Preparing Family Caregivers to Recognize Delirium Symptoms in Older Adults After Elective Hip or Knee Arthroplasty

An online delirium detection tool: Cross-cultural adaptation of a Chinese version of the Family Confusion Assessment Method

BACKGROUND

Intensive care unit (ICU) delirium is a common complication in older critically ill patients that has a significant impact. The Family Confusion Assessment Method (FAM-CAM) is a vital tool for assisting family members in identifying delirium; however, no study has yet been reported on the Chinese version of the scale.

OBJECTIVES

The objective of this study was to translate the FAM-CAM into a Chinese version and to verify its effectiveness for delirium detection in an online patient visit setting.

METHODS

This was a cross-sectional study. The FAM-CAM was translated to Chinese according to the International Society for Pharmacoeconomics and Outcomes Research guidelines. Patients and family members were recruited to participate in delirium assessments in three ICUs of one hospital. Family members then used the Chinese version of the FAM-CAM to assess for delirium via online visitation, and ICU nurses assessed patients for delirium using the Intensive Care Delirium Screening Checklist (ICDSC). Results were then compared between family members' and nurses' assessments.

RESULTS

Overall, 190 critically ill patients and 190 family members were included, of whom 117 (61.6%) were assessed for delirium using the Intensive Care Delirium Screening Checklist. The Cohen's kappa coefficient between the Intensive Care Delirium Screening Checklist and FAM-CAM was 0.759 (P < 0.01). The sensitivity of the Chinese version of the FAM-CAM was 0.880, specificity was 0.890, positive predictive value was 0.928, negative predictive value was 0.823, and area under the receiver operating characteristic curve was 0.881 (95% confidence interval: 0.872-0.935, P < 0.01).

CONCLUSION

The Chinese version of the FAM-CAM was shown to effectively help families detect delirium and was suggested as a crucial tool for assisting ICU nurses in the early identification of delirium. This tool may effectively be used to assess delirium during online visits.

Diagnostic accuracy of the Family Confusion Assessment Method for delirium detection: A systematic review and meta-analysis

BACKGROUND

Delirium is frequently disproportionately under-recognized despite its high prevalence, detrimental impact, and potential lethality. Informant-based delirium detection tools can offer structured assessment and increase the timeliness and frequency of detection. We aimed to examine the diagnostic accuracy of the Family Confusion Assessment Method (FAM-CAM) for delirium detection.

METHODS

We systematically searched the MEDLINE, EMBASE, PsycINFO, CINAHL, CNKI, WANFANG, and SinoMed databases from January 1988 to December 2022. Two reviewers independently screened studies and evaluated methodological quality using the revised quality assessment of diagnostic accuracy studies (QUADAS-2) tool. A bivariate random effects model was undertaken, and univariable meta-regression was carried out to explore heterogeneity.

RESULTS

Seven studies with 483 dyads of participants and family caregivers were identified. Pooled sensitivity and specificity were 0.74 (95% CI: 0.59, 0.86) and 0.91 (95% CI: 0.83, 0.95), respectively, with an area under curve (AUC) of 0.91. The positive likelihood ratio was 8.27 (95% CI: 3.97, 17.25), and the negative likelihood ratio was 0.28 (95% CI: 0.16, 0.50). Settings impacted specificity (p = 0.02).

CONCLUSIONS

Available evidence indicates that FAM-CAM exhibits moderate sensitivity and high specificity for delirium screening in adults. The FAM-CAM is concise and easy to use, making it appropriate for routine clinical practice, which might benefit early delirium detection and potentially foster delirium management.

PROSPERO REGISTRATION NUMBER

CRD42022378742.

Does early or late discharge after total knee replacement affect the burden and stress of caregivers?

BACKGROUND

Since patients may experience difficulties in their daily activities after total knee replacement surgery, the role of the caregiver is important in supporting the daily needs of the patients. Caregivers are involved in the day-to-day care activities of the patient during the recovery process, managing their symptoms and providing support. All these factors can affect the burden and stress of caregivers.

METHODS

It was aimed to compare the caregiver burden and stress of caregivers of total knee replacement patients who were discharged on the same day of surgery and at a later point. Data were collected from 140 caregivers by using the Bakas Caregiving Outcomes Scale, Zarit Caregiving Burden Scale, and Stress Coping Styles Scale.

RESULTS

There was no significant difference between on the same day of surgery discharge and later discharge in terms of care burden and stress of caregivers (p > 0.05). While the burden of care was mild to moderate (22.15 ± 13.76) on the same day of surgery discharge group, the burden of care in the later discharge group was very low (19.03 ± 13.65).

CONCLUSION

In order to reduce the care burden and stress levels of caregivers, it is important that nurses determine the problems related to caregiving and provide the necessary support.

Delirium education for family caregivers of patients in the intensive care unit: A pilot study

Objectives

Delirium, an acute change in mental state, seen in hospitalized older adults is a growing public health concern with implications for both patients and caregivers; however, there is minimal research on educating caregivers about delirium. Utilizing family caregivers to assist with delirium management in acute care settings demonstrates improved health outcomes supporting the need for patient and family centered care. The primary aims of the study were to determine feasibility of implementing a delirium education video for caregivers of patients in an adult oncology intensive care unit and compare delirium knowledge to caregivers in a control group.

Methods

A quasi-experimental design comprised of 31 family caregivers of adult patients in an oncology intensive care unit to determine feasibility of implementing a delirium education video.

Results

The results demonstrate feasibility of implementing a caregiver education video in-person and virtually. While total delirium knowledge scores were not statistically significant, knowledge gained within the delirium presentation subgroup was significant (p = .05).

Conclusion

This study demonstrates feasibility of implementing a caregiver education video and findings support further research in this area.

Innovation

Collaborating with caregivers to develop virtual video education for delirium allows for a versatile approach to connect with caregivers to support their caregiving role.

Educational intervention for family caregivers of older adults with delirium: An integrative review

AIM

To propose educational strategies to prevent delirium in older adults.

DESIGN

Integrative review.

METHODS

This review followed the methodology of Whittemore and Knafl (J Adv Nurs 52(5):546-553, 2005. 10.1111/j.1365-2648.2005.03621.x).

DATA SOURCES

A literature search was performed of the PubMed, CINAHL, Embase, Cochrane Library CENTRAL, and Scopus databases on 8 July 2022.

RESULTS

Three themes of educational interventions were identified: capacity building, resource provision and enhancement of relationships, collectively termed Fa-CARE. Educational interventions improved family caregivers' knowledge about delirium, their anxiety; depression; self-efficacy; and attitudes. Among older adults, these interventions improved the duration, severity and incidence of delirium; functional abilities; and length of hospital stay.

CONCLUSION

Providing education to family caregivers benefits both those caregivers and the older adults. When planning educational intervention, diverse and innovative approaches need to be considered.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

This study can guide family education regarding the care of older adults with delirium.

IMPACT

Educational interventions positively impacted both family caregivers and older adults with delirium. Educational interventions provide family caregivers with resources, improve their capacity for delirium management, and enhance their relationships with older adults. This study suggests future directions in education for family caregivers of older adults with delirium.

REPORTING METHOD

This review adhered to the EQUATOR guidelines by using the PRISMA 2020 checklist.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Geriatric Preoperative Optimization: A Review

This review summarizes best practices for the perioperative care of older adults as recommended by the American Geriatrics Society, American Society of Anesthesiologists, and American College of Surgeons, with practical implementation strategies that can be readily implemented in busy preoperative or primary care clinics. In addition to traditional cardiopulmonary screening, older patients should undergo a comprehensive geriatric assessment. Rapid screening tools such as the Mini-Cog, Patient Health Questionnaire-2, and Frail Non-Disabled Survey and Clinical Frailty Scale, can be performed by multiple provider types and allow for quick, accurate assessments of cognition, functional status, and frailty screening. To assess polypharmacy, online resources can help providers identify and safely taper high-risk medications. Based on preoperative assessment findings, providers can recommend targeted prehabilitation, rehabilitation, medication management, care coordination, and/or delirium prevention interventions to improve postoperative outcomes for older surgical patients. Structured goals of care discussions utilizing the question-prompt list ensures that older patients have a realistic understanding of their surgery, risks, and recovery. This preoperative workup, combined with engaging with family members and interdisciplinary teams, can improve postoperative outcomes.

Education and skills training for care partners of hospitalised older adults: A scoping review

Background

The care partners of hospitalised older adults often feel dissatisfied with the education and skills training provided to them, resulting in unpreparedness and poor health outcomes.

Objective

This review aimed to characterise and identify gaps in the education and skills training used with the care partners of older adults in the hospital.

Methods

We conducted a scoping review on the education and skills training practices used with the care partners of hospitalised older adults in the USA via sources identified in the PubMed, PsychINFO and CINAHL databases.

Results

Twelve studies were included in this review. Results illustrate that nurses utilise multiple modes of delivery and frequently provide education and skills training tailored to the needs of care partners at the latter end of hospital care. The provision of education and skills training varies greatly, however, including who provides education, in what way information is conveyed, and how care partner outcomes are measured.

Conclusion

This is the first scoping review to describe and synthesise the education and skills training practices used with care partners of hospitalised older adults. Findings highlight the need for education and skills training to be interprofessional, tailored to individual care partners' needs and begin at, or even before, the hospital admission of older adult patients.

What prompts patients to present with delirium?

PURPOSE

To explore the recognition, response and understanding of delirium in families and carers of hospitalised patients.

METHODS

All adults with delirium admitted to an acute medical unit were included. Delirium was diagnosed by a specialist geriatrician. The responder who sought medical advice for each patient was interviewed using a delirium recognition questionnaire. Vital status was ascertained at four months.

RESULTS

Sixty patients were included (mean age 85, SD 6.8 years). Reported symptoms included drowsiness and lack of responsiveness, though these were less commonly recognised as being due to delirium. 76% received medical advice within 24 h, although two responders took > 1 week. One-third of responders had never heard of delirium. Delirium knowledge among responders was variable.

CONCLUSION

Overall awareness and knowledge of delirium was poor. Community delirium education and public health initiatives may improve rapidity of recognition, delirium assessment, and potentially health outcomes.

Implementation of ABCDEF care bundle in intensive care units: A cross-sectional survey

BACKGROUND

Delirium affects up to 80% of patients in intensive care units (ICUs) and is associated with higher mortality, physical dependence, and health care costs. The 2018 pain, agitation, delirium, immobility, and sleep guideline recommended ABCDEF care bundle for delirium prevention and management. However, limited information is available regarding the adoption of the care bundle in ICUs in Mainland China.

AIMS AND OBJECTIVES

To assess the current implementation of the ABCDEF care bundle for delirium prevention as reported by ICU nurses in Mainland China.

DESIGN

A cross-sectional study was conducted.

METHODS

A cross-sectional online survey using a validated questionnaire about the practices of the ABCDEF care bundle was conducted among 334 registered nurses in 167 ICUs of 65 cities in Mainland China.

RESULTS

Almost 50% of the sampled ICU nurses were unaware of the ABCDEF care bundle, though 86.83% of the surveyed ICUs implemented pain assessments and 95.51% implemented sedation assessments. Nearly half (46.41%) of the surveyed ICUs performed routine spontaneous awaking trials, with 21.26% performing them daily. Spontaneous breathing trials were performed in 38.32% of the surveyed ICUs. Only 47% of the surveyed ICUs routinely monitored patients for delirium. About one-third (38.35%) of the surveyed ICUs were supported by specialist teams that implemented the mobilization programmes. Most ICUs restricted the duration of family visits per day (<0.5 hour: 61.67%; 0.5-2 hours: 23.65%; >2 hours: 3.29%) and only 28.14% of the surveyed ICUs employed dedicated staff to support the families.

CONCLUSIONS

Although most of the surveyed ICUs implemented pain and sedation assessments, many of them did not implement structured delirium assessments. Early mobilization programmes and family participation should be encouraged.

RELEVANCE TO CLINICAL PRACTICE

Promoting the uses of a reliable delirium assessment tool such as Confusion Assessment Method for Intensive Care Unit patients, building an early mobilization team, and engaging family caregivers in the care plan may contribute to improved patients' clinical outcomes.

Effectiveness of an intensive care unit family education intervention on delirium knowledge: a pre-test post-test quasi-experimental study

PURPOSE

To create, validate, and refine an intensive care unit (ICU) delirium education intervention to prepare family members to partner with the ICU care team to detect delirium symptoms and prevent and manage delirium using nonpharmacological strategies.

METHODS

In this pre-test post-test quasi-experimental study, consecutive eligible family members of critically ill patients admitted to an ICU completed an ICU Family Education Delirium intervention in two parts: 1) six-minute video on ICU delirium (risk factors, prevention/management, symptoms, communication with the ICU care team), and 2) two case vignettes to practice detecting delirium using family-administered delirium detection questionnaires (Family Confusion Assessment Method [FAM-CAM] and Sour Seven). Family members' delirium knowledge was measured before, immediately after, and two weeks following the intervention using the Caregiver ICU Delirium Knowledge Questionnaire (CIDKQ).

RESULTS

Of 99 family members recruited over eight months, 81 (82%) completed the intervention and 63 (63/81, 78%) completed all follow-up questionnaires. Family members' delirium knowledge improved significantly following the intervention (pre-CIDKQ, 14; 95% confidence interval [CI], 13 to 15; post-CIDKQ, 17; 95% CI, 16 to 17; P < 0.001) and was retained two weeks after the intervention (CIDKQ 16; 95% CI, 16 to 17; P < 0.001). This included increased knowledge regarding delirium risk factors (e.g., medication, mechanical ventilation), prevention/management (e.g., orientation, day/night routine), and symptoms of delirium. More family members correctly detected delirium symptoms in case vignettes using the Sour Seven (92%) compared with the FAM-CAM (78%).

CONCLUSIONS

A video-based ICU delirium education intervention is effective in educating family members about prevention, detection, and management of delirium.

Integration of family caregivers in delirium prevention care for hospitalized older adults: A case study analysis

AIM

To understand how family caregivers of older adults hospitalized for orthopaedic surgery are integrated by nurses in delirium prevention care.

DESIGN

Multiple case study.

METHODS

The sample consisted of eight cases. Each case comprised an older adult, a family caregiver, and a nurse. Data were collected from September 2017 - April 2018 through various instruments, including semi-structured interviews and family caregiver logs. Within- and across-case analyses were conducted, based on the model of The Care Partner Engagement developed by Hill, Yevchak, Gilmore-Bykovskyi, & Kolanowski (Geriatric Nursing, 35, 2014, 272).

RESULTS

Two themes emerged: (a) family caregivers were engaged in caring for the older adults during their hospital stay, though they had differences in terms of views and needs; and (b) family caregivers communicated with nurses but nurses did not recognize their role and did not integrate them much in care.

CONCLUSION

The presence and availability of family caregivers, their sense of responsibility towards the hospitalized older adults, and their positive effects on them suggest that family caregivers could be integrated more systematically in a care partnership with nurses. Poor integration of family caregivers in delirium prevention care shows that nurse delirium prevention competencies and their relational skills for communicating effectively with family caregivers need to be developed further.

IMPACT

Integrating family caregivers in delirium prevention care for older adults is a challenge for nurses. Family caregivers are engaged during the hospitalization of older adults, though differences and problems exist between the two groups. While there is communication between patients, family caregivers, and nurses, nurses do not recognize the role of family caregivers and hardly integrated them in the delirium prevention care of hospitalized older adults. Nurses must adopt a patient- and family-centred approach. Care and training facilities must make resources available to implement this approach in nursing practice.

Family Caregiver Strain and Challenges When Caring for Orthopedic Patients: A Systematic Review

Background: Caregivers represent the core of patients’ care in hospital structures, in the process of care and self-care after discharge. We aim to identify the factors that affect the strain of caring for orthopedic patients and how these factors are related to the quality of life of caregivers. We also want to evaluate the role of caregivers in orthopedic disease, focusing attention on the patient–caregiver dyad. Methods: A comprehensive search on PubMed, Cochrane, CINAHL and Embase databases was conducted. This review was reported following PRISMA statement guidance. Studies were selected, according to inclusion and exclusion criteria, about patient–caregiver dyads. For quality assessment, we used the MINORS and the Cochrane Risk of BIAS assessment tool. Results: 28 studies were included in the systematic review; in these studies, 3034 dyads were analyzed. Caregivers were not always able to bear the difficulties of care. An improvement in strain was observed after behavioral interventions from health-care team members; Conclusions: The role of the caregiver can lead to a deterioration of physical, cognitive and mental conditions. The use of behavioral interventions increased quality of life, reducing the strain in caregivers of orthopedic patients. For this reason, it is important to consider the impact that orthopedic disease has on the strain of the caregiver and to address this topic.

Family Identification of Delirium in the Emergency Department in Patients With and Without Dementia: Validity of the Family Confusion Assessment Method (FAM-CAM)

OBJECTIVE

To examine the ability of the family-rated Family Confusion Assessment Method (FAM-CAM) to identify delirium in the emergency department (ED) among patients with and without dementia, as compared to the reference-standard Confusion Assessment Method (CAM).

DESIGN

Validation study.

SETTING

Urban academic ED.

PARTICIPANTS

Dyads of ED patients, aged 70 years and older, and their family caregivers (N = 108 dyads).

MEASUREMENTS

A trained reference standard interviewer performed a cognitive screen, delirium symptom assessment, and scored the CAM. The caregiver self-administered the FAM-CAM. Dementia was assessed using the Informant Questionnaire on Cognitive Decline in the Elderly and the medical record. For concurrent validity, performance of the FAM-CAM was compared to the CAM. For predictive validity, clinical outcomes (ED visits, hospitalization, and mortality) over 6 months were compared in FAM-CAM positive and negative patients, controlling for age, sex, comorbidity, and cognitive status.

RESULTS

Among the 108 patients, 30 (28%) were CAM positive for delirium and 58 (54%) presented with dementia. The FAM-CAM had a specificity of 83% and a negative predictive value of 83%. Most false negatives (n = 9 of 13, 69%) were due to caregivers not identifying the inattention criteria for delirium on the FAM-CAM. In patients with dementia, sensitivity was higher than in patients without (61% vs 43%). In adjusted models, a hospitalization in the following 6 months was more than three times as likely in FAM-CAM positive compared to negative patients (odds ratio = 3.4; 95% confidence interval = 1.2-9.3).

CONCLUSIONS

Among patients with and without dementia, the FAM-CAM shows qualities that are important in the ED setting for identification of delirium. Using the FAM-CAM as part of a systematic screening strategy for the ED, in which families' assessments could supplement healthcare professionals' assessments, is promising. J Am Geriatr Soc 68:983-990, 2020.

Understanding the integration of family caregivers in delirium prevention care for hospitalized older adults: A case study protocol

AIM

To understand family caregiver involvement in delirium prevention care for older adults hospitalized for orthopaedic surgery hospitals and family caregiver integration by nurses.

DESIGN

Multiple-case study.

METHODS

The model of Care Partner Engagement was selected as theoretical framework. Eight cases will comprise an older adult hospitalized a family caregiver and a ward nurse. They will be recruited with a non-probability sampling on two orthopaedic surgery wards in two hospitals. Semi-structured interviews with participants will be audiotaped. Sociodemographic data will be collected. These data, researcher field notes and interview transcripts will be subjected to within- and across-case thematic analysis. Regional ethics committee approved the study protocol in August 2018.

DISCUSSION

The study will allow surgical nursing teams to gain a better understanding of the issues and possibilities regarding family caregiver integration in delirium prevention care for older adults.

Incidence of postoperative delirium in elderly ambulatory patients: A prospective evaluation using the FAM-CAM instrument

BACKGROUND

While the incidence of postoperative delirium is high in aged hospitalized patients undergoing major surgery, little is known concerning patients undergoing ambulatory surgery.

OBJECTIVE

To determine the incidence of postoperative delirium in aged patients after hospital discharge from an ambulatory surgery unit.

DESIGN

Prospective observational study.

PATIENTS

Elderly patients (≥75 years) scheduled for a surgical procedure on an ambulatory basis.

INTERVENTIONS

Filling of the Family Confusion Assessment Method (FAM-CAM) questionnaire (11 items) during a phone interview of family caregivers on two separate occasions: five to three days before surgery, and three to five days after surgery.

MAIN OUTCOME MEASURES

The detection of acute onset and fluctuating course inattention, disorganized thinking, altered level of consciousness, disorientation, perceptual disturbances, and psychomotor agitation from the observations of family caregivers.

RESULTS

Signs of delirium appeared de novo in 2 of 141 patients (incidence 1.4%) in the postoperative period: a 80-years old man who was disoriented and had incoherent and illogical speech on postoperative day 1 of resection of a cephalic cutaneous melanoma under local anesthesia and sedation (midazolam, sufentanil, and propofol), and a 83-years old woman with a pre-existing mental confusion, who experienced visual and hearing hallucinations and had inappropriate behaviour on postoperative day 2 of cataract surgery performed under episcleral block. Both patients returned to their preoperative states within a few days.

CONCLUSIONS

Using the FAM-CAM instrument for the detection of postoperative delirium in ambulatory patients, the study showed that the incidence of cognitive changes in the ambulatory setting is very low. Among several putative factors, the lightness of the surgical procedure, the wide use of regional anesthesia, and the short hospital stay may be contributing factors to this result. The findings of this study need to be confirmed in a larger sample of patients.

Validation of Caregiver-Centered Delirium Detection Tools: A Systematic Review

OBJECTIVES

To summarize the validity of caregiver-centered delirium detection tools in hospitalized adults and assess associated patient and caregiver outcomes.

DESIGN

Systematic review.

SETTING

We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and Scopus from inception to May 15, 2017.

PARTICIPANTS

Hospitalized adults.

INTERVENTION

Caregiver-centered delirium detection tools.

MEASUREMENTS

We drafted a protocol from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Two reviewers independently completed abstract and full-text review, data extraction, and quality assessment. We summarized findings using descriptive statistics including mean, median, standard deviation, range, frequencies (percentages), and Cohen's kappa. Studies that reported on the validity of caregiver-centered delirium detection tools or associated patient and caregiver outcomes and were cohort or cross-sectional in design were included.

RESULTS

We reviewed 6,056 titles and abstracts, included 6 articles, and identified 6 caregiver-centered tools. All tools were designed to be administered in several minutes or less and had 11 items or fewer. Three tools were caregiver administered (completed independently by caregivers): Family Confusion Assessment Method (FAM-CAM), Informant Assessment of Geriatric Delirium (I-AGeD), and Sour Seven. Three tools were caregiver informed (administered by a healthcare professional using caregiver input): Single Question in Delirium (SQiD), Single Screening Question Delirium (SSQ-Delirium), and Stressful Caregiving Response to Experiences of Dying. Caregiver-administered tools had better psychometric properties (FAM-CAM sensitivity 75%, 95% confidence interval (CI)=35-95%, specificity 91%, 95% CI=74-97%; Sour Seven positive predictive value 89.5%, negative predictive value 90%) than caregiver-informed tools (SQiD: sensitivity 80%, 95% CI=28.4-99.5%; specificity 71%, 95% CI=41.9-91.6%; SSQ-Delirium sensitivity 79.6%, specificity 56.1%).

CONCLUSION

Delirium detection is essential for appropriate delirium management. Caregiver-centered delirium detection tools show promise in improving delirium detection and associated patient and caregiver outcomes. Comparative studies using larger sample sizes and multiple centers are required to determine validity and reliability characteristics.