Category: Delirium

The geriatric population goes through many changes in both physical and mental health with age. Thus, some conditions may be difficult to diagnose or predict because of their rapid onset and similar symptoms. For example, delirium often goes unrecognized or confused with dementia, since the two issues share multiple features (Fong, Davis, Growdon, Albuquerque, & Inouye, 2015; Resnick, 2016). It is crucial for medical professionals to understand their differences and treat patients with delirium adequately. The first case study presents an older woman who shows signs of delirium in her behavior. The patient should be evaluated further with the CAM (Confusion Assessment Method), and, if possible, her family should be contacted to gather more information about the possible causes and drug treatments.

Analysis

The woman in the case study is described as inattentive, confused, and agitated. The evaluation shows signs of her having an episode of delirium that is characterized by altered cognition, disturbed consciousness, and loss of focus (Holroyd-Leduc & Reddy, 2012). According to the latest description in the DSM-5, the characteristics of delirium include the acute onset and development of symptoms, disorientation, speech disturbances, and an overall lack of attention and awareness (European Delirium Association & American Delirium Society, 2014). Older people are among the main groups who are affected by delirium, and the patient’s age further corroborates the suspicions (Oh, Fong, Hshieh, & Inouye, 2017).

The patient’s description matches these classification factors, thus supporting the diagnosis of dementia. She has difficulty answering questions, and the medical professional cannot gain her attention without multiple attempts. Moreover, she cannot communicate or explain herself clearly, and her speech is incoherent. The patient’s behavior before arriving at the healthcare facility also suggests an acute episode of delirium. The woman tried to enter her neighbor’s house using her keys, indicating a high level of confusion. Her agitated behavior implies a disturbance in memory and cognition.

Patient Evaluation

The presentation of the patient described above can be used to determine that the older woman had an episode of delirium. However, as no physical examination or patient information could be obtained during the woman’s arrival at the facility, healthcare specialists should take some additional steps to assess her state. First of all, the CAM is a bedside screening tool that can be used by a healthcare provider (Holroyd-Leduc & Reddy, 2012). It is the most widely used tool for evaluating delirium, since it can be utilized in different settings, including the emergency unit (Inouye, Westendorp, & Saczynski, 2014). Furthermore, one needs to obtain more information about the patients’ current drug treatments, other illnesses, and possible socioeconomic or psychological problems.

Therefore, medical professionals should contact the patient’s family to establish potential causes of delirium. This condition can develop as a response to a wide variety of factors, such as medications, surgeries, dementia, old age, or other health-related problems (Zaal, Devlin, Peelen, & Slooter, 2015). If the patient takes drugs that put her at risk of dementia, a change in her therapy plan may improve the patient’s cognition. After assessing the patient’s current state, she should be referred to a neurologist to avoid reoccurring incidents and adverse outcomes.

Conclusion

The diagnosis of delirium may be challenging for healthcare providers since it has many similarities to dementia and lowers patients’ ability to explain their symptoms. The patients should be assessed with such instruments as the CAM, and their loved ones should assist in gathering more information about the patients’ health. Older people are affected by delirium more often than younger ones, and the causes of the disturbance range from medications to infectious diseases and surgeries.

References

European Delirium Association, & American Delirium Society. (2014). The DSM-5 criteria, level of arousal and delirium diagnosis: Inclusiveness is safer. BMC Medicine, 12(141), 1-4.

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

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

Inouye, S. K., Westendorp, R. G., & Saczynski, J. S. (2014). Delirium in elderly people. The Lancet, 383(9920), 911-922.

Oh, E. S., Fong, T. G., Hshieh, T. T., & Inouye, S. K. (2017). Delirium in older persons: Advances in diagnosis and treatment. JAMA, 318(12), 1161-1174.

Resnick, B. (Ed.). (2016). Geriatric nursing review syllabus: A core curriculum in advanced practice geriatric nursing (5th ed.). New York, NY: American Geriatrics Society.

Zaal, I. J., Devlin, J. W., Peelen, L. M., & Slooter, A. J. (2015). A systematic review of risk factors for delirium in the ICU. Critical Care Medicine, 43(1), 40-47.

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.

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.

The task of identifying the etiological significance of behaviorally abnormal patterns, exhibited by a particular individual, has always been considered a rather challenging one. This is because, even today, the pathogenesis of many mental illnesses remains the subject of continual debates. Nevertheless, it is still quite possible to gain a preliminary insight into what may account for the proper approach towards diagnosing mentally ill persons by the mean of analyzing and classifying the qualitative subtleties of their visually observed behavioral inadequateness. In this paper, I will aim to do just that, while promoting the idea that the symptoms, described in the provided case scenario, suggest that the individual in question (Jack) may, in fact, have suffered from the specific form of mental impairment, commonly known as delirium. According to Duppils and Wikblad, “Delirium is a disturbance of consciousness with reduced ability to focus, sustain or shift attention. Further, it is a change in cognition… that develops over a short period of time” (2004, p. 610).

The integral elements of a rationale for me to come up with this preliminary diagnosis can be outlined as follows:

1. As it was mentioned in the case scenario, the concerned 28 years old male began exhibiting abnormal behavior while he was at the restaurant. In its turn, this presupposes the spatially non-continual nature of his illness. This is because the case scenario’s description implies that for some time, prior to the catadrome, this individual was acting in a socially appropriate manner (he would not be able to make it to the restaurant if he was in a delirious state of mind all along). And, as psychiatrists are being well aware of, one of the foremost aspects of how delirium manifests itself in affected people is this mental condition’s spatial briefness and the fact that the severity of associated symptoms fluctuates over the course of time (Schuurmans, Duursma & Shortridge-Baggett 2001).
2. The relevant information, contained in the case scenario, points out to two predisposing factors of delirium, which might have contributed towards the triggering of this mental condition in Jack – his gender affiliation and the contextual possibility that, prior to having started to exhibit the behavioral emanations of delirium, he might have had a few drinks (the scenario of 28 years old male spending time at the restaurant, well after 8 pm, makes this suggestion rather plausible). This assumption is based upon the earlier mentioned logical possibility, which is I consider it appropriate to elaborate on the scenario’s would-be consequences. The factor of gender affiliation concerns the available statistical data, according to which it is specifically males who are being more susceptible to delirium than females (Hare et al. 2008). The second factor refers to the fact that one’s excessive consumption of alcohol has been well proven as such that significantly increases his or her chances to become delirious (Branco 2011).
3. In the provided case scenario, we can also find mentioning of the fact that, one of the reasons why the members of a restaurant’s staff decided to call the ambulance is that Jack appeared abnormally agitated. This gave me another reason to consider that this individual’s visually observable mental abnormality should be discussed within the conceptual/diagnostic framework of delirium. After all, extreme and irrational agitation has been traditionally considered one of hyperactive delirium’s most definitive symptoms. As it was noted by Gillis and MacDonald, “Hyperactive delirium is characterized by hyper-vigilance, agitation, restlessness and disruptive behavior” (2006, p. 20). This again confirms the validity of my preliminary diagnosis.
4. d). Another reason why I think that there is indeed a good rationale for diagnosing Jack with delirium is that the case scenario mentioned the fact that, while exhibiting clearly abnormal behavior, Jack appeared thoroughly disoriented. In its turn, the sensation of spatial/cognitive disorientation has been commonly referred to as yet another classic symptom of one’s delirious mental state (Parmet, Lynm & Glass 2004). Therefore, the fact that Jack experienced a hard time while trying to stand on his feet unassisted, may be well regarded as an additional indication that the actual nature of his sporadically manifested mental impairment should be discussed within the context of what we know about the disorder of delirium. It appears that the reason why he demanded to be allowed to call his sister is that the sensation of spatial disorientation, on his part, strengthened the acuteness of Jack’s insecurity-anxieties. Apparently, Jack never ceased being aware that there was something wrong with how he felt, which means that the integrity of his overall ability to indulge in cognition was not strongly affected. This can serve as another indication that Jack was in fact experiencing a delirious state of mind. The only delirium’s feature that does not quite fit the deployed argumentative logic is the fact that this mental disorder targets predominantly elderly people.
5. The provided case scenario also specifies that, while exhibiting the signs of mental instability, Jack strived to share what he considered the actual ‘truth’ about the ‘wicked world’ with others. This may suggest that he could have been diagnosed with schizophrenia because one of the schizophrenics’ most common psychological traits is their tendency to remain thoroughly committed to imposing the so-called ‘fixed ideas’ upon other people (Harrow, et al. 2000). Nevertheless, the fact that Jack appeared to be obsessed with the idea of ‘world’s wickedness’ can be well discussed within the conceptual framework of the proposed diagnosis. The reason for this is quite apparent – the observable symptoms of delirium and schizophrenia (in regards to how affected individuals perceive the significance of the surrounding reality) often overlap. Moreover, in some cases, they actually derive out of each other (Fink 1999).
6. The state of Jack’s mind appeared to have gone a certain transformation, as he was behaving in a mentally abnormal manner. This indicates a rather rapid development of his mental condition – another common symptom of delirium (Karnik 2007).
7. The case scenario also mentioned that, during the course of the incident, Jack was pacing up and down the restaurant – hence, attracting the attention of other people, as they rightly perceived this kind of behavior clearly abnormal. This suggests that, while the incident was taking place, Jack’s psychomotor activity sustained a powerful boost, which provided me with an additional reason to suggest that the concerned individual was experiencing a specifically delirious state of mind (Kiely et al. 2007).

As of today, the exact triggers of delirium remain largely unknown. Whereas some researchers suggest that delirium should be discussed as a genetically predetermined form of mental inadequateness, others stress out what they consider the indications of this condition being environmentally triggered. During the course of recent decades, however, more and more healthcare professionals were growing to assume an essentially mixed (environmental and genetic) nature of the delirium’s etiology. Nevertheless, the majority of researchers agree, as to what may be considered the foremost risk factors, commonly associated with delirium. In their turn, these factors can be classified as predisposing, on the one hand, and precipitating, on the other. The main predisposing factors include the overall worsening of one’s physical health, visual impairment, alcohol misuse/medical intoxication, male gender, race (Caucasians are more susceptible to delirium), presence of neurological disorders and the lower rate of educational attainment. Precipitating factors include acute fracture, cardiothoracic surgery, blood loss, pre-existing functional impairment, untreated pain and advanced cancer (Farley & McLafferty 2007).

There are also a number of phenomenological aspects to what can be considered the delirium’s discursive significance. For example, it has been noted that the especially acute emanations of this specific form of mental abnormality may well represent a societal danger. That is, individuals in the state of uncontrolled delirium appear to be capable of causing physical injuries to themselves and others. In its turn, this suggests that delirium may be reflective of the innate lack of social empathy in the affected individuals. Because the lack of social empathy is being often regarded as an indication of those who experience it is deprived of a biological vitality, in the evolutionary sense of this word, there is nothing particularly odd about the fact that delirium appears to target predominantly Caucasians. For example, according to Irwin et al. (2008), Caucasians account for 79.8% of all delirious patients in American long-term/hospice care settings. Yet, as the representatives of a distinct racial community, Caucasians also stand on the threshold of extinction – the essence of demographic dynamics in the world validates this statement’s legitimacy. What it means is that the discursive significance of delirium may be discussed as such that is being related to the process of Caucasians finding themselves increasingly incapable to reproduce in sufficient numbers – as opposed to what is being the case with the representatives of racial minorities, for example (Reanne, Redstone & Bo 2010).

In the light of this suggestion, the hypothesis that delirium should be regarded as the biologically predetermined form of a mental illness appears to be not altogether deprived of a certain rationale. Apparently, there are indeed a number of good reasons to draw parallels between the etiology of delirium and the etiology of ageing, for example. After all, ageing is caused by the fact that, at a particular point in time, one’s organism simply refuses (with no apparent reason) to ensure the genetic integrity of the process of his or her body cells being duplicated (Skulachev 2010). The purpose of ageing is death and the purpose of death is freeing the available environmental niches to be occupied by more evolutionary adapted forms of life. Therefore, the fact that delirium (as well as other ‘mysterious’ forms of mental inadequacy, such as autism and Asperger syndrome) seem to ‘prefer’ Caucasians and the fact that even today, this condition’s exact triggering mechanism remains unknown, may suggest that the representatives of this ethnic group have simply fallen out of favor with nature. It is understood, of course, that this suggestion is rather speculative. Still, I believe that it deserves to be considered (Hughey 2010).

The foremost aspect of current treatment methodologies, designed to reduce the acuteness of delirium symptoms, is that their practitioners stress out the importance of the so-called ‘preventive interventions’. These interventions can be discussed in terms of therapeutic strategies, based upon the assumption that physicians should strive to refrain from exposing delirious patients to antipsychotic drugs, for as long as possible, while placing a therapeutic emphasis on prevention rather than on pharmacological treatments. As Attard, Ranjith and Taylor noted, “Preventing delirium is the most effective strategy for reducing both its frequency and the complications associated with this disorder” (2008, p. 634). By definition, preventive interventions are applied on a long-term basis. For example, given the fact that delirium’s most common symptom is disorientation, clinicians are being often concerned with trying to create objective preconditions for patients to never cease experiencing the sensation of an ‘existential wholesomeness’. In its turn, this can be achieved by the mean of encouraging patients to reflect upon what they consider their self-identity. Prompting delirious patients to read newspapers and to watch TV often comes in particularly handy, in this respect, because it helps them to remain in close touch with the surrounding reality – hence, increasing the spatial integrity of their view of themselves. Other, commonly deployed preventive interventions include encouraging patients to take lengthy walks, socialize with other people and pets, and listen to emotionally soothing music.

Nevertheless, because some delirious individuals tend to behave in a rather anti-social manner, physicians are left with no option but to prescribe them antipsychotics and sedatives, which produce short-term beneficiary effects on these individuals’ state of mind. The most commonly prescribed antipsychotic is Haloperidol, which has been proven particularly effective when dealing with the patients’ delirium-driven hyperactivity is being concerned. The other drugs that are being used in the treatment of delirium include Chlorpromazine (which causes heavy sedation), Risperidone (a prolonged application of this particular drug decreases the acuteness of a delirium-driven emotional agitation) and Lorazepam (which reduces the negative effects of an alcohol-withdrawal). In addition, delirious patients have often been prescribed medications for sleep, such as Trazodone and Rozerem (Briskman, Dubinski & Barak 2010).

The main controversy about the practice of prescribing delirious patients with the earlier mentioned medications is the fact that it is being conceptually inconsistent with what should be the actual aim of medical interventions, in the first place – namely, reducing the extent of patients’ cognitive disorientation. This is because, being essentially sedatives, these drugs in fact cause patients to become even more disoriented. This, however, is assumed to be the ‘lesser evil’, as compared to what would be the result of allowing particularly agitated and violently behaving patients to be left on their own (Geffen 2000). The main guidelines, which physicians are expected to observe while subjecting delirious patients to medication-based therapies, are as follows: making sure that patients are not prescribed more than one medication at a time, tailoring the dosage of every particular medication according to the patient’s body size, age and the extent of their agitation’s acuteness and assessing the effects of every medication intake on a daily basis (Tabet & Howard 2009).

I believe that the deployed line of argumentation, in regards to what should be considered the preliminary diagnostic explanation of why Jack acted in the way he did (case scenario), and in regards to what may account for the overall discursive significance of a mental disorder in question, is fully consistent with this paper’s initial thesis. I also think that the analytical insights, regarding delirium’s etiology and treatment, contained in the paper; represent an objective truth-value – even if the provided preliminary diagnosis ends up deemed speculative.

References

Attard, A, Ranjith, G & Taylor, D 2008, ‘Delirium and its treatment’, CNS Drugs, vol. 22 no. 8, pp. 631-644.

Branco, B et al. 2011, ‘Risk factors for delirium in trauma patients: The impact of ethanol use and lack of insurance’, The American Surgeon, vol. 77 no 5, pp. 621-626.

Briskman, I, Dubinski, R & Barak, Y 2010, ‘Treating delirium in a general hospital: A descriptive study of prescribing patterns and outcomes’, International Psychogeriatrics, vol. 22 no. 2, pp. 328-31.

Duppils, S & Wikblad, K 2004, ‘Delirium: Behavioral changes before and during the prodromal phase’, Journal of Clinical Nursing, vol. 13 no. 5, pp. 609-616.

Farley, A & McLafferty, E 2007, ‘Delirium part one: Clinical features, risk factors and assessment’, Nursing Standard, vol. 21 no. 29, pp. 35-40.

Fink, M 1999, ‘Delirious mania’, Bipolar Disorders, vol. 1 no. 1, pp. 54-60.

Geffen, J 2000, ‘Management of acute psychosis’, Australian and New Zealand Journal of Psychiatry, vol 34 no.2, Apr, pp. 339-340.

Gillis, A & MacDonald, B 2006, ‘Unmasking delirium’, The Canadian Nurse, vol. 102 no. 9, pp.18-24.

Hare, M et al. 2008, ‘A questionnaire to determine nurses’ knowledge of delirium and its risk factors’, Contemporary Nurse: A Journal for the Australian Nursing Profession, vol. 29 no.1, pp. 23-31.

Harrow, M et al. 2000, ‘Thought disorder in schizophrenia and mania: Impaired context’, Schizophrenia Bulletin, vol. 26 no. 4, pp. 879-891.

Hughey, M 2010, ‘The (dis)similarities of white racial identities: The conceptual framework of hegemonic whiteness’, Ethnic & Racial Studies, vol. 33 no. 8, pp. 1289-1309.

Irwin, S et al. 2008, ‘Psychiatric issues in palliative care: Recognition of delirium in patients enrolled in hospice care’, Palliative & Supportive Care, vol. 6 no. 2, pp. 159-64.

Karnik, N 2007, ‘Subtypes of pediatric delirium: A treatment algorithm’, Psychosomatics, vol. 48 no. 3, pp. 253-257.

Kiely, D et al. 2007, ‘Association between psychomotor activity delirium subtypes and mortality among newly admitted postacute facility patients’, The Journals of Gerontology, vol. 62 no. 2, pp. 174-179.

Parmet, S, Lynm, C & Glass, R 2004, ‘Delirium’, JAMA: Journal of the American Medical Association, vol. 291 no.14, pp. 1794-1794.

Reanne, F, Redstone, I & Bo, L 2010, ‘Latino immigrants and the U.S. racial order: How and where do they fit in?’, American Sociological Review, vol. 75 no. 3, pp. 378-401.

Schuurmans, M, Duursma, S & Shortridge-Baggett, L 2001, ‘Early recognition of delirium: review of the literature’, Journal of Clinical Nursing, vol. 10 no. 6, pp. 721-729.

Skulachev, V 2010, ‘How to cancel the program of body aging?’, Russian Journal of General Chemistry, vol. 80 no. 7, p1523-1541.

Tabet, N & Howard, R 2009, ‘Pharmacological treatment for the prevention of delirium: Review of current evidence’, International Journal of Geriatric Psychiatry, vol. 24 no.10, pp.1037-1044.

Health care givers should work to ensure that they intervene with the people who do not suffer from delirium. They should ensure that they involve all the family members to cooperate in helping their parents and grandparents handle the condition. There are a lot of studies done examining this issue. For example, Noyan, Elbi and Aksu studied delirium caused by amitriptyline overdose. In such a case, it is possible to cure it with the cholinesterase inhibitor donepezil, as suggested by the authors (2005).

However, when it concerns elderly people, there should be teaching plans aimed to educate both the patients and their family how to behave to handle delirium since that is the only way in which the intervention can work. “Management strategies for delirium are focused on prevention and symptom management.” (Fong, Tulebaev, & Inouye, 2009, p. 885) This condition is very delicate, that is why relatives of the patient must be ready to work with the health care givers to ensure that quality intervention is administered.

In elderly people, delirium is common hence affecting their cognitive aspects of human behaviors. As people get old, delirium can affect their mental coordination, hence leading to a situation where they cannot depend on themselves to carry out normal tasks. This means that their mind is affected making them dependent on others because they cannot even wash themselves without somebody’s help (Restrepo, 2008). If not controlled in time, it may lead to their untimely death, but if detected and controlled early enough, the lives of the patients can be prolonged.

Delirium is preventable and when diagnosed and prevented, it remains controlled. Drugs which are known as precipitants of delirium should be avoided as they increase the chances of one developing the condition as he/she becomes old. Another strategy used in prevention of this condition is the hospital elder life program that involves strategies tested in laboratories on how to prevent delirium in elderly patients in hospitals. This involves controlling the physical environment surrounding the patients, their nutrition intake and the number of hours they sleep. All these combined result in a quality and effective method of intervening and treating the condition among the elderly hospitalized.

Another effective strategy for preventing delirium is home rehabilitation. After hospitalization, the elderly people are eventually taken to their homes where they stay with their relatives (Oliver, 2011). The home setting is more relaxing than the hospital setting hence helping these elderly people to recover fast and avoid chances of delirium recurring again. This should be associated with stress management whereby the elderly people are given a conducive, environment free of stresses hence reconditioning their minds.

There are several treatment strategies applied by the medical practitioners to cure delirium among the elderly in the society. There are non-pharmacological strategies used to treat all the delirium patients. This is where caregivers reorient and intervene behaviors of patients to ensure that they eliminate the confusion state (Hamby, 2000). The caregivers should involve patients physically looking into their eyes; in case they have impaired eyesight or hearing, spectacles and hearing aids should be used to assist their sensory organs. Physical movements should be emphasized to enhance mobility among the patients. This works as the first line treatment for all the patients with this condition (Caraceni and Grassi, 2011).

There are also pharmacological strategies, which include the use of drugs meant to recondition the minds of people, hence curing delirium. Medication should be administered only under prescription by a medical doctor who has examined the patient (Manuel and Madera, 2003). Depending on their conditions, different patients may require different dosage and only a qualified medical practitioner can be trusted with the administration of drugs to those patients.

However, the use of these drugs may have an impact on the mental status of patients. Therefore, medical practitioners should take precaution when administering this treatment and recommend other forms of medication to people which drug use can affect their mental status.

References

Caraceni, A., & Grassi, L. (2011). Delirium: Acute Confusional States in Palliative Medicine. London: Oxford University Press.

Fong, T. G., Tulebaev, S.R. and Inouye, S. K. (2009). Delirium in elderly adults: Diagnosis, prevention and treatment. Nat. Rev. Neurol. 5, 210–220. Web.

Hamby, B. (2000). Delirium. Texas: University Of North Texas Press.

Noyan, M. A., Elbi, H. & Aksu, H. (2005). Donepezil for anticholinergic drug intoxication: a case report. Prog Neuropsychopharmacol Biol Psychiatry 27(5), 885–887.

Oliver, L. (2011). Delirium. New York: HarperCollins.

Restrepo, L. (2008). Delirium. London: Random House.

The Delirium Rating Scale is a tool used to assess delirium that assigns numbers to a person’s cognitive state and helps doctors decide what kind of medical intervention to employ. The cost of the DRS varies depending on the version that is used. The standard version of the scale costs $5 per copy, while the abbreviated version costs $2 per copy (Hshieh et al., 2018). The Confusion Assessment Method (CAM) is a reliable and valid delirium rating scale that clinicians can use to identify patients with delirium quickly. The CAM comprises four objective criteria: an altered level of consciousness, disorganized thinking, acute onset, and fluctuating course (Hshieh et al., 2018). A patient must meet all four criteria to be diagnosed with delirium (Hshieh et al., 2018). The Memorial Delirium Assessment Scale (MDAS) is another evidence-based rating scale for delirium.

The MDAS consists of five items: orientation, recent memory, remote memory, attention, and language. Each item is rated on a three-point scale, with a total score ranging from 0 to 15. A score of 7 or higher indicates the presence of delirium (Hshieh et al., 2018). The MDAS has good inter-rater reliability and convergent validity with other delirium rating scales. The CAM and MDAS delirium rating scales can be found on the websites of several mental health organizations, including the National Institute of Mental Health and the American Psychiatric Association (Gross et al., 2018).

These scales are designed to help clinicians assess the severity of delirium symptoms in adults and can be used to track a person’s progress over time (Gross et al., 2018). They can also be found by searching for them on government websites, such as the Centers for Disease Control and Prevention or the National Institutes of Health. Both scales are widely used in clinical practice and are available for free on the internet.

The CAM and MDAS are two of the most popular delirium rating scales. Both scales have strengths and weaknesses, but I believe the CAM scale is more accurate and user-friendly. The CAM scale is specifically designed to assess delirium, while the MDAS scale includes several items that are not directly related to delirium. In addition, the CAM scale is easier to administer, as it only requires a few minutes to complete. For these reasons, I would recommend the CAM scale to my colleagues.

References

Hshieh, T. T., Fong, T. G., Schmitt, E. M., Marcantonio, E. R., D’Aquila, M. L., Gallagher, J., Xu, G., Guo, Y. R., Abrantes, T. F., Bertrand, S. E., Jones, R. N., Inouye, S. K., & for the BASIL Study Group. (2019). The better assessment of illness study for delirium severity: Study design, procedures, and cohort description. Gerontology, 65(1), 20–29. Web.

Gross, A. L., Tommet, D., D’Aquila, M., Schmitt, E., Marcantonio, E. R., Helfand, B., Inouye, S. K., & Jones, R. N. (2018). Harmonization of delirium severity instruments: A comparison of the DRS-R-98, MDAS, and CAM-S using item response theory. BMC Medical Research Methodology, 18(1), 92. Web.

I am going to present a case of a 53-year-old male patient, Mr. M, who arrived at the emergency department for treatment with a panic attack and confusion concerns. Mr. M is a surgeon, and his staff members have reported that he has been having trouble carrying out certain chart documentation-related tasks following a surgical procedure in the past four months. Mr. M has a history of major depressive disorder, hypertension, hyperlipidemia, and type 2 diabetes (Ra et al., 2023). Given these symptoms and medical history, we have arrived at a differential diagnosis of Acute Stress Reaction, Delirium, Depression with Psychosis, and Cognitive Impairment due to a medical condition such as hypoglycemia or infection.

However, after careful evaluation of the patient’s symptoms and medical history, our most highly suspected diagnosis is delirium. Delirium is a sudden change in mental function that a medical condition, medication side effects, or substance abuse can cause (Wilson et al., 2020). The patient’s recent panic attack, confusion, and problems completing tasks that he previously was able to complete, as well as his history of hypertension, hyperlipidemia, and type 2 diabetes, increase the likelihood that Mr. M may be experiencing delirium.

Given this suspected diagnosis, our emergency treatment plan for Mr. M includes administering benzodiazepines to treat his panic attacks and anxiety and obtaining a complete medical evaluation, incorporating blood tests to eliminate other possible contributing factors of delirium, such as infection, hypoglycemia, or medication toxicity. Our pharmacologic treatments for Mr. M include prescribing antipsychotic medication to help manage his confusion and agitation and considering adjusting medications for his hypertension, hyperlipidemia, and diabetes, as these conditions can contribute to delirium.

In addition to pharmacologic treatments, we will also be implementing non-pharmacologic treatments for Mr. M. This includes encouraging him to participate in rehabilitation activities such as physical therapy and occupational therapy to help him regain his mental and physical abilities, as well as providing psychological support to Mr. M and his family through counseling or support groups (Wilson et al., 2020). Our short-term goals for Mr. M’s treatment include:

• stabilizing his mental state and managing his symptoms of confusion and agitation,
• identifying and addressing the underlying cause of his delirium and
• ensuring that he can complete his daily tasks with minimal assistance.

Our long-term goals for Mr. M include maintaining his mental stability, preventing further episodes of delirium, and improving his overall quality of life through physical and mental rehabilitation. Moreover, In terms of health promotion and patient education, we will be teaching Mr. M and his family about the importance of managing his underlying medical conditions, such as hypertension, hyperlipidemia, and diabetes, to prevent future episodes of delirium (Thom et al., 2019). We will also educate them about the signs and symptoms of delirium and the importance of seeking medical attention immediately.

In conclusion, delirium is a sudden change in mental function that various medical conditions and medications can cause. Mr. M’s recent panic attack, confusion, and problems completing tasks, along with his medical history, make delirium the most highly suspected diagnosis. Our treatment plan for Mr. M includes a combination of pharmacologic and non-pharmacologic treatments to stabilize his mental state, improve his quality of life, and prevent further episodes of delirium.

References

Ra K., Ramanathan S., Duleep A., & Chabrashvili T. (2023). Subtle cognitive decline in a patient with depression and anxiety. Current Psychiatry, 22(2), 41-48. Web.

Thom, R. P., Levy-Carrick, N. C., Bui, M., & Silbersweig, D. (2019). Delirium. American Journal of Psychiatry, 176(10), 785-793. Web.

Wilson, J. E., Mart, M. F., Cunningham, C., Shehabi, Y., Girard, T. D., MacLullich, A. M., & Ely, E. W. (2020). Delirium. Nature Reviews Disease Primers, 6(1), 90. Web.

Introduction

Critically ill patients face more challenges than other hospitalized individuals due to the nature of their health conditions. Patients receiving treatment at intensive care units (ICUs) face the risk of developing delirium more often than other healthcare facility clients. Particularly, the complication of brain function is likely to develop in elderly patients. Delirium is an acute dysfunction of a person’s brain associated with changing levels of cognition, attention, and consciousness (Whalin, Kreuzer, Halenda, & García, 2015).

Apart from posing difficulties to patients, this severe health condition also places a considerable financial burden on the system of healthcare. Delirium is most common in post-operative patients, with the prevalence varying between 10% and 80% depending on the type of population under analysis (Whalin et al., 2015). While delirium is a serious condition itself, it can also lead to significant adverse outcomes, such as patient falls, an increase in hospital stay duration, high mortality risks, and functional decline (Whalin et al., 2015). Therefore, there is an increased need for assessing ICU patients for delirium in order to find the most viable prevention and treatment strategies for each case.

ICU delirium may be typified into several classes based on patients’ reactions to surgery and mechanical ventilation. Hence, one can be either agitated and aggressive (hyperactive) or apathetic and slow in bodily movements (hypoactive) or fluctuate between the two forms (mixed delirium) (Tate & Balas, 2019). The major problem at the initial stage is to diagnose delirium correctly and timely. The best tool for such an evaluation is the Confusion Assessment Method (CAM) for the ICU. The use of the CAM enables physicians to detect delirium at an early stage by receiving appropriate neurocognitive data, which allows developing an effective plan of treatment (Tate & Balas, 2019).

The CAM-ICU consists of several rated items, the evaluation of which of them serving as a basis for the physician’s decision on the patient’s syndrome severity. The tool is specially designed for ICU patients who have restricted communication abilities (Boettger et al., 2017). There are four items on the CAM scale, each one containing an absent or a present level (Boettger et al., 2017). This assessment tool is helpful in identifying whether one is delirious or not, which promotes the success of treatment.

The CAM-ICU evaluates the patient’s condition on the acute onset and changing course of development, inattention, modified consciousness level, and disorganization of thinking. Delirium intensity is diagnosed based on such factors as short- and long-term memory problems, sleep disturbances, delusions, psychomotor agitation or retardation, and others (Gross et al., 2018). Based on patients’ responses or reactions, the following levels of delirium are differentiated: no delirium, mild to moderate, and severe delirium (Khan et al., 2017).

The major purpose of the project is to investigate solutions for patients who have been diagnosed as having a severe (high) level of delirium. Due to the seriousness of adverse outcomes associated with delirium, this health condition requires urgent establishment and treatment. The paper will offer an overview of pharmacological and non-pharmacological interventions for delirious ICU patients. The background and the nature of the project will be explained, along with the PICO question. The literature review section contains a synthesis of scholarly studies on the topic. A summary of the project includes a brief reiteration of the main points made in the paper.

Problem Statement

The specific problem under investigation is finding viable prevention and treatment solutions for patients with high scores on the CAM delirium scale. Researchers and practitioners have offered and tested a number of pharmacological and non-pharmacological approaches to delirium treatment (Barbateskovic et al., 2016; Carbone and Gugliucci, 2015; Herling et al., 2018; Hshieh et al., 2015). The project aims at comparing the effect of pharmacological delirium interventions to that of non-pharmacological ones. The quantitative methodology (a randomized control trial) will be employed to guide the research question.

Background

Delirium is a severe psychiatric syndrome that most frequently occurs in ICU patients. According to statistical data, about 12 million elderly Americans are diagnosed with delirium annually (Gross et al., 2018). Delirium affects nearly 70% of patients who undergo cardiac surgery, and nearly 80% of those admitted to ICUs (Boettger et al., 2017). Short- and long-term adverse effects of delirium include a longer hospital stay, a prolonged or more frequent mechanical ventilation, and a higher incidence of mortality and morbidity (Boettger et al., 2017). As a result of delirium, a person may experience the weakening of cognitive and functional abilities.

The cost of hospitalization in patients with delirium is rather high. According to different sources, the cost amounts to $38-152 billion, which is more than twice higher than expenditures on non-delirious patients’ hospitalization (Whalin et al., 2015).

The most typical type of delirium is hypoactive, which involves a decline in physical movements and lethargy. Although the prevalence of delirium is rather high among hospitalized patients, the mechanisms of its identification are still not sufficient (Whalin et al., 2015). Hence, the problem is both of oppressing societal concern and theoretical interest. The social value of the issue is that by solving it, researchers will be able to relieve complications to many patients’ health condition. The theoretical significance is in the ability to test the available approaches and come up with the most relevant one.

One of the problems making the prevalence of delirium in ICU patients so high is that the main stressors capable of causing delirium cannot be avoided. For instance, individuals undergoing surgery may develop an adverse reaction to such components of general anesthesia as benzodiazepine, anticholinergic, antihistamine, and opioid agents (Whalin et al., 2015). Furthermore, the risk of delirium grows with increased exposure to anesthetic agents, as determined by processed electroencephalography (Whalin et al., 2015).

Critical illness can lead to sepsis and inflammation disturbances, and circadian rhythm disruptions (Bannon, McGaughey, Clarke, McAuley, & Blackwood, 2016). Along with the potential to alleviate sleep pattern disturbances, sedatives can cause the development of delirium and damage the immune system (Bannon et al., 2016). Therefore, further elucidation of the problem is necessary in order to reduce its development and adverse outcomes.

Cognitive dysfunction caused by delirium Is not limited only to the patient’s hospital stay. According to Munro et al. (2017), cognitive dysfunction may continue to be noticed for several months or even become permanent. As a result, individuals may develop impairments in their daily activities. These adverse effects make it crucial for ICU nurses to be able to identify delirium as soon as possible (Piao, Jin, & Lee, 2016).

Carbone and Gugliucci (2015) emphasize two perplexing factors concerning delirium. On the one hand, the condition is preventable, which makes it difficult to understand why its incidence is so high. On the other hand, delirium is frequently misdiagnosed and, as a result, mistreated (Carbone & Gugliucci, 2015). The lack of experience or excessive workload of nurses can lead to their restricted ability to evaluate patients for delirium.

In such conditions, an effective method of patient assessment is required. Researchers note that it is highly possible to modify delirium in some patients (Bannon et al., 2016). Recently, scholars’ interest in effective delirium-screening programs has increased. The problem is that without a valid screening approach, as many as 70% of patients may be not diagnosed, which results in the lack of treatment (Bannon et al., 2016). The majority of researchers acknowledge the effectiveness of the CAM-ICU as a diagnostic tool for delirium (Bannon et al., 2016; Boettger et al., 2017; Gross et al., 2018; Tate & Balas, 2019; Whalin et al., 2015).

The gold standard for diagnosing delirium is the DSM-IV criteria, but since psychiatric services are not available in many ICUs, the CAM approach is preferred (Bannon et al., 2016). According to some reviews, the sensitivity of the CAM varies between 46.7% and 100%, which makes this method rather reliable (Boettger et al., 2017). Hence, the use of the CAM in ICUs is justified as it enables nurses to detect delirium in patients.

Timely screening for delirium and recognition of the related risk factors are reciprocally conditional for the successful management of the syndrome. The ratings of delirium severity are of utmost importance in clinical settings since they offer directly classified and consistent measures (Gross et al., 2018). These rates can serve as an effective prognostic measure and help to enhance clinical outcomes.

With the help of the CAM, a nurse can track changes in a patient’s condition, monitor modifications in the syndrome over time, and control recovery (Gross et al., 2018). Patients that score high on the CAM scale require immediate attention from nurses, which implies finding the most viable solution to mitigate delirium. The available interventions include pharmacological, non-pharmacological, and educational ones, depending on the individuals involved (nurses and family caregivers). Since the issue has considerable societal value, the search for an effective solution is an urgent need.

Purpose

The main purpose of the project is to evaluate various interventions suggested for patients scoring high on the CAM scale. Since it is impossible to incorporate all available interventions in one project, the most typical ones will be selected. The reason why the effectiveness of delirium-relieving interventions has to be addressed is that the syndrome under consideration affects patients’ mental health severely. Moreover, delirious individuals suffer from a variety of healthcare complications, which develop quickly, but require a long time for recovery. Hence, by running the project, it will be possible to find the most effective solution to delirium and further apply it in healthcare settings to reduce the incidence of this dangerous condition.

The project is an important issue for nurses, organizations, and leaders. Each of these members and units of the healthcare system has to realize the need for positive change in ICUs. It is possible to speak about the project in the context of Lewin’s theory of change. According to Lewin, there are challenges that can affect the durability of change in an organization (Batras, Duff, & Smith, 2016).

Hence, Lewin suggested a three-step model of change consisting of the stages of unfreezing, moving, and refreezing (Batras et al., 2016). It will be useful to apply this model to the project to make it easier for nurses to implement the intervention for delirium management. At the unfreezing stage, the problem will be outlined, and its significance will be discussed. During the moving stage, the selected interventions will be implemented. Finally, the refreezing phase will presuppose adding the best intervention to the regular practices of the healthcare unit.

The Nature of the Project

Interventions for delirium patients may be divided into pharmacological (Barbateskovic et al., 2016; Serafim et al., 2015), non-pharmacological (Bannon et al., 2016; Hshieh et al., 2015), educational (Carbone & Gugliucci, 2015), and automated reorientation (Munro et al., 2017). Most frequently, researchers focus on pharmacological and non-pharmacological approaches, so these two intervention types will be utilized in the project. The experimental design of the study, namely, a randomized control trial (RCT), will allow receiving the most reliable and valid results.

Participants will be randomly divided into three groups: the first group will receive a pharmacological intervention, the second group will receive a non-pharmacological intervention, and the third group will receive no intervention. In each group, there will be fifteen subjects, which will make it possible to analyze the obtained data promptly. The main inclusion criterion will be a high score of delirium on the CAM scale.

Other inclusion criteria will be the age of 65 and older, staying in an ICU for at least 24 hours, having undergone surgery, and the ability to sign a consent form. Exclusion criteria are being younger than 65, not being able to sign the consent form, receiving intensive care for less than 24 hours, and abusing substances that can affect the intervention’s results. Also, patients who do not speak English or whose providers anticipate their imminent death will be excluded.

The use of an RCT will promote the accomplishment of the study’s goals in the following ways:

• there will be a possibility to compare and contrast results received from equal groups of participants;
• a high level of reliability will be gained due to randomization;
• by using a quantitative approach, it will be possible to measure findings;
• by enrolling three groups of participants, the researchers will be able to compare two different types of interventions and to compare each of them to the placebo group.

The above reasons justify the viability of selecting an RCT as a research design. In the study were non-randomized, its procedures and results would be biased. If a qualitative design were selected instead of a quantitative one, there would be no possibility of measuring findings. A correlational study would be inappropriate since it aims at comparing variables, while the present project focuses on finding out the effects of interventions on delirious patients. Overall, an RCT is the most suitable research design for the current study.

The selection of interventions to include in the study will be based on existing research and recommendations. Among pharmacological approaches, antipsychotics, sedatives, cholinesterase inhibitors, opioids, and melatonin antagonists are suggested (Barbateskovic et al., 2016; Serafim et al., 2015). Since researchers give the most prominence to the effect of antipsychotics on delirious patients, the pharmacological intervention in the present project will use this group of medications. Non-pharmacological delirium interventions researched in scholarly literature involve the Hospital Elder Life Program (HELP) (Hshieh et al., 2015), education and orientation programs (Bannon et al., 2016), and automated reorientation (Munro et al., 2017).

Since the project aims at enrolling older adults, the HELP will be utilized as a non-pharmacological intervention. Patients will be allocated to groups randomly upon being evaluated with the CAM scale and indicating high delirium rates. The study will last for five days, upon which the results will be collected and evaluated. The project aims at interventions’ ability to decrease the incidence of delirium, falls, and length of hospital stay.

Research Question

The research question to be answered by the end of the project is, “What kind of interventions is the most successful when coping with the ICU patients’ high delirium rate on the CAM scale?” The following PICO process will be utilized to guide the research question: P – patients with high delirium scores on the CAM scale; I – non-pharmacological intervention; C – pharmacological intervention and no intervention; O – the decreased incidence of delirium, patient falls, and length of hospital stay. Thus, the PICO question is, “In ICU patients demonstrating high delirium scores on the CAM scale, will a non-pharmacological intervention, compared to a pharmacological intervention and no intervention, lead to better improvement in delirium incidence, patient falls, and hospitalization time?

Summary

The paper has outlined the nature of the problem to be investigated in the project. Delirium among ICU patients is a rather severe syndrome, and it is of utmost importance to find effective solutions to it. With the help of the CAM, nurses can evaluate patients’ rate of delirium even if no psychologist is available at the site. A variety of interventions signifies both the level of researchers’ interest in the topic and the lack of a unanimous opinion on their success. Hence, the project will help to identify the most productive intervention.

Literature review

The intent of this chapter is to provide a review of literature that will guide the capstone project. Scholarly articles from peer-reviewed journals focused on ICU patients’ delirium, the CAM approach to assessment, and interventions suggested for improving delirium rates will be reviewed in this chapter. The analysis of existing sources will help to single out the most relevant information on the identified research question.

Historical Overview

Scholars’ interest in delirium prevention and management strategies has increased over the years. However, both in the past decade and at present, scientists could not come to a single conclusion as to what approaches were the most effective when trying to reduce delirium prevalence in ICU patients. In their analysis of ICU patients’ delirium, Schiemann, Hadzidiakos, and Spies (2011) noted that the syndrome’s pathophysiology was not clear, and that pharmacological approaches to decreasing the development of delirium should be used.

The study by Hamdan-Mansour, Farhan, Othman, and Yacoub (2010) also acknowledged a lack of knowledge about delirium among critical care nurses. Meanwhile, research by Martinez, Tobar, Beddings, Vallejo, and Fuentes (2012), which focused on a non-pharmacological approach to delirium prevention, noted the existence of different strategies used for that aim. Thus, it is possible to conclude that in the course of time, researchers became more and more aware of the severity of delirium, but still, many questions remained unanswered.

Current Findings

More recent findings on delirium allowed gaining a deeper understanding of the topics related to the research question. The general issues investigated by scholars can be divided into the following major topics: the CAM for ICU, pharmacological interventions, and non-pharmacological approaches to managing delirium. It is viable to note that all research articles analyzing the CAM acknowledge the effectiveness of this assessment method (Boettger et al., 2017; Gross et al., 2018; Khan et al., 2017; Tate et al., 2019). Hence, the selection of this method for rating patients’ delirium was a beneficial decision.

The works analyzing pharmacological interventions admit that despite a variety of such approaches, their success rate is not high (Barbateskovic et al., 2016; Serafim et al., 2015). Barbateskovic et al. (2016) note that recommendations about various pharmacological treatments differ, which makes it difficult to select the most appropriate one. Serafim et al. (2015) report that none of the variety of pharmacological approaches analyzed in their systematic review demonstrated a considerable decrease in delirium incidence.

Meanwhile, the studies on non-pharmacological delirium interventions report more positive results. Specifically, educational interventions for family caregivers are considered to be promising as methods of delirium treatment (Carbone & Gugliucci, 2015). Family members’ role in positive delirium management is also acknowledged in the study by Munro et al. (2017). Scholars have found that an automated reorientation intervention brings the best outcomes when family members participate in the process of recording instructions for patients (Munro et al., 2017). Bannon et al. (2016) and Hshieh et al. (2015) have found that non-pharmacological interventions promote the decrease in patient falls, length of hospitalization, and delirium incidence.

Conclusion

The review of literature helps to find an answer to the research question, which is concerned with finding the most successful intervention to cope with the ICU patients’ high delirium rate on the CAM scale. The review has allowed singling out both positive and negative findings related to the topic. Specifically, it has been found that pharmacological interventions, though numerous, do not lead to beneficial outcomes. Also, despite the high prevalence and incidence of delirium in ICU patients, the syndrome remains insufficiently investigated. On the bright side, non-pharmacological interventions have proved to have a positive effect on delirious patients. Based on the reviewed studies, the continued need for the capstone project is justified since it has the potential to help solve a burning health issue.

Summary

The major points covered in the review of literature are concerned with the use of the CAM as the most common delirium assessment method and the variety of interventions available for delirium treatment. The review indicates that while scholars’ interest in ICU delirium has increased with time, the management of the problem is still to be enhanced. The most effective approach so far is the implementation of non-pharmacological interventions.

References

Bannon, L., McGaughey, J., Clarke, M., McAuley, D. F., & Blackwood, B. (2016). Impact of non-pharmacological interventions on prevention and treatment of delirium in critically ill patients: Protocol for a systematic review of quantitative and qualitative research. Systematic Reviews, 5(1). Web.

Barbateskovic, M., Larsen, L. K., Oxenbøll-Collet, M., Jakobsen, J. C., Perner, A., & Wetterslev, J. (2016). Pharmacological interventions for delirium in intensive care patients: A protocol for an overview of reviews. Systematic Reviews, 5(1). Web.

Batras, D., Duff, C., & Smith, B. J. (2016). Organizational change theory: Implications for health promotion practice. Health Promotion International, 31(1), 231–241. Web.

Boettger, S., Nuñez, D. G., Meyer, R., Richter, A., Fernandez, S. F., Rudiger, A., … Jenewein, J. (2017). Delirium in the intensive care setting: A reevaluation of the validity of the CAM–ICU and ICDSC versus the DSM–IV–TR in determining a diagnosis of delirium as part of the daily clinical routine. Palliative and Supportive Care, 15(6), 675–683. Web.

Carbone, M. K., & Gugliucci, M. R. (2015). Delirium and the family caregiver: The need for evidence-based education interventions. The Gerontologist, 55(3), 345–352. Web.

Gross, A. L., Tommet, D., D’Aquila, M., Schmitt, E., Marcantonio, E. R., Helfand, B., … Jones, R. N. (2018). Harmonization of delirium severity instruments: A comparison of the DRS-R-98, MDAS, and CAM-S using item response theory. BMC Medical Research Methodology, 18(1). Web.

Hamdan-Mansour, A. M., Farhan, N. A., Othman, E. H., & Yacoub, M. I. (2010). Knowledge and nursing practice of critical care nurses caring for patients with delirium in intensive care units in Jordan. The Journal of Continuing Education in Nursing, 41(12), 571–576. Web.

Herling, S. F., Greve, I. E., Vasilevskis, E. E., Egerod, I., Bekker Mortensen, C., Møller, A. M., … Thomsen, T. (2018). Interventions for preventing intensive care unit delirium in adults. Cochrane Database of Systematic Reviews. Web.

Hshieh, T. T., Yue, J., Oh, E., Puelle, M., Dowal, S., Travison, T., & Inouye, S. K. (2015). Effectiveness of multicomponent nonpharmacological delirium interventions: A meta-analysis. JAMA Internal Medicine, 175(4), 512. Web.

Khan, B. A., Perkins, A. J., Gao, S., Hui, S. L., Campbell, N. L., Farber, M. O., … Boustani, M. A. (2017). The Confusion Assessment Method for the ICU-7 delirium severity scale. Critical Care Medicine, 45(5), 851–857. Web.

Martinez, F. T., Tobar, C., Beddings, C. I., Vallejo, G., & Fuentes, P. (2012). Preventing delirium in an acute hospital using a non-pharmacological intervention. Age and Ageing, 41(5), 629–634. Web.

Munro, C. L., Cairns, P., Ji, M., Calero, K., Anderson, W. M., & Liang, Z. (2017). Delirium prevention in critically ill adults through an automated reorientation intervention – A pilot randomized controlled trial. Heart & Lung: The Journal of Acute and Critical Care, 46(4), 234–238. Web.

Piao, J., Jin, Y., & Lee, S.-M. (2016). Triggers and nursing influences on delirium in intensive care units. Nursing in Critical Care, 23(1), 8–15. Web.

Schiemann, A., Hadzidiakos, D., & Spies, C. (2011). Managing ICU delirium. Current Opinion in Critical Care, 17(2), 131–140. Web.

Serafim, R. B., Bozza, F. A., Soares, M., do Brasil, P. E. A. A., Tura, B. R., Ely, E. W., & Salluh, J. I. F. (2015). Pharmacologic prevention and treatment of delirium in intensive care patients: A systematic review. Journal of Critical Care, 30(4), 799–807. Web.

Tate, J. A., & Balas, M. (2019). The Confusion Assessment Method for the ICU (CAM-ICU). Try This: Best Practices in Nursing Care to Older Adults, 25. Web.

Whalin, M. K., Kreuzer, M., Halenda, K. M., & García, P. S. (2015). Missed opportunities for intervention in a patient with prolonged postoperative delirium. Clinical Therapeutics, 37(12), 2706–2710. Web.