Background: Delirium is a highly prevalent disorder in older individuals admitted to the acute hospital (Inouye et al. 2014). It indicates an underlying pathological process and is a medical emergency (NICE 2010). Nurses can facilitate its early recognition and improve patient outcomes through early treatment (Cerejeira & Mukaetova-Ladinska 2011). However, delirium frequently goes unrecognised and is undiagnosed or misdiagnosed in up to two-thirds of cases (Inouye et al. 2014).
Aim: The aim of this literature review is to explore barriers and facilitators to nurses recognition of delirium in older patients in the acute hospital setting.
Search strategy: Six electronic databases were searched. Manual searching of academic journals, the reference lists of relevant articles, and the websites of relevant organisations was also conducted. Grey literature was accessed via Opengrey.eu and the Virginia Henderson Global Nursing e-Repository. Postgraduate dissertations were accessed from Trinity College Dublin and screened for relevance. 21 studies were included in the review. The following themes were identified: Lack of Knowledge, Education and Training and Organisational Factors.
I would like to thank my parents, my aunt Bernice, and my facilitator Louise for their ongoing advice and support throughout the literature review process.
1. Lack of knowledge of delirium 5-11
1.1. Lack of knowledge of the importance of delirium assessment 5-6
1.2. Approaching delirium assessment inconsistently or inappropriately 6-7
1.3. Poor knowledge of hypoactive delirium 7-9
1.4. Difficulty differentiating delirium and dementia 9-11
2. Education and training 11-14
2.1. The benefits of education and training 11
2.2. Educational interventions 12-14
3. Organisational factors 14-15
Appendix 1. Summary Table for Research Studies Included in the Review 18-37
Appendix 2. Summary Table for Literature Reviews and Systematic Reviews 38
Appendix 3. Tabulation of Database Searches 39-44
Delirium is a reversible neuropsychiatric syndrome characterised by acute deterioration in cognitive function, altered level of consciousness, impaired attention, and fluctuating course (Cerejeira & Mukaetova-Ladinska 2011). It is the most common complication affecting older patients in the acute hospital setting, with an estimated prevalence of 29-64% (Sampson et al. 2009, Inouye et al. 2014). In Ireland, research suggests a prevalence of 20-52.1%, (Ryan et al. 2013, FitzGerald et al. 2017). Numerous factors predispose older adults to delirium, including multimorbidity, increased incidence of dementia, polypharmacy, central nervous system degeneration and age-associated brain changes (Trzepacz & Meagher 2010).
Delirium indicates an underlying pathological process and is a medical emergency (National Institute for Health and Care Excellence (NICE) 2010, NICE 2017). Early identification, diagnosis, and treatment is essential to improve prognosis (OHanlon et al. 2014). Failure to detect delirium is associated with significant patient mortality (Kakuma et al. 2003, Jackson et al. 2016, Marcantonio 2017, Oh et al. 2017). One study found that mortality increases by 11% for every 48 hours of delirium duration (Gonz?lez et al. 2009).
Delirium in older individuals is associated with other adverse outcomes including increased post-discharge mortality, increased length of hospital stay, increased healthcare expenditure, increased likelihood of requiring institutionalization, and increased risk of cognitive and functional deterioration (Gonz?lez et al. 2009, Cerejeira & Mukaetova-Ladinska 2011, Pandharipande et al. 2013, Fong et al. 2015, Jackson et al. 2016, Oh et al. 2017). In addition to its impact on patient outcomes, delirium is intensely distressing for patients and their caregivers (Brietbart et al. 2002, Grover et al. 2015, Morandi et al. 2015).
NICE (2010) recommends that patients aged 65 or older receive ongoing monitoring for delirium throughout the care trajectory. Similarly, in Ireland, guidelines by the National Clinical Programme for Older People and the Integrated Care Programme for Older Persons (Health Service Executive 2017) recommend that older patients be screened for delirium upon presentation to the Emergency Department or the Acute Medical Assessment Unit. Nurses are the professional group with the most patient contact, so are in a prime position to facilitate early diagnosis and treatment via ongoing patient monitoring and cognitive screening (Cerejeira & Mukaetova-Ladinska 2011). However, despite its clinical significance and high prevalence, delirium frequently goes unrecognised, and is undiagnosed or misdiagnosed in up to two-thirds of cases (Cerejeira & Mukaetova-Ladinska 2011, Inouye et al. 2014, Marcantonio 2017, Oh et al. 2017).
To identify areas of future research that could address this problem, this literature review aims to explore factors that inhibit or facilitate nurses recognition of delirium in older patients in the acute setting. The author developed an interest in this topic whilst caring for an older woman whose cognitive function suddenly deteriorated whilst in hospital. Nursing staff initially dismissed it due to age, but she was later found to be experiencing delirium secondary to a urinary tract infection.
A comprehensive search was conducted to identify relevant literature. As recommended by Cronin et al. (2015), a variety of literature sources were explored to reduce the risk of publication bias. Manual searching of academic journals, the reference lists of relevant articles, and the websites of organisations such as the European Delirium Association was conducted. One piece of seminal research (Inouye et al. 2001) was selected for inclusion following repeated identification upon reference list searching. Grey literature was accessed via Opengrey.eu and the Virginia Henderson Global Nursing e-Repository; five results were reviewed by abstract and excluded as they were not research literature. Three postgraduate dissertations were accessed from Trinity College Dublin and excluded as their study population was not older hospitalised patients.
Six academic databases were searched: MEDLINE, Pubmed, EMBASE, CINAHL Complete, PsycINFO and Health Source: Nursing/Academic Edition. Following experimental searching and reflection upon the aim of the literature review, the research question was broken into five core concepts:
2) factors influencing recognition
4) older adults
5) the acute hospital setting.
Free text search keywords were created for each concept using mind-mapping to identify synonyms and alternate spellings. Terminology used in relevant articles that were encountered during initial searching was also included. Using the Boolean operator OR, keywords were combined into search strings for each core concept. See Appendix 3 for an overview of the database searches.
Databases were searched by title and abstract to increase the relevance of retrieved material. Searches were limited to peer-reviewed material to ensure retrieval of high-quality material (Ecker & Skelly 2010). To obtain empirical evidence, only research studies, literature reviews or systematic reviews were included. Material not written in English was excluded due to lack of access to translation services. The limitation aged 65+ years was imposed as this was the population of interest.
Due to limited time and resources, and the identification of a large amount of material upon initial searching, the search was restricted to material published from 2011. This was the year following publication of the internationally-recognised NICE (2010) guidelines on delirium prevention, diagnosis, and management.
Database searching with limiters yielded 678 results. Following screening by title and exclusion of duplicates, 89 articles were reviewed by abstract. Of these, 21 were excluded as they were not research literature and 16 more as, despite attempts to contact the authors, access to the full text was not obtained. 52 articles were reviewed by full text; 30 were rejected as they did not contain relevant findings.
Of the 21 studies finally included in the review, six were qualitative, 10 quantitative, four were mixed-methods studies, and one was a scoping review. Locations of research studies included Australia (4), the USA (8), the UK (1), the Netherlands (1), Belgium (1), Canada (1), Switzerland (1), South Korea (1), Thailand (1) and India (1).
The critical appraisal framework by Cronin & Huntley-Moore (2013) was used to analyse the research. Through thematic analysis, recurring barriers and facilitators to nurses recognition of delirium in older adults in the acute setting were identified and organised into the following themes:
Lack of knowledge of delirium;
Education and training;