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.

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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