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Implementation of guidelines on delirium in a general hospital: A before-after study of their impact on caregivers' knowledge and clinical skills
Abstract
Introduction: Delirium is a highly prevalent disorder, with serious consequences for the hospitalised patient. Nevertheless, it remains under-diagnosed and under-treated. We developed evidence-based clinical practice guidelines (CPGs) focusing on prevention, screening, diagnosis, and treatment of delirium in a general hospital. This article presents the implementation process of these CPGs and a before-after study assessing their impact on healthcare professionals' knowledge and on clinical practice. Methods: CPGs on delirium were first implemented in two wards (Neurology and Neurosurgery) of the Lausanne university hospital. Interactive one-hour educational sessions for small groups of nurses and physicians were organised. Participants received a summary of the guidelines and completed a multiple choice questionnaire, assessing putative changes in knowledge, before and three months after the educational session. Other indicators such as "diagnosis of delirium" reported in the discharge letters, and mean duration of patients' hospital stay before and after implementation were compared. Results: Eighty percent of the nurses and physicians from the Neurology and Neurosurgery wards attended the educational sessions. Both nurses and physicians significantly improved their knowledge after the implementation (+9 percentage-points). Other indicators were not modified by the intervention. Conclusion: A single interactive intervention improved both nurses' and physicians' knowledge on delirium. Sustained and repeated interventions are probably needed to demonstrate changes in clinical practice.
... The large number of patients affected by delirium during hospitalization, the negative clinical outcomes, and the severe economic consequences all call for action. In recent years, several delirium management guidelines and / or standardized programs were developed for the prevention, early recognition, and / or treatment of delirium across all hospital departments [28][29][30][31][32]. The results indicate that multicomponent delirium management guidelines or programs are most efficient to reduce the delirium rates and the delirium-linked negative outcomes, i.e., decreasing LOS and institutionalization [31,33,34]. ...
Abstract Background Delirium is a well-known complication in cardiac surgery and intensive care unit (ICU) patients. However, in many other settings its prevalence and clinical consequences are understudied. The aims of this study were: (1) To assess delirium prevalence in a large, diverse cohort of acute care patients classified as either at risk or not at risk for delirium; (2) To compare these two groups according to defined indicators; and (3) To compare delirious with non-delirious patients regarding hospital mortality, ICU and hospital length of stay, nursing hours and cost per case. Methods This cohort study was performed in a Swiss university hospital following implementation of a delirium management guideline. After excluding patients aged
... (11) The final study examined nursing and physician knowledge before and after delirium education sessions as part of a delirium BPG implementation process. (12) Overall, little literature exists to guide implementation of delirium BPGs. ...
Background
Our hospital identified delirium care as a quality improvement target. Baseline characterization of our delirium care and deficits was needed to guide improvement efforts.
Methods
Two inpatient units were selected: 1) A general internal medicine unit with a focus on geriatrics, and 2) a surgical unit. Retrospective chart audits were conducted for all patients over age 50 admitted during a one-month period to compare delirium care with best practice guideline (BPG) recommendations, and to determine the incidence of missed cases of delirium and negative outcomes in patients with delirium. The aim was to gather local data to prioritize improvement efforts and mobilize stakeholders.
Results
186 charts were reviewed: 17 patients had physician-diagnosed delirium, 21 patients had missed delirium, and 148 patients had no delirium. Compliance with delirium BPGs was variable, but generally poor. There was a trend towards missed delirium and physician-diagnosed delirium being associated with greater odds of having above-median length of stay and lower odds of discharge home compared to no delirium diagnosis.
Conclusion
Overall, the chart audits confirmed delirium underrecognition and poor adherence to best practices in delirium management. Granular analysis of this data was used to mobilize stakeholders and prioritize improvement plans.
Objective
To determine the accessibility and currency of delirium guidelines, guideline summary papers and evaluation studies, and critically appraise guideline quality.
Design
• Systematic literature search for formal guidelines (in English or French) with focus on delirium assessment and/or management in adults (≥18 years), guideline summary papers and evaluation studies.
• Full appraisal of delirium guidelines published between 2008 and 2013 and obtaining a ‘Rigour of Development’ domain screening score cut-off of >40% using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.
Data sources
Multiple bibliographic databases, guideline organisation databases, complemented by a grey literature search.
Results
3327 database citations and 83 grey literature links were identified. A total of 118 retrieved delirium guidelines and related documents underwent full-text screening. A final 21 delirium guidelines (with 10 being >5 years old), 12 guideline summary papers and 3 evaluation studies were included. For 11 delirium guidelines published between 2008 and 2013, the screening AGREE II ‘Rigour’ scores ranged from 3% to 91%, with seven meeting the cut-off score of >40%. Overall, the highest rating AGREE II domains were ‘Scope and Purpose’ (mean 80.1%, range 64–100%) and ‘Clarity and Presentation’ (mean 76.7%, range 38–97%). The lowest rating domains were ‘Applicability’ (mean 48.7%, range 8–81%) and ‘Editorial Independence’ (mean 53%, range 2–90%). The three highest rating guidelines in the ‘Applicability’ domain incorporated monitoring criteria or audit and costing templates, and/or implementation strategies.
Conclusions
Delirium guidelines are best sourced by a systematic grey literature search. Delirium guideline quality varied across all six AGREE II domains, demonstrating the importance of using a formal appraisal tool prior to guideline adaptation and implementation into clinical settings. Adding more knowledge translation resources to guidelines may improve their practical application and effective monitoring. More delirium guideline evaluation studies are needed to determine their effect on clinical practice.
Characteristics of Included Studies
Studies estimate that approximately one-third of episodes of delirium are preventable and that delirium prevention and management are often suboptimal in practice. While there is no doubt that prevention is desirable, the evidence of the benefits of early intervention and treatment for older hospitalised patients with dementia is unclear.
To determine the effects of DemDel, a comprehensive delirium management programme, in inpatient acute care elders with cognitive impairment.
This paper reports the quantitative part of a mixed methods study, comparing an intervention with treatment as usual using validated outcome measures. After training, ward nurses and physicians administered the intervention based on the DemDel algorithm that focused on delirium prevention, including an intensive systematic screening schedule for cognitive impairment and delirium, as well as comprehensive delirium management. The delirium management regimen included timely administration of pro re nata medication.
The study was conducted within four medical wards of an acute care university hospital in urban Switzerland.
A total of 268 patients with cognitive impairment participated in the pre/post comparison study. The intervention and treatment as usual groups consisted of 138 and 130 patients, respectively.
Eighty-seven (32.5%) out of 268 patients developed delirium, of whom 51 (58.6%) were of mixed, 10 (11.5%) hyperactive and 26 (29.9%) hypoactive delirium subtypes. Delirium appeared within the first five days after admission in 81.6% of cases. The 44 (31.9%) patients with delirium in the intervention group with systematic delirium management had less severe episodes of delirium and required medication for management than the 43 (33.1%) delirious patients in the control group. Intervention compliance was good on three of the four units.
The DemDel programme was effective with regard to improvement of outcomes associated with delirium in patients with cognitive impairment. The intervention was feasible and possible to be embedded within routine practice on four busy general medical wards.
Copyright © 2015 Elsevier Ltd. All rights reserved.
Objective: Delirium is highly prevalent in general hospitals but remains underrecognized and undertreated despite its association with increased morbidity, mortality, and health services utilization. To enhance its management, we developed guidelines covering all aspects, from risk factor identification to preventive, diagnostic, and therapeutic interventions in adult patients. Methods: Guidelines, systematic reviews, randomized controlled trials (RCT), and cohort studies were systematically searched and evaluated. Based on a synthesis of retrieved high-quality documents, recommendation items were submitted to a multidisciplinary expert panel. Experts scored the appropriateness of recommendation items, using an evidence-based, explicit, multidisciplinary panel approach. Each recommendation was graded according to this process' results. Results: Rated recommendations were mostly supported by a low level of evidence (1.3% RCT and systematic reviews, 14.3% nonrandomized trials vs. 84.4% observational studies or expert opinions). Nevertheless, 71.1% of recommendations were considered appropriate by the experts. Prevention of delirium and its nonpharmacological management should be fostered. Haloperidol remains the first-choice drug, whereas the role of atypical antipsychotics is still uncertain. Conclusions: While many topics addressed in these guidelines have not yet been adequately studied, an explicit panel and evidence-based approach allowed the proposal of comprehensive recommendations for the prevention and management of delirium in general hospitals.
This is a systematic review on how innovations in health service practice and organisation can be disseminated and implemented. This is an academic text, originally commissioned by the Department of Health from University College London and University of Surrey, using a variety of research methods. The results of the review are discussed in detail in separate chapters covering particular innovations and the relevant contexts. The book is intended as a resource for health care researchers and academics.
Objectives: A systematic review of the
effectiveness and costs of different guideline development,
dissemination, and implementation strategies wasundertaken. The resource
implications of these strategies was estimated, and a framework for
deciding when it is efficient to develop and introduce clinical
guidelines was developed.
delirium is under-diagnosed and under-treated in comparison to other common and serious acute disorders. The reasons for this are unclear.
we conducted a multicentre survey of knowledge of and attitudes to delirium in trainee general physicians.
questionnaire-based survey in 34 acute hospitals in the UK.
we developed a questionnaire designed to test knowledge of delirium prevalence, DSM-IV diagnostic criteria, use of specific screening tools, association with adverse outcomes, and pharmacological management. Questionnaires were completed and returned by hand to the researchers immediately after recruitment. Participants were a convenience sample of trainee doctors in general and emergency medicine.
784 trainee physicians participated. Most participants expressed the view that delirium has a high prevalence and that it is associated with serious adverse outcomes. However, they had poor knowledge of its diagnosis and treatment, reporting the need for better training. Experience working in geriatric medicine had only a modest effect on the ability to diagnose delirium.
UK training doctors' lack of basic knowledge of the diagnosis and management of delirium, rather than a lack of awareness of its high prevalence and clinical significance, appears to be important in determining its under-recognition.
Delirium, a common and often overlooked syndrome in acutely ill elderly patients, may present with signs and symptoms of depression.
To determine (1) how often health care providers mistake delirium for a depressive disorder in older hospitalized patients referred to a psychiatric consultation service for depressive symptoms and (2) which signs and symptoms of depression and delirium characterize these patients.
Patients older than 60 years, admitted to a Veterans Affairs teaching hospital, and consecutively referred to a psychiatric consultation service for evaluation and treatment of a depressive disorder.
The diagnosis of delirium was based on two independent assessments: (1) a clinical interview by a member of the psychiatric consultation service and (2) a structured bedside evaluation performed by one of the investigators, who was not a member of the psychiatric consultation service. The investigator administered the Confusion Assessment Method Instrument, Mini-Mental State Examination, digit span forward, and months of year backward. The investigator also administered the Diagnostic Interview Schedule items for depression to elicit depressive symptoms.
Twenty-eight (41.8%) of the 67 subjects referred for evaluation or treatment of a depressive disorder were found to be delirious. Compared with nondelirious subjects, the delirious subjects were older and more impaired in activities of daily living. The delirious subjects often endorsed depressive symptoms, such as low mood (60%), worthlessness (68%), and frequent thoughts of death (52%). The referring health care provider had considered delirium in the differential diagnosis of the mood disturbance in only three subjects.
Health care providers should consider the diagnosis of delirium in hospitalized elderly patients who appear to be depressed.
Since in hospitalized older patients delirium is associated with poor outcomes, we evaluated the effectiveness of a multicomponent strategy for the prevention of delirium.
We studied 852 patients 70 years of age or older who had been admitted to the general-medicine service at a teaching hospital. Patients from one intervention unit and two usual-care units were enrolled by means of a prospective matching strategy. The intervention consisted of standardized protocols for the management of six risk factors for delirium: cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration. Delirium, the primary outcome, was assessed daily until discharge.
Delirium developed in 9.9 percent of the intervention group as compared with 15.0 percent of the usual-care group, (matched odds ratio, 0.60; 95 percent confidence interval, 0.39 to 0.92). The total number of days with delirium (105 vs. 161, P=0.02) and the total number of episodes (62 vs. 90, P=0.03) were significantly lower in the intervention group. However, the severity of delirium and recurrence rates were not significantly different. The overall rate of adherence to the intervention was 87 percent, and the total number of targeted risk factors per patient was significantly reduced. Intervention was associated with significant improvement in the degree of cognitive impairment among patients with cognitive impairment at admission and a reduction in the rate of use of sleep medications among all patients. Among the other risk factors per patient there were trends toward improvement in immobility, visual impairment, and hearing impairment.
The risk-factor intervention strategy that we studied resulted in significant reductions in the number and duration of episodes of delirium in hospitalized older patients. The intervention had no significant effect on the severity of delirium or on recurrence rates; this finding suggests that primary prevention of delirium is probably the most effective treatment strategy.
To develop consensus guidelines for management of delirium and to assess their effectiveness in improving the outcomes and process of care in delirium.
Guidelines for delirium were developed following a literature search and a formal multi-disciplinary consensus process using a two-stage Delphi technique. The process and outcomes of patients with delirium were then observed in a 'before' (211 patients) and an 'after' study (125 patients). Three levels of intervention were made in the 'after' study. (i) Feedback of baseline data only (low intensity intervention). (ii) As in (i), but also formal distribution of the guidelines to nurses and doctors (medium intensity intervention). (iii) As in (ii), but in addition the guidelines were reinforced with teaching sessions for the nurses and doctors (high intensity intervention).
Older people (aged over 65 years) with delirium admitted to acute medical or acute elderly care wards in five district general hospitals in England.
Only in the high intervention group was there an improvement in process and outcome of care, but this failed to reach statistical significance.
Delirium is a poorly managed condition in older people and guidelines alone fail to improve the process and outcomes of care.
Little is known about the impact of implementing nursing-oriented best practice guidelines on the delivery of patient care in either hospital or community settings.
A naturalistic study with a prospective, before and after design documented the implementation of six newly developed nursing best practice guidelines (asthma, breastfeeding, delirium-dementia-depression (DDD), foot complications in diabetes, smoking cessation and venous leg ulcers). Eleven health care organisations were selected for a one-year project. At each site, clinical resource nurses (CRNs) worked with managers and a multidisciplinary steering committee to conduct an environmental scan and develop an action plan of activities (i.e. education sessions, policy review). Process and patient outcomes were assessed by chart audit (n = 681 pre-implementation, 592 post-implementation). Outcomes were also assessed for four of six topics by in-hospital/home interviews (n = 261 pre-implementation, 232 post-implementation) and follow-up telephone interviews (n = 152 pre, 121 post). Interviews were conducted with 83/95 (87%) CRN's, nurses and administrators to describe recommendations selected, strategies used and participants' perceived facilitators and barriers to guideline implementation.
While statistically significant improvements in 5% to 83% of indicators were observed in each organization, more than 80% of indicators for breastfeeding, DDD and smoking cessation did not change. Statistically significant improvements were found in > 50% of indicators for asthma (52%), diabetes foot care (83%) and venous leg ulcers (60%). Organizations with > 50% improvements reported two unique implementation strategies which included hands-on skill practice sessions for nurses and the development of new patient education materials. Key facilitators for all organizations included education sessions as well as support from champions and managers while key barriers were lack of time, workload pressure and staff resistance.
Implementation of nursing best practice guidelines can result in improved practice and patient outcomes across diverse settings yet many indicators remained unchanged. Mobilization of the nursing workforce to actively implement guidelines and to monitor the delivery of their care is important so that patients may learn about and receive recommended healthcare.
Purpose (1) The purpose of this paper is to construct a comprehensive framework of research dissemination and utilization that is useful for both health policy and clinical decision-making. Organizing Construct (2) The framework illustrates that the process of the adoption of research evidence into health-care decision-making is influenced by a variety of characteristics related to the individual, organization, environment and innovation. The framework also demonstrates the complex interrelationships among these characteristics as progression through the five stages of innovation-namely, knowledge, persuasion, decision, implementation and confirmation-occurs. Finally, the framework integrates the concepts of research dissemination, evidence-based decision-making and research utilization within the diffusion of innovations theory. Methods (3) During the discussion of each stage of the innovation adoption process, relevant literature from the management field (i.e., diffusion of innovations, organizational management and decision-making) and health-care sector (i.e., research dissemination and utilization and evidence-based practice) is summarized. Studies providing empirical data contributing to the development of the framework were assessed for methodological quality. Conclusions (4) The process of research dissemination and utilization is complex and determined by numerous intervening variables related to the innovation (research evidence), organization, environment and individual.
Delirium is a frequent complication of hospital admission, especially among the elderly. It can have serious consequences in terms of morbidity, mortality and decreased quality of life. Nevertheless, an extensive literature review found that it is poorly recognised and poorly managed by medical and nursing staff. Although some researchers have found that education programs for nurses can improve outcomes for patients with delirium, no research assessing nurses' knowledge was found. The objective of this research was to determine nurses' level of knowledge regarding delirium and its risk factors. A questionnaire survey sent to nurses at a teaching hospital found that nurse's knowledge of delirium was generally inadequate, although one ward which had had in-service education attained better results. It is recommended that cognitive assessment in general and delirium in particular be incorporated into nursing education. Improved education could potentially lead to improved health outcomes and considerable cost savings.
Delirium is one of the most frequent symptoms of disease in the elderly. A large variation of incidence and prevalence data is reported probably due to different patient populations and inconsistent diagnostic criteria. In medical and surgical elderly inpatients recent studies report a prevalence rate of approximately 15% and in postoperative patients the incidence and prevalence rates vary greatly, 7-52%, depending on patient population and clinical setting. In nursing homes the prevalence is even higher and delirium is often combined with dementia. Data supports the statement that delirium is most often found in hospitalized somatically ill elderly patients. As a consequence of the rising number of elderly in hospitals we have to expect an increase in the prevalence and incidence of delirium.
Delirium is a complex medical disorder associated with high morbidity and mortality among elderly patients. The goals of our study were to determine the prevalence of delirium in emergency department (ED) patients aged 65 years and over and to determine the sensitivity and specificity of a conventional clinical assessment by an ED physician for the detection of delirium in the same population.
All elderly patients presenting to the ED in a primary acute care, university-affiliated hospital who were triaged to the observation room on a stretcher because of the severity of their illness were screened for delirium by a research psychiatrist using the Mini-Mental State Examination and the Confusion Assessment Method. The diagnosis of "delirium" or an equivalent term by the ED physician was determined by 2 methods: completion of a mental status checklist by the ED physician and chart review. The prevalence of delirium and the sensitivity and specificity of the ED physician's clinical assessment were calculated with their 95% confidence intervals. The demographic and clinical characteristics of patients with detected delirium and those with undetected delirium were compared.
A sample of 447 patients was screened. The prevalence of delirium was 9.6% (95% confidence interval 6.9%-12.4%). The sensitivity of the detection of delirium by the ED physician was 35.3% and the specificity, 98.5%. Most patients with delirium had neurologic or pulmonary diseases, and most patients with detected delirium had neurologic diseases.
Despite the relatively high prevalence of delirium in elderly ED patients, the sensitivity of a conventional clinical assessment for this condition is low. There is a need to improve the detection of delirium by ED physicians.
We sought to determine the prevalence of mental status impairment in elderly emergency department patients and to assess documentation of and referrals by emergency physicians for mental status impairment after discharge from the ED.
We performed a prospective, observational study of a convenience sample of 297 patients 70 years or older presenting to an urban teaching hospital ED over a 12-month period. Patients were screened with the Orientation-Memory-Concentration examination for cognitive impairment and the Confusion Assessment Method for delirium. Documentation, dispositions, and referrals were abstracted from chart review.
Two hundred ninety-seven of the 337 eligible patients were enrolled. Seventy-eight of the 297 (26%; 95% confidence interval [CI] 21% to 31%) patients had mental status impairment; 30 (10%; 95% CI 7% to 14%) had delirium; 48 (16%; 95% CI 12% to 20%) had cognitive impairment without delirium; 17 (6%; 95% CI 3% to 9%) screened positive on both examinations. Only 22 (28%; 95% CI 19% to 40%) of the 78 patients had any documentation of mental status impairment by the emergency physician. Specific mention of delirium, cognitive impairment, or an acceptable synonym was noted in 13 (17%; 95% CI 9% to 27%). Of 34 (44%; 95% CI 32% to 55%) patients with mental status impairment discharged home, only 6 (18%; 95% CI 7% to 35%) had plans documented by the emergency physician to address impairment. Eleven (37%; 95% CI 20% to 56%) of the 30 patients with delirium were discharged home. Sixteen (70%; 95% CI 47% to 87%) of the 23 patients with cognitive impairment who were discharged home had no prior history of dementia; these patients were less likely to have specialized assistance with care (13%; 95% CI 4% to 27%) than those with known dementia (58%; 95% CI 28% to 85%).
Impaired mental status is common among older ED patients. Lack of documentation, admission, or referral by emergency physicians suggests a lack of recognition of this important problem.
Delirium is common and often goes undetected in older patients admitted to medical services. It is associated with poor outcomes. We conducted a randomized clinical trial to determine whether systematic detection and multidisciplinary care of delirium in older patients admitted to a general medical service could reduce time to improvement in cognitive status.
Consecutive patients aged 65 or more who were newly admitted to 5 general medical units between Mar. 15, 1996, and Jan. 31, 1999, were screened with the Confusion Assessment Method within 24 hours after admission to detect prevalent delirium and rescreened within a week to detect incident cases. Patients with delirium were randomly allocated to receive the intervention or usual care. Subjects in the intervention group were seen by a geriatric specialist consultant and followed in hospital for up to 8 weeks by an intervention nurse who liaised with the consultant, attending physicians, family and the primary care nurses. Subjects in the usual care group received standard hospital services but could consult geriatric specialists as needed. A research assistant, blinded as to treatment allocation, administered within 24 hours after enrolment the MiniMental Status Exam (MMSE), Delirium Index (measuring the severity of the delirium) and Barthel Index (measuring independence of personal care). Improvement was defined as an increase in the MMSE score of 2 or more points, with no decrease below baseline plus 2 points, or no decrease below a baseline MMSE score of 27. A short form of the Informant Questionnaire on Cognitive Decline in the Elderly was completed to identify patients with possible dementia. Subjects were assessed 3 times during the first week and weekly thereafter for up to 8 weeks in hospital or until discharge. Data on clinical severity of illness, length of stay and living arrangements after discharge were also collected. The primary outcome measure was time to improvement in MMSE score.
Of the 1925 patients who met the inclusion criteria and were screened, 227 had prevalent or incident delirium and consented to participate (113 in intervention group and 114 in usual care group). There were no clinically significant differences between the intervention and usual care groups except for sex (female 58.4% v. 50.0%) and marital status (married 34.8% v. 41.2%). Overall, 48% of the patients in the intervention group and 45% of those in the usual care group met the predetermined criteria for improvement. The Cox proportional hazards ratio (HR) for a shorter time to improvement with the intervention versus usual care, adjusted for age, sex and marital status, was 1.10 (95% confidence interval [CI] 0.74-1.63). There were no significant differences within 8 weeks after enrolment between the 2 groups in time to and rate of improvement of the Delirium Index, the Barthel Index, length of stay, rate of discharge to the community, living arrangements after discharge or survival. Outcomes between the 2 groups did not differ statistically significantly for patients without dementia (HR 1.54, 95% CI 0.80-2.97), for those who had less co-morbidity (HR 1.36, 95% CI 0.75-2.46) or for those with prevalent delirium (HR 1.15, 95% CI 0.48-2.79).
Systematic detection and multidisciplinary care of delirium does not appear to be more beneficial than usual care for older patients admitted to medical services.
Delirium and pain are common following hip fracture. Untreated pain has been shown to increase the risk of delirium in older adults undergoing elective surgery. This study was performed to examine the relationship among pain, analgesics, and other factors on delirium in hip fracture patients.
We conducted a prospective cohort study at four New York hospitals that enrolled 541 patients with hip fracture and without delirium. Delirium was identified prospectively by patient interview supplemented by medical record review. Multiple logistic regression was used to identify risk factors.
Eighty-seven of 541 patients (16%) became delirious. Among all subjects, risk factors for delirium were cognitive impairment (relative risk, or RR, 3.6; 95% confidence interval, or CI, 1.8-7.2), abnormal blood pressure (RR 2.3, 95% CI 1.2-4.7), and heart failure (RR 2.9, 95% CI 1.6-5.3). Patients who received less than 10 mg of parenteral morphine sulfate equivalents per day were more likely to develop delirium than patients who received more analgesia (RR 5.4, 95% CI 2.4-12.3). Patients who received meperidine were at increased risk of developing delirium as compared with patients who received other opioid analgesics (RR 2.4, 95% CI 1.3-4.5). In cognitively intact patients, severe pain significantly increased the risk of delirium (RR 9.0, 95% CI 1.8-45.2).
Using admission data, clinicians can identify patients at high risk for delirium following hip fracture. Avoiding opioids or using very low doses of opioids increased the risk of delirium. Cognitively intact patients with undertreated pain were nine times more likely to develop delirium than patients whose pain was adequately treated. Undertreated pain and inadequate analgesia appear to be risk factors for delirium in frail older adults.
To improve outcomes for cognitively impaired and delirious older adults.
Pretest, posttest.
A university-affiliated hospital.
Physicians and nurses in the emergency department (ED) and on an acute geriatric unit (AGU).
Multifactorial and targeted to the processes of care for cognitively impaired and delirious older adults admitted to medicine service from the ED.
Prevalence of delirium, admission to AGU, psychotropic medication use, hospital length of stay.
Patient characteristics did not differ between baseline and the two outcome cohorts 4 and 9 months postintervention. Prevalence of delirium was 40.9% at baseline, 22.7% at 4 months (P<.002), and 19.1% at 9 months (P<.001). More delirious patients were admitted to the AGU than to non-AGU units at 4 months (P<.01) and 9 months (P<.01). Postintervention medication use in the hospital differed from baseline. Antidepressant use was greater at 4 months (P<.05). Benzodiazepine and antihistamine use were lower at 9 months (P>.01). Antidepressant and neuroleptic use were higher (P<.02) and antihistamine use was lower (P<.02) at 4 months on the AGU than for the baseline group. Benzodiazepine (P<.01) and antihistamine (P<.05) use were lower at 9 months. Each case of delirium prevented saved a mean of 3.42 hospital days.
A multifactorial intervention designed to reduce delirium in older adults was associated with improved psychotropic medication use, less delirium, and hospital savings.
The aim of this study was to investigate the existence and content of delirium guidelines of the national psychiatric associations in Europe.
A survey was sent by email to national coordinators of the European Association for Consultation-Liaison Psychiatry and Psychosomatics.
Responses were obtained for 12 of the 14 countries that were approached. Of these 12 countries, only two national psychiatric associations reported having national delirium guidelines. The Dutch Psychiatric Association was the only national psychiatric association that had developed a comprehensive multidisciplinary guideline on the diagnosis and treatment of delirium. The German Association of Scientific Medical Societies has a comprehensive guideline on the treatment of alcohol withdrawal delirium, in which the German Society for Psychiatry, Psychotherapy, and Mental Disorders participated. In addition, the delirium guideline of the British Geriatrics Society and the guideline for alcohol withdrawal delirium of the German Neurological Society were mentioned by respondents.
Although the development of evidence-based treatment guidelines is considered an important way to improve clinical practice, the national psychiatric associations of only two countries have such a guideline for the diagnosis and treatment of delirium. The advantages of supranational collaboration in the development of guidelines are stressed.
Background:
Delirium is a common mental disorder with serious adverse outcomes in hospitalised patients. It is associated with increases in mortality, physical morbidity, length of hospital stay, institutionalisation and costs to healthcare providers. A range of risk factors has been implicated in its aetiology, including aspects of the routine care and environment in hospitals. Prevention of delirium is clearly desirable from patients' and carers' perspectives, and to reduce hospital costs. Yet it is currently unclear whether interventions for prevention of delirium are effective, whether they can be successfully delivered in all environments, and whether different interventions are necessary for different groups of patients.
Objectives:
Our primary objective was to determine the effectiveness of interventions designed to prevent delirium in hospitalised patients. We also aimed to highlight the quality and quantity of research evidence to prevent delirium in these settings.
Search strategy:
We searched the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 28th September, 2005. As the searches in MEDLINE, EMBASE, CINAHL and PsycINFO for the Specialized Register would not necessarily have picked up all delirium prevention trials, these databases were searched again on 28th October, 2005. We also examined reference lists of retrieved articles, reviews and books. Experts in this field were contacted and the Internet searched for further references and to locate unpublished trials.
Selection criteria:
Randomised controlled trials evaluating any interventions to prevent delirium in hospitalised patients.
Data collection and analysis:
Data collection and quality assessment were performed by three reviewers independently and agreement reached by consensus.
Main results:
Six studies with a total of 833 participants were identified for inclusion. All were conducted in surgical settings, five in orthopaedic surgery and one in patients undergoing resection for gastric or colon cancer. Only one study of 126 hip fracture patients comparing proactive geriatric consultation with usual care was sufficiently powered to detect a difference in the primary outcome, incident delirium. Total cumulative delirium incidence during admission was reduced in the intervention group (OR 0.48 [95% CI 0.23, 0.98]; RR 0.64 [95% CI 0.37, 0.98]), suggesting a 'number needed to treat' of 5.6 patients to prevent one case. The intervention was particularly effective in preventing severe delirium. In logistic regression analyses adjusting for pre fracture dementia and Activities of Daily Living impairment, there was no reduction in effect size, OR 0.6, but this no longer remained significant [95% CI 0.3,1.3]. There was no effect on the duration of delirium episodes, length of hospital stay, and cognitive status or institutionalisation at discharge. There was also no significant difference in cumulative delirium incidence between treatment and control groups in a sub-group of 50 patients with dementia (RR 0.9 [95% CI 0.59, 1.36]). In another trial of low dose haloperidol prophylaxis, there was no difference in delirium incidence but the severity and duration of a delirium episode, and length of hospital stay were all reduced. We identified no completed studies in hospitalised medical, care of the elderly, general surgery, cancer or intensive care patients. In outcomes, no studies examined for death, use of psychotropic medication, activities of daily living, psychological morbidity, quality of life, carers or staff psychological morbidity, cost of intervention and cost to health care services. Outcomes were only reported up to discharge, with no studies reporting medium or longer-term effects.
Authors' conclusions:
Research evidence on effectiveness of interventions to prevent delirium is sparse. Based on a single study, a programme of proactive geriatric consultation may reduce delirium incidence and severity in patients undergoing surgery for hip fracture. Prophylactic low dose haloperidol may reduce severity and duration of delirium episodes and shorten length of hospital admission in hip surgery. Further studies of delirium prevention are needed.
Delirium is the most common complication of hospitalization in frail elderly. The prognosis is poor with increased mortality and morbidity. Confusion results from one or several precipitating factors in patients at risk. In a randomized study, a preventive multicomponent intervention reduced the incidence of delirium by 40%. The aim of our study was to evaluate the efficacy of such a preventive strategy, in the setting of an acute geriatric care unit.
The study was conducted in a French 26-bed geriatric acute care ward. The primary outcome was the comparison of the incidence of delirium among patients aged 75 years and older, before and after the implementation of a preventive strategy. The overall adherence of the ward staff to the prevention procedures was also determined.
Before intervention, 367 patients were admitted (mean age: 80.6 years). The incidence of delirium was of 8.99%. In the subgroup of 123 demented patients, the incidence of delirium was of 15.4%. After intervention, 372 patients were admitted (mean age 84.9). The incidence of delirium was of 2.4% (relative risk reduction of 73%, P=0.001). In the subgroup of 133 demented patients, the incidence of delirium was 5.3% (relative risk reduction of 66%, P=0.01). The ward staff applied the prevention procedures in 96% of the 10 230 patients-day during the study period.
This study shows that it is possible to apply the results of clinical research in clinical practice to prevent delirium in frail elderly hospitalized in an acute geriatric care unit. Such an easy preventive strategy could be applied in medical units admitting old patients at risk, in the context of a quality procedure.