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

Development of a curriculum for interdisciplinary e-learning on delirium in nursing homes-a modified Delphi study

BACKGROUND

Health care professionals (HCPs) in nursing homes, such as nurses and general practitioners (GPs), indicate a need for delirium-specific education. However, establishing educational interventions in the nursing home setting is challenging. e-learning is one method of compensating for these difficulties. Therefore, this study aims to develop a curriculum for interdisciplinary e-learning to improve delirium-specific knowledge in HCPs in nursing homes.

METHODS

Delirium-specific competencies were formulated on the basis of exploratory setting-independent literature. The competencies were assessed for relevance (very relevant, relevant, less relevant and not relevant) by an expert panel through a two-stage Delphi study that included an integrated workshop. A consensus was assumed if 80% of the experts rated a competence as very relevant or relevant in the first round. Competencies with approval ratings between 75% and 80% after the first round and/or that were critically commented upon were discussed in the subsequent workshop and assessed again in the second round. The competencies that received approval ratings below 75% in the first Delphi round were removed. In the second Delphi round, competencies that did not achieve at least 80% approval were ultimately excluded.

RESULTS

A total of 120 competencies were formulated, including 108 that addressed both disciplines, 4 addressed nurses, and 8 addressed GPs. Nineteen experts participated in the first Delphi round, after which n=92 (76.7%) of the competences were approved and n=18 (15%) were deleted. A total of 10 (8.3%) of the competencies were critically discussed by 10 experts in the subsequent workshop, of which 6 were deleted. Four competencies (3 addressed nurses and 1 GP) were evaluated by 11 experts in the second Delphi, 3 of which were confirmed (the competence addressing GPs was deleted). Overall, n=97 (81.2%) competencies were included in the final curriculum. Of these, n=64 (66%) addressed both disciplines, n=16 (16.5%) addressed nurses, and n=17 (17.5%) addressed GPs.

CONCLUSIONS

Delirium is an interdisciplinary challenge. Hence, the majority of our newly developed competencies address both disciplines. However, discipline-specific competencies must be addressed in the development of e-learning. A competence-based curriculum is a necessary basis for providing interdisciplinary e-learning for HCPs in nursing homes.

Clear Minds: Unravelling Delirium in Older Adults

With an explosive population growth of older adults, the incidence rates of neuropsychiatric syndromes, particularly delirium, are increasing in the community and hospital settings. Delirium is an acute disturbance in cognition and attention that may signify a serious medical, life-threatening condition and may mimic psychiatric-mental health issues. Although its prevalence rate is lower in the community, delirium affects up to 87% of hospitalized older adults and can cost up to $152 billion each year. Despite its common occurrence, delirium is often undetected in 50% to 60% across all care settings, delaying treatment and resulting in poor patient outcomes, such as increased mortality, prolonged hospital stays, cognitive and functional impairment, decreased quality of life, and institutionalization. The current article addresses strategies to recognize delirium and presents evidence-based approaches and future considerations for delirium management. [Journal of Psychosocial Nursing and Mental Health Services, 62(11), 11-18.].

Barriers to healthcare professionals recognizing and managing delirium in older adults during a hospital stay: A mixed-methods systematic review

AIM

To investigate barriers to healthcare professionals recognizing and managing delirium in hospitalized older people.

DESIGN

A mixed-methods systematic review.

PROSPERO ID

CRD42020187932.

DATA SOURCES

MEDLINE, EMBASE, PsycINFO and CINAHL were searched (2007 to February 2023).

REVIEW METHODS

Included studies focused on healthcare professionals' recognition and management of delirium for patients aged 65 years and over in a hospital ward or emergency department. Enhancing rigour, screening of results was conducted independently by two researchers. Qualitative and quantitative data were tabulated separately and grouped. Data were compared to identify similarities and differences. All studies were quality appraised.

RESULTS

43 studies were included; 24 quantitative, 16 qualitative and three mixed-methods. Data synthesis highlighted synergy between qualitative and quantitative findings. Barriers were reflected in six themes: (1) healthcare professionals' knowledge and understanding; (2) communication; (3) workforce development; (4) interprofessional working; (5) confounders; and (6) organizational constraints.

CONCLUSIONS

Of significance, for older adults in hospital experiencing delirium, there is variability in whether and how well it is recognized and managed. To prevent adverse outcomes best practice guidance for screening, recognizing, diagnosing and managing delirium in older people needs to be agreed and disseminated widely. Supporting healthcare professionals to care for this patient population using an integrated approach is essential, how to involve and communicate with patients and their family and friends, how to recognize and manage delirium for patients with additional needs, e.g., those living with dementia and/or a learning disability. Hospitals need to have policy and guidance in place for the recognition and management of delirium in older adults presenting to a ward or to an emergency department. An IT infrastructure is needed that integrates assessments and care management plans in patient electronic records and makes them accessible within and across teams in hospital, primary and community care settings.

PATIENT OR PUBLIC CONTRIBUTION

There was no patient or public contribution to this systematic review.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

Healthcare professionals can be better supported to be able to recognize and manage delirium during an acute hospital stay for older adults. This includes maximizing best care for those patients living with dementia, involving families and friends to help understand patients' baseline status and changes and supporting families and friends during this process. Of significance, attention to hospital IT infrastructures is warranted, integrating screening, assessment and care management plans in patients' electronic records and making these accessible to healthcare professionals caring for this patient population across care settings.

IMPACT

What problem did the study address? Delirium is a common condition experienced by older hospitalized patients, but it is consistently under-recognized which has implications for patient and organization outcomes. To help address this, understanding barriers to healthcare professionals recognizing and managing delirium for this patient population is paramount. What were the main findings? Barriers to healthcare professionals recognizing and managing delirium for this patient population were synthesized in six themes: (1) healthcare professionals' knowledge and understanding, (2) communication; (3) workforce development; (4) interprofessional working; (5) confounders; and (6) organizational constraints. Where and on whom will the research have an impact? The findings of this original systematic review can contribute to hospital policy and protocol for the recognition and management of delirium in older patients. The findings can meaningfully contribute to workforce professional development for practitioners caring for older people during an acute hospital stay and for practitioners in primary and community settings involved in the follow-up of patients post hospital discharge. For researchers, the findings indicate several research recommendations including investigating the impact of an education programme for nurses and other healthcare professionals on the recognition and management of the condition and understanding and investigating how best to support delirium-related distress experienced by patients and their families and practitioners.

REPORTING METHOD

This systematic review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Page et al., 2021).