Delirium: Clinical approach and prevention

doi:10.1016/j.bpa.2012.07.001

Best Practice & Research Clinical Anaesthesiology

Volume 26, Issue 3, September 2012, Pages 311-326

https://doi.org/10.1016/j.bpa.2012.07.001 Get rights and content

Delirium, defined as an acute fluctuating change in mental state, with consciousness and cognitive impairment, has been found to have a high incidence in hospitalised patients, as well as being associated with increased morbidity and mortality, prolonged stays in the intensive care unit (ICU) and in hospital and higher costs. However, delirium is not easy to detect, since its diagnosis is mainly clinical. Yet the importance of early diagnosis and possible prevention in the different clinical scenarios is clear, to improve patient prognosis. This review provides a practical approach to delirium management through: (a) its classification and diagnosis utilising validated tools and (b) the use of non-pharmacological protocols and of an early prediction model to identify high-risk patients, who are more likely to benefit from pharmacological prophylaxis.

Section snippets

Classification

International literature defines delirium as ‘prevalent’ when it is detected at admission, and ‘incidental’ when it develops during the hospital stay. Delirium can also be classified into sub-types, based on its clinical characteristics. Lipowski⁸ identified three forms of delirium: hyperactive, hypoactive and mixed. Hyperactive delirium is characterised by agitation, restlessness and attempts to remove invasive tools. Hypoactive delirium is characterised by withdrawal, flat affect, apathy,

Early recognition of risk factors, signs and symptoms

Prevention that involves understanding the predisposing and precipitating risk factors is considered the most effective way to reduce delirium incidence.18, 30, 61 A crucial point is early detection of the so-called ‘sentinel events’. On patient admission, changes from normal behaviour, as reported by next of kin, should be investigated. Hereafter, signs indicating hypoactive delirium are listed:

•
cognitive function: deterioration of concentration, slowed responses and mental confusion;
•
perceptive

Summary

Delirium is a common, and frequently misdiagnosed, syndrome in hospitalised patients, associated with both increased morbidity and mortality, as well as long-term disability. Despite years of evidence revealing the risks connected with delirium development, there is still a gap between current practice and ideal processes of care, since health professionals show little sensitivity towards this morbidity.

Since early delirium diagnosis is the first step towards prevention and treatment, the

Conflict of interest

None.

Acknowledgements

The authors thank Linda Canali and Paolo Martini for editing the English.

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2023, Perioperative Care and Operating Room Management
Older patients with clinical osteoarthritis are more likely to have a greater degree of physical frailty. These patients, when subject to a surgical procedure such as arthroplasty, often present with complex perioperative challenges and are more likely to experience adverse postoperative outcomes.
The objective of this study was to evaluate the effect of geriatrician-led comprehensive geriatric assessment (CGA) and interventions administered through a POPS (Perioperative care for Older People undergoing Surgery) Service on postoperative length of stay and complications in patients who were pre frail and frail waiting for elective hip or knee arthroplasty.
This was a retrospective observational cohort study comparing a post intervention cohort with historic controls. Patients ≥ 65 years of age who were waiting for hip or knee arthroplasty with a Clinical Frailty Scale (CFS) ≥4, were evaluated in our POPS @NALHN (Northern Adelaide Local Health Network) service between October 2018 and December 2019. Post-operative outcomes were compared with patients who underwent hip or knee arthroplasty between July 2017 and September 2018, who received usual care.
Following multi-domain frailty assessment and interventions through the POPS Service, the average postoperative length of stay was shorter (6.0 days in the control group vs 3.6 days in the intervention group (Incidence Rate Ratio (IRR)=1.66, 95% CI: 1.35, 2.04; P= <0.0001). The control group was 2.5 times more likely to have postoperative complications than the intervention group (Odds Ratio= 2.55, 95% CI 1.17, 5.56, P = 0.018). The control group had a higher incidence of medical complications than the intervention group (IRR =2.01, 95% CI: 1.11, 3.64, P = 0.021).
Providing a geriatrician-led CGA and interventions to prefrail and frail older adults prior to elective hip or knee arthroplasty was associated with reduced acute hospital length of stay and medical complications. Frailty screening and intervention through CGA in the perioperative setting has the potential to enhance patient care.
A nurse-led intervention to reduce the incidence and duration of delirium among adults admitted to intensive care: A stepped-wedge cluster randomised trial
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Delirium is an acute change in behaviour, characterised by a fluctuating course, inattention, and disorganised thinking. For critically ill adults in the intensive care, the incidence of delirium has been reported to be at least 30% and is associated with both short-term and long-term complications, longer hospital stay, increased risk of mortality, and long-term cognitive problems.
The objective of this study was to determine the effectiveness of a nurse-led delirium-prevention protocol in reducing the incidence and duration of delirium among adults admitted to intensive care.
A hybrid stepped-wedge cluster randomised controlled trial was conducted to assess the effectiveness of the implementation and dissemination of the nurse-led intervention to reduce the incidence and duration of delirium among adults admitted to the four adults intensive care units in the southwest of Sydney, Australia.
Between May 2019 and February 2020, over a 10-month period, 2618 admissions, among 2566 patients, were included in the study. After an initial 3-month baseline period, each month there was a random crossover to the nurse-led intervention in one of the four intensive care units, and by the 7th month of the trial, all units were exposed to the intervention for at least 3 months. The incidence of acute delirium was observed to be 10.7% (95% confidence interval [CI] = 9.1–12.4%), compared to 14.1% (95% CI = 12.2–16.2%) during the preintervention (baseline) period (adjusted rate ratio [adjRR] = 0.78, 95% CI = 0.57–1.08, p = 0.134). The average delirium-free-days for these preintervention and postintervention periods were 4.1 days (95% CI = 3.9–4.3) and 4.4 days (95% CI = 4.2–4.5), respectively (adjusted difference = 0.24 days [95% CI = −0.12 to 0.60], p = 0.199).
Following the introduction of a nurse-led, nonpharmacological intervention to reduce the burden of delirium, among adults admitted to intensive care, we observed no statistically significant decrease in the incidence of delirium or the duration of delirium.
Delirium in a surgical context from a nursing perspective: A hybrid concept analysis
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The term delirium has been defined in medical diagnosis criteria as a multidimensional disorder, and the term acute confusion is included in nursing classifications. Delirium can be a serious complication assessed in a patient after a surgical procedure. Still, the patient's delirium frequently remains unrecognised. Care of patients with delirium after surgical procedure is complex, and it challenges nursing expertise. From the nurses’ viewpoint, delirium is associated with ambiguity of concepts and lack of knowledge. Therefore, reseach on how nurses perceive patients with delirium in a surgical context is needed.
The aim of this study was to describe the concepts of delirium and acute confusion, as well as the associated dimensions, in adult patients in a surgical context from the nursing perspective.
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Surgical wards, surgical intensive care units, and post-anaesthesia care units.
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Registered nurses and licensed practical nurses (n = 105) participated in the fieldwork phase.
In the theoretical phase, the concepts’ working definitions were formulated based on a systematic literature search with the year limitations from 2000 until February 2021. At the fieldwork phase, the nurses’ descriptions of patients with delirium were analysed using the deductive content analysis method. At the final analytical phase, findings were combined and reported.
The concepts of delirium, subsyndromal delirium, and acute confusion are well defined in the literature. From the perspective of the nurses in the study, concepts were seen as a continuum not as individual diagnoses. Nurses described the continuum of delirium as a process with acute onset, duration, and recovery with the associated dimensions of symptoms, symptom severity, risk factors, and early signs. The acute phase of delirium was emphasised, and preoperative or prolonged disturbance did not seem to be relevant in the surgical care context. Patients’ compliance with care may be decreased with the continuum of delirium, which might challenge both patients’ recovery from surgery and the quality of nursing care.
In clinical practice the nurses used term confusion inaccurately. The term acute confusion might be used when illustrating an early stage of delirium. Nurses could benefit from further education where the theoretical knowledge is combined with the clinical practice. The discussion about the delirium, which covers the time both before surgery and after the acute phase should be increased.
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Citation Excerpt :
Delirium is an acute decline in attention, cognition, and behaviour that occurs among patients in the intensive care unit (ICU).1 For critically ill adults, the incidence of delirium is approximately 30%;2–6 however, this increases to 60%–80% in older male trauma patients, in patients undergoing mechanical ventilation, and/or in patients for whom the length of stay (LOS) is greater than 48 h.7,8,53 Importantly, an acute episode of delirium is associated with increased morbidity and mortality, including increased mechanical ventilation days, longer LOS, and increased risk of intensive care unit (ICU) and hospital mortality. Patients experiencing an episode of delirium, particularly those who experience hypoactive delirium, have an increased risk of long-term cognitive impairment.9,10
Delirium is an acute disorder of attention and cognition with the highest rates among adults receiving intensive care. An acute episode of delirium is associated with morbidity and mortality, as well as a significant psychological sequela. Importantly, an increasing body of evidence supports the benefit of nonpharmacological, nurse-led interventions to reduce the incidence and duration of delirium among adults cared for in the intensive care unit (ICU).
This study will evaluate the impact of a nursing-led delirium prevention protocol that is aimed at reducing the incidence and duration of delirium among adults admitted to the ICU. The delirium prevention nursing protocol specifically targets risk factors for delirium.
A stepped-wedge cluster randomised controlled trial approach will be used to assess the effectiveness of the nurse-led intervention, in four adult ICUs across the South Western Sydney Local Health District (SWS-LHD), over a 12-month period. The primary outcomes of interest are (i) the incidence of delirium before and after the implementation of the nurse-led intervention and (ii) the number of delirium-free days during an ICU stay, before and after the implementation of the nurse-led intervention.
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2018, Intensive and Critical Care Nursing
Evaluate music listening for delirium prevention among patients admitted to a Trauma Intensive Care and Trauma Orthopaedic Unit. The Roy Adaptation Model provided the theoretical framework focusing on modifying contextual stimuli.
Randomised controlled trial, 40 patients aged 55 and older.
Participants randomly assigned to receive music listening or usual care for 60 minutes, twice a day, over three days. Pre-recorded self-selected music using an iPod and headsets, with slow tempo, low pitch and simple repetitive rhythms to alter physiologic responses.
Heart rate, respiratory rate, systolic and diastolic blood pressure, confusion assessment method.
Repeated measures ANOVA, F(4, 134) = 4.75, p = .001, suggested statistically significant differences in heart rate pre/post music listening, and F(1, 37) = 10.44, p = .003 in systolic blood pressure pre/post music listening. Post-hoc analysis reported changes at three time periods of statistical significance; (p = .010), (p = .005) and (p = .039) and a change in systolic blood pressure pre/post music listening; (p = .001) of statistical significance. All participants screened negative for delirium.
Music addresses pathophysiologic mechanisms that contribute to delirium; neurotransmitter imbalance, inflammation and acute physiologic stressors. Music to prevent delirium is one of few that provide support in a critical care setting.

View all citing articles on Scopus

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4Delirium: Clinical approach and prevention

Section snippets

Classification

Early recognition of risk factors, signs and symptoms

Summary

Conflict of interest

Acknowledgements

Heart Lung

Geriatr Nurs

Chest

J Am Med Dir Assoc

J Am Med Dir Assoc

Lancet

Lancet

Lancet

Arch Phys Med Rehabil

J Crit Care

Intensive Crit Care Nurs

Diagnostic and statistical manual of mental disorders

Delirium in hospitalized elderly patients: recognition, evaluation, and management

Conn Med

Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU)

JAMA

Evaluation of delirium in critically ill patients: validation of the confusion assessment method for the intensive care unit (CAM-ICU)

Crit Care Med

Subsyndromal delirium in the ICU: evidence for a disease spectrum

Intensive Care Med

Prevalence and risk factors for development of delirium in surgical and trauma intensive care unit patients

J Trauma

Delirium epidemiology in critical care (DECCA): an international study

Crit Care

Transient cognitive disorders (delirium, acute confusional states) in the elderly

Am J Psychiatry

Delirium severity and psychomotor types: their relationship with outcomes after hip fracture repair

J Am Geriatr Soc

The prognostic significance of subsyndromal delirium in elderly medical inpatients

J Am Geriatr Soc

Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit

JAMA

The prognostic significance of delirium in older hospital patients

J Am Geriatr Soc

The duration of delirium in medical and postoperative patients referred for psychiatric consultation

Ann Clin Psychiatry

Delirium superimposed on dementia in a community-dwelling managed care population: a 3-year retrospective study of occurrence, costs, and utilization

J Gerontol A Biol Sci Med Sci

Diagnostic dilemma: cognitive impairment in the elderly

J Gerontol Nurs

Different assessment tools for intensive care unit delirium: which score to use?

Crit Care Med

Screening methods for delirium: don't get confused!

Intensive Care Med

Implementation of a delirium assessment tool in the ICU can influence haloperidol use

Crit Care

Occurrence of delirium is severely underestimated in the ICU during daily care

Intensive Care Med

Recognizing delirium superimposed on dementia: assessing nurses' knowledge using case vignettes

J Gerontol Nurs

Implementation, reliability testing, and compliance monitoring of the confusion assessment method for the intensive care unit in trauma patients

Intensive Care Med

Routine delirium monitoring in a UK critical care unit

Crit Care

Delirium assessment in the critically ill

Intensive Care Med

4
Delirium: Clinical approach and prevention