Delirium diagnosis, screening and management

Abstract

Purpose of reviewOur review focuses on recent developments across many settings regarding the diagnosis, screening and management of delirium, so as to inform these aspects in the context of palliative and supportive care.Recent findingsDelirium diagnostic criteria have been updated in the long-awaited Diagnostic Statistical Manual of Mental Disorders, fifth edition. Studies suggest that poor recognition of delirium relates to its clinical characteristics, inadequate interprofessional communication and lack of systematic screening. Validation studies are published for cognitive and observational tools to screen for delirium. Formal guidelines for delirium screening and management have been rigorously developed for intensive care, and may serve as a model for other settings. Given that palliative sedation is often required for the management of refractory delirium at the end of life, a version of the Richmond Agitation-Sedation Scale, modified for palliative care, has undergone preliminary validation.SummaryAlthough formal systematic delirium screening with brief but sensitive tools is strongly advocated for patients in palliative and supportive care, it requires critical evaluation in terms of clinical outcomes, including patient comfort. Randomized controlled trials are needed to inform the development of guidelines for the management of delirium in this setting.

End-of-Life Delirium: Issues Regarding Recognition, Optimal Management, and the Role of Sedation in the Dying Phase

“…In the terminal phase of illness, it can be challenging to use the currently available validated delirium screening and diagnostic tools, especially for hypoactive delirium and for patients with a reduced level of consciousness and communication because of natural disease progression (30)(31)(32)(33). The final item on the observational Nursing Delirium Screening Scale (Nu-DESC) (34) on psychomotor retardation was designed to detect hypoactive delirium, but may be rated by nurses observing increasing fatigue and patients spending more time in bed as part of the terminal phase.…”

The Impact of a Novel Tool for Comprehensive Assessment of Palliative Care (MPCAT) on Assessment Outcome at 6- and 12-Month Follow-Up

“…45,46 Delirium or cognitive failure is particularly prevalent in the terminal stages of palliative care patient's illness trajectory and should be screened for at the time of admission in order to be able to detect changes in patient status. 47 Evidence suggests that standardised systematic assessment is a critical component of a comprehensive admission assessment and can increase accuracy and efficiency of the assessment process. 16,48 Increasing the comprehensiveness of assessments has increased the accuracy of assessments.…”

Educational Intervention to Improve Delirium Recognition by Nurses

“…A common finding was that the knowledge level of nurses was determined to be average when examined for delirium and risk factors and complications from delirium (Baker, et Establishing accuracy of the delirium recognition screenings was not specifically addressed in this project, however is essential to further implement interventions to mitigate short and longterm consequences from delirium (Lawlor & Bush, 2014) and could be a natural evolution for this project.…”

“…1 Delirium prevalence rates vary from 20-27% in acute care and up to 87% in intensive care unit (ICU) patients. 2 Adverse outcomes for the critically ill patient experiencing delirium are widely published and include prolonged mechanical ventilation, lengths of stay, persistent cognitive impairment, and increased mortality. [3][4][5][6] Statistically significant increases in ventilator days, re-intubation rates, and accidental removal of tubes are also described.…”

“…Trogrlic et al, (2015) quoted the work of Engel and Romano (1959): 'the problem of delirium is far from an academic one' (p. 158) and the insufficiencies in the education of healthcare professionals to recognize and respond to delirium are of crucial importance. Delirium prevalence rates vary from 20-27% in acute care and up to 87% in intensive care unit (ICU) patients (Lawlor & Bush, 2014). recommended the use of validated tools to perform assessments and the initiation of guidelines and protocols to improve the care of delirious hospitalized patients.…”