A Multifactorial Intervention to Reduce Prevalence of Delirium and Shorten Hospital Length of Stay

Naughton, Bruce J.; Saltzman, Susan; Ramadan, Fadi; Chadha, Noshi; Priore, Roger L.; Mylotte, Joseph M.

doi:10.1111/j.1532-5415.2005.53005.x

Cited by 114 publications

(100 citation statements)

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“…Multimodal approaches to delirium prevention have been described in the literature. [43][44][45][46][47] Marcantonio and colleagues evaluated the impact of proactive geriatric consultation on delirium occurrence in elderly individuals admitted for emergency surgical repair of hip fracture. 48 The intervention focused on 10 components: central nervous system oxygen supply, fluid and electrolyte balance, pain management, reduction of unnecessary medications, adequate nutrition, regular bowel and bladder function, early mobilization and rehabilitation, prevention and management of postoperative complications, environmental stimuli, and appropriate delirium management.…”

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confidence: 99%

Improving Delirium Care

Kostas

Zimmerman

Rudolph

2013

The Neurohospitalist

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Delirium is an acute change in awareness and attention and is common, morbid, and costly for patients and health care systems. While hyperactive delirium is easily identifiable, the hypoactive form is more common and carries a higher mortality. Hospital systems to address delirium should consist of 3 critical steps. First, hospitals must identify patients who develop or are at intermediate or high risk for delirium. Delirium risk may be assessed using known patient-based and illness-based risk factors, including preexisting cognitive impairment. Delirium diagnosis remains a clinical diagnosis that requires a clinical assessment that can be structured using diagnostic criteria. Hospital systems may be useful to efficiently allocate delirium resources to prevent and manage delirium. Second, it is crucial to develop a systematic approach to prevent delirium using multimodal nonpharmacologic delirium prevention methods and to monitor all high-risk patients for its occurrence. Tools such as the modified Richmond Agitation and Sedation Scale can aid in monitoring for changes in mental status that could indicate the development of delirium. Third, hospital systems can utilize established methods to assess and manage delirium in a standardized fashion. The key lies in addressing the underlying cause/causes of delirium, which often involve medical conditions or medications. With a sustained commitment, standardized efforts to identify and prevent delirium can mitigate the long-term morbidity associated with this acute change. In the face of changes in health care funding, delirium serves as an example of a syndrome where care coordination can improve short-term and long-term costs.

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confidence: 99%

Improving Delirium Care

Kostas

Zimmerman

Rudolph

2013

The Neurohospitalist

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“…166,167 These units typically have multidisciplinary team of physicians, nurses, and social workers or case managers who specialize in geriatrics care and have expertise in managing delirious patients. They also implement non-pharmacologic, multi-component delirium interventions which 1) minimize the use of psychoactive medications such as benzodiazepines and medications with anticholinergic properties, 2) maximize mobility and limit the use of urinary bladder catheters and physical restraints, 3) implement the TADA approach as described above, 4) reduce sensory deprivation by offering eye-glasses or hearing devices, 5) provide cognitive stimulation and reorientation, and 5) encourage normal sleep-wake cycles (e.g.…”

Section: Dispositionmentioning

confidence: 99%

Altered Mental Status in Older Emergency Department Patients

Wilber

2006

Emergency Medicine Clinics of North America

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SynopsisAltered mental status is a common chief complaint among older emergency department (ED) patients. Acute changes in mental status are more concerning and are usually secondary to delirium, stupor, and coma. These forms of acute brain dysfunction are commonly precipitated by an underlying medical illness that can be potentially life-threatening and are associated with a multitude of adverse outcomes. Though stupor and coma are easily identifiable, the clinical presentation of delirium can be subtle and is often missed without actively screening for it. For patients with acute brain dysfunction, the ED evaluation should focus on searching for the underlying etiology. Infection is one of the most common precipitants of delirium, but multiple etiologies may exist concurrently. Keywordsdelirium; coma; stupor emergency department; epidemiology; diagnosis; management IntroductionAltered mental status is a common chief complaint among older emergency department (ED) patients. Despite the frequency of this complaint, the term "altered mental status" is vague and has several synonyms such as confusion, not acting right, altered behavior, generalized weakness, lethargy, agitation, psychosis, disorientation, inappropriate behavior, inattention, and hallucination. 1 Such lack of standardized terminology not only hinders the assessment and appropriate management of patients with altered mental status, but also the advancement of knowledge through research.Altered mental status has varying time courses and degrees of severity. Acute changes in mental status are usually secondary to delirium, stupor, and coma, which are forms of acute brain dysfunction. These changes occur over a period of hours or days and are usually © 2012 Elsevier Inc. All rights reserved. Correspondence to: Jin H. Han, jin.h.han@vanderbilt.edu. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. NIH Public Access NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript precipitated by an underlying medical illness that is potentially life threatening. Chronic alterations in mental status (e.g. dementia) occur over a period of months and years and are less likely to be precipitated by a life-threatening illness. 2 For these reasons, acute changes in mental status will be the focus of this review. Altered mental status is rarely caused by psychiatric illnesses such as depression or schizophrenia, and in elder patients, these should be diagnoses of exclusion. Acute brain dysfunction (delirium, stupor, and coma) and their underlying etiology should be ruled out prior to considering any psychiatric d...

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“…13,19 C Regular audit should be undertaken to assess the processes and outcomes of care of patients with delirium eg use of cognitive scores, ward moves, length of stay, complications and mortality.…”

Section: Staff Training Education Auditmentioning

confidence: 99%

The prevention, diagnosis and management of delirium in older people: concise guidelines

2006

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-Delirium (acute confusional state) is a common condition in older people, affecting up to 30% of all older patients admitted to hospital. Patients who develop delirium have high mortality, institutionalisation and complication rates, and have longer lengths of stay than non-delirious patients. Delirium is often not recognised by clinicians, and is often poorly managed. Delirium may be prevented in up to a third of older patients. The aim of this guideline update is to aid prevention as well as the recognition of delirium and to provide guidance on how to manage these complex and disadvantaged patients.KEY WORDS: acute confusion, clinical guideline, delirium, older people IntroductionThe aim of these guidelines is to aid recognition of delirium and to provide guidance on how to manage this complex and challenging condition. Delirium is characterised by a disturbance of consciousness and a change in cognition that develop over a short period of time. The disorder has a tendency to fluctuate during the course of the day, and there is evidence from the history, examination or investigations that the delirium is a direct consequence of a general medical condition, drug withdrawal or intoxication. Diagnostic and Statistical Manual of Mental Disorders (DSM IV) 1In order to be diagnosed with delirium, a patient must show all of the four features listed below. 1 A disturbance of consciousness (ie reduced clarity of awareness of the environment) is evident, with reduced ability to focus, sustain or shift attention. 2 There is a change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting or evolving dementia. 3 The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day. 4 There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition, substance intoxication or substance withdrawal. 1 Delirium may have more than one causal factor (ie multiple aetiologies). A diagnosis of delirium can also be made when there is insufficient evidence to support criterion 4, if the clinical presentation is consistent with delirium, and the clinical features cannot be attributed to any other diagnosis, for example delirium due to sensory deprivation.Some older people come to hospital with delirium (prevalent) while others develop delirium during their hospital stay (incident). Hospital prevalence rates for delirium vary widely because of different patient characteristics in the different studies -the highest rates are seen in older patients in critical care settings. The average prevalence of delirium in older people in general hospitals is 20% (range 7% to 61%). 2 After fracture of the neck of the femur, the prevalence varies from 10% to 50%.Patients with delirium have increased length of stay, increased mortality and increased ...

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A Multifactorial Intervention to Reduce Prevalence of Delirium and Shorten Hospital Length of Stay

Abstract: A multifactorial intervention designed to reduce delirium in older adults was associated with improved psychotropic medication use, less delirium, and hospital savings.

Cited by 114 publications

References 20 publications

Improving Delirium Care

Improving Delirium Care

Altered Mental Status in Older Emergency Department Patients

The prevention, diagnosis and management of delirium in older people: concise guidelines

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