Delirium: Prevent, Identify, Treat

General

De, J., & Wand, A. F. (2015). Delirium screening: A systematic review of delirium screening tools in hospitalized patients. The Gerontologist, 55(6), 1079-1099. doi:10.1093/geront/gnv100

This review aimed to identify, compare, and evaluate delirium screening tools used in non-critically ill hospitalized patients and to provide guidance on using the tools in different patient populations. A search of MEDLINE, CINAHL, and PsychInfo databases identified 31 studies of 21 delirium screening tools. Most studies were conducted in mixed populations of older hospitalized patients. Others were conducted in surgical, emergency department, oncology, and palliative care patients exclusively. The Confusion Assessment Method (CAM) was the most widely studied tool. Considerations for selecting a delirium screening tool and suggestions for using specific tools in different populations are provided.

Hshieh, T. T., Yue, J., Oh, E., Puelle, M., Dowal, S., Travison, T., & Inouye, S. K. (2015). Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Internal Medicine, 175(4), 512-520. doi:10.1001/jamainternmed.2014.7779

This study drew articles from PubMed, Google Scholar, ScienceDirect, and the Cochrane Database of Systematic Reviews and specifically looked at 14 studies for the impact of 12 unique nonpharmacological interventions on delirium incidence, falls, length of stay, rate of discharge to a long term institutionalization, and change in status (functional or cognitive). Interventions were based on Hospital Elder Life Program (HELP) protocols. Meta-analysis was performed only for outcomes of delirium incidence, falls, length of stay, and institutionalization. Authors summarize that non-pharmacologic interventions have shown to decrease not only delirium incidence but preventing falls, an outcome that has not been as well investigated as other outcomes.

Inouye, S. K., Westendorp, R. J., & Saczynski, J. S. (2014). Delirium in elderly people. Lancet, 383(9920), 911-922. doi:10.1016/S0140-6736(13)60688-1

A review was performed of original articles on delirium occurring in those aged 65 and older. Utilizing the data bases of Medline, PubMed, article reference lists, and other reviews, articles published between 1990-2012 were selected. The epidemiology, diagnosis, etiology, pathophysiology, evaluation, prevention and treatment methods, controversies, and recommendations for research regarding delirium in the elderly were summarized. Findings for elderly patients with delirium were listed. These included: use cognitive screening and the CAM on all elderly hospitalized patients for delirium; evaluate the necessity of medications prescribed; use nonpharmacological approaches when appropriate; involve the patient’s family; encourage movement; involve patient in care and self-care; ensure availability of assistive devices; and keep patients informed of their schedule.

Kalish, V. B., Gillham, J. E., & Unwin, B. K. (2014). Delirium in older persons: evaluation and management. American Family Physician, 90(3), 150-158.

This article provides a concise yet comprehensive overview of best practices in evaluation and management of delirium in diverse settings. After presenting a case study, the article summarizes the definition, diagnostic criteria, incidence, prevalence and risk factors for delirium. Methods to identify delirium are provided, including the Confusion Assessment Method (CAM) and recommendations are given for appropriate evaluation of associated symptoms to identify underlying illnesses. The article reviews non-pharmacologic and pharmacologic interventions and best practices. This is a useful resource for nurses and advanced practice nurses working in all settings including ICU, acute care, long-term care, community and hospice. CME credits offered.

Maldonado, J. R. (2013). Neuropathogenesis of delirium: Review of current etiologic theories and common pathways. American Journal of Geriatric Psychiatry, 21(12), 1190-1222. doi:10.1016/j.jagp.2013.09.005

This article is a review of the literature and summary of the seven proposed theories that attempts to explain what happens on a neuronal level during illness leading to the cognitive and behavioral changes seen in delirium. These theories include: Neuroinflammatory, Neuronal Aging, Oxidative, Neurotransmitter, Neuroendocrine and Network Disconnectivity Hypotheses. The article further discusses how these theories complement each other and the intersections and reciprocal influences they share.

Martinez, F., Tobar, C., & Hill, N. (2015). Preventing delirium: should non-pharmacological, multicomponent interventions be used? A systematic review and meta-analysis of the literature. Age and Ageing, 44(2), 196-204. doi:ageing/afu173

This study obtained articles from 7 data bases including PubMed/MEDLINE, EMBASE, PsychInfo, CINAHL, Cochrane Library, Cochrane Register Controlled Trials (CENTRAL), LILACS, ScieELO, and grey literature repositories. A systematic review of randomized trials included 7 studies exploring multicomponent interventions to reduce delirium incident and accidental falls during hospitalization. A non-significant reduction in delirium duration, hospital stay and mortality were also discovered. Authors summarized the systematic review and meta-analysis, thus concluding that multicomponent interventions were effective in reducing incident of delirium and reducing accidental falls. The effects did not differ according to clinical setting and should be standard of care for elderly inpatients.

Yue, J., Tabloski, P., Dowal, S. L., Puelle, M. R., Nandan, R., & Inouye, S. K. (2014). NICE to HELP: Operationalizing National Institute for Health and Clinical Excellence Guidelines to improve clinical practice. Journal of the American Geriatrics Society, 62(4), 754-761. doi:10.1111/jgs.12768

The purpose of the article was to share results of a rigorous process to align intervention protocols of the HELP program with the NICE guidelines. The authors conducted a systematic review of all English language articles that were accessed through the PubMed and CINAHL databases from January 1, 2008 through December 31, 2012 on the topics of hypoxia, infection, and pain, which were part of the NICE guidelines, but were not included in the HELP program. Likewise, they explored the same literature to expand the existing dehydration protocol in the HELP program so as to include constipation as one of the target areas. As a result, the NICE guidelines for delirium prevention were fully operationalized and align with the HELP program.

Surgical

American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults. (2015). American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults. (2015). Journal of the American Geriatrics Society, 63(1), 142-150. doi:10.1111/jgs.1328

This American Geriatrics Society (AGS) clinical practice guideline was developed to identify evidence-based pharmacological and non-pharmacological strategies that should be implemented in the perioperative period for the prevention and treatment of postoperative delirium in older patients who are identified as at risk for delirium with delirium risk prediction models. Guideline development was based upon the AGS framework, with a standardized process for literature review, and rating the quality and strength of the recommendations. The nonpharmacological recommendations address (1) health professionals’ education about delirium, (2) multicomponent interventions performed by an interdisciplinary team for delirium prevention and management, (3) identification and management of delirium’s causes and (4) specialized hospital units. Pharmacological interventions address (1) anesthesia depth, (2) regional anesthesia, (3) analgesia, (4) avoidance of inappropriate medications, (5) medications including antipsychotics, cholinesterase inhibitors, benzodiazepines and medications for severe agitation, and (6) pharmacological management of hypoactive delirium.

ICU

Balas, M. C., Vasilevskis, E. E., Burke, W. J., Boehm, L., Pun, B. T., Olsen, K. M., Peitz, G. J., & Ely, E. W. (2012). Critical care nurses' role in implementing the "ABCDE bundle" into practice. Critical Care Nurse, 32(2), 35-38, 40-47; quiz, 48. doi:10.4037/ccn2012229

This article focuses on the implementation of the “ABCDE Bundle” as an evidenced based strategy to decrease the incidence an duration of delirium in the ICU setting. Awakening and breathing, delirium monitoring and early mobilization are strategies that are proven to help lessen the negative effects of an ICU admission. The article reviews the evidence, the importance of the inter-professional team as well as the importance of consistent adherence to the bedside routines to create successful implementation. A strength of the article is a real time “walk through” of how the bundle is implemented in the clinical setting. It includes many useful charts and work flow diagrams which make this article highly appealing for bedside providers.

Barr, J., Fraser, G. L., Puntillo, K., Ely, E. W., Gelinas, C., Dasta, J. F., Davidson, J., E., Devlin, J. W., Kress, J. P., Joffe, A. M., Coursin, D. B., Herr, D. L., Tung, A., Robinson, B. R. H., Fontaine, D. K., Ramsay, M. A., Riker, R. R., Sessler, C. N., Pun, B., Skrobik, Y., & Jaeschke, R. (2013). Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Critical Care Medicine, 41(1), 263-306. Doi: 10.1097/CCM.0b013e3182783b72

The article updates and includes evidence-based guidelines and recommendations for healthcare professionals for the prevention and management of delirium in the critical care setting. This was done by an interdisciplinary task force of twenty individuals over a six year period.

Trogrlic, Z., van der Jagt, M., Bakker, J., Balas, M. C., Ely, E. W., van der Voort, P. H., & Ista, E. (2015). A systematic review of implementation strategies for assessment, prevention, and management of ICU delirium and their effect on clinical outcomes. Critical Care, 19(1), 157-157. doi:10.1186/s13054-015-0886-9

This study was a systematic review of 21 articles pulled from 5 different databases (PubMed, Embase, PsychINFO, Cochrane and CINAHL) that analyzed the implementation strategies for assessment, prevention and management of ICU delirium. All of the studies reviewed included process measures and nine of the studies used both process measures and clinical outcomes. Results from the study showed that implementation of successful interventions often changed process measures but strong data supporting outcome measures was not evident. The study’s findings indicated that implementing multi-component programs with more strategies that targeted ICU delirium assessment; prevention and treatment are more likely to improve clinical outcomes when combined with pain agitation and delirium (PAD) or awakening, breathing coordination, choice of sedative, delirium monitoring and early mobility (ABCDE) bundles.

Cancer

Lawlor, P. G., & Bush, S. H. (2015). Delirium in patients with cancer: assessment, impact, mechanisms and management. Nature Reviews Clinical Oncology, 12(2), 77-92. doi:10.1038/nrclinonc.2014.147

This comprehensive review looks at delirium in patients with cancer. The authors searched MEDLINE and Scopus databases for articles between January 1990 and October 2013. It acknowledges that delirium is common with rates up to 90% with advanced cancer. The authors review validated assessment tools available for screening, and monitoring the severity of Delirium. They also discuss predisposing and precipitating factors, reversibility of delirium, and pathophysiology of delirium in the cancer population. Lastly, the article discusses non-pharmacological and pharmacological interventions to treat delirium and refractory delirium.

Palliative

Hosie, A., Davidson, P. M., Agar, M., Sanderson, C. R., & Phillips, J. (2013). Delirium prevalence, incidence, and implications for screening in specialist palliative care inpatient settings: a systematic review. Palliative Medicine, 27(6), 486-498. doi:10.1177/026921631245721

The purpose of this article was to look at how delirium occurrence was measured in inpatient palliative or hospice settings and to also report on the overall quality and results of that research. A total of eight articles published from 1980 until now were included in this systematic review across the CINAHL and Medline databases. The authors found that the majority of research included both delirium screening and formal assessment, typically diagnosed using DSM criteria. Eight different screening and assessment tools were used across the studies, including delirium tools (i.e., CAM or DRS) and cognition tools (i.e., MMSE). Overall results found that delirium occurrence was lowest upon admission and increased closer to the time of death, with rates as high as 88%. Hypoactive delirium was also found to be the most predominant subtype in this population.

Delirium & Dementia

Fong, T. G., Davis, D., Growdon, M. E., Albuquerque, A., & Inouye, S. K. (2015). The interface between delirium and dementia in elderly adults. The Lancet Neurology, 14(8), 823-832.

This paper reviews scientific evidence from laboratory and clinical studies that support a link between delirium and dementia. The paper describes evidence that supports the role of dementia as an independent risk factor for delirium; delirium as an independent risk factor for dementia; and evidence from clinicopathological, neuroimaging and biomarker studies that suggest both shared and distinct mechanisms of neuronal injury. The role of delirium as a marker of brain vulnerability, mediator of noxious insults and/or contributor to neuronal damage is described. This paper is useful for nurses seeking deeper understanding of the relationship between acute and chronic cognitive impairment.

Family

Halloway, S. (2014). A family approach to delirium: a review of the literature. Aging & Mental Health, 18(2), 129-139. doi:10.1080/13607863.2013.814102

This article reviews studies that explore a family approach to the prevention and management of delirium. It explores the current state of research related to delirium identification and treatment through the lens of family involvement. The review exposes a need for much further exploration and research on the use of family in the management of delirium, especially for the at risk elder patient. The majority of studies reviewed were lower level evidence but two high quality studies, one multi-component intervention and one bedside intervention improved delirium outcomes significantly. Eleven articles met criteria for the review, which demonstrated a need to further explore this understudied topic.

Pediatrics

Kelly P. & Frosch E. (2012). Recognition of delirium on pediatric hospital services. Psychosomatics, 53(5), 446-51. doi: 10.1016/j.psym.2012.04.012.

A retrospective chart review noting that out of 515 pediatric patients in which psychiatry was consulted; only 6 of the consults were delirium noted by the medical team. An additional 47 were diagnosed with delirium by psychiatry, which means the medical team missed 88%. The article brings to light not only the need for the use of bedside tools to detect delirium by the medical staff but also the importance of the psychiatry team.

Williams, S. R. (2016). How to recognize delirium in pediatric patients. American Nurse Today, 11(5), 8-11.

This article provides nurses an overview on how to identify delirium in the pediatric patient. It gives detailed information on commonly used delirium assessment tools used specifically for the pediatric population. Each description includes the tool’s background, sensitivity/specificity, and age range. Nursing actions are then listed with the appropriate reasoning behind the action, as well as suggestions for care in specific circumstances.

Early Mobility

Balas, M. C., Vasilevskis, E. E., Olsen, K. M., Schmid, K. K., Shostrom, V., Cohen, M. Z., Peitz, G., Gannon, D. E., Sisson, J., Sullivan, J., Stothert, J., C., Lazure, J., Nuss, S. L., Jawa, R., S., Freihaut, F., Ely, E. W., & Burke, W. J. (2014). Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Critical Care Management, 42(5), 1024-36. DOI: 10.1097/CCM.0000000000000129

This article evaluates the effectiveness as well as the safety of implementing the Awakening, Breathing, Coordination, Delirium monitoring/management and Early Exercise mobility (ABCDE) bundle into everyday practice. Following 296 patients this study was an eighteen-month prospective, cohort, before-after study. Regression models were used to quantify relationships between the ABCDE bundle and prevalence/duration of delirium and coma, early mobilization, mortality, time to discharge and change in residence. Results of the study showed that critically ill patients who were managed with the ABCDE bundle spent three more days breathing without assistance, were more likely to be up and mobile during their ICU stay and experienced less delirium than patients who were treated with usual care not including the ABCDE bundle.

Balas, M. C., Burke, W. J., Gannon, D., Cohen, M., Z., Colburn, L., Bevil, C., Franz, D., Olsen, K., M., Ely, E. W., & Vasilevskis, E. E. (2013). Implementing the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle into everyday care: Opportunities, challenges, and lessons learned for implementing the ICU pain, agitation and delirium guidelines. Critical Care Management, 41(9), S116-S127. DOI: 10.1097/CCM.0b013e3182a17064

The purpose of this was to examine what worked and what did not when implementing the ABCDE bundle in a prospective study in multiple units in an academic medical center. The 18 month project focused on barriers and facilitators for interdisciplinary staff implementing the bundle. Four factors were identified that helped implementation (e.g. daily rounds of interdisciplinary team, commitment of operational leaders) and five barriers were noted (treatment issues like timing of interventions, workload). Both survey and focus groups with the participants revealed they felt the bundle caused an improvement in practice.