Family caregiver's experience of caring for an older adult with delirium: A systematic review

A Toolkit for Delirium Identification and Promoting Partnerships Between Carers and Nurses: A Pilot Pre-Post Feasibility Study

BACKGROUND

Delirium is frightening for people experiencing it and their carers, and it is the most common hospital-acquired complication worldwide. Delirium is associated with higher rates of morbidity, mortality, residential care home admission, dementia, and carer stress and burden, yet strategies to embed the prevention and management of delirium as part of standard hospital care remain challenging. Carers are well placed to recognize subtle changes indicative of delirium, and partner with nurses in the prevention and management of delirium.

OBJECTIVE

To evaluate a Prevention & Early Delirium Identification Carer Toolkit (PREDICT), to support partnerships between carers and nurses to prevent and manage delirium.

DESIGN

A pre-post-test intervention and observation study.

MAIN MEASURES

Changes in carer knowledge of delirium; beliefs about their role in partnering with nurses and intended and actual use of PREDICT; carer burden and psychological distress. Secondary measures were rates of delirium.

PARTICIPANTS

Participants were carers of Indigenous patients aged 45 years and older and non-Indigenous patients aged 65 years and older.

INTERVENTION

Nurses implemented PREDICT, with a view to provide carers with information about delirium and strategies to address caregiving stress and burden.

KEY RESULTS

Participants included 25 carers (43% response rate) (n = 17, 68% female) aged 29-88 (M = 65, SD = 17.7 years). Carer delirium knowledge increased significantly from pre-to-post intervention (p =  < .001; CI 2.07-4.73). Carers' intent and actual use of PREDICT was (n = 18, 72%; and n = 17, 68%). Carer burden and psychological distress did not significantly change. The incidence of delirium in the intervention ward although not significant, decreased, indicating opportunity for scaling up.

CONCLUSION

The prevention and management of delirium are imperative for safe and quality care for patients, carers, and staff. Further comprehensive and in-depth research is required to better understand underlying mechanisms of change and explore facets of nursing practice influenced by this innovative approach.

Understanding family carer experiences and perceptions of engagement in delirium prevention and care for adults in hospital: Qualitative systematic review

AIM

To identify, describe and synthesise what is known about family carers' experiences and perspectives of engagement in delirium prevention and care for adults in hospital.

DESIGN

Systematic review and synthesis of qualitative evidence.

DATA SOURCES

Comprehensive literature search within PubMed, CINAHL, EMBASE, Scopus, Cochrane Central and PsycInfo databases to August 2022. Peer reviewed original qualitative research published in English.

METHODS

Data were extracted using Covidence systematic review software. Methodological quality was reviewed against the Critical Appraisal Skills Program (CASP) Qualitative Checklist. Thematic synthesis was used to develop analytical themes. Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual) framework was applied to findings.

RESULTS

Of 3429 records identified, 29 met criteria for final inclusion. Studies included a range of settings (intensive care, medical and surgical wards) and family carer types (spouse, daughter, parent and friend). Three primary themes Shared Caregiving, Partnership and Support, Communication for Shared Understanding and three cross-cutting contextual themes Care Transitions, Family Carer Context and Hospital Context were identified. Family carers have mixed experiences of involvement in delirium care and prevention. Family carer engagement in care impacted perceptions of care quality and their own self-efficacy. Where person-centred care expectations were not met, some family carers adopted compensatory or care contingency strategies. Information sharing and timely support from hospital staff who understood the carer context supported carer involvement. Supportive physical environments and addressing power imbalances allowed greater engagement.

CONCLUSION

Family carers often wish to be involved in delirium prevention and care, but need to be recognised as individuals, listened to, informed and supported to optimise their contribution.

IMPACT

The review findings can guide health professional and decision makers to optimise family carer involvement in delirium care programs.

PROTOCOL REGISTRATION

PROSPERO [CRD42020221854].

REPORTING

ENTREQ. No Patient or Public Contribution.

Tau and delirium superimposed on dementia: A case report

We present a case involving a 60-year-old man with subacute delirium characterized by challenging attention shifts and obstinate behavior, contrasting with his usual mild-mannered personality. The patient developed pneumonia and a urinary tract infection following the onset of subacute delirium. Despite exhaustive investigations, the cause remained elusive until cerebrospinal fluid analysis revealed Tau positivity. Our overview suggests neurodegenerative diseases as the primary cause, rather than infectious or autoimmune factors. The case underscores a significant association between Tau and delirium superimposed on dementia, offering guidance to clinicians managing such patients.

Development of a complex intervention to prevent delirium in older hospitalized patients by optimizing discharge and transfer processes and involving caregivers: A multi-method study

BACKGROUND

Delirium is a common yet challenging condition in older hospitalized patients, associated with various adverse outcomes. Environmental factors, such as room changes, may contribute to the development or severity of delirium. Most previous research has focused on preventing and reducing this condition by addressing risk factors and facilitating reorientation during hospital stay.

OBJECTIVE

We aimed to systematically develop a complex intervention to prevent delirium in older hospitalized patients by optimizing discharge and transfer processes and involving caregivers during and after these procedures. The intervention combines stakeholder and expert opinions, evidence, and theory. This article provides guidance and inspiration to research groups in developing complex interventions according to the recommendations in the Medical Research Council framework for complex interventions.

DESIGN AND METHODS

A stepwise multi-method study was conducted. The preparation phase included analysis of the context and current practice via focus groups. Based on these results, an expert workshop was organized, followed by a Delphi survey. Finally, the intervention was modeled and a program theory was developed, including a logic model.

RESULTS

A complex intervention was developed in an iterative process, involving healthcare professionals, delirium experts, researchers, as well as caregiver and patient representatives. The key intervention component is an 8-point-program, which provides caregivers with recommendations for preventing delirium during the transition phase and in the post-discharge period. Information materials (flyers, handbook, videos, posters, defined "Dos and Don'ts", discharge checklist), training for healthcare professionals, and status analyses are used as implementation strategies. In addition, roles were established for gatekeepers to act as leaders, and champions to serve as knowledge multipliers and trainers for the multi-professional team in the hospitals.

CONCLUSIONS

This study serves as an example of how to develop a complex intervention. In an additional step, the intervention and implementation strategies will be investigated for feasibility and acceptability in a pilot study with an accompanying process evaluation.

TWEETABLE ABSTRACT

Delirium prevention can benefit from optimizing discharge and transfer processes and involving caregivers of older patients in these procedures.

STUDY REGISTRATION

DRKS00017828, German Register of Clinical Studies, date of registration 17.09.2019.

Delirium in Home Care: A Case Report

Delirium is a challenging medical problem, particularly in the home care setting, and greatly affects both patients and family caregivers. When delirium is not immediately detected and effectively managed, various outcomes are adversely affected. This report describes delirium in an older home-bound man and offers strategies for detecting and managing delirium in a home care setting. The patient is a frail 86-year-old man with multiple medical comorbidities and functional decline after bronchitis that was diagnosed by a general practitioner. Following the diagnosis and subsequent treatment of bronchitis, the patient suffered a major decline in cognitive and physical functioning during normal daily activities. Medical screening revealed confusion, apathy, and extreme fatigue. Using the assessment tool of the Functional Independence Measures and Delirium Observation Screening Scale (DOSS), the presence of functional decline and delirious symptoms were found. Through multidisciplinary collaboration, a treatment plan was initiated. It consisted of hydration following a fixed schedule, adapted nutrition, a temporary adapted medication schedule for pre-diabetes, and an exercise plan. No specific pharmaceuticals were given. The patient made a full recovery over time. All professional and informal caregivers should be aware of the potential presence of delirium when an older patient with a deteriorating physical or mental condition presents itself. Good diagnostics for delirium and possible underlying diseases are necessary. Adequate treatment, with the help of paramedics such as dieticians, physiotherapists, etc. must be provided when necessary.

Experiences of relatives of patients with delirium due to an acute health event - A systematic review of qualitative studies

OBJECTIVE

Evaluate relatives' experience of delirium due to an acute health event in a loved person and to compile practical suggestions for health care professionals from these synthesized results.

BACKGROUND

Delirium resulting from an acute health event places patients at increased risk for prolonged hospitalization and mortality. A delirium episode also affects family members who may assist in the diagnosis and recovery from this condition.

INCLUSION CRITERIA

Qualitative studies of family members or other caregivers who witnessed patient delirium in a clinical setting were included if they had appropriate verbatim evidence. Studies dealing exclusively with delirium in the context of dementia, cancer, palliative care, or drug dependence were excluded, and if quotes could not be clearly allocated to relatives.

METHODS

A systematic review of qualitative studies adapted from the Joanna Briggs Institute meta-aggregation approach. A systematic literature search was conducted in CINAHL complete®, MEDLINE®, and several dissertation databases in September 2022.

RESULTS

Eight qualitative studies based on semi-structured interviews were included. In total 75 findings from 105 relatives were aggregated into 13 categories. Finally, three synthesized findings reveal suggestions for health care professionals: providing information adequately, communication and integration during health care and understanding relatives' perspective on delirium experience.

CONCLUSION

The identified burdens and needs of relatives should be considered by health care professionals to enhance the delirium experience for them, thus improving patient care by involving relatives with a better understanding.

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.

A Review of Biomarkers in Delirium Superimposed on Dementia (DSD) and Their Clinical Application to Personalized Treatment and Management

Delirium superimposed on dementia (DSD) occurs when patients with pre-existing dementia develop delirium. This complication causes patients to become impaired, posing safety concerns for both hospital staff and patients. Furthermore, there is an increased risk of worsening functional disability and death. Despite medical advances, DSD provides both diagnostic and therapeutic challenges to providers. Identifying at-risk patients and providing personalized medicine and patient care can decrease disease burden in a time-efficient manner. This review delves into bioinformatics-based studies of DSD in order to design and implement a personalized medicine-based approach. Our findings suggest alternative medical treatment methods based on gene-gene interactions, gene-microRNA (miRNA) interactions, gene-drug interactions, and pharmacogenetic variants involved in dementia and psychiatric disorders. We identify 17 genes commonly associated with both dementia and delirium including apolipoprotein E (ApoE), brain-derived neurotrophic factor (BDNF), catechol-O-methyltransferase (COMT), butyrylcholinesterase (BChE), acetylcholinesterase (AChE), DNA methyltransferase 1 (DNMT1), prion protein (PrP), tumor necrosis factor (TNF), serine palmitoyltransferase long chain base subunit 1 (SPTLC1), microtubule-associated protein tau (MAPT), alpha-synuclein (αS), superoxide dismutase 1 (SOD1), amyloid beta precursor protein (APP), neurofilament light (NFL), neurofilament heavy, 5-hydroxytryptamine receptor 2A (HTR2A), and serpin family A member 3 (ERAP3). In addition, we identify six main genes that form an inner concentric model, as well as their associated miRNA. The FDA-approved medications that were found to be effective against the six main genes were identified. Furthermore, the PharmGKB database was used to identify variants of these six genes in order to suggest future treatment options. We also looked at previous research and evidence on biomarkers that could be used to detect DSD. According to research, there are three types of biomarkers that can be used depending on the stage of delirium. The pathological mechanisms underlying delirium are also discussed. This review will identify treatment and diagnostic options for personalized DSD management.

Caregiving for Persons Living With Dementia During the COVID-19 Pandemic: Perspectives of Family Care Partners

Persons living with dementia (PLWD) are at increased risk for coronavirus disease 2019 (COVID-19) and poorer outcomes if they contract the disease. COVID-19 may also change and exacerbate usual stresses of family caregiving. The current qualitative descriptive study examined 14 family care partners' (FCPs) experiences and perspectives on how the COVID-19 pandemic impacted them, their care recipients, and their caregiving for their care recipients. Thematic analysis of interviews generated five themes: Cautious of COVID-19 Exposure, Challenges of Balancing COVID-19 Restrictions With Caregiving, Shared Loneliness, Functional Decline, and Communication Challenges With PLWD and Health Care Professionals (HCPs). FCPs are integral to the care of PLWD across care settings. The time is now to plan for changes in policy that will safely maintain FCPs' visitation with their care recipients with dementia and allow for partnering with HCPs to avoid the long-lasting negative effects on older adults' health and function. [Journal of Gerontological Nursing, 49(3), 27-33.].

Recognition of Delirium Superimposed on Dementia: Is There an Ideal Tool?

Delirium in persons with dementia (DSD) is a common occurrence. Over the past three decades, several tools have been developed and validated to diagnose delirium, yet there is still a shortage of tools recommended in persons with dementia and there is a lack of sufficient research on the accuracy of performance of such tools in this growing population. The purpose of this article is to (1) conduct a clinical review of the detection of DSD across settings of care by formal health care professionals and informal family members and care partners; (2) identify barriers and facilitators to detection and highlight delirium tools that have been tested in person with dementia; and (3) make recommendations for future research, practice, and policy. Given this review, an "ideal" tool for DSD would point to tools being brief, easy to integrate into the EMR, and accurate with at least 90% accuracy given the poor outcomes associated with delirium and DSD. Knowing the baseline and communication between family members and healthcare professionals should be a top priority for education, research, and health systems policy. More work is needed in better understanding DSD and optimizing and standardizing feature assessment, especially the acute change feature at the bedside for DSD.

Putting "the broken bits together": A qualitative exploration of the impact of communication changes in dementia

INTRODUCTION

Communication is an area of health and functioning that is profoundly affected by dementia. While it is known that people living with dementia and their care partners experience disruptions to daily activities and social engagement, detailed knowledge about the lived impact of dementia-related communication changes is lacking. This study sought an in-depth understanding of the lived experience of dementia-related communication changes and the associated impact, needs, and strategies.

METHODS

As part of an overarching participatory design study, a qualitative (interpretive description) exploration was undertaken with people living with dementia and their care partners. Data from semi-structured interviews were analysed using thematic analysis.

RESULTS

We interviewed 13 people living with dementia and 21 care partners and drew three themes and 10 subthemes from the interviews. The first theme illustrates how dementia changes communication which in turn changes life; the second captures the impact of changes on people living with dementia and care partners emotionally and in the context of relationships; and the third describes some positive and constructive ways of moving forward with dementia-related communication changes.

CONCLUSIONS

Interventions to enhance function, participation, and wellbeing for people living with dementia and their care partners need to encompass support for communication changes. There is a need to ensure that people living with dementia feel dignified and respected during communication, and that care partners and inclusive communities are educated, trained, and supported to facilitate communication.

Delirium in a surgical context from a nursing perspective: A hybrid concept analysis

Background

The term delirium has been defined in medical diagnosis criteria as a multidimensional disorder, and the term acute confusion is included in nursing classifications. Delirium can be a serious complication assessed in a patient after a surgical procedure. Still, the patient's delirium frequently remains unrecognised. Care of patients with delirium after surgical procedure is complex, and it challenges nursing expertise. From the nurses' viewpoint, delirium is associated with ambiguity of concepts and lack of knowledge. Therefore, reseach on how nurses perceive patients with delirium in a surgical context is needed.

Objective

The aim of this study was to describe the concepts of delirium and acute confusion, as well as the associated dimensions, in adult patients in a surgical context from the nursing perspective.

Design

The study used Schwartz and Barcott's hybrid concept analysis with theoretical, fieldwork, and final analytical phases.

Settings

Surgical wards, surgical intensive care units, and post-anaesthesia care units.

Data sources

A systematic literature search was performed through Pubmed (Medline), Cinahl, PsycInfo, and Embase.

Participants

Registered nurses and licensed practical nurses (n = 105) participated in the fieldwork phase.

Methods

In the theoretical phase, the concepts' working definitions were formulated based on a systematic literature search with the year limitations from 2000 until February 2021. At the fieldwork phase, the nurses' descriptions of patients with delirium were analysed using the deductive content analysis method. At the final analytical phase, findings were combined and reported.

Results

The concepts of delirium, subsyndromal delirium, and acute confusion are well defined in the literature. From the perspective of the nurses in the study, concepts were seen as a continuum not as individual diagnoses. Nurses described the continuum of delirium as a process with acute onset, duration, and recovery with the associated dimensions of symptoms, symptom severity, risk factors, and early signs. The acute phase of delirium was emphasised, and preoperative or prolonged disturbance did not seem to be relevant in the surgical care context. Patients' compliance with care may be decreased with the continuum of delirium, which might challenge both patients' recovery from surgery and the quality of nursing care.

Conclusions

In clinical practice the nurses used term confusion inaccurately. The term acute confusion might be used when illustrating an early stage of delirium. Nurses could benefit from further education where the theoretical knowledge is combined with the clinical practice. The discussion about the delirium, which covers the time both before surgery and after the acute phase should be increased.

Improving delirium screening and recognition in UK hospitals: results of a multi-centre quality improvement project

BACKGROUND

delirium is an acute severe neuropsychiatric condition associated with adverse outcomes, particularly in older adults. However, it is frequently under-recognised.

METHODS

this multi-centre quality improvement project utilised a collaborative approach to implementation of changes at sites, with the aim to improve delirium screening, recognition and documentation on discharge summaries. Resources, including delirium guidelines and presentations, were shared between sites, and broad details of local interventions were collected. Three timepoints of data collection (14 March 2018, 14 September 2018 and 13 March 2019) were conducted to assess screening, recognition and documentation of delirium in unscheduled admissions of adults aged ≥65 years old. The impact of local interventions and site-specific factors was assessed using logistic regression analysis, adjusting for patient factors.

RESULTS

a total of 3,013 patients (mean age 80.2, 53.8% females) were recruited across the three timepoints. Screening for delirium was associated with increased odds of recognition (aOR 4.75, CI 2.98-7.56; P < 0.001); this was not affected by grade/profession of screener. Rates of screening, recognition and discharge documentation improved across the three timepoints of data collection. The presence of a local delirium specialist team was associated with increased rates of screening for delirium (aOR 1.75, CI 1.41-2.18; P < 0.001), and the presence of a geriatric medicine team embedded into the admissions unit was associated with increased recognition rates (aOR 1.78, CI 1.09-2.92; P = 0.022).

CONCLUSION

delirium screening is associated with improved recognition. Interventions that strive to improve screening within a culture of delirium awareness are encouraged.

A complex intervention to promote prevention of delirium in older adults by targeting caregiver's participation during and after hospital discharge - study protocol of the TRAnsport and DElirium in older people (TRADE) project

Background

Among potentially modifiable risk factors for delirium, transfers between wards, hospitals and other facilities have been mentioned with low evidence. TRADE (TRAnsport and DElirium in older people) was set up to investigate i) the impact of transfer and/or discharge on the onset of delirium in older adults and ii) feasibility and acceptance of a developed complex intervention targeting caregiver’s participation during and after hospital discharge or transfer on cognition and the onset of delirium in older adults.

Methods

The study is designed according to the guidelines of the UK Medical Research Council (MRC) for development and evaluation of complex interventions and comprises two steps: development and feasibility/piloting. The development phase includes i) a multicenter observational prospective cohort study to assess delirium incidence and cognitive decline associated with transfer and discharge, ii) a systematic review of the literature, iii) stakeholder focus group interviews and iv) an expert workshop followed by a Delphi survey. Based on this information, a complex intervention to better and systematically involve family caregivers in discharge and transport was developed. The intervention will be tested in a pilot study using a stepped wedge design with a detailed process and health economic evaluation. The study is conducted at four acute care hospitals in southwest Germany. Primary endpoints are the delirium incidence and cognitive function. Secondary endpoints include prevalence of caregiver companionship, functional decline, cost and cost effectiveness, quality of discharge management and quality of admission management in admitting hospitals or nursing homes. Data will be collected prior to discharge as well as after 3, 7 and 90 days.

Discussion

TRADE will help to evaluate transfer and discharge as a possible risk factor for delirium. In addition, TRADE evaluates the impact and modifiability of caregiver’s participation during patient’s transfer or discharge on delirium incidence and cognitive decline providing the foundation for a confirmatory implementation study.

Trial registration

DRKS (Deutsches Register für klinische Studien) DRKS00017828. Registered on 17th September 2019. Retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02585-0.

In the digital age: a systematic literature review of the e-health literacy and influencing factors among Chinese older adults

Aim

This study aimed to explore the current status of e-health literacy among Chinese older adults, and to summarize and analyze the related influencing factors.

Subject and methods

Following the PRISMA Checklist, we searched MEDLINE, CINAHL Complete (EBSCO), PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, WanFang Data, and China Science and Technology Journal Database to identify the relevant literature published between January 2000 and December 2020. The Mixed Methods Assessment Tool (MMAT) was used to appraise the quality of the studies.

Results

Five articles were included for the systematic review. The results showed that the e-health literacy of Chinese older adults was low. Based on the social-ecological model, the influencing factors at the individual level included age, gender, educational attainment, socioeconomic status, physical and psychological conditions, frequency of internet use, and credibility perception of online health resources; at the interpersonal level, the influencing factors included marital status, being the family carer and being taught how to use internet to find health resources; at the social/community level, influencing factors included language barriers and cultural barriers.

Conclusion

Current e-health literacy among Chinese older adults is low, which is affected by a number of factors. Medical staff should provide detailed health information with guaranteed accuracy and reliability for elderly people. It is necessary to develop intervention programs tailored to varied educational needs of the elderly with different backgrounds (i.e., age, gender, educational attainment, and socioeconomic status) need to be developed in the near future. Family members are encouraged to teach older adults how to use e-health resource in appropriate ways.

Current Challenges in the Recognition and Management of Delirium Superimposed on Dementia

Delirium occurring in a patient with preexisting dementia is referred to as delirium superimposed on dementia (DSD). DSD commonly occurs in older hospitalized patients and is associated with worse outcomes, including higher rates of mortality and institutionalization, compared to inpatients with delirium or dementia alone. This narrative review summarizes the screening, diagnosis, management, and pathophysiology of DSD and concludes by highlighting opportunities for future research. Studies were identified via Medline and PsycINFO keyword search, and handsearching reference lists. Conceptually, DSD could be considered an "acute exacerbation" of dementia precipitated by a noxious insult akin to an acute exacerbation of heart failure or acute on chronic renal failure. However, unlike other organ systems, there are no established biomarkers for delirium, so DSD is diagnosed and monitored clinically. Because cognitive dysfunction is common to both delirium and dementia, the diagnosis of DSD can be challenging. Inattention, altered levels of arousal, and motor dysfunction may help distinguish DSD from dementia alone. An informant history suggestive of an acute change in cognition or alertness should be investigated and managed as delirium until proven otherwise. The key management principles include prevention, identifying and treating the underlying precipitant(s), implementing multicomponent interventions to create an ideal environment for brain recovery, preventing complications, managing distress, and monitoring for resolution. Informing and involving family members or caregivers throughout the patient journey are essential because there is significant prognostic uncertainty, including the risk of persistent cognitive and functional decline following DSD and relapse. Furthermore, informal carers can provide significant assistance in management. Emerging evidence demonstrates that increased exposure to delirium is associated with neuronal injury and worse cognitive outcomes although the mechanisms through which this occurs remain unclear. Given the clinical overlap between delirium and dementia, studying shared pathophysiological pathways may uncover diagnostic tests and is an essential step in therapeutic innovation.