Delirium 67
Delirium
A THESISPresented to the Professional Studies
DepartmentCalifornia State University, Long BeachIn Partial
Fulfillment of the Requirements for the DegreeMaster of Science in
Emergency Services Administration
ByDella Kay Bradford, B.S., M.Ed.EDLD Doctoral CandidateTexas
Tech University
April 2011
Dr. Sylvia Mendez-MorseCommittee ChairDr. Dr. Joann
KlinkerCommittee MemberDr. Fernando ValleCommittee Member
Copyright 2011Della Kay Bradford ALL RIGHTS RESERVED
ACKNOWLEDGMENT
I would like to take this chance for thanking my research
facilitator, friends & family for support they provided &
their belief in me as well as guidance they provided without which
I would have never been able to do this research.
DECLARATION
I, (Your name), would like to declare that all contents included
in this thesis/dissertation stand for my individual work without
any aid, & this thesis/dissertation has not been submitted for
any examination at academic as well as professional level
previously. It is also representing my very own views & not
essentially which are associated with university.
Signature:
Date:
ABSTRACT
Delirium is the most common complication associated with
hospitalization of older adults with incidence of 25% to 60%.
Delirium is responsible for approximately 17.5 million hospital
days annually, yet nurses fail to recognize it as much as 70% of
the time. The main aim of this research was to critically appraise
the literature regarding early recognition of delirium in ICU,
formulating conclusions and recommendations to practice. The
research is based on secondary data collection. The data is
extracted from various journals, articles and books. The research
approach used is qualitative. The literature search revealed that
delirium in the hospitalized elderly patient, particularly in ICU,
is a prevalent geriatric syndrome which is under recognized and
under diagnosed. Misdiagnosis of delirium often results in
mismanagement and poor health outcomes, the older patient. It was
also demonstrated with the help of literature review that there is
a significant impact of early recognition of delirium in ICU and
this could help in reducing the length of stay in ICU as well.The
research revealed that many delirium assessment tools have been
developed, but that in many cases the tools are too time consuming
for acute care nurses to use, don't give a complete picture of the
whole delirium phenomena, don't address functional and cognitive
behaviour, and were not specifically developed for nursing
professionals to use. The data clearly shows the impact that
delirium can have on the ICU patient. This information should
empower the nursing community to study this topic further and to
develop strategies to assist the bedside nurse to overcome barriers
and develop techniques to improve outcomes for our patients. The
results of this study clearly show that nurses need additional
education on delirium to correct their misconceptions and provide
an accurate assessment to critically ill patients. Education will
give them the tools that they need and help them base their
practice on evidence not tradition. The first step to take will be
the education of current nurse educators.
TABLE OF CONTENTS
ACKNOWLEDGMENTiiDECLARATIONiiiABSTRACTivCHAPTER 01:
INTRODUCTION1The Problem2Delirium Outcomes2Aims and Objectives3Aims
How to Achieve3Structure of Dissertation4CHAPTER 02:
METHODS6Methodology6Background and Rationale7Inclusion and
Exclusion Criteria9Literature Sources10Literature
Critique11Authors12Titles and Abstracts13Ethical
Considerations14Purpose/Problem of Study14Key Words15Appraisal
Framework15CHAPTER 03: LITERATURE REVIEW16Literature
Review16Hypotheses18Operational Definitions18Sample and
Design20Critique on Quantitative Research Approach21Statistical
Analysis23Results24Themes26CHAPTER 04: DISCUSSION28Psychosocial
Impact28Nursing Assessment30Barriers to Delirium
Assessment31CHAPTER 05: REFLECTIONS34Predisposing and Precipitating
Factors for Delirium34Prevalence of Delirium35Evaluation of
Delirium36Assessment Methods36Documenting Delirium37Assessing and
Diagnosing Delirium38CHAPTER 06: CONCLUSION40Implications for
Nursing40Implications for Future Research42REFERENCES43Literature
Sources51BIBLIOGRAPHY54APPENDIX61
Delirium ii
CHAPTER 01: INTRODUCTION
Delirium is an acute reversible, disturbance of consciousness,
attention, cognition and the perception that is due to a general
medical condition, a substance, or a combination of these factors.
It is a significant health problem for acutely ill older adults,
affecting 2.3 millions persons each year, with an estimated cost of
more than 4 billion annually (Inouye, 1999). In fact, it is the
most frequent complication associated with hospitalization of older
adults. The serious squeal of delirium associated with failure to
diagnose older adults and treat early are well documented as they
relate to significantly increased morbidity and mortality (Covinsky
et al., 2003).Despite the significant negative impact of delirium
on clinical outcomes and healthcare expenditures, delirium is
probably the most misunderstood phenomenon that faces nurses
working with older adults in acute care settings (Inouye, 2004).
Although delirium is clearly defined as a medical diagnosis, it is
frequently either completely missed or misinterpreted as dementia
or depression by both nurses and physicians. Because delirium is
frequently misunderstood, it is not uncommon to see the use of
physical restraints or sedatives to control its' manifestations,
rather than appropriate management of the underlying cause of
delirium-related behaviors.Factors such as the fluctuating nature
of symptoms and varied clinical presentations make delirium
difficult to diagnose. Because nurses spend a considerable amount
of time at the bedside, they are in the best position to identify
the subtle changes associated with early delirium. However, nurses
are more likely to under recognize delirium than physicians
(Inouye, Foreman, Mion, Katz, & Cooney, 2001). Nurse
recognition of delirium requires a clear understanding of the
clinical manifestations and potential causes, particularly in
high-risk groups such as the oldest old ( 85 years) or those with
dementia.
The ProblemDelirium is the most common complication associated
with hospitalization of older adults with incidence of 25% to 60%.
Delirium is responsible for approximately 17.5 million hospital
days annually, yet nurses fail to recognize it as much as 70% of
the time (Foreman, 1999). The negative impact of delirium-related
consequences has been linked to the failure to recognize delirium
early (Inouye, Schlesinger, & Lydon, 1999). Many factors have
been attributed to failure to detect delirium, such as lack of
knowledge about cognitive disorders and assessment methods; failure
to detect quietly delirious patients; failure to correctly
interpret signs and symptoms; failure to recognize delirium
superimposed on dementia; the atypical presentation of delirium in
the older adult; and nurses' philosophical perspective towards
aging. Still others have suggested that certain patients' risk
factors, such as dementia, advanced age, visual impairment, and
hypoactive delirium, are associated with a 20-fold chance of
nurses' failing to recognize delirium (Inouye et al.), Despite all
of these investigations, reasons for nurses' under the recognition
of delirium and the clinical decision making processes they use
remain speculative and poorly understood.
Delirium OutcomesPatients who suffer from delirium in the
hospital often have poor outcomes compared to other patients. The
mortality rate for persistent delirium is substantially higher than
the one year mortality rates of acute conditions such as heart
disease, influenza and pneumonia. An estimated twenty-five percent
of patients who develop delirium while hospitalized will die within
six months (Cole et al., 2008).
Aims and ObjectivesThe research has following aims and
objectives to be achieved after the research:1. To critically
appraise the literature regarding early recognition of delirium in
ICU addressing implementation of the tools formulating conclusions
about the interventions that could be provided to ICU patients of
delirium and recommendations to practice.2. To evaluate the
findings of prior researches in the context of delirium in ICU and
form conclusions keeping into view the discussions and reflections
of the researches.3. To reflect on the effectiveness of some
elements of tools in the early recognition of delirium.4. To
critically appraise the review literature on intervention that
could help in reduction of delirium occurrence.5. To formulate
conclusions and establish further recommendations to clinical
practice in delirium management within ICU.
Aims How to AchieveThe purpose of this dissertation is to
understand early recognition of delirium in ICU by increasing
theoretical knowledge, consequently improving clinical practice and
minimising the length of stay in ICU. Throughout this assignment,
my attention will focus on the early detection and diagnosis of
Delirium in ICU but also touching on some of the other areas of
delirium, which is the implementation of routine systematic tools.
This will be achieved by means of performing extended literature
review. Polit & Beck (2004) says that literature review helps
to lay the foundations for a study, assisting, and interpreting the
study findings and to understanding current knowledge on topics and
illuminating the impact of the study.
Structure of DissertationChapter 01: provides a very broad but
concise introduction & the background of the problem to be
addressed for the readers, so that they could have an overview of
the topic. The chapter also gives the objectives of the research
& the research questions. Additionally, it presents the aims
and outcomes of the literature review as well. Chapter 02: opens up
with the discussion of the research methodology, philosophy of the
research & the approach of dissertation. At the end, it defined
the data collection methods as well as the empirical
construction.Chapter 03: provide very clear and critical review of
the literature that is applicable & quite close to the related
subject, on the other hand, it also provides the explanation,
discussion & crucial thinking for providing the involvement in
the same area.Chapter 04: presents the findings of the critical
review conducted in chapter 03.Chapter 05: provides reflection on
the topic under discussionChapter 06: offers the research question
results & results shortened in the form of a conclusion to the
dissertation along with the recommendations, suggestions &
future areas for research in the same context.Chapter 07: comprise
of references and bibliography.
CHAPTER 02: METHODS
MethodologyThe research is based on secondary data collection.
The data is extracted from various journals, articles and books.
Secondary research describes information gathered through
literature, publications, broadcast media, and other nonhuman
sources (Cryer 2000). This type of research does not involve human
subjects.The research approach used is qualitative. Qualitative
research is much more subjective than quantitative research and
uses very different methods of collecting information which could
be both primary and secondary. As already mentioned, this study
chooses the secondary method. The nature of this type of research
is exploratory and open-ended.The basic methodology followed
particularly for the medical researches is the systematic review of
literature with the help of meta-analytic techniques of statistics.
This serve as the basis for this research too as this would enable
is finding better results and interventions for the patients of
delirium in ICU setting. The results of past researches will be
evaluated on a uniform criteria for inclusion and exclusion which
will result into better recommendations and conclusions of this
paper. This type of research is often less costly than surveys and
is extremely effective in acquiring information. It is often the
method of choice in instances where quantitative measurement is not
required.For the purpose of evaluation, the CASP model has been
used. All the studies have been criticized on the bases of CASP
criterion. The critical evaluation of the studies has been
presented in Chapter 03, literature review. The most significant
reason for the secondary research was the ease of access to
secondary data sources. The cost involved in secondary research is
relatively low in comparison to the primary research. The research
questions and objectives of this research are in accordance with
format of secondary research and they could only be achieved by
following the pattern of secondary research. The use of this
research pattern will be helping in the alignment of large scale
researches. The required information for the research might be
available through the secondary sources. This will help in
effective elimination of the expense and need for carrying out
primary research. In the case of research on delirium, the details
found about the previous primary researches showed that there will
be numerous difficulties in collection of primary data and the
potential of the information obtained will not be justifying the
efforts and cost involved for conducting the primary research.
Background and RationaleWith the ageing of our population, this
problem may potentially will continue to worsen unless we improve
our assessment and treatment. According to the U.S. Census Bureau
over the next two decades, the percentage of persons over the age
of sixty-five will increase from thirteen to nineteen percent of
the total population. A small community study based in United
Kingdom found out that delirium prevalence among the people ranging
from the age 18 to 55 yrs was 0.4%, the people ranging from the
age55 to 85 was 1.1% and the people falling in the age bracket of
85 yrs or above was 13.6% (Folstein et al, 1991). So, it can be
said that the delirium prevalence shows variation depending over
the study setting and the population. Rationale for selecting these
topics is best of my interest, which is relevant to my clinical
area. Having worked in intensive care looking after mechanically
ventilated patients I have become increasingly mindful of the need
for early diagnosis of delirium in this group of patients, and
recognising the subtypes of delirium. More so I have been more
involved in looking after ventilated patients in the general care
of this group of patient, I realised that nurses has immense
pressure to prioritise and deliver the best care and as such,
assessment of delirium (early diagnosis-CAM-ICU tool) in the
majority of cases has not taken precedence. Omission or ignorance
of such important tools can potentially lead to patient safety in
jeopardy, and develop hyperactive delirium, and it is distressing
to the family and staffs. In support of my realisation OBrien D
(2002) pointed out that occurrences of delirium in intensive care
causes high health care cost, upsetting the family and the staffs,
however, the cost is not only monetary but also the mortality rate
is higher, ranges from 10% to 65% which is compared to non
occurring delirium patients. Although most of the staff, including
clinicians considers that delirium in ICU is an expected outcome
(Cole et al., 2008), recent studies shows that it increases the
length of stay, medical complications, and poor outcome.Ely (2004)
conducted a study in ICU ventilated patients, found that those who
developed delirium has had a high-mortality rate and spent 10 days
longer in hospital. Delirium is a common problem in ICU especially
in postoperative cardiac patients. Patients those undergoing
elective major surgery developed delirium 11% less when compared to
elective cardiac surgery 14% (Covinsky 2003).Nurses have been
crucially identified as pivotal in decreasing the patients risk of
developing delirium or recognising the in the early stages by
placing the best possible care (assessment) timely using the
protocols and strategies to diagnose the occurrence The main aspect
within the process of care is the need of comprehensive assessment.
This includes the nurse having the capability to recognise various
mental health issues and to be able to undertake and participate
in, comprehensive holistic, needs based assessment. More over are
the nurses able to recognise the delirium in the primary stage with
tools, which is currently using in the unit. Hypoactive period of
delirium is often unrecognised and unnoticed, so prognosis is most
worse in this case related to its complication and other outcome
related immobility and it is also reflected in NICE guidelines
2010.As per the NICE guidelines 2010, ensure that people at risk of
delirium are cared for by a team of healthcare professionals who
are familiar to the person at risk. Avoid moving people within and
between wards or rooms unless absolutely necessary. Give a tailored
multicomponent intervention package: Within 24 hours of admission,
assess people at risk for clinical factors contributing to
delirium. Based on the results of this assessment, provide a
multicomponent intervention tailored to the persons individual
needs and care setting. The tailored multicomponent intervention
package should be delivered by a multidisciplinary team trained and
competent in delirium prevention.
Inclusion and Exclusion CriteriaPolit Hungeler have provided
very clear illustrations of inclusion and exclusion criteria the
guide for the systematic review focused over the relationship of
written nursing care manual planning, patient outcomes and record
keeping. Keeping this into view, every study in this research has
been selected on the basis of relevance, recent research and
validity of the research. Other criteria followed for the research
were that articles must be published in English, which reported
research studies and that included data measuring nurses assessment
of delirium. Relevance was also kept as a primary factor, it was
judged with the help of abstracts and titles of the studies found
on internet. Only those journals and articles were selected, which
were in context of ICU patients, studies associated with patients
of other ward and hospital units were not taken into
consideration.
Literature SourcesFirstly, the computerised databases of Cinahl
(from year 1990-2010), PsycoInfo (from year 1990 to 2010) and
Medline (from year 1990-2010) were explored for with the help of
the following process. The use of subject related and specific
keywords were used for describing interventions and patients
related to the review were selected with the help of databases
thesaurus function. The selected keywords specifically related to
the psychosocial interventions and patients were combined
separately (by the usage of OR Boolean operator) with the
appropriate free text. Then the combination of two searches was
made (by the usage of AND Boolean operator) for limiting the search
and exploration to the advanced stage cancer patients, that are
relating, to the interventions of psychosocial aspects or any
synonyms that are approximate for the psychosocial
interventions.After that the above mentioned combination of search
was respectively joint-up with a specific methodological filter of
database acclimatized from Dickersin and Robinson (2002) for
limiting the exploration and search to the studies which were
controlled. The search for the literature was then limited to the
researches published in the years 1990-2011, as it was found
through various researches and that advanced cancer was most
prevalent in the same time duration and the highest number of
deaths were reported too, because of this reason numerous
researches were made during this time. Secondly, the abstract of
all the mentioned references of relevant papers was retrieved and
reviewed for the identification of any additional researches.
Thirdly, for the identification of related researches Science
Citation Index was utilized for searching for the researches that
have the relevant papers. Fourthly, the field leaders were also
contacting for locating relevant but the unpublished studies in the
time of 1990-2010 or give suggestions about others who might know
about any unpublished researches or work.The search and exploration
of databases Cinahl, PsycInfo and Medline gave away a total of five
hundred and eighty four citations. After the duplication
adjustment, only 300 studies remained. Out of 300 researches, 258
were excluded after reviewing and evaluating the abstracts. The
abstracts of studies were reviewed with the help of various
databases like Pubmed, Cinahl, PsycoInfo and Medline. The abstracts
of any study consist of the objectives of the paper, methods used
for the research, population and sample, tools and techniques
applied and the main findings along with the conclusion. The
abstract of the paper helped in determination of the relevancy of
the research to the topic and how useful is the research going to
be for the researcher. It appeared that these papers did not meet
the relevancy criteria clearly. Among the 42 studies, 8 were
selected as primary because of the relevancy to the topic and the
validity of the research. The remaining 32 researches were studied
in detail, 9 were found lacking validity of the research and the
results of 13 researches were vague and were not making any
significant contribution to the literature. 9 researches were
relevant to the topic in various parts, those parts were made part
of the critique section and have been discussed in detail.
Literature CritiqueA comprehensive review of the literature was
conducted on research articles for the last ten years utilizing the
search terms of delirium, delirium assessment, acute confusion, and
ICU psychosis. Cumulative Index to Nursing and Allied Health
Literature and MEDLINE databases were used to facilitate research.
Selection criteria were articles that were published in English,
which reported research studies and that included data measuring
nurses assessment of delirium.The chart for the literature analysis
has been attached in the appendix. It presents the authors of the
study, study design, participants, methods used and results of the
research. It includes 9 studies which were focused primarily
because of the relevance to the topic. Analysis of rest 7
researches was not found to be specifically related to the patients
in ICU. So, they were also eliminated from the literature
analysis.The critique over the literature has been done on the
basis of variables by Ryan-Wenger (1992) analysis of the study
articles: 1. Authors 2. Titles and Abstracts 3. Ethical
Consideration 4. Purpose of Study 5. Literature Review 6.
Hypotheses 7. Sample, Selection and Design 8. Results
AuthorsThe studies included for the literature review were
conducted by the authors who are mainly health professionals having
doctorate qualifications and medical doctors from diverse
backgrounds of specialisation. This serves as the basis for
indicating that the authors studies must be extremely knowledgeable
for the processes of research as they have been involved with
various types of researches and experiments during their academic
life and now in their careers. All the authors have been into
publishing work associated with delirium like, Bruce J. Naughton
MD, Susan Saltzman ND, Fadi Ramadan MD, Noshi Chadha MD, Roger
Priore ScD, Joseph M. Mylotte MD, (2005) Milbrandt EB, Deppen S,
Harrison PL, Shintani AK, Speroff T, Stiles RA, Truman B, Bernard
GR, Dittus RS, Ely EW. (2004) Maria Lundstrm RN, Agneta Edlund RN,
Stig Karlsson RN, Benny Brnnstrm RN, Gsta Bucht MD, Yngve Gustafson
MD, (2005) Robinson BR, Mueller EW, Henson K, Branson RD, Barsoum
S, Tsuei BJ. (2008) Ely EW, Gautam S, Margolin R, Francis J, May L,
Speroff T, Truman B, Dittus R, Bernard R, Inouye SK. (2001) Wesley
Ely, E. Ayumi Shintani, Brenda Truman, Theodore Speroff, Sharon M.
Gordon, Frank E. Harrell, Jr, Sharon K. Inouye, Gordon R. Bernard,
Robert S. Dittus, (2004) Shehabi Y, Riker RR, Bokesch PM,
Wisemandle W, Shintani A, Ely EW; SEDCOM (Safety and Efficacy of
Dexmedetomidine Compared With Midazolam) Study Group, (2010) Hare,
M., McGowan, S., Wynaden, D., Speed, G., Landsborough, I.,(2008)
and Truman B & Ely EW (2003), which eventually shows that they
have expertise in the related field. So, this literature review can
be considered as an in-depth analysis of the most recent and
accurate researches conducted in the context of ICU patients
suffering with delirium and the process of its development along
with the measures that could be taken for mitigating the causes
behind it.
Titles and AbstractsThe studies titles are the clear identifiers
of the research questions answered at the end of the research. It
was found in the selected researches that the key words that have
been utilized for studies have been summarized in the titles used
for the researches. This consistency was found in all the selected
studies which at the end made the selection process quicker and
easier. It has been argued by Ryan-Wenger (1992) that a few
terminologies and words could be used for enhancing studys
reliability and credibility. On the other hand, asserted that the
innovative and catchy titles of research could serve as a research
of detracting the quality of work done for the research. On the
contrary, it has been argued that obscured and odd titles of
studies results in attracting the reader enquiring. For overcoming
these issues, articles and papers included and identified for
literature review have been appraised with the help of CASP tool
for validating the exclusion and inclusion in the process of
review. The abstracts of studies also provided the information for
taking the decision of continuing reading or skipping the
article.
Ethical ConsiderationsIt was found out that the all the nine
included studies had sort approval from the relevant bodies of
ethical review in order to carry out the experiments, treatments
and patients were only entered into the study if the informed
consent to treatment was provided to them. These entities were
there for ensuring that the principles of ethics have been applied
and the individual rights have been adhered. This has been of
utmost importance for ensuring the rights of patients were
protected as most of them would been incapacitated generally or
there would be no legal or family representation at times of
treatments and intubations would be generally required for starting
fairly soon after the process of intubations. The approval from the
ethical bodies served for adding credibility and reliability to the
research and studies.
Purpose/Problem of Study After going through the very first
paragraph of the research and sections of 7 studies, delirium in
the patients of ICU was found to be the focal point of the
research. In the two researches, Maria Lundstrm RN, et al (2005)
and SEDCOM (Safety and Efficacy of Dexmedetomidine Compared With
Midazolam) Study Group, (2010) the titles were pretty in compliance
with this research but the focus in the first section was not on
ICU patients in the first section. Later, the focus of the research
was then directed towards the patients in the ICU. The first
section of the paper didnt describe the focus at the patients of
ICU particularly, but later on the specification in the research
was made.
Key WordsThe key words used for searching relevant studies are
as follows: delirium, delirium assessment, acute confusion, ICU
psychosis, ICU, Length of stay, Ventilated patients, Cardiac post
operative patients etc.
Appraisal FrameworkUsing the CASP (Dellinger, 2005) 20 articles
that had been selected as relevant for this literature review were
then appraised using the CASP program which involves a thorough
examination of all parts of the study (e.g appropriate allocation
and blinding of participant), accounting for all trial participants
in the conclusion, minimisation of play of chance and reliability
of study results/findings which then gave the author a much more
refined selection of the most valid and reliable articles to use in
the review (Guyatt et al 1993). I further refined the identified
the remaining 25 studies using the Ryan- Wengers (1992), critiquing
guidelines (see appendix 3 for critiquing guidelines), to remain
with 9 empirical research articles (see table 1 below for selected
literature). Results and findings of studies are illustrated in
table 2 below.
CHAPTER 03: LITERATURE REVIEW
Literature ReviewIn a study conducted by Bruce J. (2005) patient
characteristics were not differing between stand line and the 2
outcome cohorts 9 and 4 months after providing the intervention. At
the baseline delirium prevalence was 40.9%, at the four months it
was 22.7% (P