Delirium in Geriatric Patients and Treatment Options

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Table of Contents

PICO Analysis of Research Topic
Search Strategy
Analysis of Literature
Treatment Options
Conclusion
References

Delirium is a condition that may affect geriatric patients during their stay at a hospital, after major surgery, or as a result of taking certain medications. Other reasons for delirium exist as well, which makes this healthcare problem complex and vital for research. The onset of this issue is often rapid, and the consequences of failure to treat delirium in time may be devastating to the person’s mental health (Holroyd-Leduc & Reddy, 2012). Thus, an introduction of an early detection system to the healthcare organization should be discussed. This paper aims to gather information about early recognition and prevention of delirium in geriatric patients, evaluate existing evidence, and determine the approaches to the timely treatment of this disorder.

PICO Analysis of Research Topic

Delirium in geriatric patients is a significant issue that should be analyzed to improve nursing care. This problem occurs in more than a quarter of all older patients (Holroyd-Leduc & Reddy, 2012). Moreover, due to its quick onset and difficulty to recognize symptoms, delirium often goes undiagnosed in older patients for long periods or at all. The treatment of delirium may greatly affect the period of the condition’s influence on the patient, and the person’s health-related outcomes that follow the development of the issue. In this case, the question of timely and appropriate treatment arises. For example, one may assess whether early pharmacologic and nonpharmacologic strategies may improve the patient’s delirium episode duration and outcomes. The PICO question for this research sounds as follows: In geriatric patients (P), does early recognition and treatment of delirium with a dose of antipsychotic medication (I), in comparison to no early detection and psychopharmacological treatment (C), reduce the duration and severity of delirium (O)?

Search Strategy

As this problem can be turned into an opportunity for practice change, practical improvement studies and systematic reviews of pharmacologic and nonpharmacologic intervention programs can be taken as the basis of research. Search databases such as PubMed, CINAHL, and Science Direct were utilized for locating peer-reviewed articles. The search included such terms as “delirium,” “treatment,” and “early.” Primary sources of analysis that have been published in 2014 and after were considered. One systematic review and four research-based studies were chosen to discuss early detection and treatment of delirium. Such Boolean search strings as “[delirium] AND [early] AND [treatment*]” and “[delirium] AND ([pharmacologic*] OR [nonpharmacologic*]) AND [treatment*]) were used. As a result of these operations, five articles were selected; their review is presented below.

Analysis of Literature

The first article is a systematic review with the first level of evidence that discusses treatments for delirium by Cerveira, Pupo, Santos, and Santos (2017). As it is an evaluation of previous research, no theory is used for the foundation of this study. The authors use major healthcare search databases to locate articles about delirium treatment. Cerveira et al. (2017) find that nonpharmacologic approaches such as early mobilization, sleep regulation, social interaction, and spatial orientation positively impact patients’ severity of the condition but have no effect on its duration or mortality. Pharmacological treatments (antipsychotics) were found to reduce the duration and severity of delirium, as well as decrease remission rates and length of hospitalization (Cerveira et al., 2017). The study’s strength lies in its detailed account of all treatments, but the main weakness is the small number of utilized articles.

In the second study, Hasemann et al. (2016) appraise the effects of a nurse-led intervention program for early delirium management. This is a quantitative retrospective cohort study with the fifth level of evidence. The authors use multiple screening tests as the basis of their framework including the Swiss Mini-Mental Status and the Confusion Assessment Method (CAM). Hasemann et al. (2016) determine that the program focused on early screening and management is effective in reducing patients’ health outcomes. The study’s strong point is the fact that the researchers acknowledged the rate of nurses’ compliance with the program. Nevertheless, its implementation example is too small to make a definitive conclusion.

The next retrospective cohort analysis (fifth evidence level) by Michaud, Thomas, and McAllen (2014) is focused on the connection between the early treatment of delirium and the use of physical restraint. The scholars do not have a theoretical base, as they use data from a tertiary hospital that treated some patients within 24 hours of the first delirium assessment. Michaud et al. (2014) establish that patients who underwent pharmacological therapy had a less severe delirium progression and required less mechanical ventilation. The retrospective nature of the study is a weakness, while its rare research of early treatment and physical restraint is strength.

Weaver et al. (2017) also conduct a retrospective analysis (fifth evidence level) without a theoretical framework to evaluate the effectiveness of antipsychotics on delirium in intensive care. They compare treatment strategies with and without antipsychotics and find that these drugs do not reduce the resolution of delirium. Weaver et al. (2017) admit that they were unable to determine the time of the first medication administration as well as the time of screening. Nonetheless, their study may be used to show the underlying problems of using antipsychotics.

Finally, Weiss and Scheeringa (2014) evaluate the electronic records of a hospital (fifth level of evidence) to determine whether early treatment of delirium can improve patient outcomes. The authors analyze data and conclude that patients who received antipsychotics earlier had a shorter duration of delirium than others. They note that scheduled assessments and medication dosing can improve patients’ delirium treatment outcomes. The study’s clear distinction between patients’ time of drug administration allowed the authors to see the effects of early treatment – this is a strong point of this research. However, its randomized nature and small sample decrease its reliability.

Evidence Table.

Citation	Conceptual Framework/ Theory	Main Finding	Research Method	Strengths of Study	Weaknesses	Level of Evidence
Cerveira, C. C. T., Pupo, C. C., Santos, S. D. S. D., & Santos, J. E. M. (2017). Delirium in the elderly: A systematic review of pharmacological and non-pharmacological treatments. Dementia & Neuropsychologia, 11(3), 270-275.	No	Nonpharmacologic approaches such as early mobilization, sleep regulation, social interaction, and special orientation positively impact patients’ severity of the condition but do not affect its duration or mortality. Pharmacological treatments (antipsychotics) were found to reduce the duration and severity of delirium, as well as decrease remission rates and length of hospitalization.	Systematic review	A detailed account of all treatment.	A small number of utilized articles.	I
Hasemann, W., Tolson, D., Godwin, J., Spirig, R., Frei, I. A., & Kressig, R. W. (2016). A before and after study of a nurse-led comprehensive delirium management program (DemDel) for older acute care in patients with cognitive impairment. International journal of nursing studies, 53, 27-38.	No	The program focused on early screening and management is effective in reducing patients’ health outcomes.	Retrospective cohort study	Researchers acknowledged the rate of nurses’ compliance with the program.	The implementation example is too small.	V
Michaud, C. J., Thomas, W. L., & McAllen, K. J. (2014). Early pharmacological treatment of delirium may reduce physical restraint use: A retrospective study. Annals of Pharmacotherapy, 48(3), 328-334.	No	Patients who underwent pharmacological therapy had a less severe delirium progression and required less mechanical ventilation.	Retrospective cohort study	Rare research of early treatment and physical restraint.	The retrospective nature of the study.	V
Weaver, C. B., Kane-Gill, S. L., Gunn, S. R., Kirisci, L., & Smithburger, P. L. (2017). A retrospective analysis of the effectiveness of antipsychotics in the treatment of ICU delirium. Journal of Critical Care, 41, 234-239.	No	Antipsychotic drugs do not reduce the resolution of delirium.	Retrospective cohort study	Shows underlying problems of using antipsychotics.	Researchers were unable to determine the time of the first medication administration as well as the time of screening.	V
Weiss, A., & Scheeringa, M. S. (2014). Psychopharmacological treatment of delirium: Do earlier treatment and scheduled dosing to improve outcomes? The Journal of the Louisiana State Medical Society,166(6), 242-247.	No	Scheduled assessments and medication dosing can improve patients’ delirium treatment outcomes.	Retrospective cohort study	The study’s clear distinction between patients’ time of drug administration.	The randomized nature and small sample.	V

Treatment Options

As can be derived from the literature review, antipsychotics may be beneficial in treating delirium, if taken on time. Such nonpharmacologic treatments as social and special orientation and occupational therapy can be a part of the nurses’ strategy to enhance the results of medications. The combination of the early assessment and timely medication administration can reduce the severity of delirium and its outcomes for older patients.

Conclusion

The early treatment of delirium in geriatric patients is a concept that needs to be researched in detail. The PICO question should reflect the comparison of effects of early and late treatment options. The formulated question is: “In geriatric patients (P), does early recognition and treatment of delirium with a dose of antipsychotic medication (I), in comparison to no early detection and treatment (C), reduce the duration and severity of delirium (O)?” To find reliable evidence, recent peer-reviewed systematic reviews and cohort studies were located. Such Boolean search string as “delirium] AND [early] AND [treatment*]” and “[delirium] AND ([pharmacologic*] OR [nonpharmacologic*]) AND [treatment*]) were utilized. As a result, five studies about treatment options and early detection systems were found. Based on the evidence, the best treatment options are early drug therapy and nonpharmacologic interventions.

References

Cerveira, C. C. T., Pupo, C. C., Santos, S. D. S. D., & Santos, J. E. M. (2017). Delirium in the elderly: A systematic review of pharmacological and non-pharmacological treatments. Dementia & Neuropsychologia, 11(3), 270-275.

Hasemann, W., Tolson, D., Godwin, J., Spirig, R., Frei, I. A., & Kressig, R. W. (2016). A before and after study of a nurse-led comprehensive delirium management programme (DemDel) for older acute care in patients with cognitive impairment. International journal of nursing studies, 53, 27-38.

Holroyd-Leduc, J., & Reddy, M. (Eds.). (2012). Evidence-based geriatric medicine: A practical clinical guide. Hoboken, NJ: Blackwell Publishing.

Michaud, C. J., Thomas, W. L., & McAllen, K. J. (2014). Early pharmacological treatment of delirium may reduce physical restraint use: A retrospective study. Annals of Pharmacotherapy, 48(3), 328-334.

Weaver, C. B., Kane-Gill, S. L., Gunn, S. R., Kirisci, L., & Smithburger, P. L. (2017). A retrospective analysis of the effectiveness of antipsychotics in the treatment of ICU delirium. Journal of Critical Care, 41, 234-239.

Weiss, A., & Scheeringa, M. S. (2014). Psychopharmacological treatment of delirium: Does earlier treatment and scheduled dosing improve outcomes? The Journal of the Louisiana State Medical Society, 166(6), 242-247.

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