The Literature Review And Searching For Evidence

The Literature Review And Searching For Evidence

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The Literature Review And Searching For Evidence

D elirium : W hy Are Nurses Confused? Nidsa D. Baker

Helen M. Taggart Anita Nivens

Paula Tillman

Nurses have a key role in detection of delirium, yet this condition remains under recognized and poorly managed. The aim of this study was to explore nurses’ knowledge of delirium-related infor­ mation as well as their perception of their level o f knowledge.

D elirium is a serious, costly, potentially preventable com­plication for hospitalized patients age 65 and older (Wofford & Vacchiano, 2011). This acute, short­ term disturbance of consciousness may last from a few hours to as long as a few months. It is characterized by an acute onset of inattention, dis­ organized thinking, and/or altered level of consciousness.

Delirium can be categorized as hyperactive, hypoactive, or mixed based on symptoms that can fluctu­ ate and change during the course of the disorder. Hyperactive or excited delirium involves agitation and hal­ lucinations (American Psychiatric Association, 2011; Holly, Cantwell, & Jadotte, 2012). Patients with hyperactive delirium are more likely to receive earlier treatment than patients who exhibit the less easily recognized signs of hypoactive deliri­ um: lethargy, drowsiness, and inat­ tention. In addition, patients may show signs of both hyperactive and hypoactive delirium in a condition described as mixed variant delirium (Holly et al., 2012). Health care providers often confuse delirium with depression and/or dementia (Fick, Hodo, & Lawrence, 2007; Holly et al., 2012; Voyer, Richard, Doucet, Danjou, & Carmichael, 2008). Unlike delirium, which hap­ pens suddenly over a few hours or days, dementia usually develops gradually over months or years, while depression generally develops over weeks or months, or, less often, after a sudden event (Holly et al., 2012; Young & Inouye, 2007) (see Table 1).

Delirium is a common multifac­ torial disorder that involves a vul­ nerable patient with predisposing

factors and exposure to precipitat­ ing factors (Sendelbach & Guthrie, 2009). It can occur at various ages. However, older adults are particu­ larly vulnerable to delirium, espec­ ially when they are ill (Featherstone & Hopton, 2010) (see Table 2). Underlying risk factors are often contributory to delirium in older adults. Common triggers are infec­ tion, medications, general pain, constipation, dehydration, and environmental factors (Dahlke & Phinney, 2008; Quinlan et al., 2011). Although delirium occurs commonly in acute care settings, older adult residents of long-term care and assisted living homes are vulnerable as well. Rates of delirium in long-term care settings range from 1% to 60% (Lee, Ha, Lee, Kang, & Koo, 2011; Siddiqi, Young, & Cheater, 2008). Delirium is asso­ ciated with poor patient outcomes that include longer hospital stays, increased costs, increased need for

post-acute care, and significant stress for patients and families (O’Mahony, Murthy, Akunne, & Young, 2011). At least 20% of the 12.5 million patients age 65 or older hospitalized each year have deliri­ um as a complication, causing a $9,000 to $15,000 increase depend­ ing on the severity in hospital costs per patient. Delirium attributes to annual estimated cost of $38 – $152 billion (Kalish, Gillham, & Unwin, 2014; Young & Inouye, 2007).

The prevalence of delirium varies from 1% to 80% depending on pop­ ulation, the time of delirium assess­ ment, and the assessment method. In addition, the documented inci­ dence of delirium extended from 3% to 61% (Kalish et al., 2014; Young & Inouye, 2007). Addition­ ally, the prevalence of this condi­ tion reported in medical and surgi­ cal intensive care unit cohort stud­ ies varied from 20% to 80% (Girard, Panharipande, & Ely, 2008; Kalish

Nidsa D. Baker, MSN, RN, ANP-BC, is Adult Nurse Practitioner, St. Joseph’s/Candler Health System St. Mary’s Health Center, Savannah, GA.

Helen M. Taggart, PhD, RN, ACNS-BC, is Professor, Department of Nursing, College of Health Professions, Armstrong Atlantic State University, Savannah, GA.

Anita Nivens, PhD, RN, FNP-BC, is Graduate Nursing Program Coordinator and Professor, Department of Nursing, College of Health Professions, Armstrong Atlantic State University, Savannah, GA.

Paula Tillman, DNP RN, ACNS-BC, is Assistant Professor, Armstrong Atlantic State University, Savannah, GA, and Informatics Specialist, Memorial Health University Medical Center, Savannah, GA.

Acknowledgments: The authors thank Malcolm Hare, Fremantle Hospital and Health Service and Curtin University School of Nursing in Australia, for granting permission to utilize the ques­ tionnaire.

MEDSURG n u r s i n g . January-February 2015 • Vol. 24/No. 1 15



Research for Practice

TABLE 1. C o m p a ris o n o f D e liriu m , D e m e n tia , a n d D epression

Delirium Dementia Depression Onset Sudden: Hours or days Gradual over months or years

‘ Gradual over weeks or months, or after an event

Alertness/ Attention

Fluctuates: Sleepy or agitated, unable to concentrate

Generally stable Generally stable, some difficulty concentrating

Sleep Sudden changes in sleeping pattern, unusual confusion at night

Can be disturbed, with habitual night-time wandering

Early morning waking

Thinking Disorganized, rambling Specific, difficulty with short-term memory

Preoccupied with negative thoughts, hopelessness, help­ lessness, self-depreciation

Perception Delusions, hallucinations common Generally normal Generally normal

Source: Holly et al., 2012

TABLE 2. P redisposing a n d P re c ip ita tin g Factors fo r D e liriu m

Predisposing Factors Precipitating Factors

Age a 65 Use of sedative hypnotics, opioids, or Male sex anticholinergic drugs Co-existing dementia/cognitive Stroke

impairment Infections History of delirium Hypoxia Depression Shock Functional dependence Fever or hypothermia Immobility Anemia Low level of activity Poor nutritional status History of falls Recent surgery (major/minor) Visual impairment Admission to an intensive care unit Hearing impairment Use of physical restraints Dehydration Use of indwelling urinary catheter Malnutrition Multiple procedures Polypharmacy Pain Alcohol/drug abuse Emotional stress

Prolonged sleep deprivation

Source: Sendelbach & Guthrie, 2009

et al., 2014). Delirium is com m on am ong elders in long-term care (LTC) facilities, with its prevalence ranging from 9.6% to 89% (Voyer et al., 2008).

Although com m on, delirium often is under-recognized and under-diagnosed (O’Mahony et al., 2011). Because of the high incidence and costs associated with delirium, prevention should be a high priority for health care professionals, espe­ cially nurses (Harris, Chodosh, Vassar, Vickrey, & Shapiro, 2009).

Nurses spend more time with patients, allowing them to observe any changes in patients’ attention, level of consciousness, and cognitive function (Brixey & Mahon, 2010). As a result, frequent assessments by nurses are crucial for early detection of delirium (Girard et al., 2008).

Literature Review A comprehensive review of the

literature was conducted of all orig­ inal research published 2001-2014

using MEDLINE, CINAHL, and ProQuest Psychology Journals. Search terms included delirium or acute confusion and nurses, nurses’ recognition, nurses’ identification, or nurses’ knowledge. Exclusion criteria were studies not reporting primary data and studies th a t did n o t include m easurem ent of nurse recognition or knowledge of deliri­ um. A lthough now dated, the selected research specifically evalu­ ated nurses’ knowledge deficit for delirium in studies of various designs. In addition, fewer studies actually assessed th e levels of knowledge about delirium factors, such as definition, available and appropriate assessment scales/tools, and risks (Hare, Dianne, Sunita, Ian, & Gaye, 2008).

Many studies of delirium focused on th e advantages of educated intervention, such as prevention practices, increased early detection, and proper medical management (Bergmann, Murphy, Kiely, Jones, & Marcantonio, 2005; Featherstone & Hopton, 2010; Rapp, Mentes, & Titler, 2001). Researchers also found a positive correlation between use of an educational intervention for nursing and medical professionals and positive patient outcomes such as decreased length of hospital stay (Meako, Thompson, & Cochrane, 2011; Tabet et al., 2005). Fick and co-authors (2007) found using case vignettes could evaluate nurses’

16 la n u a ry -F e b ru a ry 2015 • Vol. 2 4 /N o . 1 MEDSURG N U R S IISTO



Delirium: Why Are Nurses Confused?

knowledge of delirium in patients with dementia.

Hare and colleagues (2008) tar­ geted 1,097 clinical nurses in a hos­ pital setting with a questionnaire to assess their knowledge of delirium and its associated risk factors. Of the 338 (30.8%) returned responses, 64% (n=217) scored 50% or better on the questionnaire. In addition, 36.3% (n=123) scored 50% or better for the risk factor questions while 81.9% («=227) scored 50% or better for the knowledge questions. Find­ ings indicated orthopedic nurses who had participated in a delirium education forum prior to the research scored better on the gener­ al facts portion of the questionnaire when compared to nurses having no pre-survey educational interven­ tion. However, the orthopedic nurs­ es did not score higher compared to other surveyed nurses on the risk factor questions. The researchers thus found nurses were n o t as knowledgeable about delirium risk factors as they were about general facts concerning delirium.

Fick and co-authors (2007) also assessed nurses’ knowledge of deliri­ um but more narrowly focused on delirium superimposed on dementia (DSD), with the goal of determining if nurses were able to recognize these conditions using case vignettes. The case vignettes were designed to eval­ uate knowledge of delirium, its risk factors, and management. The study also assessed nurses’ geropsychiatric knowledge using the Mary Starke Harper Aging Knowledge Exam (MSHAKE), a tool that measures gen­ eral geropsychiatric knowledge. Of 29 participating nurses, 41% (n=12) were able to identify dementia cor­ rectly in the dementia vignette but had difficulty differentiating deliri­ um factors from DSD factors and specifically identifying hypoactive delirium. While this study had a small sample size, its findings sug­ gested nurses are more likely to dis­ tinguish dementia and hyperactive delirium than DSD and hypoactive delirium alone.

Dahlke and Phinney (2008) eval­ uated how nurses assess, prevent, and treat delirium in older hospital­ ized patients, and identified deliri­

um-related challenges and barriers faced by nurses when caring for patients with delirium. This descrip­ tive qualitative study comprised interviews with nurses who worked in a hospital. A convenience sam­ pling included 12 registered nurses in a mid-sized regional hospital in western Canada who had manageri­ al, educational, and bedside roles and worked in various areas such as medical and surgical units. The nurs­ es in the study had 6-43 years of nursing experience. Level of profes­ sional education included diploma («=7), baccalaureate (n=4), and mas­ ter’s degree {n= 1). Each respondent was interviewed for approximately 1.5 hours with open-ended ques­ tions about his or her clinical and personal experience with delirium assessment, recognition, and inter­ vention. Analysis of the recorded interviews yielded three main deliri­ um-related strategies: Taking a Quick Look, Keeping an Eye on Them, and Controlling the Situation.

Taking a Quick Look suggested nurses quickly assess patients because of the limited time general­ ly available in a fast-paced acute care setting (Dahlke & Phinney, 2008). Keeping an Eye on Them rec­ om m ended frequent rounding and m onitoring of patients assessed to be at risk for delirium. Controlling the Situation focused on intervening as needed to prevent injury and provide appropriate therapy. Au­ thors found nurses repeatedly reported having little to no formal education about older adults and had sparse formal knowledge of delirium; they concluded nurses would benefit from increased deliri­ um-related educational support.

Additional research assessing nurses’ knowledge of delirium has been completed in LTC settings. Voyer and co-authors (2008) assessed nurse detection of delirium in older adults. This prospective study identified th e signs and symptoms m ost challenging to dis­ tinguish, as well as delirium factors most likely to go unnoticed. At three LTC facilities and a large regional hospital LTC unit over two 7-day periods, trained research assistants (nurses who had complet­

ed 15 hours of instruction on delir­ ium and dementia detection) inter­ viewed 160 consenting patients age 65 and over with no history of psy­ chiatric illness. Investigators collect­ ed relevant dem ographic and health inform ation and assessed patients for delirium as part of their interviews. Nurses were questioned about their ability and experience in assessing delirium in patients. The incidence of delirium among patient participants was 71.5% (n=108); of those, nurses identified delirium in just 13% (n=14). Authors concluded nurses under­ recognize delirium in older adults in the LTC setting.

Purpose Nurses’ failure to differentiate and

recognize delirium early may be due to lack of knowledge about delirium, risk factors, preventive measures, and treatment. Therefore, the pur­ pose of this study was to assess nurs­ es’ knowledge of delirium and its risk factors, and correlate findings to demographic variables, such as nurs­ es’ years of experience, level of edu­ cation, and area of practice. The study also was designed to evaluate nurses’ perception of their own level of competency related to delirium recognition and management.

Research Questions Research questions addressed in

this study included the following: 1. W hat was nurses’ level of

knowledge of delirium? 2. What was nurses’ level of know­

ledge of delirium risk factors? 3. Was there a correlation be­

tween nurses’ years of experi­ ence, education, and practice area, and their knowledge of delirium and its risk factors?

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