Delirium

A THESIS
Presented to the Professional Studies Department
California State University, Long Beach
In Partial Fulfillment
of the Requirements for the Degree
Master of Science in Emergency Services Administration

By
Della Kay Bradford, B.S., M.Ed.
EDLD Doctoral Candidate
Texas Tech University

April 2011

Dr. Sylvia Mendez-Morse

Committee Chair
Dr. Dr. Joann Klinker
Committee Member
Dr. Fernando Valle
Committee Member

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Copyright 2011
Della Kay Bradford
ALL RIGHTS RESERVED

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ACKNOWLEDGMENT

I would like to take this chance for thanking my research facilitator, friends & family for support
they provided & their belief in me as well as guidance they provided without which I would have
never been able to do this research.

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DECLARATION

I, (Your name), would like to declare that all contents included in this thesis/dissertation stand for
my individual work without any aid, & this thesis/dissertation has not been submitted for any
examination at academic as well as professional level previously. It is also representing my very
own views & not essentially which are associated with university.

Signature:

Date:

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ABSTRACT

Delirium is the most common complication associated with hospitalization of older adults with
incidence of 25% to 60%. Delirium is responsible for approximately 17.5 million hospital days
annually, yet nurses fail to recognize it as much as 70% of the time. The main aim of this
research was to critically appraise the literature regarding early recognition of delirium in ICU,
formulating conclusions and recommendations to practice. The research is based on secondary
data collection. The data is extracted from various journals, articles and books. The research
approach used is qualitative. The literature search revealed that delirium in the hospitalized
elderly patient, particularly in ICU, is a prevalent geriatric syndrome which is under recognized
and under diagnosed. Misdiagnosis of delirium often results in mismanagement and poor health
outcomes, the older patient. It was also demonstrated with the help of literature review that there
is a significant impact of early recognition of delirium in ICU and this could help in reducing the
length of stay in ICU as well.The research revealed that many delirium assessment tools have
been developed, but that in many cases the tools are too time consuming for acute care nurses to
use, don't give a complete picture of the whole delirium phenomena, don't address functional and
cognitive behaviour, and were not specifically developed for nursing professionals to use. The
data clearly shows the impact that delirium can have on the ICU patient. This information should
empower the nursing community to study this topic further and to develop strategies to assist the
bedside nurse to overcome barriers and develop techniques to improve outcomes for our patients.
The results of this study clearly show that nurses need additional education on delirium to correct
their misconceptions and provide an accurate assessment to critically ill patients. Education will

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give them the tools that they need and help them base their practice on evidence not tradition.
The first step to take will be the education of current nurse educators.

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TABLE OF CONTENTS

ACKNOWLEDGMENT.............................................................................................................................................II
DECLARATION........................................................................................................................................................III
ABSTRACT................................................................................................................................................................IV
CHAPTER 01: INTRODUCTION..............................................................................................................................1

The Problem.............................................................................................................................2
Delirium Outcomes..................................................................................................................2
Aims and Objectives................................................................................................................3
Aims How to Achieve............................................................................................................3
Structure of Dissertation..........................................................................................................4
CHAPTER 02: METHODS.........................................................................................................................................6

Methodology............................................................................................................................6
Background and Rationale......................................................................................................7
Inclusion and Exclusion Criteria.............................................................................................9
Literature Sources..................................................................................................................10
Literature Critique.................................................................................................................11
Authors...................................................................................................................................12
Titles and Abstracts................................................................................................................13
Ethical Considerations..........................................................................................................14
Purpose/Problem of Study.....................................................................................................14
Key Words..............................................................................................................................15
Appraisal Framework............................................................................................................15
CHAPTER 03: LITERATURE REVIEW................................................................................................................16

Literature Review...................................................................................................................16
Hypotheses.............................................................................................................................18
Operational Definitions.........................................................................................................18
Sample and Design................................................................................................................20
Critique on Quantitative Research Approach........................................................................21

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Statistical Analysis.................................................................................................................23
Results....................................................................................................................................24
Themes...................................................................................................................................26
CHAPTER 04: DISCUSSION...................................................................................................................................28

Psychosocial Impact..............................................................................................................28
Nursing Assessment...............................................................................................................30
Barriers to Delirium Assessment...........................................................................................31
CHAPTER 05: REFLECTIONS...............................................................................................................................34

Predisposing and Precipitating Factors for Delirium...........................................................34

Prevalence of Delirium..........................................................................................................35
Evaluation of Delirium..........................................................................................................36
Assessment Methods..............................................................................................................36
Documenting Delirium..........................................................................................................37
Assessing and Diagnosing Delirium......................................................................................38
CHAPTER 06: CONCLUSION.................................................................................................................................40

Implications for Nursing........................................................................................................40

Implications for Future Research..........................................................................................42
REFERENCES............................................................................................................................................................43

Literature Sources..................................................................................................................51
BIBLIOGRAPHY.......................................................................................................................................................54
APPENDIX..................................................................................................................................................................61

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CHAPTER 01: INTRODUCTION

Delirium is an acute reversible, disturbance of consciousness, attention, cognition and the

perception that is due to a general medical condition, a substance, or a combination of these
factors. It is a significant health problem for acutely ill older adults, affecting 2.3 millions
persons each year, with an estimated cost of more than 4 billion annually (Inouye, 1999). In fact,
it is the most frequent complication associated with hospitalization of older adults. The serious
squeal of delirium associated with failure to diagnose older adults and treat early are well
documented as they relate to significantly increased morbidity and mortality (Covinsky et al.,
2003).

Despite the significant negative impact of delirium on clinical outcomes and healthcare
expenditures, delirium is probably the most misunderstood phenomenon that faces nurses
working with older adults in acute care settings (Inouye, 2004). Although delirium is clearly
defined as a medical diagnosis, it is frequently either completely missed or misinterpreted as
dementia or depression by both nurses and physicians. Because delirium is frequently
misunderstood, it is not uncommon to see the use of physical restraints or sedatives to control its'
manifestations, rather than appropriate management of the underlying cause of delirium-related
behaviors.
Factors such as the fluctuating nature of symptoms and varied clinical presentations make
delirium difficult to diagnose. Because nurses spend a considerable amount of time at the
bedside, they are in the best position to identify the subtle changes associated with early
delirium. However, nurses are more likely to under recognize delirium than physicians (Inouye,
Foreman, Mion, Katz, & Cooney, 2001). Nurse recognition of delirium requires a clear

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understanding of the clinical manifestations and potential causes, particularly in high-risk groups
such as the oldest old ( 85 years) or those with dementia.

The Problem
Delirium is the most common complication associated with hospitalization of older adults
with incidence of 25% to 60%. Delirium is responsible for approximately 17.5 million hospital
days annually, yet nurses fail to recognize it as much as 70% of the time (Foreman, 1999). The
negative impact of delirium-related consequences has been linked to the failure to recognize
delirium early (Inouye, Schlesinger, & Lydon, 1999). Many factors have been attributed to failure
to detect delirium, such as lack of knowledge about cognitive disorders and assessment methods;
failure to detect quietly delirious patients; failure to correctly interpret signs and symptoms;
failure to recognize delirium superimposed on dementia; the atypical presentation of delirium in
the older adult; and nurses' philosophical perspective towards aging. Still others have suggested
that certain patients' risk factors, such as dementia, advanced age, visual impairment, and
hypoactive delirium, are associated with a 20-fold chance of nurses' failing to recognize delirium
(Inouye et al.), Despite all of these investigations, reasons for nurses' under the recognition of

delirium and the clinical decision making processes they use remain speculative and poorly
understood.

Delirium Outcomes
Patients who suffer from delirium in the hospital often have poor outcomes compared to
other patients. The mortality rate for persistent delirium is substantially higher than the one year

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mortality rates of acute conditions such as heart disease, influenza and pneumonia. An estimated
twenty-five percent of patients who develop delirium while hospitalized will die within six
months (Cole et al., 2008).

Aims and Objectives

The research has following aims and objectives to be achieved after the research:
1.

To critically appraise the literature regarding early recognition of delirium in ICU

addressing implementation of the tools formulating conclusions about the
interventions that could be provided to ICU patients of delirium and

2.

recommendations to practice.
To evaluate the findings of prior researches in the context of delirium in ICU and
form conclusions keeping into view the discussions and reflections of the

3.

researches.
To reflect on the effectiveness of some elements of tools in the early recognition

4.

of delirium.
To critically appraise the review literature on intervention that could help in

5.

reduction of delirium occurrence.

To formulate conclusions and establish further recommendations to clinical
practice in delirium management within ICU.

Aims How to Achieve

The purpose of this dissertation is to understand early recognition of delirium in ICU by
increasing theoretical knowledge, consequently improving clinical practice and minimising the
length of stay in ICU. Throughout this assignment, my attention will focus on the early detection
and diagnosis of Delirium in ICU but also touching on some of the other areas of delirium, which

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is the implementation of routine systematic tools. This will be achieved by means of performing
extended literature review. Polit & Beck (2004) says that literature review helps to lay the
foundations for a study, assisting, and interpreting the study findings and to understanding
current knowledge on topics and illuminating the impact of the study.

Structure of Dissertation
Chapter 01: provides a very broad but concise introduction & the background of the
problem to be addressed for the readers, so that they could have an overview of the topic. The
chapter also gives the objectives of the research & the research questions. Additionally, it
presents the aims and outcomes of the literature review as well.
Chapter 02: opens up with the discussion of the research methodology, philosophy of the
research & the approach of dissertation. At the end, it defined the data collection methods as well
as the empirical construction.
Chapter 03: provide very clear and critical review of the literature that is applicable &
quite close to the related subject, on the other hand, it also provides the explanation, discussion
& crucial thinking for providing the involvement in the same area.
Chapter 04: presents the findings of the critical review conducted in chapter 03.
Chapter 05: provides reflection on the topic under discussion
Chapter 06: offers the research question results & results shortened in the form of a
conclusion to the dissertation along with the recommendations, suggestions & future areas for
research in the same context.
Chapter 07: comprise of references and bibliography.

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CHAPTER 02: METHODS

Methodology
The research is based on secondary data collection. The data is extracted from various
journals, articles and books. Secondary research describes information gathered through
literature, publications, broadcast media, and other nonhuman sources (Cryer 2000). This type of
research does not involve human subjects.
The research approach used is qualitative. Qualitative research is much more subjective
than quantitative research and uses very different methods of collecting information which could
be both primary and secondary. As already mentioned, this study chooses the secondary method.
The nature of this type of research is exploratory and open-ended.
The basic methodology followed particularly for the medical researches is the systematic
review of literature with the help of meta-analytic techniques of statistics. This serve as the basis
for this research too as this would enable is finding better results and interventions for the
patients of delirium in ICU setting. The results of past researches will be evaluated on a uniform
criteria for inclusion and exclusion which will result into better recommendations and
conclusions of this paper.
This type of research is often less costly than surveys and is extremely effective in
acquiring information. It is often the method of choice in instances where quantitative
measurement is not required.
For the purpose of evaluation, the CASP model has been used. All the studies have been
criticized on the bases of CASP criterion. The critical evaluation of the studies has been
presented in Chapter 03, literature review.

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The most significant reason for the secondary research was the ease of access to
secondary data sources. The cost involved in secondary research is relatively low in comparison
to the primary research. The research questions and objectives of this research are in accordance
with format of secondary research and they could only be achieved by following the pattern of
secondary research. The use of this research pattern will be helping in the alignment of large
scale researches. The required information for the research might be available through the
secondary sources. This will help in effective elimination of the expense and need for carrying
out primary research. In the case of research on delirium, the details found about the previous
primary researches showed that there will be numerous difficulties in collection of primary data
and the potential of the information obtained will not be justifying the efforts and cost involved
for conducting the primary research.

Background and Rationale

With the ageing of our population, this problem may potentially will continue to worsen
unless we improve our assessment and treatment. According to the U.S. Census Bureau over the
next two decades, the percentage of persons over the age of sixty-five will increase from thirteen
to nineteen percent of the total population. A small community study based in United Kingdom
found out that delirium prevalence among the people ranging from the age 18 to 55 yrs was
0.4%, the people ranging from the age55 to 85 was 1.1% and the people falling in the age
bracket of 85 yrs or above was 13.6% (Folstein et al, 1991). So, it can be said that the delirium
prevalence shows variation depending over the study setting and the population.
Rationale for selecting these topics is best of my interest, which is relevant to my clinical
area. Having worked in intensive care looking after mechanically ventilated patients I have

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become increasingly mindful of the need for early diagnosis of delirium in this group of patients,
and recognising the subtypes of delirium. More so I have been more involved in looking after
ventilated patients in the general care of this group of patient, I realised that nurses has immense
pressure to prioritise and deliver the best care and as such, assessment of delirium (early
diagnosis-CAM-ICU tool) in the majority of cases has not taken precedence. Omission or
ignorance of such important tools can potentially lead to patient safety in jeopardy, and develop
hyperactive delirium, and it is distressing to the family and staffs. In support of my realisation
OBrien D (2002) pointed out that occurrences of delirium in intensive care causes high health
care cost, upsetting the family and the staffs, however, the cost is not only monetary but also the
mortality rate is higher, ranges from 10% to 65% which is compared to non occurring delirium
patients. Although most of the staff, including clinicians considers that delirium in ICU is an
expected outcome (Cole et al., 2008), recent studies shows that it increases the length of stay,
medical complications, and poor outcome.
Ely (2004) conducted a study in ICU ventilated patients, found that those who developed
delirium has had a high-mortality rate and spent 10 days longer in hospital. Delirium is a
common problem in ICU especially in postoperative cardiac patients. Patients those undergoing
elective major surgery developed delirium 11% less when compared to elective cardiac surgery
14% (Covinsky 2003).
Nurses have been crucially identified as pivotal in decreasing the patients risk of
developing delirium or recognising the in the early stages by placing the best possible care
(assessment) timely using the protocols and strategies to diagnose the occurrence The main
aspect within the process of care is the need of comprehensive assessment. This includes the
nurse having the capability to recognise various mental health issues and to be able to undertake

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and participate in, comprehensive holistic, needs based assessment. More over are the nurses
able to recognise the delirium in the primary stage with tools, which is currently using in the
unit. Hypoactive period of delirium is often unrecognised and unnoticed, so prognosis is most
worse in this case related to its complication and other outcome related immobility and it is also
reflected in NICE guidelines 2010.
As per the NICE guidelines 2010, ensure that people at risk of delirium are cared for by a
team of healthcare professionals who are familiar to the person at risk. Avoid moving people
within and between wards or rooms unless absolutely necessary. Give a tailored multicomponent
intervention package: Within 24 hours of admission, assess people at risk for clinical factors
contributing to delirium. Based on the results of this assessment, provide a multicomponent
intervention tailored to the persons individual needs and care setting. The tailored
multicomponent intervention package should be delivered by a multidisciplinary team trained
and competent in delirium prevention.

Inclusion and Exclusion Criteria

Polit Hungeler have provided very clear illustrations of inclusion and exclusion criteria
the guide for the systematic review focused over the relationship of written nursing care manual
planning, patient outcomes and record keeping. Keeping this into view, every study in this
research has been selected on the basis of relevance, recent research and validity of the research.
Other criteria followed for the research were that articles must be published in English, which
reported research studies and that included data measuring nurses assessment of delirium.
Relevance was also kept as a primary factor, it was judged with the help of abstracts and titles of
the studies found on internet. Only those journals and articles were selected, which were in

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context of ICU patients, studies associated with patients of other ward and hospital units were
not taken into consideration.

Literature Sources
Firstly, the computerised databases of Cinahl (from year 1990-2010), PsycoInfo (from
year 1990 to 2010) and Medline (from year 1990-2010) were explored for with the help of the
following process. The use of subject related and specific keywords were used for describing
interventions and patients related to the review were selected with the help of databases
thesaurus function. The selected keywords specifically related to the psychosocial interventions
and patients were combined separately (by the usage of OR Boolean operator) with the
appropriate free text. Then the combination of two searches was made (by the usage of AND
Boolean operator) for limiting the search and exploration to the advanced stage cancer patients,
that are relating, to the interventions of psychosocial aspects or any synonyms that are
approximate for the psychosocial interventions.
After that the above mentioned combination of search was respectively joint-up with a
specific methodological filter of database acclimatized from Dickersin and Robinson (2002) for
limiting the exploration and search to the studies which were controlled. The search for the
literature was then limited to the researches published in the years 1990-2011, as it was found
through various researches and that advanced cancer was most prevalent in the same time
duration and the highest number of deaths were reported too, because of this reason numerous
researches were made during this time. Secondly, the abstract of all the mentioned references of
relevant papers was retrieved and reviewed for the identification of any additional researches.
Thirdly, for the identification of related researches Science Citation Index was utilized for

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10

searching for the researches that have the relevant papers. Fourthly, the field leaders were also
contacting for locating relevant but the unpublished studies in the time of 1990-2010 or give
suggestions about others who might know about any unpublished researches or work.
The search and exploration of databases Cinahl, PsycInfo and Medline gave away a total
of five hundred and eighty four citations. After the duplication adjustment, only 300 studies
remained. Out of 300 researches, 258 were excluded after reviewing and evaluating the
abstracts. The abstracts of studies were reviewed with the help of various databases like Pubmed,
Cinahl, PsycoInfo and Medline. The abstracts of any study consist of the objectives of the paper,
methods used for the research, population and sample, tools and techniques applied and the main
findings along with the conclusion. The abstract of the paper helped in determination of the
relevancy of the research to the topic and how useful is the research going to be for the
researcher. It appeared that these papers did not meet the relevancy criteria clearly. Among the 42
studies, 8 were selected as primary because of the relevancy to the topic and the validity of the
research. The remaining 32 researches were studied in detail, 9 were found lacking validity of the
research and the results of 13 researches were vague and were not making any significant
contribution to the literature. 9 researches were relevant to the topic in various parts, those parts
were made part of the critique section and have been discussed in detail.

Literature Critique
A comprehensive review of the literature was conducted on research articles for the last
ten years utilizing the search terms of delirium, delirium assessment, acute confusion, and ICU
psychosis. Cumulative Index to Nursing and Allied Health Literature and MEDLINE databases

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11

were used to facilitate research. Selection criteria were articles that were published in English,
which reported research studies and that included data measuring nurses assessment of delirium.
The chart for the literature analysis has been attached in the appendix. It presents the
authors of the study, study design, participants, methods used and results of the research. It
includes 9 studies which were focused primarily because of the relevance to the topic. Analysis
of rest 7 researches was not found to be specifically related to the patients in ICU. So, they were
also eliminated from the literature analysis.
The critique over the literature has been done on the basis of variables by Ryan-Wenger
(1992) analysis of the study articles:
1.

Authors

2.

Titles and Abstracts

3.

Ethical Consideration

4.

Purpose of Study

5.

Literature Review

6.

Hypotheses

7.

Sample, Selection and Design

8.

Results

Authors
The studies included for the literature review were conducted by the authors who are
mainly health professionals having doctorate qualifications and medical doctors from diverse
backgrounds of specialisation. This serves as the basis for indicating that the authors studies
must be extremely knowledgeable for the processes of research as they have been involved with

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12

various types of researches and experiments during their academic life and now in their careers.
All the authors have been into publishing work associated with delirium like, Bruce J. Naughton
MD, Susan Saltzman ND, Fadi Ramadan MD, Noshi Chadha MD, Roger Priore ScD, Joseph M.
Mylotte MD, (2005) Milbrandt EB, Deppen S, Harrison PL, Shintani AK, Speroff T, Stiles RA,
Truman B, Bernard GR, Dittus RS, Ely EW. (2004) Maria Lundstrm RN, Agneta Edlund RN,
Stig Karlsson RN, Benny Brnnstrm RN, Gsta Bucht MD, Yngve Gustafson MD, (2005)
Robinson BR, Mueller EW, Henson K, Branson RD, Barsoum S, Tsuei BJ. (2008) Ely EW,
Gautam S, Margolin R, Francis J, May L, Speroff T, Truman B, Dittus R, Bernard R, Inouye SK.
(2001) Wesley Ely, E. Ayumi Shintani, Brenda Truman, Theodore Speroff, Sharon M. Gordon,
Frank E. Harrell, Jr, Sharon K. Inouye, Gordon R. Bernard, Robert S. Dittus, (2004) Shehabi Y,
Riker RR, Bokesch PM, Wisemandle W, Shintani A, Ely EW; SEDCOM (Safety and Efficacy of
Dexmedetomidine Compared With Midazolam) Study Group, (2010) Hare, M., McGowan, S.,
Wynaden, D., Speed, G., Landsborough, I.,(2008) and Truman B & Ely EW (2003), which
eventually shows that they have expertise in the related field. So, this literature review can be
considered as an in-depth analysis of the most recent and accurate researches conducted in the
context of ICU patients suffering with delirium and the process of its development along with the
measures that could be taken for mitigating the causes behind it.

Titles and Abstracts

The studies titles are the clear identifiers of the research questions answered at the end of
the research. It was found in the selected researches that the key words that have been utilized for
studies have been summarized in the titles used for the researches. This consistency was found in
all the selected studies which at the end made the selection process quicker and easier. It has

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13

been argued by Ryan-Wenger (1992) that a few terminologies and words could be used for
enhancing studys reliability and credibility. On the other hand, asserted that the innovative and
catchy titles of research could serve as a research of detracting the quality of work done for the
research. On the contrary, it has been argued that obscured and odd titles of studies results in
attracting the reader enquiring. For overcoming these issues, articles and papers included and
identified for literature review have been appraised with the help of CASP tool for validating the
exclusion and inclusion in the process of review. The abstracts of studies also provided the
information for taking the decision of continuing reading or skipping the article.

Ethical Considerations
It was found out that the all the nine included studies had sort approval from the relevant
bodies of ethical review in order to carry out the experiments, treatments and patients were only
entered into the study if the informed consent to treatment was provided to them. These entities
were there for ensuring that the principles of ethics have been applied and the individual rights
have been adhered. This has been of utmost importance for ensuring the rights of patients were
protected as most of them would been incapacitated generally or there would be no legal or
family representation at times of treatments and intubations would be generally required for
starting fairly soon after the process of intubations. The approval from the ethical bodies served
for adding credibility and reliability to the research and studies.

Purpose/Problem of Study
After going through the very first paragraph of the research and sections of 7 studies,
delirium in the patients of ICU was found to be the focal point of the research. In the two

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14

researches, Maria Lundstrm RN, et al (2005) and SEDCOM (Safety and Efficacy of
Dexmedetomidine Compared With Midazolam) Study Group, (2010) the titles were pretty in
compliance with this research but the focus in the first section was not on ICU patients in the
first section. Later, the focus of the research was then directed towards the patients in the ICU.
The first section of the paper didnt describe the focus at the patients of ICU particularly, but
later on the specification in the research was made.

Key Words
The key words used for searching relevant studies are as follows: delirium, delirium
assessment, acute confusion, ICU psychosis, ICU, Length of stay, Ventilated patients, Cardiac
post operative patients etc.

Appraisal Framework
Using the CASP (Dellinger, 2005) 20 articles that had been selected as relevant for this
literature review were then appraised using the CASP program which involves a thorough
examination of all parts of the study (e.g appropriate allocation and blinding of participant),
accounting for all trial participants in the conclusion, minimisation of play of chance and
reliability of study results/findings which then gave the author a much more refined selection of
the most valid and reliable articles to use in the review (Guyatt et al 1993). I further refined the
identified the remaining 25 studies using the Ryan- Wengers (1992), critiquing guidelines (see
appendix 3 for critiquing guidelines), to remain with 9 empirical research articles (see table 1
below for selected literature). Results and findings of studies are illustrated in table 2 below.

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15

CHAPTER 03: LITERATURE REVIEW

Literature Review
In a study conducted by Bruce J. (2005) patient characteristics were not differing between
stand line and the 2 outcome cohorts 9 and 4 months after providing the intervention. At the
baseline delirium prevalence was 40.9%, at the four months it was 22.7% (P<.002), and at nine
months it was 19.1% (P<.001). There was a difference found at the baseline in the usage of
medications after the intervention. The use of Antidepressant was greater (P<.05) at four months.
Usage of Antihistamine and Benzodiazepine was found to be lowered at (P>.01) nine months.
Usage of neuroleptic and Antidepressant was comparatively found to be higher (P<.02) and
lower usage was found for antihistamine at four months (P<.02) on AGU in comparison to the
baseline group. Antihistamine (P<.05) and Benzodiazepine (P<.01) usage was found to be lower
at nine months. Each saved prevented delirium case had a mean of 3.42 days at hospital. So it
was concluded, that an intervention with multifactorial design for reducing older adults delirium
was related with improved use of medication of psychotropic, hospital savings and less delirium.
In a study by Ely EW, (2001) the onset delirium mean was (S.D.+/-1.7) 2.6 days, and the
duration of mean was approximately 3.4+/-1.9 days. Out of the 48 studied patients, delirium was
developed in 81.3% (39), and among them 60.4% (29) complications were developed while they
were in the ICU. The delirium duration was related with ICU length of stay (P=0.0001, r=0.65)
and in the hospital (P<0.0001, r=0.68). With the help of multivariate analysis, the strongest
predictor for was the hospital length of stay (P=0.006), even after the adjustment of illness
severity, race, gender, age and narcotic drug and benzodiazepine administration days. So it was
made evident that in this patient cohort, the mostly the delirium was developed by the patient

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16

particularly in the ICU, and delirium was found to be the strongest determinant (independent) of
hospital length of stay. Further monitoring and study regarding delirium in the intensive care unit
and the factors of risk for its prevalence and development are acceptable and warranted.
With the help of Organic Brain Syndrome Scale and the Mini-Mental State Examination,
the assessment of patients was done on day one, three and seven after their admission in the ICU,
in a research conducted by Maria Lundstrm RN, (2005). The average hospital stay length +/deviation from the standard was considerably lower on the ward of intervention than on the ward
of control particularly for the patients who were delirious. Two patients who were delirious in the
ward of intervention and nine among the patients of ward control, died during the stay at hospital
(P=.03).So, this study showed that a program of multifactorial intervention will reduce the
delirium duration, hospital stay length, and delirious patients mortality.
Delirium was categorized by Milbrandt EB, (2004) as "ever vs. never" and with the help
of severity index for cumulative delirium. The determination of costs was done from individual
ledger level charges of patient by taking into account the cost to charge ratios which were cost
center specific and in United States dollar for the year 2001. 51 of two hundred and seventy five
patients (18.5%) were constantly in coma and they died in the hospital, as a result they were
excluded from the research. Among the remaining 224 patients, development of delirium took
place in 81.7% (183) and 2.1 was the lasted median (1-3, interquartile range) days.
Demographics at baseline were quite similar among those who had delirium and who were not
suffering from this situation. Costs of ICU (inter quartile range, median) were considerably more
for those at least had one delirium episode ($22,346, $15,083-$35,521) in comparison to patients
who never had any episode of delirium (p <.001, $13,332, $8,837-$21,471). The costs of the
hospital were higher for those who went through the development process of delirium ($41,836,

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17

$22,782-$68,134 vs. $27,106, $13,875-$37,419, p =.002). After hospital mortality, nosocomial

infection, degree of dysfunction of organ, illness severity Co morbidity and age adjustment,
delirium was found to be associated with 39% higher ICU (12-72%, with 95% confidence level)
and 31% elevated hospital (1-70%, 95% confidence level) costs. He concluded that delirium is
an ordinary event at the clinical level in mechanically ventilated patients of intensive care unit
and is connected with considerably higher costs of hospitals and ICU costs.
Steis (2008) conducted a study, which provided a systematic literature review on delirium
recognition by the nurses. As delirium is termed as a problem in a global scale, costly and is
prevailing usually in the older adults. In this study, only ten articles were included for critique
and commenting over the recognition of delirium by nurses, which was ranging from 26-83%.

Hypotheses
The major aims behind the studies selected was to find the interventions for patients who
are at the breach of becoming delirium patients and what precautions could be used for
minimization of the risk of patients life. As, it was mentioned in all the studies that the older
patients in ICU are majorly at the risk of becoming delirium patients, age was kept as the main
factor for assessing the probability of getting the disease of delirium.

Operational Definitions
Maria Lundstrm RN, Agneta Edlund RN, Stig Karlsson RN, Benny Brnnstrm RN,
Gsta Bucht MD, Yngve Gustafson MD, (2005), Wesley Ely, E. Ayumi Shintani, Brenda
Truman, Theodore Speroff, Sharon M. Gordon, Frank E. Harrell, Jr, Sharon K. Inouye, Gordon
R. Bernard, Robert S. Dittus, (2004), Hare, M., McGowan, S., Wynaden, D., Speed, G.,

Delirium

18

Landsborough, I (2008) and Truman B & Ely EW (2003), defined delirium as a global cognitive
impairment and includes decreased ability to maintain attention, and disorganized thinking.
According to Bruce J. Naughton MD, Susan Saltzman ND, Fadi Ramadan MD, Noshi Chadha
MD, Roger Priore ScD, Joseph M. Mylotte MD, (2005) Research in the field of delirium,
including the clinical care of patients, has been hampered by the lack of generally recognized
definition of the condition and inconsistent terminology. In the past, delirium has been known by
a variety of names, including acute organic brain syndrome, acute confusion state, toxic
psychoses and acute encephalopathy
However, the Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSMIV) provides consistent terminology and diagnostic criteria for delirium, that are now generally
accepted. The principle elements of DSM-IV diagnosis are
1)

A disturbance of consciousness indicated by reduced awareness of the

environment, along with a diminished ability to focus, sustain or shift attention,

2)

A change in cognition (which may include deficits of memory, language or

orientation) or onset of a perceptual disturbance not better accounted for by
dementia.

3)

Development over a short period with a tendency to fluctuate during the course of
the day.
DSM-IV categorizes delirium by presumed etiology (including delirium secondary to a

medical condition, substance intoxication, and substance withdrawal), mixed or multiple

etiologies, and uncertain etiologies.
It was assumed by Milbrandt EB, Deppen S, Harrison PL, Shintani AK, Speroff T, Stiles
RA, Truman B, Bernard GR, Dittus RS, Ely EW. (2004) that the setting in which the patient

Delirium

19

receives care may also play role; delirium often develops in patients who experience frequent
room changes, lack of normal day and night cycles, and unfiuni1iar physical environment, such
as a hospital room.
According to Shehabi Y et al (2010) Delirium in the aged is also caused from substance
abuse. Alcohol is the most common drug associated with withdrawal causing delirium in the
elderly. This susceptibility of the elderly to delirium is due to the likelihood of the presence of
several concurrent disease processes, requiring multiple medications and age-related change in
drug pharmacokinetics. Based on the results from various studies, medications are acknowledged
as the most reversible causes of delirium, with psychoactive medications the most common.

Sample and Design

The design of studies for literature review was pretest and post test, prospective cohort
study or prospective intervention study. Randomisation of samples took place in all the studies
for ensuring that the subjects that are being studied had the same kind of characteristics and
therefore were not significantly different on the basis of demographics.
In the study conducted by Bruce J et al (2005) Physicians and nurses in the ED
(emergency department) and on an AGU (acute geriatric unit) were taken as the participants for
the research. On the other hand, Milbrandt EB et al (2004) took into account 275 consecutive
mechanically ventilated patients in the medical ICUs. Maria Lundstrm RN et al (2005) selected
400 patients who were whether aged 70 or were older, admitted consecutively to a control ward
or an intervention. Study of Robinson BR et al (2008) comprised of 413 participants. The
patients who were expired during the period of the study were excluded from the research except
for the ventilator analysis. Ely EW et al (2001) observed 48 patients who were admitted to the

Delirium

20

intensive care unit, among them 24 were receiving mechanical ventilation. The research by
Wesley Ely et al (2004) included 275 patients, who were mechanically ventilated and admitted to
the coronary ICUs or adult medical. Shehabi Y et al (2010) studied 344 surgical and medical ICU
patients enrolled in SEDCOM.

Critique on Quantitative Research Approach

Most of the studies used in the literature have been found to involve some kind of
primary statistical analysis for ensuring that the results and outcomes of the research conducted
are justified. The justification of the tools and techniques used for the primary analysis adds to
the validity of the research as well. The primary methods utilized for carrying out studies are as
follows:
1.

Bruce J. Naughton MD, Susan Saltzman ND, Fadi Ramadan MD, Noshi Chadha
MD, Roger Priore ScD, Joseph M. Mylotte MD, (2005) used Multifactorial
analysis and targeted to the processes of care for cognitively impaired and
delirious older adults admitted to medicine service from the ED.

2.

Milbrandt EB, Deppen S, Harrison PL, Shintani AK, Speroff T, Stiles RA,
Truman B, Bernard GR, Dittus RS, Ely EW. (2004) examined patients for
delirium using the Confusion Assessment Method for the Intensive Care Unit.

3.

Maria Lundstrm RN, Agneta Edlund RN, Stig Karlsson RN, Benny Brnnstrm
RN, Gsta Bucht MD, Yngve Gustafson MD, (2005) used the interventions
consisted of staff education focusing on the assessment, prevention, and treatment
of delirium and on caregiver-patient interaction. Reorganization from a taskallocation care system to a patient-allocation system with individualized care.

Delirium
4.

21

Robinson BR, Mueller EW, Henson K, Branson RD, Barsoum S, Tsuei BJ. (2008)
utilized medications that were titrated to a RASS of -1 to +1 and VAS/OPAS <4.
Haloperidol was used to treat delirium in CAM-ICU positive patients.
Retrospective review of the local Project IMPACT database for a 6-month period
in 2004 was compared with the same seasonal period in 2006 in which the ADS
protocol was used.

5.

In the study conducted by Ely EW, Gautam S, Margolin R, Francis J, May L,

Speroff T, Truman B, Dittus R, Bernard R, Inouye SK. (2001), all patients were
evaluated for the development and persistence of delirium on a daily basis by a
geriatric or psychiatric specialist with expertise in delirium assessment using the
Diagnostic Statistical Manual IV (DSM-IV) criteria of the American Psychiatric
Association, the reference standard for delirium ratings. Primary outcomes
measured were length of stay in the ICU and hospital.

6.

In the study of Wesley Ely, E. Ayumi Shintani, Brenda Truman, Theodore Speroff,
Sharon M. Gordon, Frank E. Harrell, Jr, Sharon K. Inouye, Gordon R. Bernard,
Robert S. Dittus, (2004) patients were followed up for development of delirium
over 2158 ICU days using the Confusion Assessment Method for the ICU and the
Richmond Agitation-Sedation Scale.

7.

Shehabi Y, Riker RR, Bokesch PM, Wisemandle W, Shintani A, Ely EW;

SEDCOM (Safety and Efficacy of Dexmedetomidine Compared With
Midazolam) Study Group, (2010) used sedative drug interruption and/or titration
to maintain light sedation with daily arousal and delirium assessments up to 30
days of mechanical ventilation.

Delirium
8.

22

Hare, M., McGowan, S., Wynaden, D., Speed, G., Landsborough, I.,(2008) paper
describes data on nurses documentation collected in the course of this audits. On
four consecutive Thursdays, the medical records of all patients identified by
nursing staff as being confused were reviewed. Where no definitive cause for the
confusion was documented, the case notes were examined for evidence of risk
factors to determine a probable cause.

9.

Truman B, Ely EW. (2003) used Confusion Assessment Method for the Intensive
Care Unit

Statistical Analysis
Milbrandt EB, (2004) found through statistical analysis that higher duration and delirium
severity were linked with greater costs incrementally (all p <.001). In the study of Maria
Lundstrm RN, (2005) the diagnosis of delirium was done in accordance with the Manual of
mental disorders, Diagnostic and Statistical, 4th edition, criterion. The prevalence of delirium
was common on the admission day at the two focused wards, but a few patients were found to be
delirious on the seventh day on the ward of intervention (37/62, 59.7%, P=.001 vs n=19/63,
30.2%).
Ely EW, (2001) showed that delirium duration was related with ICU length of stay
(P=0.0001, r=0.65) and in the hospital (P<0.0001, r=0.68). With the help of multivariate analysis,
the strongest predictor for was the hospital length of stay (P=0.006), even after the adjustment of
illness severity, race, gender, age and narcotic drug and benzodiazepine administration days.
The study of Steis (2008) found out that there is a huge difference between the delirium
documentation, assessment of the nurses, delirium recognition by the nurses and knowledge of

Delirium

23

nurses about delirium with regard to the older adults in the intensive care unit. The study
recommended that there must be improvements in the practice of nursing at various levels,
including informatics usage, system of healthcare, communication, guidelines and education.
Bruce J. (2005) asserted through statistically analysing the characteristics of patients that
the admission of more patient suffering through delirium to AGU in comparison to non AGU
was observed at four (P<.01) four months and (P<.01) at nine months.

Results
Effective management of delirium requires strategies to identify patients upon admission
with delirium or at high risk for delirium, as well as strategies to reduce the incidence of delirium
among the hospitalized elderly. A process improvement effort is required and would involve a
collaborative multidisciplinary team approach (Bruce, 2005). A team approach is needed to
implement a cognitive assessment tool that documents the patient's baseline cognitive
functioning, to provide ongoing monitoring (noting any changes in mental status or behavioral
and functional abilities) and to implement a protocol based intervention for patients identified as
being at risk for or having delirium (Milbrandt 2004).
In the study of Bruce et al (2005) delirium has been found to have a regular clinical
occurrence in the ICU patients who are mechanically ventilated and is linked to the higher
hospital and ICU costs significantly. The efforts in the future for treatment and prevention of ICU
delirium have to potential for improving the outcomes of patients and considerable reduction of
care costs. (Milbrandt, 2004)

Delirium

24

The independent determinant and predictor of six months higher mortality was delirium
and also the long duration of stay at the hospital even after the adjustment of related covariance
including analgesics, sedatives and coma in the mechanically ventilated patients. (Maria, 2005)
In the lightly sedated and ventilated ICU patients, the delirium duration was the most
strong death independent predictor, time of ventilation and ICU stay after adjustment of related
covariance (Robinson, 2008).
Most of the patients have developed delirium in intensive care unit, particularly in the
patients cohort taken into account, and the strongest independent variable and determinant for
the hospital stay was delirium (Ely, 2001). Further monitoring and studies of delirium
development in intensive care unit and the factors of risk for its growth and development are a
necessity (Wesley, 2004).
It has been shown that the intervention program of multi-factor helps in the reduction of
the delirium duration, delirious patients mortality and duration of stay at hospital (Shehabi,
2010).
Effective delirium management requires strategies for identification of the patients upon
admission with delirium or at a comparatively higher risk for delirium, as well as strategies to
reduction of the incidence of delirium among the hospitalized elderly, admitted in ICU
particularly. An effort for process improvement is required and will be involving a collaborative
multidisciplinary approach of team (Bruce, 2005). A team approach is needed to implement a
cognitive assessment tool that documents the patient's baseline cognitive functioning, to provide
ongoing monitoring (noting any changes in mental status or behavioral and functional abilities)
and to implement a protocol based intervention for patients identified as being at risk for or
having delirium (Milbrandt 2004).

Delirium

25

Effective strategies for the management for delirium would not be complete without
appropriate and timely staff education and outcome measures to determine the effectiveness of
the strategies implemented to reduce the incidence of delirium (Wesley, 2004). The education
process should include the signs and symptoms of delirium, differentiation of the signs and
symptoms of depression, dementia and delirium, and appropriate measures to prevent delirium
from occurring. Awareness of risk and surveillance for subtle changes in behavior and mental
status will improve the detection of delirium.
Since delirium is a reversible disorder, early diagnosis through assessment is imperative
to successful intervention and treatment. Primary prevention is the most effective strategy to
reduce the occurrence of delirium (Robinson, 2008). The optimal prevention strategy includes
identification of patients who are at high risk for delirium on admission to the hospital, treatment
of the underlying causes and implementation of appropriate nursing interventions to provide an
optimal supportive environment (Shehabi, 2010).
By implementing these strategies, nurses and other members of the health care team can
appropriately intervene with patients at risk for developing delirium (Ely, 2001). The routine,
systematic and comprehensive assessment, detection, and intervention with patients who are at
risk for delirium may significantly influence the management of hospitalized elderly patients
(Maria, 2005). These strategies can positively impact the negative outcomes associated with the
development of delirium and therefore improve the quality of life of the hospitalized elderly.

Themes
There have been various themes formed out of the literature review. There are various
kind of psychosocial impacts found over the patients of delirium as mentioned in various studies.

Delirium

26

The assessment of nurses involved in the treatment and interventions provided to patients. In
addition, there are various kinds of barriers that are hindering the assessment of delirium.
Along with the themes there are other aspects like precipitating factors and predisposing
factors for delirium, prevalence of delirium, delirium evaluation and methods for the assessment.

Delirium

27

CHAPTER 04: DISCUSSION

Psychosocial Impact
Delirium affects the patient physically and psychologically. The experience of delirium
has been compared to being in a borderland between reality and imagination, past and present,
between being conscious and unconscious of external events. The patients described the unreal
experiences using phrases like crazy dreams, nightmares, and stupid fantasies, changes of
perspective, illusions or dreamlike experiences. The patients experiences during the delirium
episode were often associated with intense fear. At this time, researchers are unsure of the longterm consequences that delirium can have on the psychological health of the patient. The
question whether delirium causes Post Traumatic Stress Disorder has been studied, but the
evidence is not conclusive. (Buerhaus, 1996)
After recovering from the experience of delirium, patients often experienced feelings of
shame, guilt, and fear of recurrence. Not all patients will remember the episode, but the lack of
memory can be distressing to the patient. The most successful strategy for nurses dealing with
these patients is for the nurse to try to understand the patients situation and to pay attention to
and confirm the delirious patient (Cole, 2008). This is difficult for nurses to do as they try to
manage and protect a patient who is often uncooperative and disruptive. For the patient, the
experience of delirium includes dramatic scenes, strong emotional feelings, and difficulties
communicating. Nurses with a better understanding of the patients perspective can better
intervene for the patients benefit.

Delirium

28

Delirium can also negatively impact a patients social standing. Western society tends to
value independence; subsequently elderly patients with delirium are prone to ageist practices and
beliefs. Ageism is defined as the negative and stereotypic bias resulting in older people
experiencing societys bigoted views about old age. The elderly delirious patient is totally
dependent on their caregivers for the most basic of needs (Day, 2008). Hospitals practices tend
to treat these patients as children. Adult diapers, patients being led by others, and patients being
told when to sleep and when to be awake, are all part of the experience. Delirious patients are
often at the mercy of the people around them. Therefore, this group is particularly vulnerable to
ageism. In our youth oriented society, older people are often regarded as worthless and child like.
An older patient who is suffering from delirium is unable to function independently or contribute
to the community. If nurses are able to identify delirium early then they will be able to return the
patient to be a valued member of society who has worth and deserves respect. (Pendleton. 1993)
Nursing work flow within the unit is also negatively impacted by delirium. The delirious
patient can be combative and require a large percentage of the nurses time and attention. A
patient who is loud and difficult can increase the stress level of all staff in the department. Nurses
are trying to keep the patient from hurting themselves, as the patient is trying to escape from
their delusions and hallucinations (Rice, 1993). This can be a frustrating experience for nurses,
patients, and families. Delirium can also negatively impact the nurse-patient therapeutic
relationship. If nurses do not accurately interpret the communication style of the patient then
they cannot intervene on the patients behalf. Nurses need to remember that the patient is
attempting to communicate their needs and feelings in the only way that they are able to through
their delirium.

Delirium

29

Nursing Assessment
The first step in any assessment is obtaining a complete history from the patient. Taking a
history from a delirious and confused patient is challenging. History taking from a delirious
elderly person requires patience, skills, and corroboration from someone who knows the patient
well (when possible) but should always be attempted, as it may provide vital information. Nurses
must take their time and use active listening skills to hear what a patient is saying and be able to
interpret the information in the context the patient provides. Family members or significant
others are essential (Devlin, 2008). Only someone who knows the patient well is able to
determine changes in the patients mental status and interpret the patients statements. It is
important for nurses to support the family through the assessment process as behaviours that the
patient is exhibiting may create distress in the family members as well.
There are multiple tools that have been used to assess delirium. The CAMICU
(Confusion Assessment Method for the Intensive Care Unit) tool has undergone extensive testing
in the ICU, and is recommended by international guidelines. The CAM-ICU requires only 20
minutes for training and uses very basic materials. To complete the CAM-ICU requires less than
five minutes of the nurses time (Rice, 1993). This assessment tool is based on the Richmond
Sedation Scale and is intended for use with the nonverbal patients who are in the ICU setting.
The CAM-ICU is specifically designed for use by personnel with no psychiatric training. An
assessment tool, such as the CAM-ICU gives the nurse a concrete and objective method to assess
the patient throughout their hospital stay. This tool rates the patients delirium on a numerical
scale and enables the nurse to use this scale to communicate clearly with other health care
professionals the improvement or deterioration in the patients cognitive abilities.

Delirium

30

Barriers to Delirium Assessment

The obvious question remains, as to why if delirium is such a major problem for the
hospital elderly then why are nurses not assessing for it properly. There are many factors that
negatively affect how well nurses assess for delirium in their patients. The term delirium itself
can be problematic for healthcare professionals (Wisselink, 1993). Knowledge deficits are
perpetuated because of health professionals routinely documenting cognitive and behavioural
changes under the term of confusion. This term does not allow for qualification or
quantification of significant changes in the patients functioning. If patients are labelled as
confused then it is unlikely that nurses or others will look further for causes or solutions to the
patients problems. Also, if a patient is confused then their status is gauged only by how
disruptive or difficult their behaviours are. ICU psychosis is also a term that is used
interchangeably with confusion, sundowners syndrome, and delirium. Too often behavioural
changes in the critically ill patient are dismissed as ICU psychosis and are treated accordingly
with antipsychotic medications. The behavioural changes often noted in the ICU setting are not
usually related to an acute psychiatric disorder, but to a medical cause (Money, 1994). By
labelling delirium as a psychosis then the patient is treated with psychiatric medications and the
medical team will look no further for a cause. Also, if the ICU is the cause of the behaviour then
the ICU itself becomes the causative factor, not the responsibility of the healthcare team.
Sundowners syndrome is another term that is heard frequently in the hospital setting. This
condition is so named because the changes in behaviour are seen most frequently during the
evening and night hours. Research shows us that, this behaviour is not related to the time of day
but is a result of multiple factors. Medication, pain, sleep cycles, change in vital signs, and
disease processes can all contribute to changes in mental status. Certain aspects of the care of

Delirium

31

critically ill patients are unavoidable (Rice, 1994). Patients in the ICU are subjected to multiple
invasive procedures, monitoring devices, sedative medications, interrupted sleep patterns, and
increased noise levels. But, the ICU environment and the nurse-patient interaction can be
modified to benefit the patient. Nurses need to change their thinking, to be able to look for better
ways to deliver care to critically ill patients that minimize the impact of the critical care setting
on the patients psychological health (Duppils, 2007).
Lack of education on delirium assessment is also a problem. Nurses often have had little
training in how to assess these patients. Cognitive assessment is not routinely included as a key
component in nursing curricula and therefore has not been translated into nursing practice.
Nursing assessment is focused more on the physical signs and symptoms of a patient than their
cognitive functions. In the study done by Devlin et al. only one third of nurses in the study had
received any training about delirium (2008). If nurses do not have knowledge of delirium then
their practice will be based on tradition not evidence. With no education, nurses will not
recognize delirium when it occurs and will not understand its significance for their patients.
Communication is also noted as a barrier to complete a thorough delirium assessment.
Due to the nature of delirium, patients are not able to communicate their needs to health care
personnel. If family members are not involved in the patients care then the health care team will
not have a clear understanding of the patients status and needs. Communication can also break
down between health care professionals. In a study by Spronk, Riekerk, Hofhuis, and Rommes
(2009) nurses also communicated poorly between each other, and did not relate complete
information concerning delirium to the oncoming shift. Communication between physicians and
nurses is also problematic. Without the assistance of a tool, such as the CAM-ICU nurses are
unable to relate information to other nurses or physicians in a clear and objective manner. This is

Delirium

32

especially problematic for providing care to the ICU patient. In the ICU environment, the
physician relies heavily upon the nurse for information and her assessment findings due to the 24
hour/day relationship she has with the patient. Nurses must go further than the label of
confusion for their patient, to be able to provide the patient the care they require.
A precise, easy to understand method of delirium assessment is needed for the nurse to be
able to identify patients at risk and intervene early enough to prevent further complications.
There appears to be a missed opportunity for nurses to put prevention strategies in place well
before the horse has bolted (Rice 1998). Once the patient is delirious the health care team often
must resort to medications to control the patients behaviour and prevent the patient from
harming themselves. Devlin and his team showed that the use of a validated delirium assessment
tool, such as the CAM-ICU improves the ability of physicians and nurses to identify delirium.

Delirium

33

CHAPTER 05: REFLECTIONS

Predisposing and Precipitating Factors for Delirium
Delirium occurs more commonly among patients with certain predisposing features and
age is probably the most important of all of these. However, the literature is often unclear about
describing particular markers, which would be predictive of delirium. Neelon (1990) states "the
risk of the development of delirium is cumulative function of the patient's vulnerability (level of
illness and functional impairment), the timing and magnitude of the effect of multiple added
physiologic and environmental stressors, and support of the patient's bio psychosocial integrity
by the health care team" (p 583). Patients who are highly vulnerable to delirium may develop the
disorder following only minor physiologic stresses, while those with low-baseline vulnerability
require an exposure to multiple significant precipitating factors to develop delirium.
The development of delirium involves a complex interrelationship between baseline
patient vulnerability and the precipitating factors, which occur during hospitalization. Multiple
risk factors appear to have a multiplicative rather than additive effect. Delirium particularly in
the critically ill or elderly hospitalized patient often has multiple etiologies. Francis and Kapoor
(1992) found that while 56% of elderly patients with delirium had single definite or probable
etiology, the remaining 44% had an average of 2.8 etiologies per patient.
According to Inouye (1998), delirium represents a common multi factorial geriatric
syndrome representing a complex interrelationship between a vulnerable patient with significant
predisposing or precipitating factors. Predisposing factors place a patient at risk for delirium and
are present on admission. Inouye (1998) identified the following predisposing factors: (a)
baseline cognitive impairment, (b) severity of underlying illness, (c) vision impairment, and (d)
dehydration. Inouye demonstrated that patients who are highly vulnerable to delirium on

Delirium

34

admission may develop delirium with relatively benign precipitating factors. As the number of
predisposing factors increase, the likelihood of delirium increases.
Precipitating factors of delirium are potential causes that can lead to the development of
delirium during hospitalization. Potential precipitating factors include (a) four or more
medications added on admission; or (b) the use of physical restraints, or (c) the use of indwelling
bladder catheters; and (d) iatrogenic causes, such as complications from diagnostic procedures,
transfusion reactions, over coagulation, or digoxin toxicity; and (e) malnutrition.

Prevalence of Delirium
The prevalence of delirium in the general hospitalized patient ranges form 10 % to 30%.
In the hospitalized elderly patient the rate of delirium prevalence ranges from 10% to 40%.
Estimated rates of delirium for surgical patients vary widely, ranging from 6% to 52%. Delirium
has been reported in 10% to 15% of older general surgical patients and over 50% in patients
treated for hip fractures. One of every four patients over the age of 65 may become delirious
during a hospital stay. Fitzpatrick and Stevenson (1993) report the prevalence of delirium at
discharge at 29%.
Levkoff et al (1992) investigated the occurrence and prevalence of delirium in elderly
hospitalized patients. Delirium was present in 10.5% of all patients on admission; 31.3%
developed new-onset delirium; and 32 % of the participants also experienced individual
symptoms of delirium without meeting full criteria. Only 49% experienced complete resolution
of all symptoms before discharge, and only 20.8 % and 17.7%, respectively had resolution of all
symptoms by three and six months after discharge.

Delirium

35

Delirium is a major reason for nursing home placement. One half to three quarters of
elders in the long term care environments experience cognitive impairment. The cost of caring
for the delirious elderly in the community or long term care facilities for people over the age of
65, amounts to $40 billion per year. For many patients, transfer to a long-term care facility is
followed by progressive deterioration in cognitive and physical function, increased medical
illness, and decreased quality of life and life expectancy. The adverse consequences for the
health care system and for the society as a whole and increased costs are inappropriate resource
utilization.

Evaluation of Delirium
Although standard psychiatric, general medical, neurological histories and examinations
are usually sufficient to diagnose and evaluate the severity of delirium, they can be supplemented
by assessments using formal instruments. A large number of delirium assessment methods have
been designed and are intended for both clinical evaluation and research purposes.
The literature search reveals that there is considerable disagreement over how to best
assess delirium and whether a certain assessment tool is preferable for more accurate diagnosis
than another. The apparent disparity can most likely be attributed to the fact there are multiple
disciplines researching the delirium phenomenon.

Assessment Methods

Lnaba-Roland & Maricle (1992) and Dyer et al (1995) proposed that the mental status
interview is the gold standard for the diagnosis of delirium, and that the assessment must focus

Delirium

36

on the quality of cognitive. Affective, and behavioural function, and must include the quality of
the patient's arousal, Attention, Concentration, Orientation, thought content, and perceptual
alterations.
Smith, Breitbart, and Platt (1995), reviewed several instruments for the evaluation of
delirium including the NEECHAM Scale, the Confusion Assessment Method Instrument (CAM)
and Diagnostic Statistical Manual of Mental Disorders, Third Edition (DSM-III) scales. The
authors emphasize the necessity to select the most appropriate instrument based on
administration time, patient constraints, level of expertise and training available. And type of
information desired.

Documenting Delirium
Typically, poor documentation of delirium is found in patient charts, and usually no
documentation is found concerning attempts to assess or treat cognitive disturbances. When
documentation was found, restless patients had substantially more documentation completed
than non-restless patients. According to Lipowski (1983, 1990) recognition of the agitated patient
would account for only one of three types of confusion with the lethargic and mixed (alternating
between the agitated and lethargic mood) ignored.
Abnormal motor behaviour is often an early indication of the development of delirium.
Thus accurate documentation of motor behaviour is essential to the early identification of highrisk patients. Also, nurses rather than physicians are generally found to document this problem
more frequently. This is attributed to their closer interaction with patients.
The literature indicates that the type of terminology typically documented in medical
records to suggest the risk of delirium is vague, inadequate and does not clearly describe the

Delirium

37

syndrome, thereby perpetuating the potential to overlook high-risk patients for delirium. Shedd et
al (1995) described three studies in which the investigators found that nurses used combinations
of cognitive, behavioural, and verbal terms to describe and identify the patients.

Assessing and Diagnosing Delirium

As previously noted delirium has multiple causes and therefore patterns of clinical
manifestations, making assessment difficult. The difficulty of assessing delirium is due to the
fluctuating nature of the condition within one person across time and variable manifestations
across individuals. In two studies involving elderly medical patients, nurses were found to rely
solely on the level of orientation and alertness for their cognitive assessment. In several cases,
the nursing staffs were not aware that the patient was experiencing significant confusion until
notified by the research team. Without accurate assessment, effective treatment is hindered.
The onset of delirium frequently signals a worsening of the primary illness or a
complication of treatment. The syndrome is often the first sign that brain function is
compromised and can be either the prominent presenting feature of life-threatening physical
illness or a serious complication of disease or treatment. Failures to detect, diagnose, and treat
the underlying condition causing the delirium can result in permanent brain damage or death.
Consequently, early recognition and treatment of delirium and the primary disease can return the
elderly patient to pre-morbid function.
According to Levkoffand Marcantonio (1994) the key elements to diagnosing delirium
include a thorough history, knowledge of the patient's baseline mental status, physical
examination and awareness of mental status changes, followed by a thorough search for
correlation of contributing factors, The best way to manage delirium is through primary

Delirium
prevention and effective prevention requires the early identification of patients who are at risk
for delirium.

38

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39

CHAPTER 06: CONCLUSION

The literature search revealed that delirium in the hospitalized elderly patient is a
prevalent geriatric syndrome which is under recognized and under diagnosed. Misdiagnosis of
delirium often results in mismanagement and poor health outcomes, the older patient.
The literature review also demonstrated that delirium is a syndrome of multiple etiologies
with several predisposing and precipitating factors for its development. The literature also
revealed disagreement over how to best assess and diagnose delirium. The research revealed that
many delirium assessment tools have been developed, but that in many cases the tools are too
time consuming for acute care nurses to use, don't give a complete picture of the whole delirium
phenomena, don't address functional and cognitive behaviour, and were not specifically
developed for nursing professionals to use. In addition to addressing the predisposing and
precipitating risk factors for delirium, a more complete, comprehensive, and effective evaluation
of delirium, can be made by using the criteria established by the American Psychiatric
Association's DSM-III criteria for delirium.
This research project focused on a thorough, multifaceted chart review of the hospital
record, which incorporated an evaluation of the predisposing risk factors, the precipitating risk
factors, and the DSM-III criteria for identifying delirium in the hospitalized elderly patient.

Implications for Nursing

The results of this study clearly show that nurses need additional education on delirium to
correct their misconceptions and provide an accurate assessment to critically ill patients.
Education will give them the tools that they need and help them base their practice on evidence

Delirium

40

not tradition. The first step to take will be the education of current nurse educators. As educators
we have the responsibility to keep current with the newest evidence in nursing. Students are
completely dependent on their teachers to give them the most complete and up to date
information possible. An education program will need to be designed with the understanding of
current misconceptions and educational needs for todays nurses. This education must also
include a tool that is practical to use in the high-intensity environment of the ICU. Nurses must
have a tool that is easy to understand and use. The CAM-ICU has been widely used throughout
the world (Devlin et al, 2008). It is certainly worthy of consideration for any facility to
implement. Each facility will need to determine for themselves which is the best tool for their
hospital.
With the ageing population these issues will become even more important as our patients
will be older and more susceptible to cognitive issues. Delirium has been clearly shown to be a
more significant problem for the patient over 65 years of age. The impact of an increasing
number of older patients will have a tremendous effect on our health care system. Health care
costs increase every year, and are a concern for everyone in the United States. In 2008 2.2 trillion
dollars was spent in total national health care expenditures. These numbers are astounding. It is
understandable that are government is working toward health care reform when 21.8% of total
government expenditures are spent on health care. With the ageing of the population and rising
health care costs a perfect storm may result. If delirium is not assessed properly and
interventions done in a timely fashion then the costs for these patients will be devastating. Our
health care system may not recover from that type of insult. Nurses are in the best possible
position to make a positive impact on these patients. It is our responsibility as health care
professionals.

Delirium

41

The topic of delirium is a serious issue for hospitalized patients and assessment is only
the first step in treating this patient. Assessment was the focus of this study. Further studies are
needed to look at the best ways to educate nurses and to determine how this education of nurses
can impact patients. This study was limited by the small sample size.

Implications for Future Research

Delirium is a complex problem that is difficult for ICU nurses to assess properly. Nurses
will require extensive education and support to be able to care for these patients properly. The
results of this study highlight the need for further education on methods of delirium assessment,
frequency of assessment, and overcoming barriers to completing this assessment. The data
clearly shows the impact that delirium can have on the ICU patient. This information should
empower the nursing community to study this topic further and to develop strategies to assist the
bedside nurse to overcome barriers and develop techniques to improve outcomes for our patients.

Delirium

42

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Delirium

60

APPENDIX
Authors
Bruce J. Naughton MD,
Susan Saltzman ND,
Fadi Ramadan MD,
Noshi Chadha MD,
Roger Priore ScD,
Joseph M. Mylotte
MD, (2005)

Study Design
Pretest, posttest

Participants
Physicians and
nurses in the
emergency
department (ED)
and on an acute
geriatric unit
(AGU).

Milbrandt EB, Deppen

S, Harrison PL,
Shintani AK, Speroff T,
Stiles RA, Truman B,
Bernard GR, Dittus RS,
Ely EW. (2004)

Article Name
A
Multifactorial
Intervention to
Reduce
Prevalence of
Delirium and
Shorten
Hospital
Length of Stay
Costs
associated with
delirium in
mechanically
ventilated
patients

Prospective
cohort study

Patients were 275

consecutive
mechanically
ventilated medical
intensive care unit
patients.

Maria Lundstrm RN,

Agneta Edlund RN,

A
Multifactorial

Prospective
intervention

Four hundred
patients, aged 70

Study Method
Multifactorial and
targeted to the
processes of care
for cognitively
impaired and
delirious older
adults admitted to
medicine service
from the ED.
Examined patients
for delirium using
the Confusion
Assessment
Method for the
Intensive Care
Unit.

The intervention
consisted of staff

Results
A multifactorial
intervention designed to
reduce delirium in older
adults was associated with
improved psychotropic
medication use, less
delirium, and hospital
savings.
Higher severity and
duration of delirium were
associated with
incrementally greater costs
(all p <.001). After
adjustment for age,
comorbidity, severity of
illness, degree of organ
dysfunction, nosocomial
infection, hospital
mortality, and other
potential confounders,
delirium was associated
with 39% higher intensive
care unit (95% confidence
interval, 12-72%) and 31%
higher hospital (95%
confidence interval, 1-70%)
costs.
Delirium was equally
common on the day of

Delirium
Stig Karlsson RN,
Benny Brnnstrm RN,
Gsta Bucht MD,
Yngve Gustafson MD,
(2005)

Intervention
Program
Reduces the
Duration of
Delirium,
Length of
Hospitalization
, and Mortality
in Delirious
Patients

study

and older,
consecutively
admitted to an
intervention or a
control ward.

Robinson BR, Mueller

EW, Henson K,
Branson RD, Barsoum
S, Tsuei BJ. (2008)

An analgesiadeliriumsedation
protocol for
critically ill
trauma patients
reduces
ventilator days
and hospital
length of stay

Non randomised
patient study

A total of 143
patients were
included. Patients
who died during
their
hospitalization
were excluded
except in the
analysis of
ventilator-free
days at day 28.

61

education focusing admission at the two wards,

on the assessment, but fewer patients remained
prevention, and
delirious on Day 7 on the
treatment of
intervention ward
delirium and on
(n=19/63, 30.2% vs 37/62,
caregiver-patient
59.7%, P=.001). The mean
interaction.
length of hospital
Reorganization
staystandard deviation
from a taskwas significantly lower on
allocation care
the intervention ward then
system to a
on the control ward
patient-allocation (9.48.2 vs 13.412.3 days,
system with
P<.001) especially for the
individualized
delirious patients (10.88.3
care.
vs 20.517.2 days, P<.001).
Two delirious patients in
the intervention ward and
nine in the control ward
died during hospitalization
(P=.03).
Medications were
The median duration of
titrated to a RASS
mechanical ventilation in
of -1 to +1 and
the protocol group was 1.2
VAS/OPAS <4.
days (0.5-3.0) which was
Haloperidol was
significantly reduced
used to treat
compared with 3.2 days
delirium in CAM(1.0-12.9) in the control
ICU positive
group (p = 0.027). Analysis
patients.
of ventilator-free days at
Retrospective
day 28 found that the
review of the local
protocol group had 26.4
Project IMPACT
ventilator-free days (13.9database for a 627.4) compared with 22.8

Delirium
month period in
2004 was
compared with the
same seasonal
period in 2006 in
which the ADS
protocol was used.

Ely EW, Gautam S,

Margolin R, Francis J,
May L, Speroff T,
Truman B, Dittus R,
Bernard R, Inouye SK.
(2001)

The impact of
delirium in the
intensive care
unit on hospital
length of stay

A prospective
cohort study.

The study
population
consisted of 48
patients admitted
to the ICU, 24 of
whom received
mechanical
ventilation.

62

days (10.5-26.9) in the

control group (p = 0.007).
The median ICU length of
stay was 5.9 days (2.3-18.2)
in the control group and 4.1
days (2.5-8.3) in the
protocol group (p = 0.21).
Hospital length of stay was
12 days (7-17) in the
protocol group in contrast
to 18 days (10-27) in the
control group (p = 0.036).
Opiate equivalents and
propofol use per patient
was significantly reduced in
the protocol group from
2,465 mg (1,242 mg) to
1,641 mg (1,250 mg) and
19,232 mg (22,477 mg) to
10,057 (14,616 mg),
respectively (p < 0.001, p =
0.01).
All patients were The mean onset of delirium
evaluated for the
was 2.6 days (S.D.+/-1.7),
development and
and the mean duration was
persistence of
3.4+/-1.9 days. Of the 48
delirium on a daily
patients, 39 (81.3%)
basis by a geriatric developed delirium, and of
or psychiatric
these 29 (60.4%) developed
specialist with
the complication while still
expertise in
in the ICU. The duration of
delirium
delirium was associated
assessment using
with length of stay in the

Delirium

Wesley Ely, E. Ayumi

Shintani, Brenda
Truman, Theodore
Speroff, Sharon M.
Gordon, Frank E.
Harrell, Jr, Sharon K.
Inouye, Gordon R.
Bernard, Robert S.
Dittus, (2004)

Delirium as a
Predictor of
Mortality in
Mechanically
Ventilated
Patients in the
Intensive Care
Unit

Prospective
cohort study

63

the Diagnostic
ICU ( r=0.65, P=0.0001)
Statistical Manual and in the hospital ( r=0.68,
IV (DSM-IV)
P<0.0001). Using
criteria of the
multivariate analysis,
American
delirium was the strongest
Psychiatric
predictor of length of stay
Association, the
in the hospital ( P=0.006)
reference standard
even after adjusting for
for delirium
severity of illness, age,
ratings. Primary
gender, race, and days of
outcomes
benzodiazepine and
measured were
narcotic drug
length of stay in
administration.
the ICU and
hospital.
275 consecutive
Patients were
After adjusting for
mechanically
followed up for
covariates (including age,
ventilated patients
development of
severity of illness,
admitted to adult delirium over 2158 comorbid conditions, coma,
medical and
ICU days using
and use of sedatives or
coronary ICUs of
the Confusion
analgesic medications),
a US universityAssessment
delirium was independently
based medical
Method for the
associated with higher 6center between
ICU and the
month mortality (adjusted
February 2000 and
Richmond
hazard ratio [HR], 3.2; 95%
May 2001
Agitation-Sedation
confidence interval [CI],
Scale.
1.4-7.7; P = .008), and
longer hospital stay
(adjusted HR, 2.0; 95% CI,
1.4-3.0; P<.001). Delirium
in the ICU was also
independently associated
with a longer post-ICU stay

Delirium

Shehabi Y, Riker RR,

Bokesch PM,
Wisemandle W,
Shintani A, Ely EW;
SEDCOM (Safety and
Efficacy of
Dexmedetomidine
Compared With
Midazolam) Study
Group, (2010)

Delirium
duration and
mortality in
lightly sedated,
mechanically
ventilated
intensive care
patients

Prospective
cohort analysis.

Three hundred
fifty-four medical
and surgical
intensive care
patients enrolled
in the SEDCOM
(Safety and
Efficacy of
Dexmedetomidine
Compared with
Midazolam) trial
received a
sedative study
drug and
completed at least
one delirium
assessment.

Sedative drug
interruption and/or
titration to
maintain light
sedation with daily
arousal and
delirium
assessments up to
30 days of
mechanical
ventilation.

64

(adjusted HR, 1.6; 95% CI,

1.2-2.3; P = .009), fewer
median days alive and
without mechanical
ventilation (19
[interquartile range, 4-23]
vs 24 [19-26]; adjusted P
= .03), and a higher
incidence of cognitive
impairment at hospital
discharge (adjusted HR,
9.1; 95% CI, 2.3-35.3; P = .
002).
In multivariable analysis,
the duration of delirium
exhibited a nonlinear
relationship with mortality
(p=.02), with the strongest
association observed in the
early days of delirium. In
comparison to 0 days of
delirium, an independent
dose-response increase in
mortality was observed,
which increased from 1 day
of delirium (hazard ratio,
1.70; 95% confidence
interval, 1.27-2.29;
p<.001), 2 days of delirium
(hazard ratio, 2.69;
confidence interval, 1.584.57; p<.001), and 3 days
of delirium (hazard ratio,

Delirium

Hare, M., McGowan,

S., Wynaden, D.,
Speed, G.,
Landsborough, I.,
(2008)

Nurses
descriptions of
changes in
cognitive
function in the
acute care
setting

Four audits of
progress notes
were completed
over
a four week
period at a
Western
Australian
tertiary
hospital to
identify, quantify
and categorise
cognitive and
behavioural
changes in
hospitalised
patients.

The medical
records of all
patients identified
by nursing
staff as being
confused

This paper
describes data on
nurses
documentation
collected in the
course of those
audits. On four
consecutive
Thursdays,
the medical
records of all
patients identified
by nursing
staff as being
confused were
reviewed. Where
no
definitive cause
for the confusion
was documented,
the
case notes were
examined for
evidence of risk
factors to

65

3.37; confidence interval,

1.92-7.23; p<.001). Similar
independent relationships
were observed between
delirium duration and
ventilation time and
intensive care length of
stay.
A total of 1209 patients
were surveyed over the four
audit days with 183 patients
(15%) being identified as
confused. Confusion was
the most common
descriptor
used by nurses to describe
cognitive and behavioural
changes; in many cases it
was the only term used.
Many
of these changes were
indicative of delirium.
Little use by
any health professional of
cognitive screening tools
was
found.

Delirium

Truman B, Ely EW.

(2003)

Monitoring
delirium in
critically ill
patients. Using
the confusion
assessment
method for the
intensive care
unit

CAM-ICU

determine a
probable cause.
Confusion
Assessment
Method for the
Intensive Care
Unit

66

Currently, no drugs have

been approved by the Food
and Drug Administration
for the treatment of
delirium. The guidelines of
the Society of Critical Care
Medicine recommend
haloperidol for the
treatment of delirium,
though this
recommendation is based
on sparse outcomes data
from nonrandomized case
series and anecdotal reports
(i.e., level C data).
Haloperidol is a dopamine
sreceptor antagonist and
inhibits dopamine
neurotransmission. It is
used to treat positive
symptoms (e.g.,
hallucinations, unstructured
thought patterns) and often
results in a sedative effect
(may lead to hypoactive
delirium).