ati video case study dementia and delirium

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Case report

Delirium superimposed on dementia precipitated by an unexpected bladder tumour, caio redknap.

NELFT, Rainham, UK

Daniel Kaitiff

A patient in her 70s presented with confusion, agitation and psychotic symptoms. No cause was found until the incidental discovery of urothelial carcinoma. Upon removal of the tumour, the psychiatric symptoms largely improved leaving residual symptoms indicative of dementia. The patient had not been diagnosed with dementia previously and this made for an interesting disease presentation and progression. We discuss the challenges of diagnosing delirium and dementia in complex patients such as these and the importance of identifying a cause when cognition has been impaired by a suspected delirium.

Delirium is a common and alarming condition. 1 When it affects patients who have dementia, this may be even more apparent. 2 3 The cause of delirium may not always be obvious, especially for those in a premorbid state; furthermore, not all patients with delirium are acutely medically ill, hospitalised or bed-bound. There is a complex web of potential contributing factors, and identifying a cause should be a priority when cognition has been impaired. This should take place by means of considerable mandatory physical and mental health reviews, especially in patients who are not improving on current treatment pathways. Failure to do this can not only affect patients’ experience but their overall mortality rates. 3

Case presentation

A patient in her 70s was admitted under Section 2 of the Mental Health Act to an older adult inpatient ward after the home treatment team reported worsening forgetfulness, self-neglect, weight loss and non-compliance to medication. Suicidal ideation was also noted.

She had a 4-year history of depression/anxiety which was being treated with venlafaxine and recent addition of mirtazapine. The family reported acute confusion beginning 4 weeks prior to admission, with a 6-month-long decline leading up to this. There was no remarkable family psychiatric history and her only physical health issue was possible subclinical hyperthyroidism.

On admission, she was found to be confused, disorientated, restless and incoherent, pacing up and down the corridors of the ward. She also displayed obsessions and delusions involving animals and pets, particularly dogs and puppies.

Blood tests were unremarkable; she was not anaemic (haemoglobin, 120 g/L) and inflammatory markers were within normal ranges (white cell count, 8.5×10 9 /L and C reactive protein (CRP), 2 mg/L). Urea and electrolytes, liver function test, bone studies, B12 and folate tests were also within normal ranges. Urinalysis returned as negative for leukocytes, nitrites, ketones, bilirubin and glucose. Additionally, a physical examination and an ECG yielded no abnormalities.

Shortly after the admission, we were able to ascertain (through collateral history taking) that the patient was dependent on diazepam, and had been taking this regularly at home for a period; diazepam was therefore prescribed with the aim of treating this presentation as a delirium related to benzodiazepine withdrawal. Two weeks after admission however, fluctuating confusion persisted, and we had seen no real improvement with no obvious explanation for these symptoms. Formal cognitive testing had proven difficult, with the patient becoming distracted by visual hallucinations before becoming agitated. A CT head report did not indicate dementia, and we continued to query whether this was a resolving delirium; however, no other causes were apparent at this point. Blood test parameters including inflammatory markers remained within normal ranges, and thyroid function tests showed a low thyroid-stimulating hormone (0.08 mU/L) but a free thyroxine of 11.5 pmol/L and a free triiodothyronine of 4.0 pmol/L (both within normal ranges). Additionally, a blood test for N -methyl-D-aspartate receptor antibodies returned as negative and the level of voltage-gated potassium channel antibody was <1 pmol/L. The patient’s thyroid status was discussed with the medical team, who agreed that it was not affecting her mental state and did not require immediate treatment.

She had also been experiencing persistent leg swelling on the ward, which was now being treated with furosemide (this was started by the geriatric medicine consultant who had also been reviewing the patient). Despite this, the swelling had now become quite marked, and negative ultrasound scans of the venous system in the legs prompted further investigation with an abdominal/pelvis ultrasound. This scan took place and revealed an incidental finding: an unexpected vascular lesion was reported on the right posterior wall of the bladder, highly suspicious of a bladder transitional cell carcinoma) and measuring 26×13×20 mm.

The case was discussed in a urology multidisciplinary team meeting which in turn prompted referral for a general anaesthetic cystoscopy±transurethral resection of bladder tumour (TURBT). At this time, the patient lacked the capacity to consent for this procedure, however, it was noted that it would be overwhelmingly in her best interests to go ahead with it. Further to this, the procedure was relatively short and a day case. By this time, the only significant biochemical derangement was an isolated rise in CRP (74 mg/L).

While waiting for this urological intervention, the patient was started on a small dose of memantine (5 mg), which was increased to 10 mg shortly after. At this point, increased agitation had been noted, with the patient refusing observations and pacing around the ward, visually hallucinating, failing to comply with radiological procedures, and displaying violence towards staff. She was started on carbamazepine as a result and later her memantine dose was increased to 15 mg.

Meanwhile, the previous CT head was re-reported. It was now deemed to show a moderate burden of chronic microangiopathic changes, as well as evidence of brain atrophy (with frontal lobe predominance); findings possibly suggestive with a degree of mixed dementia.

Surgery then occurred, with no complications (TURBT procedure with removal of tumour). The patient was seen in the surgical ward after surgery; now mobilising, comfortable, confused but not agitated. Pathology results showed a papillary urothelial carcinoma (TNM staging G1 pTa).

Over the next few weeks, the patient became calmer and more settled and was now sleeping and eating well, as well as putting on weight. She also exhibited improved compliance and cooperativity with all care including medication administration. Her memantine dose was increased again to 20 mg and within a month we were planning discharge and placement in a care home.

Outcome and follow-up

The delirium-like symptoms resolved after surgery, leaving a degree of derangement consistent with the progression of a more chronic, underlying dementia. At the time of discharge, the patient had regained a significant degree of functionality with no further hallucinations and significantly less agitation and anxiety; however, cognition remained partly impaired with some ongoing confusion and memory loss. She also remained partially dependent for some instrumental activities of daily living (I ADLs), necessitating placement in residential care.

Further follow-up in the community will allow observation of any further improvements, as well as providing an opportunity to perform detailed cognitive testing and to review her ongoing need for medications including the carbamazepine that was started. Her diagnoses at discharge were dementia in Alzheimer’s disease (atypical or mixed type) and her pre-existing mixed anxiety and depressive disorder.

This was an interesting case, due to the relatively incidental presentation of the tumour in the bladder, the improvement of psychiatric symptoms on its removal, and the interaction seen between acute and chronic symptoms. We interpreted this case as a delirium overlying the first presentation of dementia—that is, delirium superimposed on dementia (DSD). A range of new psychiatric symptoms were identified on admission, which then improved on the excision of cancer, leaving a selection of residual symptoms indicative of dementia. On reflection, a likely underlying aetiology may have been a recurrent urinary infection that had evaded our detection, which was associated with the bladder tumour. Other undetected cancer-related factors may have also contributed.

The patient had not been diagnosed with dementia previously and this made for an interesting disease presentation and progression. It also presented obvious clinical difficulties in which waiting for the correct diagnosis and treatment prolonged the stay of this patient on the psychiatric ward. We entered a quagmire with regards to correct treatment plans, especially as the head scan had not initially been correctly reported, alongside unremarkable investigative tests for delirium and little in terms of a progressive history of memory loss.

Delirium has been neatly described as ‘acute brain failure’, 3 and may be caused by inflammation or biochemical abnormalities, as well as other cancer-related factors such as circulating cancer byproducts and proinflammatory cytokines. 4 Other potentially contributing factors include dehydration, electrolyte/metabolic abnormalities, haematological derangement, infection and benzodiazepine withdrawal.

The following quote from a report published in the Lancet in 2014 summarises how delirium and dementia can be intertwined, and it is particularly relevant to this case: ‘ There is little doubt that occurrence of an episode of delirium can signal vulnerability of the brain with decreased cognitive reserve and increased risk for future dementia. In some cases, delirium may bring previously unrecognised cognitive impairment to medical attention ’. 3

A systematic review has shown that delirium has an incidence of 22%–89% in patients >65 years old with dementia. 5 The simultaneous occurrence of both is associated with increased rates of mortality, institutionalisation and cognitive decline, compared with in isolated dementia. 3 On a more short-term-focused note, research has shown that patients who have experienced DSD can often remember being confused, and find the experience to be distressing 6 ; this emphasises its immediate effect on the patient experience.

As previously mentioned, there is an obvious dilemma in diagnosing dementia in a patient with a limited medical history, a presentation suggestive of delirium and a head scan which was initially reported as being clear. Informing the family of the not-so-straightforward diagnosis also came with its challenges. With the number of older adult psychiatric hospital beds having been cut over the years, 7 a patient of this nature can introduce complications for services, with the above difficulties and consideration of treatment time periods leading to an extended admission.

For these vulnerable and complex patients who present with both delirium and dementia, cognitive recovery may take longer. 8 Further amelioration of symptoms may be observed during post-discharge follow-up; ultimately however, the risks of prolonged hospitalisation, re-hospitalisation and premature nursing home placement are greater in this group. 9 This case serves as a prime example, where a patient who had previously lived at home was discharged to a care home, and we must question whether factors such as earlier intervention can help avoid these types of placement.

This case highlights some imperative and applicable lessons that are relevant to all fields of medical and surgical care. It emphasises the importance of detecting delirium and dementia in patients, differentiating between them and treating them appropriately. Patients with dementia are already increasingly susceptible to developing delirium, and therefore minor, more inconspicuous changes in pathology may precipitate its occurrence more easily than expected. 3 All patients presenting with features of delirium should have a robust workup on admission including a thorough clinical history/collateral history, a physical examination and a full set of investigative tests, as well as the use of validated assessment tools such as the 4AT (4 A’s Test) or CAM (Confusion Assessment Method). 10–12

The interaction between dementia and delirium can be challenging to manage, and attention has been drawn recently to the difficulties associated with diagnosing and assessing DSD using the frameworks currently in place. 2 13 At times, it can be hard to differentiate between these two conditions and one should take a very careful history when questioning the presentation and progression. This can be practically challenging at times, particularly if the patient is acutely confused or agitated and comes with a minimal collateral history. A failure to improve clinically should be a strong indicator for revisiting the medical history and considering other elements of investigation or diagnosis.

Learning points

• Delirium is common in patients with dementia and is associated with increased rates of mortality, institutionalisation and cognitive decline.
• Delirium has an expansive range of potential underlying aetiologies.
• Identifying a cause should be a priority in patients with delirium.
• Failure to treat cases like these promptly leads to adverse outcomes for both patients and services.

Contributors: CR and DK: involved with all stages of the process, including the conception, planning, writing, reporting and interpretation of the case report.

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

Patient consent for publication: Obtained.

When up is down: Delirium superimposed on dementia

Distinguishing between the two conditions can help ensure prompt and appropriate treatment..

Learning Objectives

• Describe how to differentiate delirium and dementia and assess for delirium superimposed on dementia (DSD).
• Discuss risk factors for DSD and the three subtypes.
• Describe how to prevent DSD and manage individuals with the condition.

The authors and planners of this CNE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity. See the last page of the article to learn how to earn CNE credit.

• Delirium superimposed on dementia (DSD) occurs in 89% of older hospitalized adults.
• Avoid medications with high anticholinergic burden and antipsychotics.
• Reduced DSD-related mortality requires early recognition and treatment of the underlying cause.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) describes delirium occurring in patients with Alzheimer’s disease and Alzheimer’s disease–related dementias (AD/ ADRDs) as delirium superimposed on dementia (DSD) and delirium superimposed on Alz­heimer’s disease. Although delirium and dementia have distinctly different causes and presentations, clinicians (including bedside and advanced practice nurses) may have difficulty distinguishing between the two when they occur simultaneously, especially when the clinicians don’t know the patient’s baseline cognitive status.

Differentiating delirium and dementia

Up to 89% of older adults experience delirium, an acute neuropsychiatric syndrome and clinical emergency that requires acute care. The condition frequently goes unrecognized in individuals with dementia. Delirium, a potentially reversible acute state, is characterized by abrupt changes from baseline. Patients may experience acute mental status changes, neuropsychiatric symptoms, and psychomotor dysfunction with onset within hours or days.

In contrast, the umbrella term dementia refers to several chronic neurocognitive syndromes that cause progressive neurodegenerative changes in one or more neurocognitive domains, including language, learning and memory, social cognition, complex attention, executive function, and perceptual–motor function. As dementia progresses, some patients develop neuropsychiatric symptoms that mimic delirium, but are substantially worsened by acute medical or physiologic changes. Delirium should be ruled out in the event of acute onset of neuropsychiatric symptoms, such as hallucinations, delusions, aggression, and sleep disturbances.

These behavioral and psychological symptoms of dementia also mimic the hallucinations and delusions common with delirium and might intensify in DSD. Notably, those with Lewy body dementia may experience the same symptoms as DSD (fluctuating course, inattention, sleep disturbances) and other neuropsychiatric symptoms (vivid visual hallucinations). These symptoms may worsen over weeks or months, which differentiates DSD from Lewy body dementia.

Most skilled professionals find DSD difficult to recognize and clinically challenging because of its presentation complexity and the lack of standardized diagnostic criteria that separate dementia characteristics from the delirium assessment. ( See Delirium vs. dementia. )

DSD risk factors

Risk factors for DSD include a medical history of or acute onset of some medical conditions (for example, systemic or local infection [urinary tract or pressure injury infection], electrolyte disturbances, heart failure, coronary artery disease, stroke, or an acute exacerbation of pulmonary disease). Geriatric syndromes that may precipitate DSD include polypharmacy, depression, fecal impaction, pain, and sleep deprivation. Prescription and over-the-counter medications with high anticholinergic properties, sedatives, some calcium channel and beta antagonists, and psychotropics may cause or worsen delirium. Stressors associated with medical procedures, surgeries, or any related complications also increase the risk for DSD. Missed opportunities for prevention and early recognition compound the risk for poor outcomes, potentially life-threatening complications, and delirium-associated high mortality rates.

DSD subtypes

Knowing delirium subtypes (hypoactive, hyperactive, and mixed) can aid the initial diagnosis and help document progress in symptom resolution. Subtypes can fluctuate significantly, so perform assessments more than once daily and compare them across the previous 24 hours. Consider using the Richmond Agitation and Sedation Scale (RASS) to help identify subtypes.

Hypoactive DSD

Hypoactive DSD is characterized by one or more of the following characteristics: change within the past 24 hours with slowing or lack of movement, paucity of speech with or without prompting, difficulty arousing without auditory or tactile stimuli, or decreased responsiveness.

Case study: Charles, a 70-year-old man with a recent diagnosis of early-stage dementia, is admitted to the hospital after a fall at home. While in the emergency department (ED), he interacts appropriately with healthcare pro­viders and nursing staff. Charles is oriented and cooperates with his care plan. Twelve hours after admission, he demonstrates inattention during conversations, frequently withdrawing and responding only partially to questions.

The nurse notices from the hand-off report that Charles is experiencing an acute change in cognition from his baseline. He can’t recite the days of the week backwards and is unable to recall life events from long-term memory. Charles’ RASS assessment scale is -2. The nurse contacts the healthcare provider to report an acute change in awareness, attention, and arousal indicative of DSD. The provider completes a delirium workup and identifies a metabolic disturbance. The hypoactive DSD resolves within 24 hours after correcting the disturbance.

Hyperactive DSD

Features of hyperactive DSD range from simple restlessness to constant movement, agitation, or combativeness. Visual and perceptual disturbances (hallucinations and delusions) may become more frequent and severe. Nurses are more likely to identify hyperactive DSD as a result of the interference it creates when providing care.

Case study: Mary, an 85-year-old woman with a medical history of moderate AD/ADRD, is admitted to the hospital with dehydration and an unstageable pressure injury of her coccyx. Three days after admission, Mary shows clinical improvement with a positive response to her plan of care, but the nurse notices an acute change in her behavior. In the past 24 hours, Mary is combative during care, hyperalert, experiencing new visual hallucinations, and inattentive. Her RASS score is +4 (combative).

The chart review shows that Mary had several new incontinent voiding episodes and poorly controlled pain. The nurses’ assessment indicates new suprapubic tenderness, and lab findings reveal a urinary tract infection. With antibiotic treatment and pain medication adjustments, Mary’s hallucinations, inattention, and arousal improve over the next 48 hours.

Mixed DSD manifests as flucuating delirium with RASS scores ranging from positive values (agitation, combative) to negative values (le­thar­gic, stuporous) over 24 to 48 hours. The patient may be difficult to arouse in the morning but develops agitation and combativeness that night.

Case study: Jason, a 75-year-old man with a history of mid-stage AD/ADRD, arrives in the ED with an acute alteration in mental status and abdominal pain. His wife reports changes in mental status over the past 24 hours, which varied from confusion, disorientation, persistent sleepiness, restlessness, and agitation at night (RASS +4) to lethargy in the morning (RASS -2) with inattention not consistent with his baseline cognition.

A thorough assessment indicates a fecal impaction and fluid volume depletion. Over the next 48 hours, after the fecal impaction is removed and Jason receives I.V. fluids for 24 hours, his fluctuating mental status improves. Looking back at the electronic health record (EHR) for the past 24 hours can help prevent falsely attributing this subtype to a patient’s dementia.

The DSM-5, the gold standard reference for delirium diagnostic criteria, doesn’t include robust guidance for DSD. In the delirium section, the DSM-5 notes that the acute onset and temporal course of delirium can be difficult to ascertain in older adults with prior neurocognitive disorders or AD/ADRD. In the neurocognitive disorders section, the DSM-5 addresses the variation in the course of AD/ADRD subtypes where the possibility of DSD should be considered. If healthcare professionals follow the DSM-5 criteria to consider delirium only when an acute onset or fluctuation from a pre-existing neurocognitive disorder occurs, they may not attribute changes in level of arousal, new onset of neuropsychiatric symptoms, or inattention to possible DSD.

To prevent misinterpretation, the DSM-5 delirium diagnostic criteria include a provision that the patient must have an additional acute (days to weeks) disturbance in cognition different from their baseline. Clinicians can determine a patient’s baseline cognition using collateral sources, ideally someone with intact cognition who knows the individual well. When in doubt, nurses and providers in acute care settings may consider consulting with a geriatric psychiatrist or a geriatrician. ( See Delirium: Diagnostic criteria. )

Delirium: Diagnostic criteria

Diagnostic criteria for delirium include acute onset and disturbance in attention and arousal with an additional disturbance in one or more areas of cognition—memory, orientation, language, visual–spatial ability, and perception. An impaired state of arousal is a cardinal indicator for delirium, as is an acute change or reduction in awareness of one’s orientation to environment and attention. Changes in arousal include all states of altered arousal (except coma) in the continuum of delirium, from hyperarousal to stupor.

DSD triad assessment

DSD characteristics differ from delirium without dementia. The distinguishing features between behavior and psychological symptoms of dementia vs. DSD may be the acute onset and identification of causative triggers for cognition and function changes. Early engagement of formal or informal primary caregivers can help establish an accurate baseline cognitive assessment and prompt DSD diagnosis. Reliable DSD assessment reduces the need for medications and restraints that may result in injury to self or others and worsen DSD severity and duration.

An appropriate assessment of the DSD triad (Awareness, Arousal, and Attention) is key to early recognition and identification of the underlying causes. Long-term memory is preserved in AD/ADRD, so a brief conversation about social history (or other relevant topic) adds critical subjective data to the diagnostic criteria. However, levels of disturbance in arousal, awareness, and impairments in multiple cognitive domains are significantly more severe in patients with DSD. Disorganized thinking and lack of awareness may be a preexisting loss resulting from AD/ADRD neurocognitive deficits, so early conversations with primary caregivers can help identify cognitive changes from baseline.

Psychomotor retardation and inability to make or maintain eye contact, sustain posture, or communicate may be relevant awareness assessment findings in those with moderate-to-severe dementia. Use attention tests (such as naming the days of the week backwards) that don’t require executive function and accommodate those with hearing impairment. In those with late-moderate to advanced dementia, observe eye opening, eye contact, patient posture, movement, and communication using the Observational Scale of Level of Arousal. ( See Assess, collaborate, engage. )

DSD can result from systemic illness, dehydration, medications (such as antipsychotics), pain, and sensory deprivation.

Systemic illness

Older adults experience immunosenescence, a gradual age-related deterioration of the immune system, which makes fever and elevated white blood cell counts poor indicators of acute illness. Although not causative, a correlation exists between the presence of urinary catheters and delirium prevalence. Fecal impaction and urinary retention also may cause delirium symptoms.

A thorough nursing assessment can help the provider narrow their differential diagnosis for potential causes of DSD, which might include a typical infection, medication changes, or dehydration. Atypical causes include myocardial infarction (particularly in those with diabetes who may not experience typical symptoms), acute pulmonary conditions, or poor glycemic control (individuals with DSD are at higher risk of hypoglycemia and hyperosmolality).

Dehydration

Older adults have a decreased thirst drive and are sensitive to fluid imbalances. Monitor intake and output, encourage oral fluids, and check I.V. rehydration to maintain fluid balance and avoid fluid overload. Identifying and encouraging oral fluids of preference to maintain hydration frequently is sufficient.

Medications

Medications, both those started and stopped, have the potential to precipitate DSD. Inadvertently discontinued medications, including significant opioid dosage reductions, may exacerbate pain or lead to withdrawal symptoms. High-risk medications known to increase DSD risk include opioids, psychoactive agents, antipsychotic medications in hypoactive DSD, and medications known to have a high anticholinergic burden such as diphenhydramine and amitriptyline.

Choose non-opioid medications when possible for patients with AD/ADRD; opioids may cause delirium, especially in opioid-naïve patients. Use calcium channel blockers and beta antagonists with caution as they’ve been linked to increased delirium risk. Avoid initiating cholinesterase inhibitors to prevent or treat DSD postoperatively, and don’t use benzodiazepines for agitation associated with AD/ADRD or hyperactive DSD. Melatonin, a neurotransmitter that improves circadian rhythms, has shown promise in reducing delirium incidence, but it’s not currently recommended as an evidence-based treatment.

Current evidence doesn’t support routine use of typical (first generation) or atypical antipsychotics to prevent or treat DSD. First-generation antipsychotics, as well as risperidone, have higher anticholinergic burdens that may worsen DSD. All antipsychotics have black box warnings for use in AD/ADRD because of increased risk of stroke, myocardial infarction, and death. If used, providers should seek and document risk–benefit conversations, including verbal consent for use from the patient’s responsible party. Consider monitoring for corrected QT (QTc) intervals.

Older adults with more advanced dementia may be unable to articulate pain, which predisposes them to DSD. Use self-report in combination with observation to provide the most reliable pain assessment. Assess for six behavioral domains—facial expression, vocalization, and body movement, as well as changes in interpersonal interactions, activity routine, and mental status. Preferred observational pain assessment tools for all stages of dementia include the Pain Assessment in Advanced Dementia (PAINAD) Scale and the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC).

The five-item PAINAD scale measures breathing, negative vocalizations, facial expression, body language, and consolability in individuals with advanced dementia. Rate each behavior on a scale of 0 to 2, where 0 represents normal functioning and 2 represents behaviors suspected of indicating pain (noisy labored breathing, loud moaning or groaning, facial grimacing, rigidity, or inconsolability).

Complete the PACSLAC based on observations of the patient during activity or movement (such as transferring out of bed or walking). This screening tool assesses individualized responses over time, so the current score is compared to the previous score. An increased score suggests a likely increase in pain; a lower score indicates decreased pain.

Sensory deprivation

Patients with vision or hearing impairments should wear their glasses and hearing aids as much as possible. If patients with DSD have hearing impairment but don’t have a hearing aid, use a pocket amplifier to improve communication. Identify and allow one designated family member at the bedside for social engagement and to reduce sensory deprivation. Lack of sleep also may trigger DSD. Ask the patient or a family member about personal preferences for sensory engagement activities and sleep routines.

Nonpharmacologic nursing interventions

Maintain a high index of suspicion for DSD in patients with a history of dementia and implement nonpharmacologic nursing interventions to help reduce its incidence and prev­alence. Effective nonpharmacologic interventions include establishing and maintaining the patient’s sleep regimen and routine, ensuring they wear eyeglasses and hearing aids as needed, assisting with feeding and hydration if indicated, promoting early mobilization with reduced time in bed, providing patient-centered engagement, and educating family members about delirium.

Your primary goals include identifying and managing causative factors as soon as possible and maintaining safety precautions. In acute care and long-term facilities, that includes hourly rounding, frequent toileting, assisting with ambulation, encouraging family presence, and avoiding restraints.

Safeguard vulnerable patients

Early recognition and communication are key to DSD identification and treatment. Communicating with the healthcare team will prompt further assessments for treatable causes, and conversations with formal or informal primary caregivers can help determine the patient’s baseline cognitive status. These critical source reports can come from a family caregiver, primary care provider, a nurse, or the EHR.

Avoiding increased morbidity, discharge to higher levels of care, and death in hospitalized patients with dementia requires that nurses have a high index of suspicion for DSD. Nurses serve as the first line of defense against DSD and have the best opportunity to safeguard these vulnerable patients using evidence-based interventions.

Candace C. Harrington is an assistant professor and gerontology NP professor at the University of Louisville School of Nursing in Louisville, Kentucky. Ardis M. Roederer is an acute care NP at Central Baptist Hospital in Lexington, Kentucky. Hope K. Eppley is a recent doctor of nursing practice graduate from the University of Louisville School of Nursing family NP track. Pamela Z. Cacchione is a professor of geropsychiatric nursing and Ralston Endowed Term Chair in Gerontological Nursing at the University of Pennsylvania School of Nursing in Philadelphia, a nurse Scientist at the Penn Presbyterian Medical Center, and a senior fellow at the Leonard Davis Institute of Health Care Economics University of Pennsylvania.

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American Nurse Journal 2022; 17 (11). Doi: 10.51256/ANJ112206

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The management of delirium in the older adult in advanced nursing practice

Registered Advanced Nurse Practitioner, Older Adult Care, Cherry Orchard Hospital and Dublin South Kildare and West Wicklow Community Healthcare Area, Dublin, Ireland

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Eileen Furlong

Associate Professor in Nursing, School of Nursing, Midwifery and Health Systems, University College Dublin. Ireland

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Delirium is a term used to describe an array of symptoms that indicate a disruption in cerebral metabolism, a condition that is often under-recognised, leading to delayed interventions. The condition is a common cause of older adults presenting in hospital, with significant morbidity and mortality associated with increased length of stay. A case study is used to illustrate the use of a diagnostic algorithm for older adults presenting with delirium to an advanced nurse practitioner (ANP)-led service. The clinical decision pathway provides four differential diagnoses, using the case study to put the decision-making process in context. The article demonstrates the ability of the ANP to practise at a high level of expertise as an autonomous practitioner and shows how the pathway supports the nurse to reach an accurate diagnosis. It shows that prompt and accurate diagnosis of delirium in older adults is crucial to avoiding the complications and cognitive decline associated with the condition.

Research shows that delirium, independent of age, dementia, illness severity and functional status, predicts multiple adverse outcomes for older adults, including morbidity and mortality, alongside increased length of hospital stay ( Pendlebury et al, 2015 ; Welch et al, 2019 ). For the advanced nurse practitioner (ANP) evidence-based practice (EBP) is paramount to providing the best possible care outcomes for the older adult.

This article sets out a logical approach to obtaining a comprehensive clinical history using the most effective clinical screening tools to provide accurate diagnosis of delirium in the older adult. It presents a short case study that is followed by the application of a diagnostic algorithm, to illustrate the role of the ANP. Algorithms are typically developed from evidence-based clinical guidelines and facilitate the transfer of research to practice, providing nurses with as step-by-step approach to make effective decisions ( Jablonski et al, 2011 )

The context for this older adult care service is a newly established ANP role in the Republic of Ireland. The ANP older adult care service is based in community settings, where independent ANP clinics are held with direct referral from acute hospital and community primary care teams, providing early supportive discharge from acute care. The ANP also facilitates an outreach service to residential units and undertakes home visits within Health Service Executive (HSE) areas that support reduced waiting times and hospital avoidance by enabling older adults to remain at home for treatment ( National Clinical Programme for Older People, 2019 ).

The ANP role encompasses knowledge, skills and competence to enable holistic patient assessment, along with the ability to capture, analyse and interpret patient information. These attributes are key to the assessment and diagnostic process, and demonstrate accountability and responsibility to the older adult ( Nursing and Midwifery Board of Ireland (NMBI), 2017 ).

Delirium is broadly described as a neuropsychiatric disorder of cognition, attention, consciousness or perception ( Maldonado, 2018 ). These symptoms generally develop over a short period and can fluctuate from hours to days as a result of precipitating and predisposing factors. The condition is classified into three subtypes: hyperactive, hypoactive and mixed ( Table 1 ). Categorisation relies on clinical presentation inclusive of psychomotor features and is associated with increased morbidity, mortality and increased length of hospital stay. Approximately 40% of older adults admitted to hospital have a diagnosis of delirium ( Han et al, 2010 ; Ahmed et al, 2014 ). The differential diagnosis for delirium is broad and often multifactorial ( Lorenzl et al, 2012 ; Maldonado, 2018 ). The use of an algorithm that provides a diagnostic pathway for four frequently presenting differential diagnoses of delirium in the older adult offers a systematic approach to accurate diagnosis. A case study is used to illustrate the application of an algorithm.

Source: van Velthuijsen, et al, 2018

Bob (not his real name), who is 84 years old, resides in a long-term care (LTC) residential facility. He is a bachelor and had worked as a builder on construction sites. Before moving into LTC, he lived alone and has a long history of smoking, alcohol excess and poor diet, resulting in raised cholesterol and subsequent atherosclerosis. His speech is clear, and he communicates appropriately in short, clear sentences with limited distraction such as environment and noise. He has many siblings who visit regularly and provide him with a good support network. His past medical and surgical history includes left carotid endarterectomy and dementia of Lewy body type, with associated cognitive deficits.

Bob had no diagnosed respiratory condition; however, on occasion he became breathless. When this occurred, he received oxygen therapy via nasal prongs which is documented in his advanced care plan ( Aasmul et al, 2018 ). Studies ( Wang et al, 2015 ; Armstrong and Weintraub, 2016 ) suggest that individuals with Lewy body dementia who are on antipsychotic medications can have adverse reactions; subsequent prescribing should be progressed with caution following careful consideration, including the risk benefit ratio. In Bob's case his previous presenting symptoms required prescription of quetiapine at low doses. While research in this area remains clinically debated, quetiapine has been shown to have the least adverse effects and is therefore the safest medication to use with this dementia type ( Fox et al, 2019 ; Hershey et al, 2019 ). Bob's prescribed medications prior to and following his hospital assessment and treatment decision are listed in Table 2 . This information was used to assist in building up the clinical picture and provide indicators for potential causes of delirium.

His comorbidities included type 2 diabetes mellitus, atherosclerosis, constipation and gout. More recently, Bob had been diagnosed with a 6.3 cm non-ruptured infrarenal abdominal aortic aneurysm located in the maximal axial diameter of the aorta. Following this diagnosis, Bob and his family met with the medical team and a decision was made to proceed with non-interventional treatment. Bob was transferred back to the residential setting and commenced on oral paracetamol 1 g three times a day, with a further 1 g dose as needed to alleviate his-left flank discomfort.

Three weeks later, Bob presented with confusion, limited attention span and disorganised thinking. On observation, he was restless and pacing the unit; staff reported that he was not sleeping well. On further assessment, Bob's vital signs were recorded as: blood pressure 140/80 mmHg; heart rate 98 beats per minute; respiratory rate 18 breaths per minute, temperature 37.6°C, oxygen saturation 97% in room air. His pain score was 17/30, category 4, according to the Carey (2018) pain tool, which was developed in Ireland for the residential setting; it incorporates behaviours and numeric values, including self-report. In Bob's case, only behaviour observation was recorded: the score of 17/30 indicated severe pain and required intramuscular tramadol 100 mg for relief. Full blood tests requested including full blood count (FBC), renal, liver and bone profile, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), vitamin B 12 and folate levels, blood glucose, arterial blood gases and a chest X-ray, which were undertaken in the residential facility. A head-to-toe physical examination raised a range of red flags including acute pain, distended abdomen with guarding of the left flank, pale bilateral conjunctive and mucous membranes, headache, reduced skin turgor, restlessness and an altered sleep-wake cycle. Bob had one episode of syncope and a drop in blood pressure caused by dehydration.

Differential diagnosis is essential to assist the practitioner in formulating an accurate diagnosis. Diseases often present with similar symptoms, so the practitioner will apply clinical reasoning to narrow down the differential diagnosis ( Reinoso et al, 2018 ; Rhoads and Murphy Jensen, 2015 ). The differentials in the case of the patient, Bob, are illustrated in Figure 1 , along with the red flags that presented on examination by the ANP. The blood results revealed elevated serum creatinine and blood urea nitrogen, low sodium, low fasting blood sugar and elevated ammonia, ESR and CRP; all other results were unremarkable. Following a comprehensive assessment and full review of symptoms using an evidenced-based clinical decision-making process, the ANP diagnosed hyperactive delirium with marked behaviour changes, increased pain levels, constipation and dehydration. The areas outlined were of concern and intervention was required to manage and treat the symptoms, as shown in Figure 2 .

Following his diagnosis in the acute setting Bob was prescribed oxycodone 5 mg orally three times a day by the palliative care team prior to discharge to the residential facility. The cause of the acute pain was identified as constipation, most likely related to pressure on the bowel and the abdominal aortic aneurysm. No further diagnostic testing was advised in accordance with Bob's advanced care plan. Fluid intake was set according to his typical daily intake and laxatives were required to manage constipation. Subcutaneous or intravenous fluids were not considered with reference to his advanced care plan. Bob's only wish was to have adequate pain relief. To achieve these outcomes a person-centred care approach is vital and should include alleviating possible anxiety experienced by Bob ( National Institute for Health and Care Excellence (NICE), 2019 ). His overall care was managed by the ANP with multidisciplinary team collaboration.

In this patient's case, his delirium was superimposing on his dementia. Prompt and accurate diagnosis was achieved, allowing for the most appropriate intervention with the least adverse effects, by avoiding lengthy cognitive and functional decline (see Figure 1 ). The advanced care plan was completed with Bob, which was paramount to avoid acute hospital admission and allowed for multicomponent approaches that were person-centred and provided in a familiar environment ( Martinez et al, 2015 ). Furthermore, advanced care planning allowed Bob and his family to plan care that was consistent with his personal values and preferences ( Aasmul et al. 2018 ). To ensure successful care planning, staff received education specific to delirium and its precipitating and predisposing factors to support early intervention and minimise the effects of future episodes if these presented ( Colomer and Vries, 2016 ). Professional knowledge and decision-making are central to the ANP's scope of practice, underpinning assessment and diagnosis, and ensuring accountability and responsibility ( NMBI 2015 ). The algorithm in Figure 1 sets out the decision-making process used to assess and establish the causes of Bob's delirium.

Pathophysiology

The pathophysiology of delirium remains poorly understood, with research looking into multiple hypotheses. These include pathogenesis, degenerating brain vulnerability, brain energy metabolism and a variety of precipitating factors to identify methods of convergence ( Wilson et al, 2020 ). This article includes discussion of the blood–brain barrier breakdown that occurs with ageing and the associated risk factors that contribute to delirium ( Varatharaj and Galea, 2017 ). In the older adult, alterations in the blood–brain barrier make the barrier more permeable, allowing blood and substances to pass from micro-vessels to the brain, including toxins and pathogens that will affect cognitive processes. It is thought that the downregulation of synthesis, release and inactivation of neurotransmitters play a vital part in the pathophysiology of delirium in the older adult ( McCaffrey and Davis, 2012 ). The case study illustrates the application of a diagnostic pathway for delirium with reference to Bobs' presenting symptoms.

Differential diagnosis in advanced practice

The differential diagnosis for delirium is broad and often multifactorial ( Lorenzl et al, 2012 ; Maldonado, 2018 ). According to Inouye et al (2014) the term delirium describes an array of symptoms that indicate a disruption in cerebral metabolism following transient biochemical disruptions caused by many conditions. The algorithm provides a systematic approach to four differential diagnoses of delirium: dehydration, infection, constipation and medication. In the author's clinical experience, and based on evidence, these four diagnoses present most frequently in older adults.

History taking and examination skills

Advanced health assessments that include comprehensive history taking, careful physical examination and sound clinical reasoning are crucial to the diagnostic process ( NMBI, 2017 ). These elements assist the practitioner to narrow down the differential diagnoses ( Rhoads and Murphy Jenson, 2015 ; Reinoso et al, 2018 ). In Bob's case, eliciting subjective and objective data through the health history interview using open-ended questions and active listening were demonstrated. As part of this process, it is essential to develop a rapport with the patient and family members: this is fundamental to alleviating anxiety and enabling the ANP to obtain a family history, and helps ensure that the physical examination and diagnostic tests address the relevant factors.

A patient's health history includes their medical history, treatments and risk factors for delirium, and a review of systems. A thorough review of all medications is completed with a specific focus on medication known to contribute to delirium symptoms in combination with associated risk factors; these medications ( Table 3 ) can predispose older adults to episodes of delirium ( Rhoads and Murphy Jenson, 2015 ; Bickley and Szilagyi, 2021 ). The mnemonic OLD CART (onset, location, duration, characteristics, associating factors, relieving/radiating factor, treatment) is a useful tool when obtaining information about a patient's current health status, including background and presenting complaints ( Bickley and Szilagyi, 2021 ). This tool is one of a number of available assessment instruments that use mnemonics: others include PQRST (provokes, quality, radiates, severity and time) and SOCRATES (site, onset, character, radiation, associations, time course, exacerbation/relieving factors, severity) ( Bickley and Szilagyi, 2021 ).

Source: Alagiakrishnan and Wiens, 2004

In clinical practice, the ANP assesses all risk factors associated with the onset of delirium and completes a comprehensive screening to guide diagnosis and treatment. Focused screening in relation to presenting symptoms will also be considered to narrow down the differential diagnosis. Risk factors for delirium and required investigations are presented in Table 4 .

Once a health history has been taken and a risk factor assessment made, a thorough physical examination is conducted, applying a systematic approach to obtain objective clinical information. The initial focus is on neurological assessment, followed by a focused examination relating to each differential diagnosis ( Bickley and Szilagyi, 2021 ; NMBI, 2017 ). Careful examination of the cranial nerves, and the motor and sensory systems will assist in identifying comorbidities or underlying pathology. If an underlying pathology is identified, the ANP will investigate further and consider referral onward, including to the GP if psychiatric manifestations present. A vital signs review is key and may detect the presence of red flags ( Bickley and Szilagyi, 2021 ). Identification of red flags may indicate a serious pathology and the need for further urgent investigations for underlying serious disease ( Reisner and Reisner, 2017 ). Red flags of significance in the case of Bob's presenting symptoms are shown in red in Figure 1 .

Screening tools

Screening tools are valid and reliable methods for assessing older adults presenting with delirium, enabling comprehensive assessment of the presenting symptom(s) ( Iragorri and Spackman, 2018 ). Delirium is diagnosed from its clinical manifestations using a recognised instrument such as the 4AT (arousal, attention, Abbreviated Mental Test 4 and acute change), developed by Shenkin et al (2018) . In Ireland, the RADAR ( r ecognising a cute d elirium a s part of your r outine) is used in daily practice, along with other tools ( Table 5 ), to assess the severity of delirium and determine the efficacy of treatments prescribed.

Extensive research recommends that delirium screening and surveillance be completed daily to establish onset, ensure accurate diagnosis and the best treatment outcomes with least adverse effects. Although standard diagnosis is made using the internationally recognised Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria ( American Psychiatric Association, 2013 ), other validated and recognised tools of choice available to the ANP to determine the effectiveness of interventions include the 4AT for diagnosis, and RADAR and Delirium O Meter ( de Jonghe et al, 2005 ; Voyer, et al, 2016 ; Shenkin et al, 2018 ).

Tieges et al (2020) suggested that early recognition of delirium, which can be achieved effectively by applying the 4AT screening tool, avoids cognitive and functional decline. This is a four-item observational test that is simple to use and easily applied in any setting. However, although it has been shown to detect delirium in older adults, it does not allow for diagnosis of the aetiology (Tieges et al, 2020). The tools listed in Table 5 are relatively short and assist the ANP in screening and monitoring delirium, in order to guide diagnosis and treatment. Should the underlying cause of a patient's delirium not be identified following advanced assessment and analysis of the presenting symptoms, along with the use of screening tools, a list of differential diagnoses will be drawn up by the ANP ( Rhoads and Murphy Jenson, 2015 ).

The following sections present the process of applying the decision-making pathway and the targeted investigations for each of the four differential diagnoses presented in Figure 1 : dehydration, infection, constipation and medication.

Dehydration

Dehydration results from a disruption in the body's fluid balance caused by decreased intake or increased output. The resulting negative balance reduces blood volume, and consequently blood pressure lowers, leading to a decline in glomerular filtration rate and electrolyte imbalances ( El-Sharkawy et al, 2014 ; Reisner and Reisner, 2017 ). According to Masento et al (2014) , dehydration is a common feature presenting in older adults, with intake deficits estimated to be as high as 30%. Even a 2% deficit will present with symptoms such as significant impairment in physical, visuo-motor, psychomotor and cognitive performances. Dehydration may prove fatal if left untreated, so it is crucial to be cognisant of the risk factors in older adults, which include decreased thirst response, impaired swallow and dementia. Older adults may also present asymptomatically, so careful examination with collateral information will help the practitioner identify signs ( Bickley and Szilagyi, 2021 ).

A concerning complication of dehydration is the development of life-threatening hypovolaemic shock. Clinical findings may include dry mouth, sunken eyes, dry cool skin, and reduced or concentrated urine. Collateral of intake and output is crucial in determining causative factors and aiding diagnosis for prompt intervention ( El-Sharkawy et al, 2014 ; Bickley and Szilagyi, 2021 ). Another important issue to consider are glucose levels: delirium has been associated with low blood sugar levels, particularly in acutely unwell older adults ( van Keulen et al, 2018 ). In Bob's case, targeted diagnostic investigations, the results of which would have warranted an alert, included blood serum osmolality of >290 mOsm/kg and a transient increase in electrolytes, FBC, paying attention to haematocrit of >0.460 ratio, blood urea nitrogen of >8.1 mmol/litre and creatinine of >84 μmol/litre. Blood analysis will determine the presence and severity of dehydration, along with other investigations. Reduced skin turgor is another diagnostic in dehydration, however, it may be difficult to assess in older adults whose skin loses elasticity with ageing.

Acute respiratory tract infection occurs due to the invasion of the respiratory system by Gram-negative and Gram-positive bacteria. Common pathogens include Streptococcus pyogenes, Haemophilus influenzae and Moraxella catarrhalis. They can affect many areas of the upper respiratory tract, including the pharynx and sinus. Pathogens involved in the lower tract include the latter, along with S pneumoniae ( Siegel and Weiser, 2015 ). According to Siegel and Weiser (2015) , respiratory infections lead in the ranking of burden of disease measured by years lost through death or disability.

Joints should also be assessed when considering infection in the older adult. Many joint problems present in the older adult, but in Bob's case this was gout, which is therefore discussed in the article. Gout frequently occurs in this patient group and is a common type of inflammatory arthritis that occurs when neutrophils, mononuclear phagocytes and lymphocytes invade the synovium of joints ( Dalbeth and Haskard, 2005 ). The condition typically presents with all features of the inflammatory process and is triggered by a diet of excess proteins, excess alcohol intake, trauma, surgery, comorbidity such as renal or cardiac disease, and subsequent treatment interventions. On examination of an older adult, the ANP will often identify clinical manifestations that include sudden onset of severe pain, swelling, warmth and redness at the local area of the joint affected ( Dalbeth et al, 2016 ).

The mechanism of urinary tract infection (UTI) is the presence of bacteria in the body and activation of the inflammatory response when microorganisms enter the urethra ( Reisner and Reisner, 2017 ). Older adults are more susceptible with risk factors such as impaired bladder emptying and decreased muscle contractility. Parish and Holliday (2012) estimated that Escherichia coli accounts for 90% of urinary tract infections (UTI) in older adults and up to 55% of antibiotic prescribing.

Following a diagnosis of respiratory tract infection and/or UTI, older adults can develop dehydration and constipation, and consequently require close monitoring ( NICE, 2015 ). An older adult with a respiratory tract infection may present asymptomatically, apart from delirium, or with a productive cough and shortness of breath; with a UTI, they may present with burning, frequency or urgency of micturition. The cardinal signs of inflammation in respiratory tract infection include cough, loss or changes to sense of smell, and congestion of the throat or larynx ( Alam et al, 2013 ; Reisner and Reisner, 2017 ). In UTIs, the older adult may present with pain on micturition secondary to sensory nerve ending irritation. In addition, symptoms of fever, tachycardia, confusion, hypotension and leucocytosis may be evident before localised symptoms present ( NICE, 2015 ).

With UTI identified as the most frequent recurring infection in older adults, clinical examination may discover pyuria as increased polymononuclear cells are present with infection. Cloudy or malodorous urine may also be evident. The presence of red flags such as pyrexia, rigors or back pain may indicate underlying pyelonephritis; males may present with urinary retention ( Rhoads and Murphy Jenson, 2015 ; Reisner and Reisner, 2017 ). Urine testing for culture and sensitivity will identify whether there is infection and, if present, the causative pathogen, enabling the most appropriate intervention. Blood testing to assist in confirming diagnosis include FBC with raised white cells, CRP and ESR. Blood urea nitrogen levels increase with infection, and in males there may also be a rise in prostate-specific antigen (PSA). Infection can irritate prostate cells, giving rise to PSA. According to Parish and Holliday (2012) 30% of older adults in long-term residential settings will have a recurrence of a UTI within 1 year.

Constipation

Constipation is a common gastrointestinal disorder affecting 20% of the general population and about 50% of older adults ( Vazquez Roque and Bouras, 2015 ). It can be defined as difficulty emptying the bowel and hardened faeces ( Bharucha and Lacy 2020 ). Older people are affected by age-related cellular dysfunction affecting plasticity, compliance, altered macroscopic structural changes and altered control of the pelvic floor. Delayed colonic transit constipation is typically seen in the older adult ( Lindberg et al, 2011 ). The aetiology of constipation is associated with inadequate fibre in the diet, reduced physical exercise, dehydration and medications such as anticholinergics and tricyclic antidepressants. The mechanism of constipation is associated with autonomic dysfunction, which can result from physical, chemical or emotional stress.

In addition, older adults or those with pre-existing conditions have a reduction in acetylcholine and serotonin, which affects gut motility altering peristalsis ( Rhoads and Murphy Jenson, 2015 ; Reisner and Reisner, 2017 ). Constipation results in hepatotoxicity and increased serum ammonia levels, which travel through the blood and cross the blood–brain barrier inducing confusion ( Camilleri et al, 2000 ).

Characteristic symptoms of constipation include nausea, vomiting, anorexia, crampy abdominal pain or distension. However, the practitioner must remain aware that older adults with delirium may present asymptomatically ( Vazquez Roque and Bouras, 2015 ). The clinical findings from abdominal examination may include distended abdomen, palpable faeces (predominantly of the left lower quadrant), but on examination the patient may have active bowel sounds and a digital rectal exam will identify hard faeces ( Lindberg et al, 2011 ). Red flags for constipation alert the practitioner to possible underlying pathologies such as cancer, for example when there is unexplained weight loss, unexplained altered bowel habit, blood in stool, a palpable mass or a family history of colonic cancer. Targeted investigations include a digital rectal exam ( Rao and Meduri, 2011 ) and use of the Bristol stool chart to record stool consistency and size.

Laboratory blood analysis will provide information such as increased white cell count and elevated inflammatory markers. Liver and thyroid function will be assessed to rule out underlying conditions that may be precipitating factors to the delirium episode. An abdominal X-ray may show faecal loading and obstruction.

Polypharmacy is commonly seen in older adults, with reduced renal flow and delayed metabolism associated with ageing. This can lead to toxicity due to medication or higher concentrations of circulating drug ( Lorenzl et al, 2012 ). Depression is also common in the older adult and involves imbalances in the brain, most notably the neurotransmitters serotonin, norepinephrine (noradrenaline) and dopamine ( Martins and Fernandes, 2012 ). The chemical basis of delirium is seen as an excess of dopaminergic activity and a deficit of cholinergic activity), with delirium occurring as a result of medication accounting for 40% of cases presenting in the older adult ( Alagiakrishnan and Wiens, 2004 ).

Drug withdrawal is another factor to be considered in relation to alcohol ( Lucas et al, 2019 ), benzodiazepines ( Gould et al, 2014 ) and selective serotonin reuptake inhibitors as these are known to precipitate delirium in the older adult ( Herron and Mitchell, 2018 ). Features that may present in the aetiology of delirium as a result of medication include drowsiness, agitation, fluctuating confusion, inattention, visual disturbances and hallucinations ( Alagiakrishnan and Wiens, 2004 ). Following history taking, careful review of all medication, including over-the-counter medications, is essential for narrowing down the differential diagnosis. Review of pain medication including drug-to-drug and drug-to-disease interactions is crucial for accurate diagnosis. The review should include newly prescribed or de-prescribed medication. A focused review of medications such as psychotropics, anticholinergic and deliriants is required in this population as listed in Table 3 . Anticholinergic burden is an important aspect of the medication review by the ANP when assessing for cognitive decline and delirium. These medications, along with alterations in blood–brain barrier and hormone imbalances, are known to play a role in medication-induced delirium ( Inouye et al, 2014 ).

The ANP must be familiar with red flags such as drug interactions, drug withdrawal, falls and dehydration as possible indicators of serious disease. Targeted investigations involve excluding dehydration, infection or constipation. Laboratory blood tests will be guided by the full assessment and an assay of drug levels may be indicated.

This article has outlined an evidenced-based decision-making pathway used by the ANP to establish possible causes of the clinical presentation of delirium in the older adult. The disease entities of delirium are overly broad, and often multifactorial, and in general present with similar symptoms. A thorough and detailed history including collateral with accompanying focused physical assessment is therefore fundamental to ensure accurate selection of diagnostic modalities. Using a structured approach enables the ANP to narrow the differential diagnosis of delirium to dehydration, infection, constipation and medication.

The article has also discussed underlying pathological processes and diagnostic modalities. An algorithm to assist the diagnostic evaluation of the presenting symptom of delirium in an older adult has been presented and critiqued using the case study of patient Bob. This algorithm is currently used by the author to guide practice and it is anticipated that colleagues in Ireland, the UK and internationally may find the algorithm useful. Additionally, they may incorporate it as part of their evidenced-based nurse-led service, enabling optimal advanced care of the older adult presenting with delirium.

A person presenting with signs and symptoms of acute delirium requires expert care and management, regardless of their demographic background.

• The ANP working in older adult care is competent and capable to effect evidence-based change in complex care settings
• The differential diagnosis of delirium is broad and multifactorial, requiring advanced comprehensive clinical decision-making, knowledge and skills
• Evidence-based algorithms guide clinical practice and facilitate the transfer of research to practice, providing nurses with a step-by-step approach for effective decision-making
• Advanced care planning is essential to achieve person-centred care for the older adult in the care setting of their choice

CPD reflective questions

• Think about the likely causes of delirium in the older adult. How would an algorithm assist with determining the cause(s)?
• Consider how you would manage a patient once you have the underlying diagnosis? Is the patient best managed in the acute or community setting?
• Consider the clinical scenario in the article. Is it useful for you practice?
• What can you do to improve your skills in the assessment and diagnostic processes?

• Open access
• Published: 19 November 2022

Nurses’ competence in recognition and management of delirium in older patients: development and piloting of a self-assessment tool

• Jonas Hoch 1 , 2 ,
• Jürgen M. Bauer 1 , 3 ,
• Martin Bizer 4 ,
• Christine Arnold 2 &
• Petra Benzinger 1 , 5  

BMC Geriatrics volume  22 , Article number:  879 ( 2022 ) Cite this article

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Delirium is a common condition in elderly inpatients. Health care professionals play a crucial role in recognizing delirium, initiating preventive measures and implementing a multicomponent treatment strategy. Yet, delirium often goes unrecognized in clinical routine. Nurses take an important role in preventing and managing delirium. This study assesses clinical reasoning of nurses using case vignettes to explore their competences in recognizing, preventing and managing delirium.

The study was conducted as an online survey. The questionnaire was based on five case vignettes presenting cases of acutely ill older patients with different subtypes of delirium or diseases with overlapping symptoms. In a first step, case vignettes were developed and validated through a multidisciplinary expert panel. Scoring of response options were summed up to a Geriatric Delirium Competence Questionnaire (GDCQ) score including recognition and management tasks The questionnaire was made available online. Descriptive analyses and group comparisons explores differences between nurses from different settings. Factors explaining variance in participants’ score were evaluated using correlations and linear regression models.

The questionnaire demonstrated good content validity and high reliability (kappa = 0.79). The final sample consisted of 115 nurses. Five hundred seventy-five case vignettes with an accuracy of 0.71 for the correct recognition of delirium presence or absence were solved. Nurses recognized delirium best in cases describing hyperactive delirium (79%) while hypoactive delirium was recognized least (44%). Nurses from geriatric and internal medicine departments had significantly higher GDCQ-score than the other subgroups. Management tasks were correctly identified by most participants.

Conclusions

Overall, nurses’ competence regarding hypoactive delirium should be strengthened. The online questionnaire might facilitate targeting training opportunities to nurses’ competence.

Peer Review reports

Delirium is a neuropsychiatric syndrome characterized by acute disturbance of attention, consciousness, cognitive function or perception with a fluctuating course [ 1 , 2 ]. Symptoms might present as hypoactive, hyperactive, or mixed motoric subtypes. Delirium occurs across all healthcare settings but is most common in acutely hospitalized patients. Older age is a strong predisposing factor in hospitalized patients resulting in a higher chance to suffer a delirium [ 3 ]. At the same time, multiple risk factors might trigger delirium onset like acute illness, trauma, surgery, and medications. The prevalence of delirium is variable across various departments and might be as high as > 20% in intensive care units and in emergency departments [ 1 , 4 ].

Although symptoms resolve within days in most patients, cognitive deficits might persist for months. Delirium is associated with adverse outcomes such as functional decline, institutionalization, dementia, and mortality [ 5 , 6 , 7 , 8 ]. Often, delirium is distressing for patients as well as their caregivers [ 9 ]. While treated in hospital, patients with delirium need more attention from nursing staff which leads to a higher workload [ 10 , 11 ]. Furthermore, patients suffering from delirium have a longer length of stay resulting in higher costs per case [ 7 , 12 ].

Delirium is a clinical bedside diagnosis based on recognition of its characteristic features by healthcare professionals [ 13 ]. There is sufficient evidence that a multicomponent nonpharmacological approach can effectively prevent the onset of delirium and reduce symptom duration [ 14 , 15 ]. For successful implementation and maintaining of a multi-dimensional diagnostic and therapeutic approach, interprofessional collaboration of physicians, nurses, therapists, as well as family members and trained volunteers is imperative [ 16 ]. Nurses play a key role in prevention and detection of delirium [ 17 ]. They spend more time in direct contact with patients than any other healthcare profession. Their attitudes and knowledge are critical to delirium recognition and management [ 18 ]. In Germany, there is currently only a limited focus on delirium in the national nursing education curriculum. However, gaps in nurses’ knowledge and understanding of delirium have already been demonstrated elsewhere [ 19 , 20 ]. In a response to this knowledge gap, an interdisciplinary statement of scientific societies specifically addressed the need for better training of healthcare professionals, and nurses in particular [ 16 ].

To make an impact on care, training of nurses should increase their clinical competences and clinical reasoning skills [ 21 ]. Clinical reasoning describes the process health care professionals go through in their daily routine to successfully solve simple to complex patient encounters. Clinical reasoning consists of clinical judgement and clinical decision making. While clinical judgment involves the process of recognizing what is wrong with the patient, clinical decision making includes adoption of preventive measures and the management of clinical problems [ 22 ]. Single choice questionnaires often do not sufficiently represent this complex process of clinical reasoning. To this end, case vignettes are established for training of medical students and physicians since they are more suitable to assess clinical judgement and decision making. Up to now, case vignettes are less frequently used for training of nursing students and nurses [ 23 ]. In the context of delirium, surveys conducted in Canada and the United States used case vignettes to assess nurses’ recognition of delirium [ 24 , 25 , 26 , 27 , 28 ]. So far, very few surveys focused on using case vignettes to assess the whole clinical reasoning process by nurses including recognition as well as management of delirium in this detail.

The aim of this study was to develop and to pilot a self-assessment instrument for nurses to evaluate their clinical reasoning skills in recognition and management of delirium in geriatric patients using case vignettes.

Study design and study population

The online version of the questionnaire was developed using LimeSurvey (Version 3.22.1 + 200,129, hosted by Heidelberg University). After ethical approval, participants were recruited between August 2021 and October 2021 through personal communication, professional organizations, and providers of continuing training. Respondents could access the survey via a link or a QR code. Due to the anonymous design, the survey was open to other health care professionals. Inclusion criteria were (1) a nursing degree and (2) current employment at a hospital, in post-acute or long-term facilities. Respondents not meeting the inclusion criteria were excluded from further analyses.

Development of case vignettes and questionnaire

The questionnaire was designed in order to assess delirium competence using five case vignettes describing scenarios in a general hospital characterizing patients suffering from different subtypes of delirium (hypoactive, hyperactive, and hyperactive superimposed on dementia) or diseases with overlapping symptoms (dementia, depression). Two authors (JH, MB) developed the case vignettes through an iterative process based on previously published vignette studies [ 24 , 26 , 29 ], review of literature and clinical relevance as judged by the authors. Careful consideration was given to the content of the vignettes so that they closely related to real clinical scenarios and included information that would facilitate delirium recognition. All vignettes presenting delirious patients described clinical signs as covered by the Confusion Assessment Method (CAM), a well-established instrument for detection of delirium [ 30 ]. Clinical signs were defined as acute onset, fluctuating course in mental status, and inattention with additional symptoms of disorganized thinking or altered levels of consciousness. A shortened example of a case vignette is presented in Fig.  1 , all case vignettes are provided as Supplementary Material .

Abridged example of the case vignette with hyperactive delirium (short version)

All case vignettes included questions about recognition of delirium including delirium subtypes, prevention and further management tasks. The questions were primarily based on selected response formats and included true/false, single-choice, short menu formats and multiple response questions [ 31 ]. The vignettes were reviewed by a geriatrician (PB).

For content validity, the questionnaire was reviewed by two psychiatrists, one physician and two nurses with a master’s degree. All had experience in clinical research, geriatrics, and delirium.

Feasibility and comprehension were tested by three nurses with a low level of self-reported experience in delirium management. They needed 25 to 35 minutes for completion of the questionnaire. Consequently, the questionnaire was shortened to reduce administration time.

To measure reliability of agreement, the survey was completed by five nurses with a master’s degree. Fleiss’ kappa was used for statistical analyses. They demonstrated 100% inter-rater agreement with the correct identification of delirium presence or absence for each case and an overall kappa of 0.79. Results between 0.61 and 0.80 can be considered as substantial agreement, results between 0.81 and 1.0 as almost perfect [ 32 ]. No further adaptation of the case vignettes was warranted.

Nurses who participated in the review process were excluded from the pilot study.

Measurement scales and independent variables

For further statistical analysis, questions of the case vignettes were aggregated to constitute a Geriatric Delirium Competence Questionnaire (GDCQ-score) with a score ranging from zero to 55. The score consisted of questions related to clinical judgement as well as clinical decision making (see Supplementary Material ).

After completion of the case vignettes, participants were grouped by their current work environment (‘geriatric and internal medicine departments’, ‘other acute hospital departments’, and ‘post-acute and long-term care facilities’). The subgroup ‘other acute hospital departments’ consisted of nurses working on any inpatient ward including intensive care units (ICU) and psychiatric wards.). Furthermore, they were asked about their previous delirium training (accumulated hours in total, training within the previous 12 months), work experience with delirious patients and satisfaction with delirium management at their current work place using a Likert-scale (1–5, higher = more frequent / higher satisfaction). Participants were asked to self-assess their knowledge on delirium before starting and after completion of the case vignettes using a Likert-scale (1–5, higher = more knowledge). The independent variable, frequent treatment of delirious patients in daily routine, was dichotomized (very often, often = 1, less = 0).

Statistical analysis

Statistical analyses were performed using the R Foundation for Statistical Computing 4.1.0. Descriptive variables were described by means and standard deviation, median and interquartile range, or percent. Differences between subgroups were tested by using the non-parametric Kruskal-Wallis-Test, which is distributed as a chi-square. Group comparisons of dichotomous variables and the GDCQ-score were performed using two-sided Welch T-test [ 33 ]. Five-point Likert-scales were treated as continuous variables in correlation analyses and further regression models [ 34 , 35 ]. Pearson’s correlation was used to test for correlations between GDCQ-score and independent variables. Univariate linear regression analyses were performed with GDCQ-score as dependent variable. Level of significance was set at p  < 0.05 (two-tailed) for all analyses.

Sample characteristics

Between August and October 2021, the survey was started 248 times of which 51% times respondents ( n  = 126) completed the questionnaire. Mean completion time of the survey was 22.2 minutes (SD 9.6 minutes). Case vignettes presented in this questionnaire were rated as ‘very good’ or ‘good’ by 88% of participants. Respondents who identified themselves as nurses were included for further analyses ( n  = 115). The average work experience of participants was 19.6 years. Fifty-two participants worked in geriatric or internal medicine departments, and 33% of participating nurses had a specialist nursing qualification in geriatric medicine. Of nurses working in geriatric and internal medicine departments, 61% reported frequent treatment of delirious patients in their departments while nurses working in other departments or facilities reported frequent treatment of delirious patients significantly less often (‘other acute care’ departments 40%, ‘post-acute and long-term care facilities’ 8%). Nearly every other nurse working in geriatric and internal medicine department reported participation in delirium training within the previous 12 months (Table  1 ).

Recognition of delirium

Overall, participants completed 575 case vignettes with an accuracy of 0.71 for the correct recognition of delirium presence or absence. The correct subtype of delirium was recognized by 48% of participating nurses. Nurses working in geriatric and internal medicine departments identified hyperactive delirium significantly better than nurses from post-acute and long-term care facilities ( p  < 0.01). There were no statistically significant differences between subgroups for the recognition of delirium in all other case vignettes (Table  2 ).

For recognition of delirium, most participants used clinical signs (81%) and information provided by relatives (71%). Respondents reported to use validated assessment tools including Delirium Observation Screening (DOS) (55%), Nursing Delirium Screening Scale (NuDesc) (47%), and Confusion Assessment Method (CAM) (44%). Use of no validated method to detect delirium was reported by 11% of participants.

Management tasks

Overall, most participants were able to differentiate whether suggested measures were appropriate. Nurses working in geriatric and internal medicine departments scored higher than the other subgroups and scored significantly higher than participants from non-acute care settings in all four items although differences reached statistical significance for recognition of risk factors and initiation of preventive measures only (Table  3 ).

GDCQ-score, correlations, and linear regression models

The mean score of the sample was 42.62 (SD = 4.86) out of a maximum of 55 points. Subgroups analyses demonstrated that nurses working in geriatric and internal medicine departments scored a mean of 44.34 (SD = 4.01). Participants from other acute hospital departments scored an average of 42.17 (SD = 4.98) and participants from post-acute and long-term facilities scored a mean of 37.77 (SD = 3.81). Difference between subgroups was significant ( p  < 0.01). Further post-hoc analyses by the Wilcoxon rank sum test with continuity correction by Holm showed a significant difference between all three subgroups ( p  < 0.05).

There were significant correlations with small effect sizes between GDCQ-score and some independent variables. While overall work experience shown no significant correlation, frequent care of delirious patients in daily routine and the subjective self-assessment after survey did (Table  4 ).

This pilot study describes the development and piloting of a questionnaire to self-assess competence in recognition and management of delirium in older patients by nurses. Case vignettes offer the opportunity to assess nurses’ clinical skills by reflecting realistic scenarios. Our results demonstrate feasibility of the questionnaire in a German setting and allow insights into delirium competence of nurses in Germany. To our knowledge, this study is the first to assess the abilities of nurses to recognize and manage delirium using case vignettes.

Overall, delirium was detected by most nurses participating in the pilot study. In our sample, nurses were better in recognizing the absence of signs of delirium than the presence of such signs. This finding is in line with previous studies [ 26 , 36 , 37 ]. In a study with home care nurses, 93% of participants recognized the absence of signs of delirium in a case vignette describing depression [ 26 ]. Other studies using case vignettes describing dementia without delirium reported correct recognition of absence of delirium by 68 and 83% of participating nurses [ 24 , 26 ]. Where there is uncertainty on the nature of cognitive alterations, dementia might appear to be a more obvious choice to many nurses as compared to delirium.

In the present study, presence of delirium was best recognized in a case vignette describing hyperactive delirium. Higher detection rates for hyperactive delirium as compared to other subtypes are in line with previous findings [ 24 , 26 ]. Yet, hypoactive delirium is more common than hyperactive delirium in inpatient settings [ 38 , 39 ]. It is associated with higher mortality and worse outcome as compared to other types of delirium [ 40 ]. One reason for poor clinical outcome of patients with hypoactive delirium might be the lower detection rates in clinical routine. During a busy shift, delirium might remain unrecognized in patients not seeking attention from nursing staff [ 41 ]. Delirium superimposed on dementia also seems to be challenging to evaluate for the participants of our study. This seems to reflect current clinical practice [ 42 ]. Low detection rates of hypoactive delirium and delirium superimposed on dementia in case vignettes, as seen in our study and previous studies, point towards gaps in nurses’ knowledge of delirium and suggest better training of health care professionals on delirium [ 16 ].

Among participants of the pilot study, nurses from post-acute and long-term facilities tended to recognize delirium less often than nurses from other settings and achieved the lowest overall GDCQ-score. These findings may in part be attributed to the content of the case vignettes. The situations described do not reflect scenarios of post-acute or long-term care settings and experiences of staff with delirious persons in these settings might be distinct from what was presented in the case vignettes. Yet, rates of correct diagnosis of delirium in this study is comparable to a larger study involving more than 500 staff members of various long-term care facilities in the United States [ 25 ]. In light of the substantial prevalence of delirium among nursing home residents, future research and efforts on delirium management should include nurses in non-acute health care settings [ 43 , 44 , 45 ].

Development of case vignettes should follow a robust methodology [ 29 ]. Professionals with different backgrounds were involved and pre-testing demonstrated high agreement of scoring between experts. Construct validity of the case vignettes developed was supported by univariate regression analyses. Frequent exposure to delirious patients and participation in delirium training were positively associated with higher scores indicating higher competence, while years of work experience did not explain variance of the overall score. These findings are supported by the findings of a study enrolling community health care nurses [ 46 ]. It is plausible that daily routine care for such patients and training have a strong impact on nurses’ delirium competence.

This study is the first in Germany using clinical case vignettes to assess nurses’ competence rather than knowledge of delirium [ 47 ]. So far, case vignettes focusing on delirium have been used to assess nurses’ ability to recognize delirium in various nursing settings [ 25 , 26 , 27 , 29 ]. In this study, based on previous case vignettes, we developed with the help of a multi-professional team a novel questionnaire for nurses that assesses not only recognition but also management of delirium. Unlike previous studies, case vignettes in this questionnaire combined multiple-choice, multiple-response questions as well as short menu lists in order to reduce cueing. It is well suited to the German health care setting and represents situation encounters well known to nurses.

Limitations

There are several limitations that need to be considered. First, case vignettes are developed to reflect realistic scenarios but in cases of delirium one has to acknowledge that signs of delirium often fluctuate over the course of the day, making detection of delirium even more challenging. For methodological reasons, it remains unclear how well scores obtained in the newly developed questionnaire reflect clinical reasoning in practice. Second, case vignettes developed in this questionnaire were describing older patients admitted to non-intensive care wards. They do not cover delirious patients on intensive care units, nor do they describe older patients cared for in post-acute or long-term care facilities. While there was a sufficient number of nurses from geriatric and general medical wards, the limited number of participants from other acute care departments did not allow for further exploration. A larger sample is needed to draw more generalizable conclusions. Third, we recruited a convenience sample for piloting the questionnaire. It is very likely that nurses with a particular interest in the topic visited the online site of the questionnaire. Only about half of the respondents visiting the website completed the questionnaire suggesting further selection. Due to data protection issues, we could only collect data of those completing the questionnaire and submitting the data. Therefore, we can only speculate on reasons for non-completion. Furthermore, a high proportion of participants had further qualifications or reported recent training in delirium. Hence, the results from our survey may overestimate delirium competence of nurses in Germany.

The newly developed questionnaire was feasible and well-appreciated by respondents. The results of this study suggest that the overall recognition of delirium by nurses should be improved. The questionnaire could augment existing training activities in the future. Although not addressed, our results implicated a particular need for nurses in long-term care facilities to strengthen their delirium competence. This should be addressed in further research with an appropriate sample size. The authors would welcome use of case vignettes and access to the online questionnaire by German instructors.

Availability of data and materials

The questionnaire was translated into English and can be seen in the supplementary data. The datasets used and/or analyzed during the current study are available from the corresponding author upon request.

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Acknowledgements

The authors would like to thank all persons taking part in the development and review process, helping to distribute the questionnaire, or taking part as participant. For the publication fee we acknowledge financial support by Deutsche Forschungsgemeinschaft within the funding programme „Open Access Publikationskosten“ as well as by Heidelberg University.

Open Access funding enabled and organized by Projekt DEAL. This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

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Jonas Hoch, Jürgen M. Bauer & Petra Benzinger

Department of General Practice and Health Services Research, Heidelberg University Hospital, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany

Jonas Hoch & Christine Arnold

Network Aging Research (NAR), Heidelberg University, Bergheimer Strasse 20, 69115, Heidelberg, Germany

Jürgen M. Bauer

Department of Internal Medicine, Heidelberg University Hospital, Im Neuenheimer Feld 672, 69120, Heidelberg, Germany

Martin Bizer

Institute of Health and Generations, University of Applied Sciences Kempten, Bahnhofstrasse 61, 87435, Kempten, Germany

Petra Benzinger

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JH did the conception of questionnaire, design, data collection, data analysis, preparation of manuscript, editing and review. PB contributed to conception, design, preparation of manuscript, editing and review. CA has contributed to conception, design, data analysis and review. MB participated in the conception of the questionnaire and review. JB contributed to the preparation of the manuscript and revised the final draft of manuscript. All Authors have read and approved the final manuscript.

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Correspondence to Petra Benzinger .

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Hoch, J., Bauer, J.M., Bizer, M. et al. Nurses’ competence in recognition and management of delirium in older patients: development and piloting of a self-assessment tool. BMC Geriatr 22 , 879 (2022). https://doi.org/10.1186/s12877-022-03573-8

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Received : 10 June 2022

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Published : 19 November 2022

DOI : https://doi.org/10.1186/s12877-022-03573-8

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Prospective observational study of dementia and delirium in the acute hospital setting

Affiliation.

• 1 Centre for Research in Geriatric Medicine, The University of Queensland, Brisbane, Queensland, Australia. [email protected]
• PMID: 22998322
• DOI: 10.1111/j.1445-5994.2012.02962.x

Background: Dementia and delirium appear to be common among older patients admitted to acute hospitals, although there are few Australian data regarding these important conditions.

Aim: The aim of this study was to determine the prevalence and incidence of dementia and delirium among older patients admitted to acute hospitals in Queensland and to profile these patients.

Method: Prospective observational cohort study (n = 493) of patients aged 70 years and older admitted to general medical, general surgical and orthopaedic wards of four acute hospitals in Queensland between 2008 and 2010. Trained research nurses completed comprehensive geriatric assessments and obtained detailed information about each patient's physical, cognitive and psychosocial functioning using the interRAI Acute Care and other standardised instruments. Nurses also visited patients daily to identify incident delirium. Two physicians independently reviewed patients' medical records and assessments to establish the diagnosis of dementia and/or delirium.

Results: Overall, 29.4% of patients (n = 145) were considered to have cognitive impairment, including 102 (20.7% of the total) who were considered to have dementia. This rate increased to 47.4% in the oldest patients (aged ≥ 90 years). The overall prevalence of delirium at admission was 9.7% (23.5% in patients with dementia), and the rate of incident delirium was 7.6% (14.7% in patients with dementia).

Conclusion: The prevalence of dementia and delirium among older patients admitted to acute hospitals is high and is likely to increase with population aging. It is suggested that hospital design, staffing and processes should be attuned better to meet these patients' needs.

© 2012 The Authors; Internal Medicine Journal © 2012 Royal Australasian College of Physicians.

Publication types

• Multicenter Study
• Randomized Controlled Trial
• Research Support, Non-U.S. Gov't
• Aged, 80 and over
• Cohort Studies
• Delirium / diagnosis*
• Delirium / epidemiology*
• Dementia / diagnosis*
• Dementia / epidemiology*
• Hospitalization / trends
• Observational Studies as Topic / methods
• Patient Admission* / trends
• Prospective Studies
• Queensland / epidemiology