Detection of Delirium and Its Symptoms by Nurses Working in a Long Term Care Facility

doi:10.1016/j.jamda.2010.11.002

Journal of the American Medical Directors Association

Volume 13, Issue 3, March 2012, Pages 264-271

https://doi.org/10.1016/j.jamda.2010.11.002 Get rights and content

Abstract

Objective

To investigate the ability of nurses to recognize delirium and its symptoms and to investigate the factors associated with undetected delirium.

Design

A prospective, observational study with repeated measurements over a 6-month period.

Setting

Seven long term care settings in Montreal and Quebec City, Canada.

Participants

Residents aged 65 and older, with or without dementia, admitted to long term care (not respite care) and able to communicate in English or French.

Measurements

Delirium and its symptoms were assessed using the Confusion Assessment Method. Ratings of delirium by nurses based on their observations during routine care were compared with delirium ratings by trained research assistants based on a one-time formal structured evaluation (Confusion Assessment Method and Mini Mental State Examination). This procedure was repeated for 10 delirium symptoms. Sensitivity, specificity, and positive and negative predictive values were calculated. The method of generalized estimating equations was used to identify factors associated with undetected delirium.

Results

Research assistants identified delirium in 43 (21.3%) of the 202 residents. Nurses identified delirium in 51% of the cases identified by the research assistants. However, for cases without delirium according to the research assistants, nurses identified 90% of them correctly. Detection rates for delirium symptoms ranged from 25% to 66.7%. Undetected delirium was associated with lower number of depressive symptoms manifested by the resident.

Conclusion

Detection of delirium is a major issue for nurses. Strategies to improve nurse recognition of delirium could well reduce adverse outcomes for this vulnerable population.

Section snippets

Design, Study Settings, and Selection of Participants

This study was a prospective, observational, multisite cohort study of LTCF residents conducted at 7 facilities located in Montreal and Quebec City, Canada. All residents aged 65 and older admitted to long term care (not respite care) and able to communicate in English or French, were eligible for the study. Two cohorts of residents were enrolled in separately funded studies that used the same staff and methods. Cohort A included residents without severe dementia (defined as a score of 10 or

Outcome

Delirium as measured with the CAM was the outcome in this study. The CAM is an established and widely used instrument to help in the detection of delirium.17, 18 The tool assesses the 9 criteria for delirium specified in the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (similar to DSM-IV criteria): (1) acute onset and fluctuation of symptoms over the course of the day; (2) inattention; (3) disorganized thinking; (4) altered level of consciousness; (5)

Results

Of the 1484 residents considered for inclusion in the study, 928 (62.6%) were eligible for enrollment (Figure 1). Consent was obtained for 283 residents: 108 (49%) of the 221 competent residents and 175 (25%) of the 707 incompetent residents. Three residents died before baseline assessment, leaving a total of 280 residents for the study. Of these, only residents with at least 1 monthly assessment of delirium conducted on the same day by the RA and bedside nurse over the 6-month period were

Discussion

The purpose of this study was to investigate bedside nurses’ ability to recognize delirium and its symptoms among long term care residents, with or without dementia, and to investigate the factors associated with undetected delirium. Although recognition of delirium by bedside nurses has been studied frequently in acute care settings, this issue has scarcely been investigated in LTCFs. Moreover, to the authors’ knowledge, this study is the first one using a prospective design with repeated

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: The authors thank the Canadian Institute of Health Research and The Canadian Alzheimer Society for their financial support to this project. Funding for this paper was also through an Investigator Award to Philippe Voyer from the Quebec Health Research Funds (Fonds de la recherche en santé du Québec) and the Quebec Nursing Research Funds (Fonds de la recherche en sciences infirmières du Québec).

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Original StudyDetection of Delirium and Its Symptoms by Nurses Working in a Long Term Care Facility

Abstract

Objective

Design

Setting

Participants

Measurements

Results

Conclusion

Section snippets

Design, Study Settings, and Selection of Participants

Outcome

Results

Discussion

Am J Geriatr Psychiatry

Gen Hosp Psychiatry

J Psychiatr Res

Psychosom

J Clin Epidemiol

J Chronic Dis

J Clin Epidemiol

Biol Psychiatry

Pain

J Prof Nurs

Nurse Educ Today

Heart Lung

J Am Med Dir Assoc

Delirium superimposed on dementia: A systematic review

J Am Geriatr Soc

Nurses’ recognition of delirium and its symptoms: comparison of nurse and researcher ratings

Arch Intern Med

Prevalence and detection of delirium in elderly emergency department patients

CMAJ

Diagnostic and statistical manual of mental disorders (DSM-IV-TR)

Detection of delirium by bedside nurses using the confusion assessment method

J Am Geriatr Soc

A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics

Ann Intern Med

Risk factors and prediction of postoperative delirium in elderly hip-surgery patients: Implementation and validation of a medical risk factor model

J Am Geriatr Soc

Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study

J Gen Intern Med

Outcomes of older people admitted to postacute facilities with delirium

J Am Geriatr Soc

Older adults discharged from the hospital with delirium: 1-year outcomes

J Am Geriatr Soc

Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability

JAMA

Acute confusion indicators: Risk factors and prevalence using MDS data

Res Nurs Health

Consequences of not recognizing delirium superimposed on dementia in hospitalized elderly individuals

J Gerontol Nurs

Are nurses recognizing delirium? A systematic review

J Gerontol Nurs

Original Study
Detection of Delirium and Its Symptoms by Nurses Working in a Long Term Care Facility