Recognition Of Delirium Research Articles

Delirium is Under-Detected on Routine Screening with the CAM: a Sub-Study from World Delirium Awareness Day

Background Delirium is an acute change in mental status that affects more than 2.6 million hospitalised adults annually. Patients who experience delirium suffer extended hospital stays and increased mortality and morbidity. Delirium screening is fundamental in driving prevention and early detection. This project aimed to examine delirium assessment, recognition for patients over 18, barriers to implementing delirium prevention treatment, and report qualitative findings for delirium care. Method In mid-March 2023, 11 Clinical Nurse Leaders in the Southeast Region of the United States participated in a study to increase awareness of delirium called World Delirium Awareness Day. Data was collected using an online survey to assess unit census, the number of CAM assessments, and positive CAM screening at 8:00 A.M (+/- 4 hrs) and 8:00 PM (+/- 4 hrs). Patients were defined as having delirium if their electronic healthcare record documentation reflected at least one occurrence of a positive CAM score. The survey comprised 39 “select all that apply” questions and three open-ended questions. Results Results show 418 (64%) CAM assessments were completed. Greater compliance was found during the morning assessment than the evening shift. Differences in nursing practice and opinions were also identified between General and High Acuity Units. Among patients receiving assessments, delirium recognition was 2% (8:00 A.M.) and 3% (8:00 P.M.). There was a significant difference in the use of multi-professional daily goals between the two unit types as a non-pharmacologic intervention for delirium (General: 0% vs. High Acuity: 100%, p=.003). Barriers identified: shortage of personnel, interprofessional communication gaps, and difficult-to-assess patients. Recommendations for delirium care include staff education and implementing an EHR tool to remind nurses to assess and document delirium. Conclusion Findings from this study reveal the need for staff education, support, and the enhancement of resources to promote delirium prevention.

1996 The use of electronic 4AT delirium identification tool in inpatient care

Abstract Introduction Delirium is an acute, fluctuating change in mental status, with inattention, disorganised thinking and altered levels of consciousness. This has serious consequences including the increased risk of dementia, death, length of hospital stay and increased chance of new admission to long term care. Therefore, prompt identification and management are essential. NICE recommends the use of the 4AT score in identification of delirium to improve subsequent management. Method A retrospective descriptive study was done identifying all patients admitted to Wigan infirmary who received a 4AT during the 1/4/22-30/9/22. Patients were excluded if aged <64, 4AT score of 1-3 (a score over 4 is positive for delirium) and had multiple admissions. This reduced the sample size to 275 from 8648 patients, of these data was collected from the individual electronic records from the first 110 patients. Results The average age of patients within the sample is 81, average 4 AT score of 6 and the average CSF was 5. There was a diagnosis of delirium in 32 (29%), and 'confusion' in 10 (15%), a past medical history of dementia in 49 (45%) and cognitive impairment/suspected dementia in a further 10 (9%), PD was found in 9 (8%) of patients. A basic blood test screen to identify a cause for delirium was done in 50 (45%) of patients. DNA CPR was present in 59 (54%) of patients, and a DOLS in 43 (39%) during the admission reviewed. Patients were on a significant number of medication (mean of 10 on discharge) and had an average of 3 ward moves. Length of stay was 20.3 days and 51 (46%) were deceased within a year of admission. Conclusion Embedding 4AT in electronic records improves recognition of delirium. Further work will be undertaken to improve management of this condition once it is recognised.

Emergency Department Recognition of Delirium: Quality Improvement Towards a Geriatric-Friendly ED

Introduction: Delirium is a common yet often undetected condition in the elderly, particularly in the Emergency Department (ED). Its subtle presentation makes timely recognition challenging. Literature shows up to 10% of older patients presenting to the Emergency Department will have Delirium, but typically only 30% of these cases are identified in the Emergency Department. Aims/Objectives: To implement quality improvement measures for early recognition of delirium in geriatric patients aged 65+ in a single center ED. Specific objectives include staff training on delirium identification, enhancing screening protocols, and implementing interventions to address delirium promptly. Materials/Methods: ED staff providers underwent systematic training to optimize integration of Delirium Triage Screening (DTS) and Confusion Assessment Method (CAM), customized to the UAE patient population, into the geriatric ED workflow. A multidisciplinary team consisting of Geriatrics, Internal Medicine, ED Staff Physicians & Nurses established Quality Improvement Projects as part of a transition to a geriatric-friendly ED. Patients diagnosed with Delirium were retrospectively studied across 3 months to assess for use of DTS and CAM in ED evaluation. Results: The collected data demonstrates a small percentage of patients with a diagnosis of Delirium. Given that the average frequency of Delirium tends to be around 10% in geriatric patients presenting to the ED, the presence of Delirium at our ED at 0.97% may represent a possible under-diagnosis of the condition. Documentation for both DTS and CAM was suboptimal, well below the target of at least 90%. While the policy prepared was comprehensive, communication of the recognition and assessment pathways could be improved. Discussion: Following suboptimal initial results, dedicated internal departmental learning lectures were organized that focused specifically on the DTS and CAM assessments, with ample time for questions and answers with discussion to best understand and integrate these assessments into our ED workflow. Conclusion: An improved understanding of Delirium, followed by an enhanced integration of validated screening tools will invariably improve ED recognition of Delirium, thereby improving patient-oriented outcomes for elderly individuals presenting to the ED.

Pediatric Delirium Educational Tool Development With Intensive Care Unit Clinicians and Caregivers in Canada: Focus Group Study.

Pediatric intensive care unit (PICU)-associated delirium contributes to a decline in postdischarge quality of life, with worse outcomes for individuals with delayed identification. As delirium screening rates remain low within PICUs, caregivers may be able to assist with early detection, for which they need more education, as awareness of pediatric delirium among caregivers remains limited. This study aimed to develop an educational tool for caregivers to identify potential delirium symptoms during their child's PICU stay, educate them on how to best support their child if they experience delirium, and guide them to relevant family resources. Web-based focus groups were conducted at a tertiary pediatric hospital with expected end users of the tool (ie, PICU health care professionals and caregivers of children with an expected PICU length of stay of over 48 h) to identify potential educational information for inclusion in a family resource guide and to identify strategies for effective implementation. Data were analyzed thematically to generate requirements to inform prototype development. Participants then provided critical feedback on the initial prototype, which guided the final design. In all, 24 participants (18 health care professionals and 6 caregivers) attended 7 focus groups. Participants identified five informational sections for inclusion: (1) delirium definition, (2) key features of delirium (signs and symptoms), (3) postdischarge outcomes associated with delirium, (4) tips to inform family-centered care, and (5) education or supportive resources. Participants identified seven design requirements: information should (1) be presented in an order that resembles the structure of the clinical discussion around delirium; (2) increase accessibility, recall, and preparedness by providing multiple formats; (3) aim to reduce stress by implementing positive framing; (4) minimize cognitive load to ensure adequate information processing; (5) provide supplemental electronic resources via QR codes; (6) emphasize collaboration between caregivers and the health care team; and (7) use prompting questions to act as a call to action for caregivers. Key design requirements derived from end-user feedback were established and guided the development of a novel pediatric delirium education tool. Implementing this tool into regular practice has the potential to reduce distress and assist in the early recognition and treatment of delirium in the PICU domain. Future evaluation of its clinical utility is necessary.

Effects of simulation-based education module on delirium care in undergraduate nursing students: A quasi-experimental study

AimTo examine the effects of a delirium education module on undergraduate nursing students’ knowledge of and perceived confidence and competence in delirium care. BackgroundDelirium is common in intensive care units (ICUs) and leads to poor clinical outcomes. The under recognition of delirium is a major problem in ICU medicine. Nurses, as first-line health care providers, can address this by recognizing patients who are experiencing delirium. Since undergraduate nursing students will be the future ICU nurses, it is important to deliver the knowledge regarding delirium care. However, education about assessing delirium in ICUs among undergraduate nursing students is lacking. DesignQuasi-experimental study. MethodsA total of 74 undergraduate students were divided into an intervention group (n=34) and a comparison group (n=40). A 2-hour simulation-based delirium education module integrated into a critical care curriculum was delivered to the intervention group only. The classroom-based intervention was administered at a medical university in northern Taiwan. Study outcomes were measured using a structured survey including (1) a 16-item delirium care knowledge quiz, (2) confidence in delirium care scale and (3) competence in delirium care scale. The survey was distributed to students before and after the module in December 2020. The Mann–Whitney U test, chi-square test and Fisher’s exact test were adopted to test the differences of all variables between groups. A generalized estimating equation model was used to investigate the adjusted treatment effects. ResultsThe participants had a median age of 22 years and 81% were female. The delirium education module yielded greater knowledge (B = 3.04, 95% confidence interval = 2.20–3.88), confidence (B = 4.20, 95% confidence interval = 2.67–5.73) and competence (B = 4.82, 95% confidence interval = 3.33–6.30) in delirium care when the treatment and control groups were compared. ConclusionsFor undergraduate nursing students, simulation-based education module is effective in improving the knowledge of and confidence and competence in delirium care. It is recommended that this be included in critical care nursing curricula.

A Multi‐disciplinary Team Approach for Educating Providers to Recognize Delirium in the Post Anesthesia Care Unit

AbstractBackgroundPostoperative delirium is common in older adults and has significant associated morbidity and mortality. However, screening is rarely performed in the post anesthesia care unit (PACU). For this reason, clinical researchers of delirium and a tertiary care interdisciplinary delirium Task Force Team proposed to address this area of patient safety.MethodA multidisciplinary team met to complete 3 hospital learning objectives. First, to develop an educational toolkit on PACU delirium identification with feedback from hospital stakeholders on topics to be trained, implementation into medical records, and finalizing training videos/powerpoint/quiz modules. Second, to train every PACU nurse on delirium identification. An EPIC form was created with detailed instructions for completing and documenting the CAM‐ICU and included in the PACU discharge checklist. All PACU nursing staff were assigned the module, and delirium screening was made mandatory for all patients aged 65 years or older. Following module assignment, perceived value, satisfaction, and barriers were surveyed to inform modification of training and implementation. Third, delirium screening rates were monitored.ResultsNurses (n = 110) were assigned postoperative delirium training modules across 3 PACUs starting July 2022 with a 2‐week deadline. Training completion rate was 83% after 3 months. Nurses provided positive feedback on the importance of delirium. Compliance in delirium screening in the PACU was low (<10%). After meeting with nursing staff to hear concerns/barriers to training and implementation, 1 on 1 training with research staff was initiated and all PACU nursing staff completed additional training between September and October. Before project implementation, no delirium screening was performed in the PACU. Over 3 months following completion of training, of 683 patients aged 65 years and older discharged from the PACU, 83 (12%) had delirium screening documented, and 0% were flagged as positive. Rate of screening differed by surgical service and hospital location.ConclusionThis hospital learning study documents the challenges and promise of implementing a PACU delirium screening program in a tertiary care academic medical center. We present data on improved delirium recognition at the hospital level, but variation in compliance rates by surgical service. Future research needs to examine reasons for variable delirium compliance screening.

A Lethal Combination of Delirium and Overcrowding in the Emergency Department.

Delirium is a common public health concern that significantly impacts older patients admitted to the Emergency Department (ED). This condition is linked to adverse outcomes such as reduced long-term functionality, higher mortality rates, extended hospital stays, and increased medical costs. The identification of risk factors is crucial for the early recognition and management of delirium in ED patients. Aging, cognitive decline, polypharmacy, and sensory impairment are some of the most common general risk factors described in the literature. Although validated delirium assessment tools already exist, they are not practical for the fast-paced ED environment because of their extended evaluation period or specialized training request. Moreover, clear guidance is needed to select the most suitable tool for detecting delirium, balancing between the accuracy and the swiftness required in an overcrowded, high-stress, and understaffed healthcare setting. This narrative review aims to analyze the updated literature on delirium risk factors in older ED patients and focuses on the methods for better screening, managing, and treating this condition in the ED.

41 Prevalence of delirium among older patients attending a Frailty service in an Emergency Department

Abstract Background Delirium is a common clinical syndrome in older patients attending the emergency department and its incidence increases with patient age, disease severity and baseline cognitive impairment. However delirium is frequently unrecognised in emergency departments. The 4AT is a simple and short delirium detection tool designed for easy and effective clinical use. Early proactive recognition of delirium in the ED may improve outcomes such as length of stay and discharge to patients own home. Methods We undertook a retrospective study of 92 patients who attended the Frailty service in the ED between 01/01/2023 and 31/01/2023. We screened for delirium using the 4AT within 12 hours of presentation to the ED and screened for frailty using the CFS with additional data collected to define age, sex, presenting complaint, length of stay and readmission rates. Results The 4AT was completed for 92/94 patients. 21/94 scored positive for delirium indicating a delirium prevalence rate of 22% among our Frailty service cohort. The average age of the patients was 84 years and 57% were female. Clinical Frailty Scale ranged from CFS 4–7 reflective of service parameters. The primary presenting reasons were fall (38% of patients) and infection (LRTI or UTI) for (38% of patients). The average length of stay was 8 days and the readmission rate was 12%. Baseline cognitive impairment was present in 71% of cases. 53% of patients were discharged to their own homes. Conclusion Delirium prevalence in the ED among frail older persons is 22%. The 4AT is a useful tool to quickly detect delirium in the ED. Delirium prevalence is greater in patients with baseline cognitive impairment.

Effect of the clinical decision assessment system on clinical outcomes of delirium in hospitalized older adults: study protocol for a pair-matched, parallel, cluster randomized controlled superiority trial

BackgroundPrompt recognition of delirium is the first key step in its proper management. A previous study has demonstrated that nurses’ delirium screening using the usual paper version assessment tool has no effect on clinical outcomes. Clinical decision assessment systems have been demonstrated to improve patients’ adherence and clinical outcomes. Therefore, We developed a clinical decision assessment system (3D-DST) based on the usual paper version (3-min diagnostic interview for CAM-defined delirium), which was developed for assessing delirium in older adults with high usability and accuracy. However, no high quality evidence exists on the effectiveness of a 3D-DST in improving outcomes of older adults compared to the usual paper version.MethodsA pair-matched, open-label, parallel, cluster randomized controlled superiority trial following the SPIRIT checklist. Older patients aged 65 years or older admitted to four medical wards of a geriatric hospital will be invited to participate in the study. Prior to the study, delirium prevention and treatment interventions will be delivered to nurses in both the intervention and control groups. The nurses in the intervention group will perform routine delirium assessments on the included older patients with 3D-DST, while the nurses in the control group will perform daily delirium assessments with the usual paper version. Enrolled patients will be assessed twice daily for delirium by a nurse researcher using 3D-DST. The primary outcome is delirium duration. The secondary outcomes are delirium severity, incidence of delirium, length of stay, in-hospital mortality, adherence to delirium assessment, prevention, and treatment of medical staff.DiscussionThis study will incorporate the 3D-DST into clinical practice for delirium assessment. If our study will demonstrate that 3D-DST will improve adherence with delirium assessment and clinical outcomes in older patients, it will provide important evidence for the management of delirium in the future.Trial registrationChinese Clinical Trial Registry, Identifier: ChiCTR1900028402. https://www.chictr.org.cn/showproj.aspx?proj=47127. Protocol version: 1, 29/7/22.

33 Audit: delirium recognition on an acute medical ward

33 Audit: delirium recognition on an acute medical ward

Non-pharmacological Management of Postoperative Delirium

Postoperative delirium is common especially in the elderly and is associated with high rates of morbidity and mortality. Non-pharmacological multicomponent interventions are effective in reducing the incidence and to a degree the duration of postoperative delirium and are recommended in international guidelines on postoperative delirium as first line intervention for management of delirium. Non-pharmacological management of postoperative delirium consists of strategies for risk stratification, risk reduction by non-pharmacological bundle interventions, early recognition of delirium by screening protocols and immediate therapy of underlying causes of delirium and continuation of non-pharmacological bundles. Non-pharmacological bundle interventions address common perioperative risk factors. Bundles comprise strategies for oxygenation, mobilization, hydration and nutrition, sensory and cognitive stimulation, reorientation, modifications of environmental factors such as design aspects and noise reduction, adequate analgesia, management of agitation and anxiety, protecting circadian rhythms for example by adequate light exposure during daytime, family involvement and timely reduction of unnecessary catheters and anticholinergic drugs. The article aims at providing an overview of non-pharmacological management of postoperative delirium in the hospital.

Amiodarone-Induced Delirium

Amiodarone is a complex drug for the treatment of atrial fibrillation (AF) and ventricular tachyarrhythmias (VTs). Amiodarone can cause a lot of side effects, including pulmonary toxicity, exacerbation of arrhythmia, hyper and hypothyroidism, and hepatic failure. Amiodarone can also cause neurological symptoms, such as tremors, poor coordination, balance disturbances, dizziness, myoclonic jerks, myopathy, and peripheral neuropathy. Amiodarone could cause delirium, depression, insomnia, agitation, confusion, and fatigue. In some cases, patients may experience sensory disturbances, such as visual or auditory hallucinations. A case report of a patient developing delirium after starting amiodarone and improved after discontinuing amiodarone. The exact mechanism of this side effect is not fully understood. In the care of patients receiving amiodarone, the patients should be closely monitored for signs of delirium, particularly with higher doses, new onset of symptoms after drug initiation, and longer treatment durations. Prompt recognition and management of amiodarone-induced delirium are essential to prevent complications and ensure optimal patient outcomes.

Inclusion of frailty improved performance of delirium prediction for elderly patients in the cardiac intensive care unit (D-FRAIL): A prospective derivation and external validation study

BackgroundThe elderly patients admitted to cardiac intensive care unit (CICU) are at relatively high risk for developing delirium. A simple and reliable predictive model can benefit them from early recognition of delirium followed by timely and appropriate preventive strategies. ObjectiveTo explore the role of frailty in delirium prediction and develop and validate a delirium predictive model including frailty for elderly patients in CICU. DesignA prospective, observational cohort study. SettingsCICU at China–Japan Friendship Hospital from March 1, 2022 to August 25, 2022 (derivation cohort); CICU at Beijing Anzhen Hospital affiliated to Capital Medical University from March 14, 2023 to May 8, 2023 (external validation cohort). ParticipantsA total of 236 and 90 participants were enrolled in the derivation and external validation cohorts, respectively. Participants in the derivation cohort were assigned into either the delirium (n = 70) or non-delirium group (n = 166) based on the occurrence of delirium. MethodsThe simplified Chinese version of the Confusion Assessment Method for the Diagnosis of Delirium in the Intensive Care Unit was used to assess delirium twice a day at 8:00–10:00 and 18:00–20:00 until the onset of delirium or discharge from the CICU. Frailty was assessed using the FRAIL scale during the first 24 h in the CICU. Other possible risk factors were collected prospectively through patient interviews and medical records review. After processing missing data via multiple imputations, univariate analysis and bootstrapped forward stepwise logistic regression were performed to select optimal predictors and develop the models. The models were internally validated using bootstrapping and evaluated comprehensively via discrimination, calibration, and clinical utility in both the derivation and external validation cohorts. ResultsThe study developed D-FRAIL predictive model using FRAIL score, hearing impairment, Acute Physiology and Chronic Health Evaluation-II score, and fibrinogen. The area under the receiver operating characteristic curve (AUC) was 0.937 (95% confidence interval [CI]: 0.907–0.967) and 0.889 (95%CI: 0.840–0.938) even after bootstrapping in the derivation cohort. Inclusion of frailty was demonstrated to improve the model performance greatly with the AUC increased from 0.851 to 0.937 (p < 0.001). In the external validation cohort, the AUC of D-FRAIL model was 0.866 (95%CI: 0.782–0.907). Calibration plots and decision curve analysis suggested good calibration and clinical utility of the D-FRAIL model in both the derivation and external validation cohorts. ConclusionsFor elderly patients in the CICU, FRAIL score is an independent delirium predictor and the D-FRAIL model demonstrates superior performance in predicting delirium.

Effectiveness of a Multi-component Delirium Prevention Program Implemented on General Medicine Hospital Units: an Interrupted Time Series Analysis

BackgroundDelirium is among the most prevalent harmful events in hospitals that is associated with an elevated risk for severe outcomes such as functional decline, falls, longer length of stay, and increased mortality.ObjectiveTo evaluate the impact of the implementation of a multi-component delirium program on the prevalence of delirium and the incidence of falls among patients staying on general medicine inpatient hospital units.DesignA pre-post intervention study using retrospective chart abstraction and interrupted time series analysis.CohortPatients were selected from adult patients that stayed at least 1 day on one of the five general medicine units in a large community hospital in Ontario, Canada. A total of 16 random samples of 50 patients per month for 8 consecutive months pre-intervention (October 2017 to May 2018) and 8 months post intervention (January 2019 to August 2019) were selected for a total of 800 patients. There were no exclusion criteria.InterventionThe delirium program included multiple components: education of staff and hospital leadership, twice per day bed-side screen for delirium, non-pharmacological and pharmacological prevention, and intervention strategies and a delirium consultation team.MeasurementDelirium prevalence was assessed using the evidence-based delirium chart abstraction method, CHART-del. Demographic data as well as fall incidence were also collected.ResultOur evaluation showed that the implementation of a multicomponent delirium program led to a reduction in delirium prevalence and fall incidences. The reduction in both delirium and falls was the largest for patients in the ages between 72 and 83 years old and varied across inpatient units.ConclusionA multi-component delirium program to improve the prevention, recognition, and management of delirium reduces the prevalence of delirium and fall incidence among patients in general medicine units.

Nurses’ Knowledge and Ability to Diagnose Delirium in Intensive Care Units of Iraq Teaching Hospitals

Background: Timely diagnosis and effective treatment of delirium, a clinical syndrome, significantly impact the outcomes of patients in intensive care units (ICUs). Despite its significance and prevalence, delirium continues to be underdiagnosed. This study aims to determine the knowledge and capability of ICU nurses in Iraq in recognizing delirium syndrome. Methods: This descriptive cross-sectional study was conducted on 154 nurses working in the ICUs of hospitals in Babylon, Al-Diwaniyah, and Karbala cities, Iraq, in 2022. The subjects were recruited by the census. The study data were collected using a demographic questionnaire, case vignettes, and the delirium knowledge questionnaire (DKQ) to assess participants’ characteristics, delirium recognition, and delirium knowledge. The data were analyzed using an independent t-test and Pearson correlation coefficient in SPSS software, version 22. The significance level was set at P&lt;0.05. Results: The Mean±SD score of nurses’ overall knowledge was 46.73±14.34. The Mean±SD score for their understanding of delirium’s incidence, symptoms, signs, and effects was 43.57±17.70, whereas the Mean±SD score for knowledge of its risk factors and causes was 49.7±18.74. Their overall ability to recognize delirium had a Mean±SD score of 1.44±1.13. There was a significant relationship between knowledge of delirium, participation in a delirium training course (P=0.008), and work experience in ICUs (P=0.046). Conclusion: Given the results of our study, it is crucial to develop plans for increasing the knowledge and recognition ability of ICU nurses in Iraq regarding delirium.

Delirium in Medically Hospitalized Patients: Prevalence, Recognition and Risk Factors: A Prospective Cohort Study.

Delirium is a common neuropsychiatric syndrome in hospitalized elderly patients and is associated with poor clinical outcomes. We aimed to determine the prevalence, recognition, risk factors, and course of delirium among hospitalized elderly (65 years of age or older) patients at Sultan Qaboos University Hospital (SQUH). A prospective cohort study included 327 elderly patients (65 years of age or older) admitted to the medical wards at SQUH. Patients were screened for delirium using the 3-Minute Diagnostic Confusion Assessment Method (3D-CAM). Additionally, medical records were reviewed to identify possible associated factors. The prevalence of delirium was 55.4% (95% CI 49.9-60.7), and 35.4% of patients with delirium were not recognized by the treating team. Hypoactive delirium is the most common type of delirium. The logistic regression analyzes demonstrated that pre-existing cognitive impairment (OR = 4.0); poor functional status (OR = 1.9); the use of medications that are known to precipitate delirium (OR = 2.3); polypharmacy (OR = 5.7); urinary catheterization (OR = 2.2); dehydration (OR = 3.1); and electrolytes derangements (OR = 2.0) were independent risk factors for delirium. Furthermore, 56.9% of patients with delirium continued to have delirium upon discharge from the hospital. Delirium is common among elderly patients hospitalized in general medical wards. Implementing effective preventive strategies for delirium during the hospital stay, including early recognition using standard sensitive and specific screening tools (i.e., 3D-CAM) and developing geriatric wards, is crucial.

‘It’s tough. It is hard’: A qualitative interview study of staff and volunteers caring for hospice in-patients with delirium

Background: Delirium is a distressing condition often experienced by hospice in-patients. Increased understanding of current multidisciplinary care of delirium is needed to develop interventions in this setting. Aim(s): To explore hospice staff and volunteers’ practice, its influences and what may need to change to improve hospice delirium care. Design: Qualitative interview study using behaviour change theory from a critical realist stance. Setting/participants: Thirty-seven staff, including different professional groups and roles, and volunteers were purposively sampled from two in-patient hospices. Results: We found that participants’ practice focus was on managing hyperactive symptoms of delirium, through medication use and non-pharmacological strategies. Delirium prevention, early recognition and hypoactive delirium received less attention. Our theoretically-informed analysis identified this focus was influenced by staff and volunteers’ emotional responses to the distress associated with hyperactive symptoms of delirium as well as understanding of delirium prevention, recognition and care, which varied between staff groups. Non-pharmacological delirium management was supported by adequate staffing levels, supportive team working and a culture of person-centred and family-centred care, although behaviours that disrupted the calm hospice environment challenged this. Conclusions: Our findings can inform hospice-tailored behaviour change interventions that develop a shared team understanding and engage staff’s emotional responses to improve delirium care. Reflective learning opportunities are needed that increase understanding of the potential to reduce patient distress through prevention and early recognition of delirium, as well as person-centred management. Organisational support for adequate, flexible staffing levels and supportive team working is required to support person-centred delirium care.

Effects of an Integrated Geriatric-Orthopedic Co-management (InGerO) on the Treatment of Older Orthopedic Patients with Native and Periprosthetic Joint Infections.

In view of our aging society, co-management with a geriatrician is becoming increasingly important. While such collaborations have been working successfully in trauma surgery for years, it is still unclear whether they are also helpful for non-trauma patients in orthopedics. The aim of this study was to investigate the effect of such a cooperation in orthopedic non-trauma patients with native and periprosthetic joint infections on the basis of five key areas.A retrospective observational study as a before and after comparison was used to compare routine data from patients with and without orthogeriatric co-management after nontraumatic surgery. Eligible patients for the study were 70 years and older, had a diagnosis of hip, knee, or shoulder infection, and had been hospitalized for at least 14 days. Co-management consisted of close follow-up by a geriatrician, Comprehensive Geriatric Assessment, and "complex early geriatric rehabilitation". The comparison group received therapy as usual, without a geriatrician and without "complex early geriatric rehabilitation". Special attention was paid to delirium, pain, mobility, postoperative complications, and renal function.Analysis was carried out with 59 patients "with" and 63 "without" geriatric co-management. In the co-management group, delirium was detected significantly more often (p<0.001), significantly lower pain intensities were measured at the time of discharge (p<0.001), transfer ability had clearly improved more (p=0.04), and renal function was more frequently noted (p=0.04). No significant differences were found with respect to principal diagnoses, surgical procedures performed, complication rates, pressure ulcer and delirium incidence, operative revisions, or length of inpatient stay.Orthogeriatric co-management in orthopedic patients with native and periprosthetic joint infections and nontraumatic surgery appears to have positive impacts on recognition and treatment of delirium, pain management, transfer performance, and attention to renal function. Further studies should follow in order to conclusively assess the value of such co-management in orthopedic nontraumatic surgery patients.

Recognition of Delirium Superimposed on Dementia: Is There an Ideal Tool?

Delirium in persons with dementia (DSD) is a common occurrence. Over the past three decades, several tools have been developed and validated to diagnose delirium, yet there is still a shortage of tools recommended in persons with dementia and there is a lack of sufficient research on the accuracy of performance of such tools in this growing population. The purpose of this article is to (1) conduct a clinical review of the detection of DSD across settings of care by formal health care professionals and informal family members and care partners; (2) identify barriers and facilitators to detection and highlight delirium tools that have been tested in person with dementia; and (3) make recommendations for future research, practice, and policy. Given this review, an "ideal" tool for DSD would point to tools being brief, easy to integrate into the EMR, and accurate with at least 90% accuracy given the poor outcomes associated with delirium and DSD. Knowing the baseline and communication between family members and healthcare professionals should be a top priority for education, research, and health systems policy. More work is needed in better understanding DSD and optimizing and standardizing feature assessment, especially the acute change feature at the bedside for DSD.

Impact of Educational Program on Critical Care Nurses' Knowledge of ICU Delirium: A Quasi-Experimental Study.

Cat Intensive care unit (ICU) delirium is a significant complication that increases the mortality, morbidity, and length of stay for critically ill patient. The aim of this study was to assess the critical care nurse's knowledge of ICU delirium and the effectiveness of an educational program about the recognition and assessment of ICU delirium on critical care nurse's knowledge. A quasi-experimental single group pre-test-post-test design was conducted using delirium knowledge assessment questionnaires. The median post test score of overall nurses' knowledge was 76.2 (range 19.1-95.2) compared to the median pre-test score of 38.1 (range 14.3 - 61.9) indicating a significant change in nurses' knowledge after conducting the educational program (p<0.001). Critical care nurses' knowledge of ICU delirium was low before the intervention and increased significantly after delivering an educational program.