
Abstract
Despite the high prevalence and the enormous medical and health economic impact, delirium syndromes are often underdiagnosed, which is mainly attributable to the high frequency of hypoactive delirium and to the frequently subtle and fluctuating psychopathology in the initial phase of delirium. These aspects also justify the need for a consequent and continuous application of standardized screening tools to detect delirium as early as possible. A multidimensional, nonpharmacological prevention of delirium is effective and still underutilized in the clinical practice. So far, there are no consensus recommendations regarding the pharmacological prevention of delirium. From a therapeutic perspective a causal approach is prioritized. Pharmacological treatment of delirium can only be considered under strict observance of specific indicators. When treating non-withdrawal-related delirium benzodiazepines should be avoided.
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Igarashi M, Okuyama K, Ueda N, Sano H, Takahashi K, P Qureshi Z, Tokita S, Ogawa A, Okumura Y, Okuda S. Incremental medical cost of delirium in elderly patients with cognitive impairment: analysis of a nationwide administrative database in Japan. BMJ Open 2022; 12:e062141. [PMID: 36521906 PMCID: PMC9756163 DOI: 10.1136/bmjopen-2022-062141] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Delirium is a neuropsychiatric disorder that commonly occurs in elderly patients with cognitive impairment. The economic burden of delirium in Japan has not been well characterised. In this study, we assessed incremental medical costs of delirium in hospitalised elderly Japanese patients with cognitive impairment. DESIGN Retrospective, cross-sectional, observational study. SETTING Administrative data collected from acute care hospitals in Japan between April 2012 and September 2020. PARTICIPANTS Hospitalised patients ≥65 years old with cognitive impairment were categorised into groups-with and without delirium. Delirium was identified using a delirium identification algorithm based on the International Classification of Diseases 10th Revision codes or antipsychotic prescriptions. OUTCOME MEASURES Total medical costs during hospitalisation were compared between the groups using a generalised linear model. RESULTS The study identified 297 600 hospitalised patients ≥65 years of age with cognitive impairment: 39 836 had delirium and 257 764 did not. Patient characteristics such as age, sex, inpatient department and comorbidities were similar between groups. Mean (SD) unadjusted total medical cost during hospitalisation was 979 907.7 (871 366.4) yen for patients with delirium and 816 137.0 (794 745.9) yen for patients without delirium. Adjusted total medical cost was significantly greater for patients with delirium compared with those without delirium (cost ratio=1.09, 95% CI: 1.09 to 1.10; p<0.001). Subgroup analyses revealed significantly higher total medical costs for patients with delirium compared with those without delirium in most subgroups except patients with hemiplegia or paraplegia. CONCLUSIONS Medical costs during hospitalisation were significantly higher for patients with delirium compared with those without delirium in elderly Japanese patients with cognitive impairment, regardless of patient subgroups such as age, sex, intensive care unit admission and most comorbidities. These findings suggest that delirium prevention strategies are critical to reducing the economic burden as well as psychological/physiological burden in cognitively impaired elderly patients in Japan.
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Affiliation(s)
| | | | | | | | | | - Zaina P Qureshi
- Center for Observational and Real-world Evidence (CORE), Merck & Co, Inc, Rahway, New Jersey, USA
| | | | - Asao Ogawa
- Division of Psycho-Oncology, Exploratory Oncology Research and Clinical Trial Center, National Cancer Center, Chiba, Japan
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Cations M, Wilton-Harding B, Laver KE, Brodaty H, Low LF, Collins N, Lie D, McKellar D, Macfarlane S, Draper B. Psychiatric service delivery for older people in hospital and residential aged care: An updated systematic review. Aust N Z J Psychiatry 2022; 57:811-833. [PMID: 36317325 DOI: 10.1177/00048674221134510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To review studies reporting on the effectiveness of psychiatry service delivery for older people and people with dementia in hospital and residential aged care. METHODS A systematic search of four databases was conducted to obtain peer-reviewed literature reporting original research published since June 2004 evaluating a psychiatry service for older people (aged 60 years and over) or people with dementia in inpatient or residential aged care settings. RESULTS From the 38 included studies, there was consistent low-to-moderate quality evidence supporting the effectiveness of inpatient older persons' mental health wards (n = 14) on neuropsychiatric symptoms, mood, anxiety and quality of life. Inpatient consultation/liaison old age psychiatry services (n = 9) were not associated with improved depression, quality of life or mortality in high-quality randomised studies. However, low-quality evidence demonstrated improved patient satisfaction with care and reduced carer stress. The highest quality studies demonstrated no effect of psychiatric in-reach services to residential aged care (n = 9) on neuropsychiatric symptoms but a significant reduction in depressive symptoms among people with dementia. There was low-quality evidence that long-stay intermediate care wards (n = 6) were associated with reduced risk for dangerous behavioural incidents and reduced costs compared to residential aged care facilities. There was no effect of these units on neuropsychiatric symptoms or carer stress. CONCLUSIONS AND IMPLICATIONS The scarcity of high-quality studies examining the effectiveness of old age psychiatry services leaves providers and policy-makers to rely on low-quality evidence when designing services. Future research should consider carefully which outcomes to include, given that staff skill and confidence, length of stay, recommendation uptake, patient- and family-reported experiences, and negative outcomes (i.e. injuries, property damage) are as important as clinical outcomes.
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Affiliation(s)
- Monica Cations
- College of Education, Psychology and Social Work, Flinders University, Adelaide, SA, Australia
| | - Bethany Wilton-Harding
- College of Education, Psychology and Social Work, Flinders University, Adelaide, SA, Australia
| | - Kate E Laver
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Henry Brodaty
- Centre for Healthy Brain Ageing, Discipline of Psychiatry & Mental Health, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia.,Discipline of Psychiatry & Mental Health, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
| | - Lee-Fay Low
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Noel Collins
- Great Southern Mental Health Service, Albany, WA, Australia.,West Australian Country Health Service, Albany, WA, Australia.,The Rural Clinical School of Western Australia, The University of Western Australia, Albany, WA, Australia
| | - David Lie
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia.,The University of Queensland, Brisbane, QLD, Australia
| | - Duncan McKellar
- Northern Adelaide Local Health Network, SA Health, Adelaide, SA, Australia.,Office of the Chief Psychiatrist, SA Health, Adelaide, SA, Australia
| | - Steve Macfarlane
- Department of Psychiatry, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Brian Draper
- Discipline of Psychiatry & Mental Health, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
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Improving Delirium Assessments in Vanderbilt Pediatric and Pediatric Cardiovascular Intensive Care Units. Pediatr Qual Saf 2022; 7:e577. [PMID: 35919397 PMCID: PMC9278948 DOI: 10.1097/pq9.0000000000000577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 06/10/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction: Delirium is a disturbance of attention and awareness that represents a change from baseline mental status. Accurate diagnosis of delirium is of paramount importance to improving the management of pediatric delirium in the intensive care unit. Despite ongoing education, inconsistencies in delirium assessments occur. Here, we aimed to determine the extent of the problem and increase compliance with delirium assessments. Methods: We collected preintervention data to assess baseline compliance of delirium assessments in the Pediatric Intensive Care Unit (PICU) and Pediatric Cardiac Intensive Care Unit (PCICU) at Monroe Carell Jr Children’s Hospital at Vanderbilt in November 2020. We executed 2 Plan-Do-Study-Act cycles with different interventions and collected data after each and approximately 1 year after the interventions. The first intervention consisted of virtual lectures on delirium assessments for the nursing staff. The second intervention included an educational handout and a new electronic medical record documentation tool. Results: Five hundred five individual nurse-patient encounters were assessed and collected throughout the project. The mean compliance of delirium documentation before the interventions was 52.5%. Target compliance after interventions was 70%. Mean compliance was 70% after cycle 1, 78% after cycle 2, and 86% in March 2022. Conclusions: Using pre- and postintervention data from chart reviews and nurse interviews regarding delirium screenings, we found that interventions targeting nurse education and EMR flowsheet improved compliance with delirium assessment and documentation in the PICU and PCICU. Future work should focus on assessing the clinical implications of this project in diagnosing and treating delirium.
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Deeken F, Sánchez A, Rapp MA, Denkinger M, Brefka S, Spank J, Bruns C, von Arnim CAF, Küster OC, Conzelmann LO, Metz BR, Maurer C, Skrobik Y, Forkavets O, Eschweiler GW, Thomas C. Outcomes of a Delirium Prevention Program in Older Persons After Elective Surgery: A Stepped-Wedge Cluster Randomized Clinical Trial. JAMA Surg 2022; 157:e216370. [PMID: 34910080 PMCID: PMC8674802 DOI: 10.1001/jamasurg.2021.6370] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 10/05/2021] [Indexed: 12/19/2022]
Abstract
Importance Delirium significantly worsens elective surgery outcomes and costs. Delirium risk is highest in elderly populations, whose surgical health care resource consumption (50%) exceeds their demographic proportion (15% to 18%) in high-resource countries. Effective nonpharmacologic delirium prevention could safely improve care in these vulnerable patients, but data from procedure-specific studies are insufficiently compelling to drive changes in practice. Delirium prevention approaches applicable to different surgical settings remain unexplored. Objective To examine whether a multifaceted prevention intervention is effective in reducing postoperative delirium incidence and prevalence after various major surgical procedures. Design, Setting, and Participants This stepped-wedge cluster randomized trial recruited 1470 patients 70 years and older undergoing elective orthopedic, general, or cardiac surgery from November 2017 to April 2019 from 5 German tertiary medical centers. Data were analyzed from December 2019 to July 2021. Interventions First, structured delirium education was provided to clinical caregivers at each site. Then, the study delirium prevention team assessed patient delirium risk factors and symptoms daily. Prevention was tailored to individual patient needs and could include: cognitive, motor, and sensory stimulation; meal companionship; accompaniment during diagnostic procedures; stress relaxation; and sleep promotion. Main Outcomes and Measures Postoperative delirium incidence and duration. Results Of 1470 included patients, 763 (51.9%) were male, and the median (IQR) age was 77 (74-81) years. Overall, the intervention reduced postoperative delirium incidence (odds ratio, 0.87; 95% CI, 0.77-0.98; P = .02) and percentage of days with delirium (intervention, 5.3%; control, 6.9%; P = .03). The effect was significant in patients undergoing orthopedic or abdominal surgery (odds ratio, 0.59; 95% CI, 0.35-0.99; P = .047) but not cardiac surgery (odds ratio, 1.18; 95% CI, 0.70-1.99; P = .54). Conclusions and Relevance This multifaceted multidisciplinary prevention intervention reduced postoperative delirium occurrence and days with delirium in older patients undergoing different elective surgical procedures but not cardiac procedures. These results suggest implementing this delirium prevention program will improve care and outcomes in older patients undergoing elective general and orthopedic procedures.
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Affiliation(s)
- Friederike Deeken
- Department of Social and Preventive Medicine, University of Potsdam, Potsdam, Germany
| | - Alba Sánchez
- Department of Social and Preventive Medicine, University of Potsdam, Potsdam, Germany
| | - Michael A. Rapp
- Department of Social and Preventive Medicine, University of Potsdam, Potsdam, Germany
- Social and Preventive Medicine, Department of Sports and Health Sciences, Intrafaculty Unit of Cognitive Sciences, Faculty of Human Science, and Faculty of Health Sciences Brandenburg, Research Area Services Research and e-Health, University of Potsdam, Potsdam, Germany
| | - Michael Denkinger
- Agaplesion Bethesda Clinic Ulm, Institute for Geriatric Research, Ulm University, Geriatric Center Ulm, Ulm, Germany
| | - Simone Brefka
- Agaplesion Bethesda Clinic Ulm, Institute for Geriatric Research, Ulm University, Geriatric Center Ulm, Ulm, Germany
- Department of Cardiothoracic and Vascular Surgery, Ulm University Hospital, Ulm, Germany
| | - Juliane Spank
- Department of Geriatric Psychiatry and Psychotherapy, Klinikum Stuttgart, Stuttgart, Germany
| | - Carola Bruns
- Department of Geriatric Psychiatry and Psychotherapy, Klinikum Stuttgart, Stuttgart, Germany
| | - Christine A. F. von Arnim
- Division of Geriatrics, University Medical Center Goettingen, Göttingen, Germany
- Department of Neurology, University Hospital Ulm, Ulm, Germany
| | | | | | - Brigitte R. Metz
- Geriatric Center Karlsruhe, ViDia Christian Clinics Karlsruhe, Karlsruhe, Germany
| | - Christoph Maurer
- Center for Geriatrics and Gerontology, Medical Center University of Freiburg, Freiburg, Germany
| | - Yoanna Skrobik
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Oksana Forkavets
- Department of Neurology, University Hospital Ulm, Ulm, Germany
- Geriatric Center at the University Hospital Tübingen, Tübingen, Germany
| | - Gerhard W. Eschweiler
- Geriatric Center at the University Hospital Tübingen, Tübingen, Germany
- Department of Psychiatry and Psychotherapy, University Hospital of Tübingen, Tübingen, Germany
| | - Christine Thomas
- Department of Geriatric Psychiatry and Psychotherapy, Klinikum Stuttgart, Stuttgart, Germany
- Department of Psychiatry and Psychotherapy, University Hospital of Tübingen, Tübingen, Germany
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Young J, Green J, Godfrey M, Smith J, Cheater F, Hulme C, Collinson M, Hartley S, Anwar S, Fletcher M, Santorelli G, Meads D, Hurst K, Siddiqi N, Brooker D, Teale E, Brown A, Forster A, Farrin A, Inouye S. The Prevention of Delirium system of care for older patients admitted to hospital for emergency care: the POD research programme including feasibility RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2021. [DOI: 10.3310/pgfar09040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
Delirium is a distressing, common and serious condition in older people in hospital. Evidence suggests that it could be prevented in about one-third of patients using multicomponent interventions targeting delirium risk factors, but these interventions are not yet routinely available in the NHS.
Objective
The objective was to improve delirium prevention for older people admitted to the NHS.
Design
Project 1 comprised case studies employing qualitative methods (observation, interviews, workshops) in three NHS hospitals to develop the Prevention of Delirium system of care. Project 2 comprised case studies using mixed methods in five NHS hospitals to test the Prevention of Delirium implementation, feasibility and acceptability, and to modify the Prevention of Delirium system of care. Project 3 comprised a multicentre, cluster randomised, controlled, pragmatic feasibility study in eight hospitals, with embedded economic evaluation, to investigate the potential clinical effectiveness and cost-effectiveness of the Prevention of Delirium system of care, compared with standard care, among older patients admitted to hospital for emergency care. The primary objectives related to gathering information to design a definitive trial. Criteria for progression to a definitive trial were as follows: a minimum of six wards (75%) completing the Prevention of Delirium manual milestone checklist and an overall recruitment rate of at least 10% of the potential recruitment pool.
Setting
This study was set in NHS general hospitals.
Participants
In project 1, participants were staff, volunteers, and patient and carer representatives. In project 2, participants were staff, volunteers, patients and carers. In project 3, participants were older patients admitted to elderly care and orthopaedic trauma wards.
Intervention
The developed intervention (i.e. the Prevention of Delirium system of care).
Main outcome measures
For the feasibility study (project 3), the primary outcome measure was the Confusion Assessment Method. The secondary outcome measures were the Nottingham Extended Activities of Daily Living scale, the Clinical Anxiety Scale and the Geriatric Depression Scale Short Form.
Results
Project 1: understanding of delirium prevention was poor. Drawing on evidence, and working with ward teams, we developed the Prevention of Delirium system of care, which targeted 10 delirium risk factors. This multicomponent intervention incorporated systems and mechanisms to introduce and embed delirium prevention into routine ward practices. Project 2: five out of six wards implemented or partially implemented the Prevention of Delirium intervention. A prominent role for hospital volunteers was intended, but most wards were unable to recruit or sustain the numbers needed. We identified four conditions necessary to implement and deliver the Prevention of Delirium intervention: (1) commitment of senior nurse, (2) a named person to drive implementation forward, (3) dedicated time (1 day per week) of an experienced nurse to lead implementation and (4) adequate ward staffing levels. Overall, the intervention was acceptable to staff, volunteers, patients and carers, and did not increase nursing staff workload. In the light of these findings, the Prevention of Delirium system of care was modified for use in project 3. Project 3: 16 wards in eight hospitals (two wards per hospital) were recruited. Out of 4449 patients screened, 3274 (73.6%) were eligible and 713 were registered, resulting in a recruitment rate of 16.0%. Thirty-three (4.6%) participants withdrew. The screened and registered participants were similar, but some between-treatment group imbalances were noted among those registered to the trial. All eight wards allocated to the intervention group completed the Prevention of Delirium manual milestone checklist and delivered the Prevention of Delirium intervention (median time 18.6 weeks for implementation). Overall, fidelity to the intervention was assessed as being high in two wards, medium in five wards and low in one ward. Of the expected 5645 Confusion Assessment Method delirium assessments, 5065 (89.7%) were completed during the first 10 days of admission. The rates of return of the patient-reported questionnaire booklets were 98.0% at baseline, 81.8% at 30 days and 70.5% at 3 months. The return rate of the EuroQol-5 Dimensions questionnaire was 98.6% at baseline, 77.5% at 1 month and 65.3% at 3 months (94–98% fully completed). The completion rate of the resource use questionnaire was lower (48.7%). The number of people with new-onset delirium at 10 days was 24 (7.0%) in the Prevention of Delirium group and 33 (8.9%) in the control group. Multilevel logistic regression analysis showed that participants in the Prevention of Delirium group had non-significant lower odds of developing delirium (odds ratio 0.68, 95% confidence interval 0.37 to 1.26; p = 0.2225). The average cost of the Prevention of Delirium intervention was estimated as £10.98 per patient and the mean costs for the Prevention of Delirium and usual-care groups were £5332 and £4412, respectively, with negligible between-group differences in quality-adjusted life-years. There was conflicting evidence from the trial- and model-based analyses relating to the cost-effectiveness of the Prevention of Delirium intervention. Given this, and in view of issues with the data (e.g. high levels of missingness), the results from the economic evaluation are highly uncertain. The criteria for continuation to a future definitive randomised controlled trial were met. Such a trial would need to recruit 5200 patients in 26 hospital clusters (200 patients per cluster).
Conclusions
The Prevention of Delirium system of care was successfully developed, and a multicentre feasibility study showed that the intervention is capable of implementation and delivery in routine care, with acceptable intervention fidelity and preliminary estimate of effectiveness.
Limitations
A prominent role for volunteers was originally intended in the Prevention of Delirium system of care, but only three of the eight wards allocated to the trial intervention group involved volunteers.
Future work
The findings indicate that a definitive multicentre evaluation of the Prevention of Delirium system of care should be designed and conducted to obtain robust estimates of clinical effectiveness and cost-effectiveness.
Trial registration
Current Controlled Trials ISRCTN28213290 (project 1), ISRCTN65924234 (project 2) and ISRCTN01187372 (project 3).
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 4. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- John Young
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds, UK
| | - John Green
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds, UK
| | - Mary Godfrey
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds, UK
| | - Jane Smith
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds, UK
| | - Francine Cheater
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Claire Hulme
- College of Medicine and Health, University of Exeter, Exeter, UK
| | | | - Suzanne Hartley
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Shamaila Anwar
- National Institute for Health Research Clinical Research Network, Huddersfield, UK
| | - Marie Fletcher
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | | | - David Meads
- Academic Unit of Health Economics, University of Leeds, Leeds, UK
| | | | - Najma Siddiqi
- Department of Health Sciences, University of York, Hull York Medical School, York, UK
| | - Dawn Brooker
- Association for Dementia Studies, University of Worcester, Worcester, UK
| | - Elizabeth Teale
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds, UK
| | - Alex Brown
- Elderly and Intermediate Care Service, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Anne Forster
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds, UK
| | - Amanda Farrin
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Sharon Inouye
- Harvard Medical School, Beth Israel Deaconess Medical Center, Marcus Institute for Aging Research, Boston, MA, USA
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12
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Jin Z, Hu J, Ma D. Postoperative delirium: perioperative assessment, risk reduction, and management. Br J Anaesth 2020; 125:492-504. [DOI: 10.1016/j.bja.2020.06.063] [Citation(s) in RCA: 357] [Impact Index Per Article: 71.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/22/2020] [Accepted: 06/20/2020] [Indexed: 12/20/2022] Open
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13
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Brooten JK, Buckenheimer AS, Hallmark JK, Grey CR, Cline DM, Breznau CJ, McQueen TS, Harris ZJ, Welsh D, Williamson JD, Gabbard JL. Risky Behavior: Hospital Transfers Associated with Early Mortality and Rates of Goals of Care Discussions. West J Emerg Med 2020; 21:935-942. [PMID: 32726267 PMCID: PMC7390558 DOI: 10.5811/westjem.2020.5.46067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 05/04/2020] [Indexed: 02/08/2023] Open
Abstract
Introduction Inter-hospital transfer (IHT) patients have higher in-hospital mortality, higher healthcare costs, and worse outcomes compared to non-transferred patients. Goals of care (GoC) discussions prior to transfer are necessary in patients at high risk for decline to ensure that the intended outcome of transfer is goal concordant. However, the frequency of these discussions is not well understood. This study was intended to assess the prevalence of GoC discussions in IHT patients with early mortality, defined as death within 72 hours of transfer, and prevalence of primary diagnoses associated with in-hospital mortality. Methods This was a retrospective study of IHT patients aged 18 and older who died within 72 hours of transfer to Wake Forest Baptist Medical Center between October 1, 2016-October 2018. Documentation of GoC discussions within the electronic health record (EHR) prior to transfer was the primary outcome. We also assessed charts for primary diagnosis associated with in-hospital mortality, code status changes prior to death, in-hospital healthcare interventions, and frequency of palliative care consults. Results We included in this study a total of 298 patients, of whom only 10.1% had documented GoC discussion prior to transfer. Sepsis (29.9%), respiratory failure (28.2%), and cardiac arrest (27.5%) were the top three diagnoses associated with in-hospital mortality, and 73.2% of the patients transitioned to comfort measures prior to death. After transfer, 18.1% of patients had invasive procedures performed with 9.7% undergoing major surgery. Palliative care consultation occurred in only 4.4%. Conclusion The majority (89.9%) of IHT patients with early mortality did not have GoC discussion documented within EHR prior to transfer, although most transitioned to comfort measures prior to their deaths, highlighting that additional work is needed in this area.
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Affiliation(s)
- Justin K Brooten
- Wake Forest School of Medicine, Department of Emergency Medicine, Winston-Salem, North Carolina.,Wake Forest School of Medicine, Department of Internal Medicine, Section on Gerontology & Geriatric Medicine, Winston-Salem, North Carolina
| | - Alyssa S Buckenheimer
- Wake Forest School of Medicine, Department of Internal Medicine, Section on General Internal Medicine, Winston-Salem, North Carolina
| | - Joy K Hallmark
- University of North Carolina, Department of Emergency Medicine, Chapel Hill, North Carolina
| | - Carl R Grey
- Wake Forest School of Medicine, Department of Internal Medicine, Section on Gerontology & Geriatric Medicine, Winston-Salem, North Carolina
| | - David M Cline
- Wake Forest School of Medicine, Department of Emergency Medicine, Winston-Salem, North Carolina
| | - Candace J Breznau
- Wake Forest School of Medicine, Department of Internal Medicine, Section on Gerontology & Geriatric Medicine, Winston-Salem, North Carolina
| | - Tyler S McQueen
- Wake Forest School of Medicine, Department of Internal Medicine, Section on Gerontology & Geriatric Medicine, Winston-Salem, North Carolina
| | - Zvi J Harris
- Wake Forest Graduate School of Arts and Science, Department of Biomedical Science, Winston-Salem, North Carolina
| | - David Welsh
- Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jeff D Williamson
- Wake Forest School of Medicine, Department of Internal Medicine, Section on Gerontology & Geriatric Medicine, Winston-Salem, North Carolina.,Wake Forest School of Medicine, Center for Health Care Innovation, Department of Internal Medicine, Winston-Salem, North Carolina
| | - Jennifer L Gabbard
- Wake Forest School of Medicine, Department of Internal Medicine, Section on Gerontology & Geriatric Medicine, Winston-Salem, North Carolina.,Wake Forest School of Medicine, Center for Health Care Innovation, Department of Internal Medicine, Winston-Salem, North Carolina
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14
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Non-pharmacological approaches in the prevention of delirium. Eur Geriatr Med 2020; 11:71-81. [DOI: 10.1007/s41999-019-00260-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 10/30/2019] [Indexed: 12/19/2022]
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15
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Grealish L, Todd JA, Krug M, Teodorczuk A. Education for delirium prevention: Knowing, meaning and doing. Nurse Educ Pract 2019; 40:102622. [DOI: 10.1016/j.nepr.2019.102622] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 05/28/2019] [Accepted: 08/31/2019] [Indexed: 11/27/2022]
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16
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Baessler F, Ciprianidis A, Rizvi AZ, Weidlich J, Wagner FL, Klein SB, Baumann TC, Nikendei C, Schultz JH. Delirium: Medical Students' Knowledge and Effectiveness of Different Teaching Methods. Am J Geriatr Psychiatry 2019; 27:737-744. [PMID: 31005497 DOI: 10.1016/j.jagp.2019.03.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 02/13/2019] [Accepted: 03/05/2019] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Medical schools are often blamed for inadequately training doctors on delirium. This study assesses the knowledge of medical students regarding delirium and evaluates different teaching methods for comparing learning outcomes. METHODS A video, a handout, and a video+handout were used as three different teaching methods. Students were randomly assigned to three groups and pre- and postintervention knowledge gains were compared. Interventions were held between 2015 and 2018 at the University of Heidelberg Medical School in Germany. Seventy-eight (video intervention 33; handout 26; video+handout 19) sixth-year medical students participated. Participants learned about delirium with the help of a video, a handout, and both a video+handout at the start of one-hour lectures dedicated to teaching about delirium. Pre- and postintervention questionnaires, comprising five multiple-choice questions and a self-estimated grade of knowledge about delirium, were used. Variables calculated were objective and subjective knowledge, recall, and accuracy of self-assessment. Microsoft Excel and analysis of covariance were used to analyze data. RESULTS Knowledge gains for all interventions were large (d>0.8) irrespective of gender. Post hoc comparison showed video and video+handout methods were more effective with high recall for video (92.8%). Students rated their knowledge as satisfactory, although they scored 11.4 out of 20. Preintervention knowledge level was correctly estimated by 31% of students, and postintervention by 40.3% students. CONCLUSION Teaching about delirium to medical students with a video resulted in better knowledge transfer and recall. Most medical students, particularly men, overestimated their knowledge about delirium.
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Affiliation(s)
- Franziska Baessler
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany.
| | - Anja Ciprianidis
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Ali Z Rizvi
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Joshua Weidlich
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Fabienne L Wagner
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Sonja B Klein
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Tabea C Baumann
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Christoph Nikendei
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Jobst-Hendrik Schultz
- Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
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17
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Koizia LJ, Wilson F, Reilly P, Fertleman MB. Delirium after emergency hip surgery – common and serious, but rarely consented for. World J Orthop 2019; 10:228-234. [PMID: 31259146 PMCID: PMC6591697 DOI: 10.5312/wjo.v10.i6.228] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 05/10/2019] [Accepted: 05/22/2019] [Indexed: 02/06/2023] Open
Abstract
A quarter of patients admitted with a proximal femoral fracture suffer from an acute episode of delirium during their hospital stay. Yet it is often unrecognised, poorly managed, and rarely discussed by doctors. Delirium is important not only to the affected individuals and their families, but also socioeconomically to the broader community. Delirium increases mortality and morbidity, leads to lasting cognitive and functional decline, and increases both length of stay and dependence on discharge. Delirium should be routinely and openly discussed by all members of the clinical team, including surgeons when gaining consent. Failing to do so may expose surgeons to claims of negligence. Here we present a concise review of the literature and discuss the epidemiology, causative factors, potential consequences and preventative strategies in the perioperative period.
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Affiliation(s)
- Louis J Koizia
- Geriatric Medicine, Imperial College NHS Trust, London W2 1NY, United Kingdom
| | - Faye Wilson
- Geriatric Medicine, City Hospitals Sunderland, Sunderland SR4 7TP, United Kingdom
| | - Peter Reilly
- Department of Trauma and Orthopaedics, Imperial College Healthcare NHS Trust, London W2 1NY, United Kingdom
| | - Michael B Fertleman
- Geriatric Medicine, Imperial College NHS Trust, London W2 1NY, United Kingdom
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18
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Abstract
Postoperative delirium is a common and harrowing complication in older surgical patients. Those with cognitive impairment or dementia are at especially high risk for developing postoperative delirium; ominously, it is hypothesized that delirium can accelerate cognitive decline and the onset of dementia, or worsen the severity of dementia. Awareness of delirium has grown in recent years as various medical societies have launched initiatives to prevent postoperative delirium and alleviate its impact. Unfortunately, delirium pathophysiology is not well understood and this likely contributes to the current state of low-quality evidence that informs perioperative guidelines. Along these lines, recent prevention trials involving ketamine and dexmedetomidine have demonstrated inconsistent findings. Non-pharmacologic multicomponent initiatives, such as the Hospital Elder Life Program, have consistently reduced delirium incidence and burden across various hospital settings. However, a substantial portion of delirium occurrences are still not prevented, and effective prevention and management strategies are needed to complement such multicomponent non-pharmacologic therapies. In this narrative review, we examine the current understanding of delirium neurobiology and summarize the present state of prevention and management efforts.
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Affiliation(s)
- Phillip Vlisides
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Center for Consciousness Science, University of Michigan Medical School,, Ann Arbor, MI, USA
| | - Michael Avidan
- Department of Anesthesiology, Washington University School of Medicine, Saint Louis, Missouri, USA
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19
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Marcantonio AJ, Pace M, Brabeck D, Nault KM, Trzaskos A, Anderson R. Team Approach: Management of Postoperative Delirium in the Elderly Patient with Femoral-Neck Fracture. JBJS Rev 2019; 5:e8. [PMID: 29064845 DOI: 10.2106/jbjs.rvw.17.00026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Andrew J Marcantonio
- Departments of Orthopaedics (A.J.M.), Anesthesiology (M.P.), Hospital Medicine (D.B.), and Rehabilitation Services (A.T.), and Surgical Critical Care Clinical Pharmacy (K.M.N. and R.A.), Lahey Hospital and Medical Center, Burlington, Massachusetts
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20
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Smithburger PL, Korenoski AS, Kane-Gill SL, Alexander SA. Perceptions of Family Members, Nurses, and Physicians on Involving Patients' Families in Delirium Prevention. Crit Care Nurse 2018; 37:48-57. [PMID: 29196587 DOI: 10.4037/ccn2017901] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Delirium occurs in up to 80% of patients admitted to an intensive care unit. Nonpharmacologic delirium-prevention strategies, which are commonly used by the bedside nurse, have reduced the incidence and duration of delirium in patients in the intensive care unit. With increasing demands on the nurse, strategies such as including the patient's family in delirium prevention activities should be investigated. OBJECTIVE To determine opinions and willingness of health care providers to involve patients' families in nonpharmacologic delirium-prevention activities in the intensive care unit, and of patients' families to be involved. METHODS Two surveys, one for intensive care unit nurses and physicians and one for patients' families, were developed and administered. The provider survey focused on current delirium-prevention practices and opinions about family involvement. The family survey concentrated on barriers and willingness to participate in prevention activities. RESULTS Sixty nurses and 58 physicians completed the survey. Most physicians (93%) and all nurses believed families could assist with delirium prevention. Only 50% reported speaking with family members about delirium and delirium prevention. The family survey was completed by 60 family members; 38% reported a provider spoke with them about delirium. Family members reported high levels of comfort in participating in delirium-prevention activities. CONCLUSIONS Health care providers and family members are supportive of the latter performing delirium-prevention activities. Family of patients in the intensive care unit may work collaboratively with nurses to reduce the incidence and duration of delirium in these patients.
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Affiliation(s)
- Pamela L Smithburger
- Pamela L. Smithburger is an associate professor of Pharmacy and Therapeutics at the University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania. She practices in the medical intensive care unit at UPMC Presbyterian Hospital, Pittsburgh, Pennsylvania. .,Amanda S. Korenoski is an assistant professor of Pharmacy and Therapeutics at the University of Pittsburgh School of Pharmacy. She is also the managing director of the Pittsburgh Poison Center, Pittsburgh, Pennsylvania. .,Sandra L. Kane-Gill is an associate professor of Pharmacy and Therapeutics at the University of Pittsburgh School of Pharmacy. .,Sheila A. Alexander is an associate professor of Acute and Tertiary Care Nursing at the University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania.
| | - Amanda S Korenoski
- Pamela L. Smithburger is an associate professor of Pharmacy and Therapeutics at the University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania. She practices in the medical intensive care unit at UPMC Presbyterian Hospital, Pittsburgh, Pennsylvania.,Amanda S. Korenoski is an assistant professor of Pharmacy and Therapeutics at the University of Pittsburgh School of Pharmacy. She is also the managing director of the Pittsburgh Poison Center, Pittsburgh, Pennsylvania.,Sandra L. Kane-Gill is an associate professor of Pharmacy and Therapeutics at the University of Pittsburgh School of Pharmacy.,Sheila A. Alexander is an associate professor of Acute and Tertiary Care Nursing at the University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania
| | - Sandra L Kane-Gill
- Pamela L. Smithburger is an associate professor of Pharmacy and Therapeutics at the University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania. She practices in the medical intensive care unit at UPMC Presbyterian Hospital, Pittsburgh, Pennsylvania.,Amanda S. Korenoski is an assistant professor of Pharmacy and Therapeutics at the University of Pittsburgh School of Pharmacy. She is also the managing director of the Pittsburgh Poison Center, Pittsburgh, Pennsylvania.,Sandra L. Kane-Gill is an associate professor of Pharmacy and Therapeutics at the University of Pittsburgh School of Pharmacy.,Sheila A. Alexander is an associate professor of Acute and Tertiary Care Nursing at the University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania
| | - Sheila A Alexander
- Pamela L. Smithburger is an associate professor of Pharmacy and Therapeutics at the University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania. She practices in the medical intensive care unit at UPMC Presbyterian Hospital, Pittsburgh, Pennsylvania.,Amanda S. Korenoski is an assistant professor of Pharmacy and Therapeutics at the University of Pittsburgh School of Pharmacy. She is also the managing director of the Pittsburgh Poison Center, Pittsburgh, Pennsylvania.,Sandra L. Kane-Gill is an associate professor of Pharmacy and Therapeutics at the University of Pittsburgh School of Pharmacy.,Sheila A. Alexander is an associate professor of Acute and Tertiary Care Nursing at the University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania
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21
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Bauernfreund Y, Butler M, Ragavan S, Sampson EL. TIME to think about delirium: improving detection and management on the acute medical unit. BMJ Open Qual 2018; 7:e000200. [PMID: 30167472 PMCID: PMC6109807 DOI: 10.1136/bmjoq-2017-000200] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 06/29/2018] [Accepted: 07/08/2018] [Indexed: 11/09/2022] Open
Abstract
Delirium affects 18%–35% patients in the acute hospital setting, yet is often neither detected nor managed appropriately. It is associated with increased risk of falls, longer hospital stay and increased morbidity and mortality rates. It is a frightening and unpleasant experience for both patients and their families. We used quality improvement tools and a multicomponent intervention to promote detection and improve management of delirium on the acute medical unit (AMU). We reviewed whether a delirium screening tool (4AT) had been completed for all patients aged over 65 years admitted to the AMU over 1 week. If delirium was detected, we assessed whether investigation and management was adequate as per national guidance. After baseline data collection, we delivered focused sessions of delirium education for doctors and nursing staff, including training on use of the 4AT tool and the TIME (Triggers, Investigate, Manage, Engage) management bundle. We introduced TIME checklists, an online delirium order set and created a bedside orientation tool. We collected data following the interventions and identified areas for further improvement. Following our first PDSA (Plan, Do, Study, Act) cycle, use of the 4AT screening tool improved from 40% to 61%. Adequate assessment for the causes of and exacerbating factors for delirium increased from 73% to 94% of cases. Use of personal orientation tools improved from 0% to 38%. In summary, a targeted staff education programme and practical aids for the ward have improved the screening and management of delirium on the AMU. This may be improved further through more frequent training sessions to account for regular change-over of junior doctors and through implementing a nursing champion for delirium.
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Affiliation(s)
| | | | - Sumathi Ragavan
- Care of the Elderly Department, North Middlesex Hospital, London, UK
| | - Elizabeth L Sampson
- Division of Psychiatry, University College London Medical School, London, UK.,Barnet, Enfield and Haringey Mental Health Liaison Service, North Middlesex Hospital, London, UK
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22
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Coyle MA, Chang HC, Burns P, Traynor V. Impact of Interactive Education on Health Care Practitioners and Older Adults at Risk of Delirium: A Literature Review. J Gerontol Nurs 2018; 44:41-48. [DOI: 10.3928/00989134-20180626-02] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 04/30/2018] [Indexed: 11/20/2022]
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23
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Ritter SRF, Cardoso AF, Lins MMP, Zoccoli TLV, Freitas MPD, Camargos EF. Underdiagnosis of delirium in the elderly in acute care hospital settings: lessons not learned. Psychogeriatrics 2018; 18:268-275. [PMID: 30133935 DOI: 10.1111/psyg.12324] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 10/10/2017] [Accepted: 02/02/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Delirium is a common and poorly diagnosed cause of behavioral change in elderly. This study aimed to estimate the prevalence, diagnostic accuracy and factors associated with the onset of delirium in the elderly admitted to an urgency unit. METHODS Cross-sectional study including clinically stable subjects aged ≥60 years between April and June of 2014. Diagnosis of delirium based on the Confusion Assessment Method (CAM, gold standard) was compared to the subjective assessment made by physicians on duty as recorded in the medical chart. Association of sociodemographic, psychological/behavioural, and clinical variables with delirium was assessed using multivariate analysis. RESULTS A sample of 110 participants with a mean age of 72.7 ± 8.3 years was studied. Of these, 56.4% were men and 28.2% had a diagnosis of delirium on CAM. Significant associations were observed between delirium and male gender (P-value = 0.019), poor or very poor self-perception of health (P-value = 0.033), previous diagnosis of dementia (P-value = 0.001), previous history of stroke (P-value = 0.014), and acute bacterial infection (P-value = 0.008). Physician diagnosis had a sensitivity of 35.5%, specificity of 100%, and accuracy of 81.8% to detect delirium. Rate of misdiagnosis was 64.5%. CONCLUSION Delirium was underdiagnosed in this urgent care hospital setting.
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Affiliation(s)
- Simone R F Ritter
- Multidisciplinary Center for the Elderly, University Hospital of Brasília, University of Brasília (UnB), Brasília/DF, Brazil.,Postgraduate in Medical Sciences, Faculty of Medicine, University of Brasilia (UnB), Brasília/DF, Brazil
| | - Anne F Cardoso
- Multidisciplinary Center for the Elderly, University Hospital of Brasília, University of Brasília (UnB), Brasília/DF, Brazil
| | - Marina M P Lins
- Multidisciplinary Center for the Elderly, University Hospital of Brasília, University of Brasília (UnB), Brasília/DF, Brazil
| | - Thayana L V Zoccoli
- Multidisciplinary Center for the Elderly, University Hospital of Brasília, University of Brasília (UnB), Brasília/DF, Brazil
| | - Marco Polo D Freitas
- Multidisciplinary Center for the Elderly, University Hospital of Brasília, University of Brasília (UnB), Brasília/DF, Brazil
| | - Einstein F Camargos
- Multidisciplinary Center for the Elderly, University Hospital of Brasília, University of Brasília (UnB), Brasília/DF, Brazil.,Postgraduate in Medical Sciences, Faculty of Medicine, University of Brasilia (UnB), Brasília/DF, Brazil
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24
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Abstract
Delirium is a common, often underdiagnosed, geriatric syndrome characterized by an acute change in attention and consciousness. As a neuropsychiatric disorder with an underlying organic cause, delirium has been considered a diagnosis reserved for the hospital setting. However, delirium is known to occur as both an acute and subacute condition that carries significant morbidity and mortality. Combined with its association with dementia and aging, this makes delirium an important topic for primary care providers to become more familiar with as they are tasked with caring for an aging population.
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Detroyer E, Dobbels F, Teodorczuk A, Deschodt M, Depaifve Y, Joosten E, Milisen K. Effect of an interactive E-learning tool for delirium on patient and nursing outcomes in a geriatric hospital setting: findings of a before-after study. BMC Geriatr 2018; 18:19. [PMID: 29351772 PMCID: PMC5775580 DOI: 10.1186/s12877-018-0715-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 01/14/2018] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Education of healthcare workers is a core element of multicomponent delirium strategies to improve delirium care and, consequently, patient outcomes. However, traditional educational strategies are notoriously difficult to implement. E-learning is hypothesised to be easier and more cost effective, but research evaluating effectiveness of delirium education through e-learning is scarce at present. Aim is to determine the effect of a nursing e-learning tool for delirium on: (1) in-hospital prevalence, duration and severity of delirium or mortality in hospitalized geriatric patients, and (2) geriatric nurses' knowledge and recognition regarding delirium. METHODS A before-after study in a sample of patients enrolled pre-intervention (non-intervention cohort (NIC); n = 81) and post-intervention (intervention cohort (IC); n = 79), and nurses (n = 17) of a geriatric ward (university hospital). The intervention included an information session about using the e-learning tool, which consisted of 11 e-modules incorporating development of knowledge and skills in the prevention, detection and management of delirium, and the completion of a delirium e-learning tool during a three-month period. Key patient outcomes included in-hospital prevalence and duration of delirium (Confusion Assessment Method), delirium severity (Delirium Index) and mortality (in-hospital; 12 months post-admission); key nurse outcomes included delirium knowledge (Delirium Knowledge Questionnaire) and recognition (Case vignettes). Logistic regression and linear mixed models were used to analyse patient data; Wilcoxon Signed Rank tests, McNemar's or paired t-tests for nursing data. RESULTS No significant difference was found between the IC and NIC for in-hospital prevalence (21.5% versus 25.9%; p = 0.51) and duration of delirium (mean 4.2 ± SD 4.8 days versus 4.9 ± SD 4.8 days; p = 0.38). A trend towards a statistically significant lower delirium severity (IC versus NIC: difference estimate - 1.59; p = 0.08) was noted for delirious IC patients in a linear mixed model. No effect on patient mortality and on nurses' delirium knowledge (p = 0.43) and recognition (p = 1.0) was found. CONCLUSION Our study, the first in its area to investigate effects of delirium e-learning on patient outcomes, demonstrated no benefits on both geriatric patients and nurses. Further research is needed to determine whether delirium e-learning nested within a larger educational approach inclusive of enabling and reinforcing strategies, would be effective. TRIAL REGISTRATION ISRCTN ( 82,293,702 , 27/06/2017).
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Affiliation(s)
- Elke Detroyer
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35-PB 7001/4, B-3000, Leuven, Belgium
| | - Fabienne Dobbels
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35-PB 7001/4, B-3000, Leuven, Belgium
| | - Andrew Teodorczuk
- School of Medicine, Griffith University, Gold Coast Campus, Southport, Qld, Australia.,Campus for Ageing and Vitality, Newcastle upon Tyne, Northumberland Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Mieke Deschodt
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35-PB 7001/4, B-3000, Leuven, Belgium.,Department of Geriatrics, University Hospitals Leuven, Leuven, Belgium
| | - Yves Depaifve
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35-PB 7001/4, B-3000, Leuven, Belgium
| | - Etienne Joosten
- Department of Geriatrics, University Hospitals Leuven, Leuven, Belgium
| | - Koen Milisen
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35-PB 7001/4, B-3000, Leuven, Belgium. .,Department of Geriatrics, University Hospitals Leuven, Leuven, Belgium.
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Mossello E, Tesi F, Di Santo SG, Mazzone A, Torrini M, Cherubini A, Bo M, Musicco M, Bianchetti A, Ferrari A, Ferrara N, Trabucchi M, Morandi A, Bellelli G. Recognition of Delirium Features in Clinical Practice: Data from the "Delirium Day 2015" National Survey. J Am Geriatr Soc 2017; 66:302-308. [PMID: 29206286 DOI: 10.1111/jgs.15211] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND/OBJECTIVES Delirium is underrecognized in clinical practice. The primary aim of the present multicenter study was to compare the ability of nurses to identify delirium features with a standardized assessment. The secondary aim was to identify predictors of missed or incorrect identifications of delirium by nurses. DESIGN Point prevalence study in 120 wards across Italy. SETTING "Delirium Day 2015." PARTICIPANTS Inpatients aged 65 and older (N = 1,867). MEASUREMENTS Participants and nurses were asked specific questions to investigate their perceptions of the presence of delirium features (acute cognitive change, inattention, cognitive fluctuations, impaired arousal). Delirium was identified according to the results of the Assessment Test for Delirium and Cognitive Impairment (4AT), completed by a physician. Comorbidities including dementia, disability, drug treatments, and delirium motor subtype according to the Delirium Motor Subtype Scale were recorded. RESULTS Delirium was present in 429 subjects (23%) according to the 4AT. Cognitive fluctuations was the delirium feature that the nurses most often recognized. Nurses' perceptions of acute cognitive change, cognitive fluctuations, or impaired arousal had 84% sensitivity and 81% specificity for delirium. The nonmotor subtype of delirium was less likely to be recognized (80%) than the hyperactive (97%), mixed (92%), and hypoactive (90%) subtypes. Incorrect perception of delirium was more frequent in subjects with dementia (specificity 64%). CONCLUSIONS The delirium feature that nurses were best able to recognize was cognitive fluctuations. The nonmotor subtype was associated with a lower recognition rate. Routine observation and registration of delirium features by nurses in clinical practice might be helpful to increase formal diagnosis of delirium.
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Affiliation(s)
- Enrico Mossello
- Research Unit of Medicine of Ageing, Department of Experimental and Clinical Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Francesca Tesi
- Research Unit of Medicine of Ageing, Department of Experimental and Clinical Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Simona G Di Santo
- Department of Clinical and Behavioral Neurology, Neuropsychiatry Laboratory, IRCCS Foundation S Lucia, Roma, Italy
| | | | - Monica Torrini
- Research Unit of Medicine of Ageing, Department of Experimental and Clinical Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Antonio Cherubini
- Geriatria, Accettazione geriatrica e Centro di ricerca per l'invecchiamento, IRCCS-INRCA, Ancona, Italy
| | - Mario Bo
- Section of Geriatrics, Città della Salute e della Scienza-Molinette, Torino, Italy
| | - Massimo Musicco
- Institute of Biomedical Technologies, National Research Council, Segrate, Italy.,Italian Society of Neurology for Dementia, Siena, Italy
| | - Angelo Bianchetti
- Medicine and Rehabilitation Department, Istituto Clinico S. Anna, Brescia, Italy
| | - Alberto Ferrari
- Geriatric Unit, Department of Neuromotor Physiology, ASMN Hospital, Reggio Emilia, Italy.,Italian Society of Hospital and Community Geriatrics, Roma, Italy
| | - Nicola Ferrara
- Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy.,Salvatore Maugeri Foundation, IRCCS, Scientific Institute of Telese, Telese Terme, Italy.,Italian Society of Gerontology and Geriatrics, Firenze, Italy
| | - Marco Trabucchi
- Tor Vergata, Rome University, Roma, Italy.,Italian Psychogeriatric Association, Brescia, Italy.,Geriatric Research Group, Brescia, Italy
| | - Alessandro Morandi
- Geriatric Research Group, Brescia, Italy.,Department of Rehabilitation and Aged Care "Fondazione Camplani" Hospital, Cremona, Italy
| | - Giuseppe Bellelli
- Geriatric Research Group, Brescia, Italy.,School of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy.,Geriatric Unit, San Gerardo University Hospital, Monza, Italy
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Smithburger PL, Korenoski AS, Alexander SA, Kane-Gill SL. Perceptions of Families of Intensive Care Unit Patients Regarding Involvement in Delirium-Prevention Activities: A Qualitative Study. Crit Care Nurse 2017; 37:e1-e9. [DOI: 10.4037/ccn2017485] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND
Nonpharmacologic delirium-prevention strategies are commonly used in the intensive care unit by bedside nurses. With up to 80% of intensive care unit patients becoming delirious, and lacking treatment options, prevention is key. However, with increasing nurse workloads, innovative delirium-prevention strategies such as involving the patient’s family are needed.
OBJECTIVE
To gain insight into opinions of patients’ families regarding active participation in delirium-prevention activities to inform specific recommendations for involving patients’ families in such activities.
METHODS
Purposeful sampling was used. Patients’ families were contacted to be interviewed about their opinions and attitudes on participation in nonpharmacologic delirium prevention activities while visiting the intensive care unit. An interview guide was created and used to facilitate discussion. Interviews were conducted, transcribed verbatim, and coded by 2 independent coders. Themes were identified, defined, and compared between independent coders; disagreements were resolved by the study team.
RESULTS
After 10 interviews were conducted, thematic saturation occurred. Three major themes emerged: (1) consistent family presence and participation in care, (2) improving ease of interactions between family and patient, and (3) delirium education for families.
CONCLUSION
Family members want to be involved with care and delirium prevention; however, many times they do not know what to do without the direction of a health care provider. Family members would benefit from open dialogue with the bedside nurse to increase family comfort and involvement in care.
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Affiliation(s)
- Pamela L. Smithburger
- Pamela L. Smithburger is an associate professor of Pharmacy and Therapeutics at the University of Pittsburgh School of Pharmacy, Pennsylvania. She practices in the medical intensive care unit at UPMC Presbyterian Hospital, Pittsburgh, Pennsylvania
| | - Amanda S. Korenoski
- Amanda S. Korenoski is an assistant professor of Pharmacy and Therapeutics at the University of Pittsburgh School of Pharmacy, Pennsylvania. She is also the managing director of the Pittsburgh Poison Center, Pennsylvania
| | - Sheila A. Alexander
- Sheila A. Alexander is an associate professor of Acute and Tertiary Care Nursing at the University of Pittsburgh School of Nursing, Pennsylvania
| | - Sandra L. Kane-Gill
- Sandra L. Kane-Gill is an associate professor of Pharmacy and Therapeutics at the University of Pittsburgh School of Pharmacy, Pennsylvania
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Maldonado JR. Acute Brain Failure: Pathophysiology, Diagnosis, Management, and Sequelae of Delirium. Crit Care Clin 2017; 33:461-519. [PMID: 28601132 DOI: 10.1016/j.ccc.2017.03.013] [Citation(s) in RCA: 207] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Delirium is the most common psychiatric syndrome found in the general hospital setting, with an incidence as high as 87% in the acute care setting. Delirium is a neurobehavioral syndrome caused by the transient disruption of normal neuronal activity secondary to systemic disturbances. The development of delirium is associated with increased morbidity, mortality, cost of care, hospital-acquired complications, placement in specialized intermediate and long-term care facilities, slower rate of recovery, poor functional and cognitive recovery, decreased quality of life, and prolonged hospital stays. This article discusses the epidemiology, known etiological factors, presentation and characteristics, prevention, management, and impact of delirium.
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Affiliation(s)
- José R Maldonado
- Psychosomatic Medicine Service, Emergency Psychiatry Service, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Suite 2317, Stanford, CA 94305-5718, USA.
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Chen CCH, Li HC, Liang JT, Lai IR, Purnomo JDT, Yang YT, Lin BR, Huang J, Yang CY, Tien YW, Chen CN, Lin MT, Huang GH, Inouye SK. Effect of a Modified Hospital Elder Life Program on Delirium and Length of Hospital Stay in Patients Undergoing Abdominal Surgery: A Cluster Randomized Clinical Trial. JAMA Surg 2017; 152:827-834. [PMID: 28538964 DOI: 10.1001/jamasurg.2017.1083] [Citation(s) in RCA: 149] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance Older patients undergoing abdominal surgery commonly experience preventable delirium, which extends their hospital length of stay (LOS). Objective To examine whether a modified Hospital Elder Life Program (mHELP) reduces incident delirium and LOS in older patients undergoing abdominal surgery. Design, Setting, and Participants This cluster randomized clinical trial of 577 eligible patients enrolled 377 older patients (≥65 years of age) undergoing gastrectomy, pancreaticoduodenectomy, and colectomy at a 2000-bed urban medical center in Taipei, Taiwan, from August 1, 2009, through October 31, 2012. Consecutive older patients scheduled for elective abdominal surgery with expected LOS longer than 6 days were enrolled, with a recruitment rate of 65.3%. Participants were cluster randomized by room to receive the mHELP or usual care. Interventions The intervention (implemented by an mHELP nurse) consisted of 3 protocols administered daily: orienting communication, oral and nutritional assistance, and early mobilization. Intervention group participants received all 3 mHELP protocols postoperatively, in addition to usual care, as soon as they arrived in the inpatient ward and until hospital discharge. Adherence to protocols was tracked daily. Main Outcomes and Measures Presence of delirium was assessed daily by 2 trained nurses who were masked to intervention status by using the Confusion Assessment Method. Data on LOS were abstracted from the medical record. Results Of 577 eligible patients, 377 (65.3%) were enrolled and randomly assigned to the mHELP (n = 197; mean [SD] age, 74.3 [5.8] years; 111 [56.4%] male) or control (n = 180; mean [SD] age, 74.8 [6.0] years; 103 [57.2%] male) group. Postoperative delirium occurred in 13 of 196 (6.6%) mHELP participants vs 27 of 179 (15.1%) control individuals, representing a relative risk of 0.44 in the mHELP group (95% CI, 0.23-0.83; P = .008). Intervention group participants received the mHELP for a median of 7 days (interquartile range, 6-10 days) and had a shorter median LOS (12.0 days) than control participants (14.0 days) (P = .04). Conclusions and Relevance For older patients undergoing abdominal surgery who received the mHELP, the odds of delirium were reduced by 56% and LOS was reduced by 2 days. Our findings support using the mHELP to advance postoperative care for older patients undergoing major abdominal surgery. Trial Registration clinicaltrials.gov Identifier: NCT01045330.
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Affiliation(s)
- Cheryl Chia-Hui Chen
- Department of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsiu-Ching Li
- Department of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Nursing, Sijhih Cathy General Hospital, New Taipei City, Taiwan
| | - Jin-Tung Liang
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - I-Rue Lai
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | | | - Yi-Ting Yang
- Taiwan Center for Disease Control, Taipei, Taiwan
| | - Been-Ren Lin
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - John Huang
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Ching-Yao Yang
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Wen Tien
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Chiung-Nien Chen
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Tsan Lin
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Guan-Hua Huang
- Institute of Statistics, National Chiao Tung University, Hsinchu, Taiwan
| | - Sharon K Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Institute for Aging Research, Hebrew Senior-Life, Boston, Massachusetts
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31
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Oosterhouse KJ, Vincent C, Foreman MD, Gruss VA, Corte C, Berger B. Intensive Care Unit Nurses' Beliefs About Delirium Assessment and Management. AACN Adv Crit Care 2017; 27:379-393. [PMID: 27959294 DOI: 10.4037/aacnacc2016535] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- Kimberly J Oosterhouse
- Kimberly J. Oosterhouse is Assistant Professor, Loyola University Chicago, 1032 W. Sheridan Road, BVM Hall 1008, Chicago, IL 60661 . Catherine Vincent is Associate Professor, University of Illinois at Chicago, Illinois. Marquis D. Foreman is John L. and Helen Kellogg Dean of Nursing, Rush University, Chicago, Illinois. Valerie A. Gruss is Clinical Assistant Professor, University of Illinois at Chicago, Illinois. Colleen Corte is Associate Professor, University of Illinois at Chicago, Illinois. Barbara Berger is Clinical Assistant Professor, University of Illinois at Chicago, Illinois
| | - Catherine Vincent
- Kimberly J. Oosterhouse is Assistant Professor, Loyola University Chicago, 1032 W. Sheridan Road, BVM Hall 1008, Chicago, IL 60661 . Catherine Vincent is Associate Professor, University of Illinois at Chicago, Illinois. Marquis D. Foreman is John L. and Helen Kellogg Dean of Nursing, Rush University, Chicago, Illinois. Valerie A. Gruss is Clinical Assistant Professor, University of Illinois at Chicago, Illinois. Colleen Corte is Associate Professor, University of Illinois at Chicago, Illinois. Barbara Berger is Clinical Assistant Professor, University of Illinois at Chicago, Illinois
| | - Marquis D Foreman
- Kimberly J. Oosterhouse is Assistant Professor, Loyola University Chicago, 1032 W. Sheridan Road, BVM Hall 1008, Chicago, IL 60661 . Catherine Vincent is Associate Professor, University of Illinois at Chicago, Illinois. Marquis D. Foreman is John L. and Helen Kellogg Dean of Nursing, Rush University, Chicago, Illinois. Valerie A. Gruss is Clinical Assistant Professor, University of Illinois at Chicago, Illinois. Colleen Corte is Associate Professor, University of Illinois at Chicago, Illinois. Barbara Berger is Clinical Assistant Professor, University of Illinois at Chicago, Illinois
| | - Valerie A Gruss
- Kimberly J. Oosterhouse is Assistant Professor, Loyola University Chicago, 1032 W. Sheridan Road, BVM Hall 1008, Chicago, IL 60661 . Catherine Vincent is Associate Professor, University of Illinois at Chicago, Illinois. Marquis D. Foreman is John L. and Helen Kellogg Dean of Nursing, Rush University, Chicago, Illinois. Valerie A. Gruss is Clinical Assistant Professor, University of Illinois at Chicago, Illinois. Colleen Corte is Associate Professor, University of Illinois at Chicago, Illinois. Barbara Berger is Clinical Assistant Professor, University of Illinois at Chicago, Illinois
| | - Colleen Corte
- Kimberly J. Oosterhouse is Assistant Professor, Loyola University Chicago, 1032 W. Sheridan Road, BVM Hall 1008, Chicago, IL 60661 . Catherine Vincent is Associate Professor, University of Illinois at Chicago, Illinois. Marquis D. Foreman is John L. and Helen Kellogg Dean of Nursing, Rush University, Chicago, Illinois. Valerie A. Gruss is Clinical Assistant Professor, University of Illinois at Chicago, Illinois. Colleen Corte is Associate Professor, University of Illinois at Chicago, Illinois. Barbara Berger is Clinical Assistant Professor, University of Illinois at Chicago, Illinois
| | - Barbara Berger
- Kimberly J. Oosterhouse is Assistant Professor, Loyola University Chicago, 1032 W. Sheridan Road, BVM Hall 1008, Chicago, IL 60661 . Catherine Vincent is Associate Professor, University of Illinois at Chicago, Illinois. Marquis D. Foreman is John L. and Helen Kellogg Dean of Nursing, Rush University, Chicago, Illinois. Valerie A. Gruss is Clinical Assistant Professor, University of Illinois at Chicago, Illinois. Colleen Corte is Associate Professor, University of Illinois at Chicago, Illinois. Barbara Berger is Clinical Assistant Professor, University of Illinois at Chicago, Illinois
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Abstract
Integrating mental and physical healthcare is difficult to achieve because of professional and organisational barriers. Psychiatrists recognise the problems resulting from fragmentation of services and want continuity of care for patients, but commissioning and service structures perpetuate these problems. One way forward may be to follow the syndromic model employed by geriatricians as a means of avoiding over-emphasis on diagnosis above the pragmatics of implementing multi-component, coordinated care. Commissioners need to be made aware of the overlap and complementarity of skills possessed by old age psychiatry and geriatric medicine to create joint services for people vulnerable to dementia and delirium. A re-forged alliance between the two specialties will be necessary to turn integrated care for frail, elderly people from rhetoric into reality.
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Abstract
Delirium is a severe and common yet under-diagnosed disorder in the clinical routine. Multiple factors may contribute to the development of delirium, which is associated with increased mortality and high healthcare costs. Treatment of delirium is often provided with delay and limited to pharmacological interventions. This article summarizes the key symptoms for delirium as well as risk factors and highlights the pharmacological and non-pharmacological options for treatment and prevention.
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Rivosecchi RM, Smithburger PL, Svec S, Campbell S, Kane-Gill SL. Nonpharmacological interventions to prevent delirium: an evidence-based systematic review. Crit Care Nurse 2016; 35:39-50; quiz 51. [PMID: 25639576 DOI: 10.4037/ccn2015423] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
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.
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Affiliation(s)
- Ryan M Rivosecchi
- Ryan M. Rivosecchi is a second-year pharmacy resident in critical care at the University of Pittsburgh Medical Center, Presbyterian Hospital, Pittsburgh, Pennsylvania.Pamela L. Smithburger is an assistant professor of pharmacy and therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, and a clinical specialist in the medical intensive care unit at the University of Pittsburgh Medical Center, Presbyterian Hospital.Susan Svec is the clinical director of the medical intensive care unit, University of Pittsburgh Medical Center, Presbyterian Hospital. She recently graduated from the master's of leadership and administration program at California University of Pennsylvania, California, Pennsylvania.Shauna Campbell is the nursing director of the medical intensive care unit at the University of Pittsburgh Medical Center, Presbyterian Hospital.Sandra L. Kane-Gill is an associate professor of pharmacy and therapeutics at the University of Pittsburgh School of Pharmacy. She has secondary appointments in the School of Medicine in the Clinical Translational Science Institute, Department of Critical Care Medicine, and the Department of Biomedical Informatics. She is also the critical care medication safety pharmacist at the University of Pittsburgh Medical Center in the Department of Pharmacy
| | - Pamela L Smithburger
- Ryan M. Rivosecchi is a second-year pharmacy resident in critical care at the University of Pittsburgh Medical Center, Presbyterian Hospital, Pittsburgh, Pennsylvania.Pamela L. Smithburger is an assistant professor of pharmacy and therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, and a clinical specialist in the medical intensive care unit at the University of Pittsburgh Medical Center, Presbyterian Hospital.Susan Svec is the clinical director of the medical intensive care unit, University of Pittsburgh Medical Center, Presbyterian Hospital. She recently graduated from the master's of leadership and administration program at California University of Pennsylvania, California, Pennsylvania.Shauna Campbell is the nursing director of the medical intensive care unit at the University of Pittsburgh Medical Center, Presbyterian Hospital.Sandra L. Kane-Gill is an associate professor of pharmacy and therapeutics at the University of Pittsburgh School of Pharmacy. She has secondary appointments in the School of Medicine in the Clinical Translational Science Institute, Department of Critical Care Medicine, and the Department of Biomedical Informatics. She is also the critical care medication safety pharmacist at the University of Pittsburgh Medical Center in the Department of Pharmacy
| | - Susan Svec
- Ryan M. Rivosecchi is a second-year pharmacy resident in critical care at the University of Pittsburgh Medical Center, Presbyterian Hospital, Pittsburgh, Pennsylvania.Pamela L. Smithburger is an assistant professor of pharmacy and therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, and a clinical specialist in the medical intensive care unit at the University of Pittsburgh Medical Center, Presbyterian Hospital.Susan Svec is the clinical director of the medical intensive care unit, University of Pittsburgh Medical Center, Presbyterian Hospital. She recently graduated from the master's of leadership and administration program at California University of Pennsylvania, California, Pennsylvania.Shauna Campbell is the nursing director of the medical intensive care unit at the University of Pittsburgh Medical Center, Presbyterian Hospital.Sandra L. Kane-Gill is an associate professor of pharmacy and therapeutics at the University of Pittsburgh School of Pharmacy. She has secondary appointments in the School of Medicine in the Clinical Translational Science Institute, Department of Critical Care Medicine, and the Department of Biomedical Informatics. She is also the critical care medication safety pharmacist at the University of Pittsburgh Medical Center in the Department of Pharmacy
| | - Shauna Campbell
- Ryan M. Rivosecchi is a second-year pharmacy resident in critical care at the University of Pittsburgh Medical Center, Presbyterian Hospital, Pittsburgh, Pennsylvania.Pamela L. Smithburger is an assistant professor of pharmacy and therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, and a clinical specialist in the medical intensive care unit at the University of Pittsburgh Medical Center, Presbyterian Hospital.Susan Svec is the clinical director of the medical intensive care unit, University of Pittsburgh Medical Center, Presbyterian Hospital. She recently graduated from the master's of leadership and administration program at California University of Pennsylvania, California, Pennsylvania.Shauna Campbell is the nursing director of the medical intensive care unit at the University of Pittsburgh Medical Center, Presbyterian Hospital.Sandra L. Kane-Gill is an associate professor of pharmacy and therapeutics at the University of Pittsburgh School of Pharmacy. She has secondary appointments in the School of Medicine in the Clinical Translational Science Institute, Department of Critical Care Medicine, and the Department of Biomedical Informatics. She is also the critical care medication safety pharmacist at the University of Pittsburgh Medical Center in the Department of Pharmacy
| | - Sandra L Kane-Gill
- Ryan M. Rivosecchi is a second-year pharmacy resident in critical care at the University of Pittsburgh Medical Center, Presbyterian Hospital, Pittsburgh, Pennsylvania.Pamela L. Smithburger is an assistant professor of pharmacy and therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, and a clinical specialist in the medical intensive care unit at the University of Pittsburgh Medical Center, Presbyterian Hospital.Susan Svec is the clinical director of the medical intensive care unit, University of Pittsburgh Medical Center, Presbyterian Hospital. She recently graduated from the master's of leadership and administration program at California University of Pennsylvania, California, Pennsylvania.Shauna Campbell is the nursing director of the medical intensive care unit at the University of Pittsburgh Medical Center, Presbyterian Hospital.Sandra L. Kane-Gill is an associate professor of pharmacy and therapeutics at the University of Pittsburgh School of Pharmacy. She has secondary appointments in the School of Medicine in the Clinical Translational Science Institute, Department of Critical Care Medicine, and the Department of Biomedical Informatics. She is also the critical care medication safety pharmacist at the University of Pittsburgh Medical Center in the Department of Pharmacy.
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Ojagbemi A, Ffytche DH. Are stroke survivors with delirium at higher risk of post-stroke dementia? Current evidence and future directions. Int J Geriatr Psychiatry 2016; 31:1289-1294. [PMID: 27396434 DOI: 10.1002/gps.4506] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 04/13/2016] [Accepted: 04/19/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The idea that delirium is a risk factor for dementia, broadly defined, is derived from heterogeneous patient samples. We reviewed available evidence as to whether stroke survivors who developed delirium during the acute phase of treatment are at a higher prospective risk of incident post-stroke cognitive impairment or dementia. DESIGN We searched 8721 records in the Cochrane database for reviews or protocols dealing with the study objective, Medline, EMBASE, PsycInfo and CINAHL for observational studies in the general adult population and PubMed for in-process articles. Additional searches of the reference lists of retrieved articles were also undertaken. Qualitative syntheses and meta-analysis were conducted according to conventional guidelines. RESULTS Twelve relevant articles were fully appraised. Four out of these studies, comprising 743 stroke survivors, including 199 with delirium, met criteria for qualitative syntheses. Overall, the studies presented low to moderate level evidence suggesting an association between post-stroke delirium and dementia. CONCLUSIONS There is a need for further studies to investigate the association of post-stroke delirium and dementia using well-defined cohorts of patients and controlling for factors such as pre-stroke cognition, stroke severity and location and the presence of persistent delirium. Such studies will help understand the place of delirium identification and prevention in reducing the risk of dementia after stroke. © 2016 The Authors. International Journal of Geriatric Psychiatry Published by John Wiley & Sons Ltd.
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Affiliation(s)
- Akin Ojagbemi
- Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Dominic H Ffytche
- Department of Old-age Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
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Stelmokas J, Gabel N, Flaherty JM, Rayson K, Tran K, Anderson JR, Bieliauskas LA. Delirium Detection and Impact of Comorbid Health Conditions in a Post-Acute Rehabilitation Hospital Setting. PLoS One 2016; 11:e0166754. [PMID: 27902744 PMCID: PMC5130207 DOI: 10.1371/journal.pone.0166754] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 11/03/2016] [Indexed: 12/03/2022] Open
Abstract
Misdiagnosis and under-detection of delirium may occur in many medical settings. This is important to address as delirium clearly increases risk of morbidity and mortality in such settings. This study assessed whether Veterans who screened positive on a delirium severity measure (Memorial Delirium Assessment Scale; MDAS) differed from those with and without corresponding medical documentation of delirium in terms of cognitive functioning, psychiatric/medical history, and medication use. A medical record review of 266 inpatients at a VA post-acute rehabilitation unit found that 10.9% were identified as delirious according to the MDAS and/or medical records. Of the Veterans who screened positive on the MDAS (N = 19), 68.4% went undetected by medical screening. Undetected cases had a higher number of comorbid medical conditions as measured by the Age-Adjusted Charlson Index (AACI) scores (median = 9, SD = 3.15; U = 5.5, p = .003) than medically documented cases. For Veterans with a score of 7 or greater on the AACI, the general relative risk for delirium was 4.46. Delirium is frequently under-detected in a post-acute rehabilitation unit, particularly for Veterans with high comorbid illness. The relative risk of delirium is up to 4.46 for those with high medical burden, suggesting the need for more comprehensive delirium screening in these patients.
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Affiliation(s)
- Julija Stelmokas
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, United States of America
- * E-mail:
| | - Nicolette Gabel
- University of Michigan Medical School, Ann Arbor, Michigan, United States of America
| | - Jennifer M. Flaherty
- Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, Norfolk, VA, United States of America
| | - Katherine Rayson
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, United States of America
| | - Kathileen Tran
- University of Michigan, Ann Arbor, Michigan, United States of America
| | | | - Linas A. Bieliauskas
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, United States of America
- University of Michigan, Ann Arbor, Michigan, United States of America
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Freter S, Koller K, Dunbar M, MacKnight C, Rockwood K. Translating Delirium Prevention Strategies for Elderly Adults with Hip Fracture into Routine Clinical Care: A Pragmatic Clinical Trial. J Am Geriatr Soc 2016; 65:567-573. [PMID: 27874185 DOI: 10.1111/jgs.14568] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To compare the feasibility (adherence) and effectiveness (prevalence of delirium, length of stay, mortality, discharge site) of delirium-friendly preprinted postoperative orders (PPOs) for individuals with hip fracture, administered by regular orthopedic nurses, with routine postoperative orders. DESIGN Pragmatic clinical trial to evaluate a quality improvement intervention. SETTING Tertiary care hospital. PARTICIPANTS Individuals aged 65 and older admitted for hip fracture repair (N = 283). INTERVENTION PPOs with delirium-friendly options and doses for nighttime sedation, analgesia, and nausea and attention to catheter removal and bowel movements. MEASUREMENTS Adherence to PPO was compared with adherence to routine orders. Drug doses were recorded. Presence of delirium was documented using the Confusion Assessment Method and the Mini-Mental State Examination on postoperative Days 1, 3, and 5. Length of stay, discharge site, and in-hospital mortality were recorded. RESULTS Orthopedic nurses adhered reasonably well with delirium-friendly PPOs. Of 283 participants, 42% developed postoperative delirium, with significantly less delirium in the intervention group (intervention 33%, control 51%, P = .001). The effect of the intervention was stronger in individuals with preexisting dementia (intervention 60%, control 97%, P < .001). Participants with postoperative delirium had longer hospital stays and were more likely to die or be discharged to a nursing home, but there was no significant between-group difference in these outcomes. CONCLUSION It is possible to introduce delirium-friendly PPOs into routine post-hip fracture care in a representative elderly population including individuals with dementia. Delirium-friendly PPOs executed by regular nursing staff resulted in a significant reduction in postoperative delirium but no difference in other outcomes.
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Affiliation(s)
- Susan Freter
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,Center for Health Care of the Elderly, QEII Health Sciences Centre, Capital District Health Authority, Halifax, Nova Scotia, Canada
| | - Katalin Koller
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,Center for Health Care of the Elderly, QEII Health Sciences Centre, Capital District Health Authority, Halifax, Nova Scotia, Canada
| | - Michael Dunbar
- Division of Orthopedics, Department of Surgery, School of Biomedical Engineering, Dalhousie University, Halifax, Nova Scotia, Canada.,Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Chris MacKnight
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,Center for Health Care of the Elderly, QEII Health Sciences Centre, Capital District Health Authority, Halifax, Nova Scotia, Canada
| | - Kenneth Rockwood
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,Center for Health Care of the Elderly, QEII Health Sciences Centre, Capital District Health Authority, Halifax, Nova Scotia, Canada
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Bellelli G, Morandi A, Di Santo SG, Mazzone A, Cherubini A, Mossello E, Bo M, Bianchetti A, Rozzini R, Zanetti E, Musicco M, Ferrari A, Ferrara N, Trabucchi M. "Delirium Day": a nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool. BMC Med 2016; 14:106. [PMID: 27430902 PMCID: PMC4950237 DOI: 10.1186/s12916-016-0649-8] [Citation(s) in RCA: 165] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 06/23/2016] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND To date, delirium prevalence in adult acute hospital populations has been estimated generally from pooled findings of single-center studies and/or among specific patient populations. Furthermore, the number of participants in these studies has not exceeded a few hundred. To overcome these limitations, we have determined, in a multicenter study, the prevalence of delirium over a single day among a large population of patients admitted to acute and rehabilitation hospital wards in Italy. METHODS This is a point prevalence study (called "Delirium Day") including 1867 older patients (aged 65 years or more) across 108 acute and 12 rehabilitation wards in Italian hospitals. Delirium was assessed on the same day in all patients using the 4AT, a validated and briefly administered tool which does not require training. We also collected data regarding motoric subtypes of delirium, functional and nutritional status, dementia, comorbidity, medications, feeding tubes, peripheral venous and urinary catheters, and physical restraints. RESULTS The mean sample age was 82.0 ± 7.5 years (58 % female). Overall, 429 patients (22.9 %) had delirium. Hypoactive was the commonest subtype (132/344 patients, 38.5 %), followed by mixed, hyperactive, and nonmotoric delirium. The prevalence was highest in Neurology (28.5 %) and Geriatrics (24.7 %), lowest in Rehabilitation (14.0 %), and intermediate in Orthopedic (20.6 %) and Internal Medicine wards (21.4 %). In a multivariable logistic regression, age (odds ratio [OR] 1.03, 95 % confidence interval [CI] 1.01-1.05), Activities of Daily Living dependence (OR 1.19, 95 % CI 1.12-1.27), dementia (OR 3.25, 95 % CI 2.41-4.38), malnutrition (OR 2.01, 95 % CI 1.29-3.14), and use of antipsychotics (OR 2.03, 95 % CI 1.45-2.82), feeding tubes (OR 2.51, 95 % CI 1.11-5.66), peripheral venous catheters (OR 1.41, 95 % CI 1.06-1.87), urinary catheters (OR 1.73, 95 % CI 1.30-2.29), and physical restraints (OR 1.84, 95 % CI 1.40-2.40) were associated with delirium. Admission to Neurology wards was also associated with delirium (OR 2.00, 95 % CI 1.29-3.14), while admission to other settings was not. CONCLUSIONS Delirium occurred in more than one out of five patients in acute and rehabilitation hospital wards. Prevalence was highest in Neurology and lowest in Rehabilitation divisions. The "Delirium Day" project might become a useful method to assess delirium across hospital settings and a benchmarking platform for future surveys.
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Affiliation(s)
- Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy.
- Geriatric Unit, San Gerardo University Hospital, Monza, Italy.
- Geriatric Research Group, Brescia, Italy.
| | - Alessandro Morandi
- Geriatric Research Group, Brescia, Italy
- Department of Rehabilitation and Aged Care "Fondazione Camplani" Hospital, Cremona, Italy
| | - Simona G Di Santo
- Department of Clinical and Behavioral Neurology, Neuropsychiatry Laboratory, IRCCS Foundation S Lucia, Roma, Italy
| | | | | | - Enrico Mossello
- Research Unit of Medicine of Ageing, Department of Experimental and Clinical Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Mario Bo
- Section of Geriatrics, Città della Salute e della Scienza - Molinette, Torino, Italy
| | - Angelo Bianchetti
- Medicine and Rehabilitation Department, Istituto Clinico S. Anna, Brescia, Italy
| | - Renzo Rozzini
- Department of Geriatric and Internal Medicine, Poliambulanza Hospital, Brescia, Italy
| | | | - Massimo Musicco
- Institute of Biomedical Technologies, National Research Council, Segrate (Milan), Italy
- Italian Society of Neurology for Dementia (SINDEM), Siena, Italy
| | - Alberto Ferrari
- Geriatric Unit, Department of Neuromotor Physiology, ASMN Hospital, Reggio Emilia, Italy
- Italian Society of Hospital and Community Geriatrics (SIGOT), Roma, Italy
| | - Nicola Ferrara
- Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy
- Salvatore Maugeri Foundation, IRCCS, Scientific Institute of Telese, Telese Terme (BN), Italy
- Italian Society of Gerontology and Geriatrics (SIGG), Florence, Italy
| | - Marco Trabucchi
- Geriatric Research Group, Brescia, Italy
- Tor Vergata, Rome University, Rome, Italy
- Italian Psychogeriatric Association (AIP), Brescia, Italy
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Toye C, Kitchen S, Hill A, Edwards D, Sin M, Maher S. Piloting staff education in Australia to reduce falls in older hospital patients experiencing delirium. Nurs Health Sci 2016; 19:51-58. [DOI: 10.1111/nhs.12300] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 04/29/2016] [Accepted: 05/24/2016] [Indexed: 01/23/2023]
Affiliation(s)
- Christine Toye
- Centre for Nursing Research; Sir Charles Gairdner Hospital; Nedlands Western Australia Australia
| | - Su Kitchen
- Centre for Nursing Research; Sir Charles Gairdner Hospital; Nedlands Western Australia Australia
| | - Andrew Hill
- Centre for Nursing Research; Sir Charles Gairdner Hospital; Nedlands Western Australia Australia
| | - Deborah Edwards
- Centre for Nursing Research; Sir Charles Gairdner Hospital; Nedlands Western Australia Australia
| | - Michelle Sin
- Centre for Nursing Research; Sir Charles Gairdner Hospital; Nedlands Western Australia Australia
| | - Sean Maher
- Centre for Nursing Research; Sir Charles Gairdner Hospital; Nedlands Western Australia Australia
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Australian and New Zealand Society for Geriatric Medicine Position Statement Abstract: Delirium in older people. Australas J Ageing 2016; 35:292. [DOI: 10.1111/ajag.12254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Siddiqi N, Harrison JK, Clegg A, Teale EA, Young J, Taylor J, Simpkins SA, Cochrane Dementia and Cognitive Improvement Group. Interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev 2016; 3:CD005563. [PMID: 26967259 PMCID: PMC10431752 DOI: 10.1002/14651858.cd005563.pub3] [Citation(s) in RCA: 186] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Delirium is a common mental disorder, which is distressing and has serious adverse outcomes in hospitalised patients. Prevention of delirium is desirable from the perspective of patients and carers, and healthcare providers. It is currently unclear, however, whether interventions for preventing delirium are effective. OBJECTIVES To assess the effectiveness of interventions for preventing delirium in hospitalised non-Intensive Care Unit (ICU) patients. SEARCH METHODS We searched ALOIS - the Cochrane Dementia and Cognitive Improvement Group's Specialized Register on 4 December 2015 for all randomised studies on preventing delirium. We also searched MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO (Ovid SP), Central (The Cochrane Library), CINAHL (EBSCOhost), LILACS (BIREME), Web of Science core collection (ISI Web of Science), ClinicalTrials.gov and the WHO meta register of trials, ICTRP. SELECTION CRITERIA We included randomised controlled trials (RCTs) of single and multi- component non-pharmacological and pharmacological interventions for preventing delirium in hospitalised non-ICU patients. DATA COLLECTION AND ANALYSIS Two review authors examined titles and abstracts of citations identified by the search for eligibility and extracted data independently, with any disagreements settled by consensus. The primary outcome was incidence of delirium; secondary outcomes included duration and severity of delirium, institutional care at discharge, quality of life and healthcare costs. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes; and between group mean differences and standard deviations for continuous outcomes. MAIN RESULTS We included 39 trials that recruited 16,082 participants, assessing 22 different interventions or comparisons. Fourteen trials were placebo-controlled, 15 evaluated a delirium prevention intervention against usual care, and 10 compared two different interventions. Thirty-two studies were conducted in patients undergoing surgery, the majority in orthopaedic settings. Seven studies were conducted in general medical or geriatric medicine settings.We found multi-component interventions reduced the incidence of delirium compared to usual care (RR 0.69, 95% CI 0.59 to 0.81; seven studies; 1950 participants; moderate-quality evidence). Effect sizes were similar in medical (RR 0.63, 95% CI 0.43 to 0.92; four studies; 1365 participants) and surgical settings (RR 0.71, 95% CI 0.59 to 0.85; three studies; 585 participants). In the subgroup of patients with pre-existing dementia, the effect of multi-component interventions remains uncertain (RR 0.90, 95% CI 0.59 to 1.36; one study, 50 participants; low-quality evidence).There is no clear evidence that cholinesterase inhibitors are effective in preventing delirium compared to placebo (RR 0.68, 95% CI, 0.17 to 2.62; two studies, 113 participants; very low-quality evidence).Three trials provide no clear evidence of an effect of antipsychotic medications as a group on the incidence of delirium (RR 0.73, 95% CI, 0.33 to 1.59; 916 participants; very low-quality evidence). In a pre-planned subgroup analysis there was no evidence for effectiveness of a typical antipsychotic (haloperidol) (RR 1.05, 95% CI 0.69 to 1.60; two studies; 516 participants, low-quality evidence). However, delirium incidence was lower (RR 0.36, 95% CI 0.24 to 0.52; one study; 400 participants, moderate-quality evidence) for patients treated with an atypical antipsychotic (olanzapine) compared to placebo (moderate-quality evidence).There is no clear evidence that melatonin or melatonin agonists reduce delirium incidence compared to placebo (RR 0.41, 95% CI 0.09 to 1.89; three studies, 529 participants; low-quality evidence).There is moderate-quality evidence that Bispectral Index (BIS)-guided anaesthesia reduces the incidence of delirium compared to BIS-blinded anaesthesia or clinical judgement (RR 0.71, 95% CI 0.60 to 0.85; two studies; 2057 participants).It is not possible to generate robust evidence statements for a range of additional pharmacological and anaesthetic interventions due to small numbers of trials, of variable methodological quality. AUTHORS' CONCLUSIONS There is strong evidence supporting multi-component interventions to prevent delirium in hospitalised patients. There is no clear evidence that cholinesterase inhibitors, antipsychotic medication or melatonin reduce the incidence of delirium. Using the Bispectral Index to monitor and control depth of anaesthesia reduces the incidence of postoperative delirium. The role of drugs and other anaesthetic techniques to prevent delirium remains uncertain.
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Affiliation(s)
- Najma Siddiqi
- University of YorkDepartment of Health SciencesHeslingtonYorkNorth YorkshireUKY010 5DD
| | - Jennifer K Harrison
- University of EdinburghCentre for Cognitive Ageing and Cognitive Epidemiology and the Alzheimer Scotland Dementia Research CentreDepartment of Geriatric Medicine, The Royal Infirmary of Edinburgh, Room S164251 Little France CrescentEdinburghUKEH16 4SB
| | - Andrew Clegg
- University of LeedsAcademic Unit of Elderly Care and RehabilitationBradford Institute for Health ResearchBradfordUKBD9 6RJ
| | - Elizabeth A Teale
- University of LeedsAcademic Unit of Elderly Care and RehabilitationBradford Institute for Health ResearchBradfordUKBD9 6RJ
| | - John Young
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust/University of LeedsAcademic Unit of Elderly Care and RehabilitationBradfordUK
| | - James Taylor
- Bradford Teaching Hospitals NHS Foundation TrustDepartment of AnaesthesiaBradfordUKBD9 6RJ
| | - Samantha A Simpkins
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust/University of LeedsAcademic Unit of Elderly Care and RehabilitationBradfordUK
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Rivosecchi RM, Kane-Gill SL, Svec S, Campbell S, Smithburger PL. The implementation of a nonpharmacologic protocol to prevent intensive care delirium. J Crit Care 2016; 31:206-11. [DOI: 10.1016/j.jcrc.2015.09.031] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 08/19/2015] [Accepted: 09/05/2015] [Indexed: 01/09/2023]
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Kersten A, Reith S. [Delirium and delirium management in critically ill patients]. Med Klin Intensivmed Notfmed 2016; 111:14-21. [PMID: 26795215 DOI: 10.1007/s00063-015-0130-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 12/14/2015] [Accepted: 12/14/2015] [Indexed: 11/29/2022]
Abstract
Delirium in critically ill patients is a common entity in the intensive care unit (ICU) and is an expression of the cerebral organ dysfunction of the patient. The hallmark signs are disturbed consciousness and cognition in combination with inattentiveness and alterations in perception, which are manifested within a time interval of hours to days during treatment on the ICU. Delirium has been shown to have negative effects on patient short-term and long-term outcome parameters and increases morbidity and mortality. Despite its significance in many cases delirium remains inadequately diagnosed during routine treatment by ICU personnel. There are two validated and easily applicable scales for the standardized diagnosis of delirium: the confusion assessment method for the ICU (CAM-ICU) and the intensive care delirium screening checklist (ICDSC). These are simple to apply by medical as well as non-medical personnel. The therapy of delirium is mostly determined by non-pharmacological measures aiming at early identification, reorientation and mobilization of the patient, improving cerebral activity and establishing adequate wake-sleep cycles. There is only sparse evidence for pharmacological treatment of delirium; however, the choice of sedative agent has a proven effect on the incidence and duration of delirium in the ICU.
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Affiliation(s)
- A Kersten
- Medizinische Klinik I, Universitätsklinikum der RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland.
| | - S Reith
- Medizinische Klinik I, Universitätsklinikum der RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
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Abraha I, Rimland JM, Trotta F, Pierini V, Cruz-Jentoft A, Soiza R, O'Mahony D, Cherubini A. Non-Pharmacological Interventions to Prevent or Treat Delirium in Older Patients: Clinical Practice Recommendations The SENATOR-ONTOP Series. J Nutr Health Aging 2016; 20:927-936. [PMID: 27791223 DOI: 10.1007/s12603-016-0719-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
DESCRIPTION The ONTOP project aims to undertake a literature search of systematic reviews concerning evidence-based non-pharmacological interventions of prevalent medical conditions affecting older people, including delirium. OBJECTIVES To develop explicit and transparent recommendations for non-pharmacological interventions in older subjects at risk of developing delirium, as well as in older subjects with delirium, based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to rating the quality of evidence and the strength of recommendations. METHODS A multidisciplinary panel was constituted comprising geriatricians, research nurse and a clinical epidemiologist. The panel developed a systematic overview of non-pharmacological interventions to prevent or treat delirium. The GRADE approach was used to rate the evidence and to formulate recommendations. RESULTS The critical outcomes were delirium incidence, for delirium prevention, and delirium improvement and functional status, for delirium treatment. The non-pharmacological interventions were identified and categorized as multicomponent and single component. Strong recommendations in favor of multicomponent interventions to prevent delirium, in surgical or medicals wards, were formulated. In the latter case the evidence applied to older patients at intermediate - high risk of developing delirium. Weak recommendations, to prevent delirium, were formulated for multicomponent interventions provided by family members (medical ward), staff education (medical ward), ear plugs (intensive care unit), reorientation protocol (intensive care unit), and the use of a software to perform drug review. Weak recommendations were provided for the use of multicomponent interventions to prevent delirium in medical wards in patients not selected according to the risk of delirium. Strong recommendations not to use bright light therapy to prevent delirium in intensive care unit settings were articulated. Weak recommendations not to use music therapy to prevent delirium for patients undergoing surgical interventions were specified. The ability to make strong recommendations was limited by the low quality of evidence and the presence of uncertainty. Moreover, weak recommendations were provided for the use of multicomponent interventions to treat delirium of older patients (medical wards). CONCLUSIONS Overall, the panel developed 12 recommendations for the delivery of non-pharmacological interventions to older patients at risk of developing or, with delirium.
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Affiliation(s)
- I Abraha
- Y Iosief Abraha, Geriatrics and Geriatric Emergency Care, Italian National Research Center on Aging (IRCCS-INRCA), Ancona, Italy, E-mail: (IA)
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Sockalingam S, James SL, Sinyi R, Carroll A, Laidlaw J, Yanofsky R, Sheehan K. A Flipped Classroom Approach to Improving the Quality of Delirium Care Using an Interprofessional Train-the-Trainer Program. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2016; 36:17-23. [PMID: 26954241 DOI: 10.1097/ceh.0000000000000025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Given the prevalence and morbidity associated with delirium, there is a need for effective and efficient institutional approaches to delirium training in health care settings. Novel education methods, specifically the "flipped classroom" (FC) and "train-the-trainer" (TTT), have the potential to address these delirium training gaps. This study evaluates the effect of a TTT FC interprofessional delirium training program on participants' perceived ability to manage delirium, delirium knowledge, and clinicians' delirium assessment behaviors. METHODS FC Delirium TTT sessions were implemented in a large four-hospital network and consisted of presession online work and a 3-hour in-session component. The 156 TTT interprofessional participants who attended the sessions (ie, trainers) were expected to then deliver delirium training to their patient care units. Delirium care self-efficacy and knowledge test scores were measured before, after, and 6 months after the training session. Clinician delirium assessment rates were measured by chart audits before and 3 months after trainer's implementation of delirium training sessions. RESULTS Delirium knowledge test scores (7.8 ± 1.6 versus 9.7 ± 1.2, P < .001) and delirium care self-efficacy were significantly higher immediately after the TTT session compared with those of presession and these differences remained significant at 6-month after the TTT session. Trainer sessions significantly improved clinician delirium assessment rates from 53% for pretraining to 66% for posttraining. DISCUSSION Our data suggest that a TTT FC delirium training approach can improve participants' perceived delirium care skills and confidence, and delirium knowledge up to 6 months after the session. This approach provides a model for implementing hospitalwide delirium education that can change delirium assessment behavior while minimizing time and personnel requirements.
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Affiliation(s)
- Sanjeev Sockalingam
- Dr. Sockalingam: Centre for Mental Health, University Health Network, Toronto, ON, Canada and Department of Psychiatry, University of Toronto, Toronto, ON, Canada. Ms. James: University Health Network, Toronto, ON, Canada. Ms. Sinyi: University Health Network, Toronto, ON, Canada. Ms. Carroll: University Health Network, Toronto, ON, Canada. Dr. Laidlaw: Surrey Memorial Hospital, Surrey, BC, Canada. Dr. Yanofsky: Centre for Mental Health, University Health Network, Toronto, ON, Canada and Department of Psychiatry, University of Toronto, Toronto, ON, Canada. Dr. Sheehan: Centre for Mental Health, University Health Network, Toronto, ON, Canada and Department of Psychiatry, University of Toronto, Toronto, ON, Canada
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Sledge WH, Gueorguieva R, Desan P, Bozzo JE, Dorset J, Lee HB. Multidisciplinary Proactive Psychiatric Consultation Service: Impact on Length of Stay for Medical Inpatients. PSYCHOTHERAPY AND PSYCHOSOMATICS 2015; 84:208-16. [PMID: 26022134 DOI: 10.1159/000379757] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 02/06/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Mental illness correlates with an increased length of stay (LOS) for patients hospitalized for medical conditions. While psychiatric consultations help manage mental illness among those hospitalized for medical conditions, consultations initiated by nonpsychiatric mental disease may lack maximum effectiveness. METHODS In a before-and-after design, in 2 contiguous years LOS for internist-initiated, conventional consultation (CC) as usual treatment was compared to LOS of a proactive, mental health professional-initiated, multidisciplinary intervention delivered by the behavioral intervention team (BIT) on the same units. The patient populations included general medical patients with a variety of illnesses. Patients were treated in 3 different inpatient settings with a total capacity of 92 beds serving 15,858 patient visits over 3 comparison years. BIT comprised a psychiatrist, a nurse, and a social worker, each of whom performed the specific tasks of their professional discipline, while collaborating among themselves and their health-care colleagues. BIT provided timely, appropriate, and effective patient care alongside consultative advice and education to their corresponding professional peers. BIT was compared to CC on the outcome of LOS. RESULTS There was a statistically significant reduction of LOS favoring BIT over CC for patients with an LOS of <31 days which persisted while controlling for multiple co-morbid factors. Also, a statistically significant spillover effect was suggested by the overall improvement of LOS on units implementing BIT. CONCLUSION BIT is a promising means of lowering LOS on general medical units while providing a high level of care and staff support.
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Affiliation(s)
- William H Sledge
- Department of Psychiatry, Yale School of Medicine, New Haven, Conn., USA
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47
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Bellelli G, Nobili A, Annoni G, Morandi A, Djade CD, Meagher DJ, Maclullich AMJ, Davis D, Mazzone A, Tettamanti M, Mannucci PM. Under-detection of delirium and impact of neurocognitive deficits on in-hospital mortality among acute geriatric and medical wards. Eur J Intern Med 2015; 26:696-704. [PMID: 26333532 DOI: 10.1016/j.ejim.2015.08.006] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 08/05/2015] [Accepted: 08/10/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Delirium is a neuropsychiatric disorder, triggered by medical precipitants causes. Study aims were to describe the prevalence and impact on in-hospital mortality of delirium identified through ICD-9 codes as well as evidence of neurocognitive deficits demonstrated in a population of older patients admitted to acute medical wards. METHODS This was a prospective cohort multicenter study of 2521 older patients enrolled in the "Registro Politerapie SIMI (REPOSI)" during the years 2010 and 2012. The diagnosis of delirium was obtained by ICD-9 codes. Cognitive function was evaluated with the Short Blessed Test (SBT) and single SBT items were used as measures of deficits in attention, orientation and memory. Combination of deficits in SBT items was used as a proxy for delirium. Logistic regression was used to evaluate the association with in-hospital mortality of delirium and combined deficits in SBT items. RESULTS Delirium was coded in 2.9%, while deficits in attention, orientation, and memory were found in 35.4%, 29.7% and 77.5% of patients. Inattention and either disorientation or memory deficits were found in 14.1%, while combination of the 3 deficits in 19.8%. Delirium, as per ICD-9 codes, was not a predictor of in-hospital mortality. In contrast, objective deficits of inattention, in combination with orientation and memory disorders, were stronger predictors after adjusting for covariates. CONCLUSIONS The documentation of delirium is poor in medical wards of Italian acute hospitals. Neurocognitive deficits on objective testing (in a pattern suggestive of undiagnosed delirium) should be used to raise awareness of delirium, given their association with in-hospital mortality.
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Affiliation(s)
- G Bellelli
- Department of Health Sciences, University of Milano Bicocca, Italy; Acute Geriatric Unit, San Gerardo Hospital, Monza, Italy; Milan Center for Neuroscience (Neuro-Mi), Milan, Italy.
| | - A Nobili
- Department of Neuroscience, IRCCS Istituto di Ricerche Farmacologiche "Mario Negri", Milano, Italy
| | - G Annoni
- Department of Health Sciences, University of Milano Bicocca, Italy; Acute Geriatric Unit, San Gerardo Hospital, Monza, Italy; Milan Center for Neuroscience (Neuro-Mi), Milan, Italy
| | - A Morandi
- Department of Rehabilitation and Aged Care, Hospital Ancelle, Cremona, Italy; Geriatric Research Group, Brescia, Italy
| | - C D Djade
- Department of Neuroscience, IRCCS Istituto di Ricerche Farmacologiche "Mario Negri", Milano, Italy
| | - D J Meagher
- Graduate Entry Medical School, University of Limerick, Ireland; Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Ireland; Department of Psychiatry, University Hospital Limerick, Ireland
| | - A M J Maclullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Division of Health Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, Scotland, United Kingdom; Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Scotland, United Kingdom
| | - D Davis
- MRC Unit for Lifelong Health and Ageing, University College London, United Kingdom
| | - A Mazzone
- Department of Health Sciences, University of Milano Bicocca, Italy
| | - M Tettamanti
- Department of Neuroscience, IRCCS Istituto di Ricerche Farmacologiche "Mario Negri", Milano, Italy
| | - P M Mannucci
- Scientific Direction, IRCCS Ca' Granda Maggiore Policlinico Hospital Foundation, Milano, Italy
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48
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Young J, Cheater F, Collinson M, Fletcher M, Forster A, Godfrey M, Green J, Anwar S, Hartley S, Hulme C, Inouye SK, Meads D, Santorelli G, Siddiqi N, Smith J, Teale E, Farrin AJ. Prevention of delirium (POD) for older people in hospital: study protocol for a randomised controlled feasibility trial. Trials 2015; 16:340. [PMID: 26253332 PMCID: PMC4529724 DOI: 10.1186/s13063-015-0847-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 07/02/2015] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Delirium is the most frequent complication among older people following hospitalisation. Delirium may be prevented in about one-third of patients using a multicomponent intervention. However, in the United Kingdom, the National Health Service has no routine delirium prevention care systems. We have developed the Prevention of Delirium Programme, a multicomponent delirium prevention intervention and implementation process. We have successfully carried out a pilot study to test the feasibility and acceptability of implementation of the programme. We are now undertaking preliminary testing of the programme. METHODS/DESIGN The Prevention of Delirium Study is a multicentre, cluster randomised feasibility study designed to explore the potential effectiveness and cost-effectiveness of the Prevention of Delirium Programme. Sixteen elderly care medicine and orthopaedic/trauma wards in eight National Health Service acute hospitals will be randomised to receive the Prevention of Delirium Programme or usual care. Patients will be eligible for the trial if they have been admitted to a participating ward and are aged 65 years or over. The primary objectives of the study are to provide a preliminary estimate of the effectiveness of the Prevention of Delirium Programme as measured by the incidence of new onset delirium, assess the variability of the incidence of new-onset delirium, estimate the intracluster correlation coefficient and likely cluster size, assess barriers to the delivery of the Prevention of Delirium Programme system of care, assess compliance with the Prevention of Delirium Programme system of care, estimate recruitment and follow-up rates, assess the degree of contamination due to between-ward staff movements, and investigate differences in financial costs and benefits between the Prevention of Delirium Programme system of care and standard practice. Secondary objectives are to investigate differences in the number, severity and length of delirium episodes (including persistent delirium); length of stay in hospital; in-hospital mortality; destination at discharge; health-related quality of life and health resource use; physical and social independence; anxiety and depression; and patient experience. DISCUSSION This feasibility study will be used to gather data to inform the design of a future definitive randomised controlled trial. TRIAL REGISTRATION ISRCTN01187372 . Registered 13 March 2014.
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Affiliation(s)
- John Young
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford Institute for Health Research, Temple Bank House, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, UK.
| | - Francine Cheater
- School of Nursing Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Edith Cavell Building, Norwich Research Park, Norwich, NR4 7TJ, UK.
| | - Michelle Collinson
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK.
| | - Marie Fletcher
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK.
| | - Anne Forster
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford Institute for Health Research, Temple Bank House, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, UK.
| | - Mary Godfrey
- Leeds Institute of Health Sciences, Charles Thackrah Building, 101 Clarendon Road, Leeds, UK.
| | - John Green
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford Institute for Health Research, Temple Bank House, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, UK.
| | - Shamaila Anwar
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK.
| | - Suzanne Hartley
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK.
| | - Claire Hulme
- Academic Unit of Health Economics, Leeds Institute of Health Science, University of Leeds, Leeds, LS2 9JT, UK.
| | - Sharon K Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA.
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, 1200 Centre Street, Boston, MA, 02131, USA.
| | - David Meads
- Academic Unit of Health Economics, Leeds Institute of Health Science, University of Leeds, Leeds, LS2 9JT, UK.
| | - Gillian Santorelli
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK.
| | - Najma Siddiqi
- Leeds Institute of Health Sciences, Charles Thackrah Building, 101 Clarendon Road, Leeds, UK.
- Bradford District NHS Care Trust New Mill, Victoria Road, Saltaire, BD18 3LD, UK.
| | - Jane Smith
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford Institute for Health Research, Temple Bank House, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, UK.
| | - Elizabeth Teale
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford Institute for Health Research, Temple Bank House, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, UK.
| | - Amanda J Farrin
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK.
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Abraha I, Trotta F, Rimland JM, Cruz-Jentoft A, Lozano-Montoya I, Soiza RL, Pierini V, Dessì Fulgheri P, Lattanzio F, O’Mahony D, Cherubini A. Efficacy of Non-Pharmacological Interventions to Prevent and Treat Delirium in Older Patients: A Systematic Overview. The SENATOR project ONTOP Series. PLoS One 2015; 10:e0123090. [PMID: 26062023 PMCID: PMC4465742 DOI: 10.1371/journal.pone.0123090] [Citation(s) in RCA: 137] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 02/27/2015] [Indexed: 01/08/2023] Open
Abstract
Background Non-pharmacological intervention (e.g. multidisciplinary interventions, music therapy, bright light therapy, educational interventions etc.) are alternative interventions that can be used in older subjects. There are plenty reviews of non-pharmacological interventions for the prevention and treatment of delirium in older patients and clinicians need a synthesized, methodologically sound document for their decision making. Methods and Findings We performed a systematic overview of systematic reviews (SRs) of comparative studies concerning non-pharmacological intervention to treat or prevent delirium in older patients. The PubMed, Cochrane Database of Systematic Reviews, EMBASE, CINHAL, and PsychINFO (April 28th, 2014) were searched for relevant articles. AMSTAR was used to assess the quality of the SRs. The GRADE approach was used to assess the quality of primary studies. The elements of the multicomponent interventions were identified and compared among different studies to explore the possibility of performing a meta-analysis. Risk ratios were estimated using a random-effects model. Twenty-four SRs with 31 primary studies satisfied the inclusion criteria. Based on the AMSTAR criteria twelve reviews resulted of moderate quality and three resulted of high quality. Overall, multicomponent non-pharmacological interventions significantly reduced the incidence of delirium in surgical wards [2 randomized trials (RCTs): relative risk (RR) 0.71, 95% Confidence Interval (CI) 0.59 to 0.86, I2=0%; (GRADE evidence: moderate)] and in medical wards [2 CCTs: RR 0.65, 95%CI 0.49 to 0.86, I2=0%; (GRADE evidence: moderate)]. There is no evidence supporting the efficacy of non-pharmacological interventions to prevent delirium in low risk populations (i.e. low rate of delirium in the control group)[1 RCT: RR 1.75, 95%CI 0.50 to 6.10 (GRADE evidence: very low)]. For patients who have developed delirium, the available evidence does not support the efficacy of multicomponent non-pharmacological interventions to treat delirium. Among single component interventions only staff education, reorientation protocol (GRADE evidence: very low)] and Geriatric Risk Assessment MedGuide software [hazard ratio 0.42, 95%CI 0.35 to 0.52, (GRADE evidence: moderate)] resulted effective in preventing delirium. Conclusions In older patients multi-component non-pharmacological interventions as well as some single-components intervention were effective in preventing delirium but not to treat delirium.
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Affiliation(s)
- Iosief Abraha
- Geriatrics and Geriatric Emergency Care, Italian National Research Center on Aging (IRCCS-INRCA), Ancona, Italy
- * E-mail:
| | - Fabiana Trotta
- Geriatrics and Geriatric Emergency Care, Italian National Research Center on Aging (IRCCS-INRCA), Ancona, Italy
| | - Joseph M. Rimland
- Scientific Direction, Italian National Research Center on Aging (IRCCS-INRCA), Ancona, Italy
| | | | | | - Roy L. Soiza
- Department of Medicine for the Elderly, Woodend Hospital, Aberdeen, United Kingdom
| | - Valentina Pierini
- Clinica di Medicina Interna e Geriatria, Politecnica University of the Marche Region, Ancona, Italy
| | - Paolo Dessì Fulgheri
- Clinica di Medicina Interna e Geriatria, Politecnica University of the Marche Region, Ancona, Italy
| | - Fabrizia Lattanzio
- Scientific Direction, Italian National Research Center on Aging (IRCCS-INRCA), Ancona, Italy
| | - Denis O’Mahony
- Department of Medicine, University College Cork, Cork, Ireland
| | - Antonio Cherubini
- Geriatrics and Geriatric Emergency Care, Italian National Research Center on Aging (IRCCS-INRCA), Ancona, Italy
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50
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Fleet J, Chen S, Martin FC, Ernst T. A multifaceted intervention package to improve the diagnosis and management of delirium. Int Psychogeriatr 2015; 27:337-342. [PMID: 25273153 DOI: 10.1017/s1041610214001938] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Delirium is a major cause of morbidity and mortality amongst hospital patients. Previous studies have shown that it is often poorly recognized and managed. We wanted to assess the impact of a multifaceted intervention on delirium management. METHODS A pre/post-intervention design was used. The local hospital delirium guideline was adapted into A7 sized cards and A3/A2 posters. Cards were distributed to junior doctors and teaching sessions were held. Computer screen savers were displayed and delirium promotion days held. The pre/post-intervention data were used to audit the following: delirium knowledge through questionnaires, documented use of the confusion assessment method (CAM) and identification and management of eight common precipitating factors. Re-audit was four months post baseline with interventions within this period. χ2 tests were used for statistical analysis. RESULTS A convenience sample of randomly selected doctors in postgraduate training posts completed 100 questionnaires and 25 clinical notes were selected via retrospective identification of delirium. Results from questionnaires demonstrated significant improvements in: recognizing CAM as the diagnostic tool for delirium (24% vs. 71%, p < 0.01); identifying haloperidol as first line in pharmacological management (55% vs. 98%, p <0.01) and its correct dose (40% vs. 67%, p <0.01). In clinical practice, there was significant improvement in documentation of CAM for inpatient delirium assessments (0% vs. 77%, p <0.01). Trainees found the delirium card "very helpful" (82%) and carried it with them at all times (70%). CONCLUSION This multifaceted intervention increased CAM use in delirium recognition and improved the knowledge of pharmacological management. The delirium card was highly popular.
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Affiliation(s)
- J Fleet
- Department of Ageing and Health, Guy's and St. Thomas' Hospital Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - S Chen
- Department of Ageing and Health, Guy's and St. Thomas' Hospital Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - F C Martin
- Department of Ageing and Health, Guy's and St. Thomas' Hospital Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - T Ernst
- Department of Ageing and Health, Guy's and St. Thomas' Hospital Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
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