Skip to content
Skip to content
Open navigation

Delirium: Prevent, Identify, Treat

A joint and interdisciplinary collaboration between the American Nurses Association and the American Delirium Society

Delirium is an acute, serious, and often preventable, medical condition characterized by confusion and a disturbed thought process, often following assault to the body such as surgery, infection, dehydration, or certain medications. Delirium affects large numbers of patients across all healthcare settings, including children, by negatively impacting patient outcomes, causing family caregiver distress and increasing financial costs.

Did you know delirium is common, serious, and often preventable?

Common

  • Delirium occurs in up to 25% hospitalized patients, 50% of surgical patients, 20% of nursing home patients, 77% of burn patients and 75% of ICU patients.1, 2
  • An estimated 37% of surgical patients experience postoperative delirium.3
  • Delirium may be higher in patients 70 years of age or older.3
  • Delirium occurs in up to 50% of patients with dementia that require hospitalization.4

Serious

  • Delirium is associated with many adverse outcomes which include: increased mortality, falls, functional decline, cognitive impairment and decline and significant costs.5
  • Delirium superimposed on dementia may accelerate the trajectory of decline and often results in long lengths of stay, readmissions, premature nursing home placement or death.4
  • Delirium is a major financial burden to medical services and costs range from $38 to $152 billion per year.3

Preventable

  • Since frontline nurses are in direct contact with patients 24 hours per day and seven days a week, RNs need to drive delirium prevention. The best prevention protocol simply consists of high-level nursing care.6

 

Who We Are

American Nurses Association/American Delirium Society Steering Committee Members

Mary Jo Assi, CO-CHAIR • Marianne Shaughnessy, CO-CHAIR

Rakesh Arora • John Devlin • Donna Marie Fick • Joseph Flaherty • Sharon Gordon • Babar Khan • Ann Marie Kolanowski • Jose Maldonado • Karin Neufeld • Pratik Pandharipande • Joyce Parks • James Rudolph • Heidi Smith • Yibing Tan • Christine Waszynski • Megan Wheeler
 

American Nurses Association Delirium Work Group Members

Claudia Smith, CHAIR

Mary Jo Assi • Stewart Bond • Edward Briggs • Matt Brown • Holly Carpenter • Mary Kate Eanniello • Petra Grami • Cheryl Haseeb • Laura Hoofring • Ruth Ludwick • Sheila Molony • Donal Palencia • Joyce Parks • Padmini Paul • Hannah Noori • Stacey Williams • Andrea Yevchak • Margarete Zalon

Introduction

Proper clinical identification of delirium and quick use of personalized evidence-based interventions is the hallmark of treatment. Failure to identify and treat can result in increased costs but even more importantly, poor patient outcomes and subsequent decreased quality of life.

Failure to or delay in identifying delirium is common in healthcare. To compound the issue of delayed diagnosis and lack of early intervention, healthcare providers, including nurses, often contribute to the incidence of delirium by administering treatments and medications that can cause this serious condition. During the last several years there has been a notable increase in research focused on evidenced-based prevention, identification, and treatment of delirium. The bedside nurse is in a unique position to make a clinical difference for these vulnerable patients by using a systematic approach.

Delirium is a condition that can be marked by fluctuating levels of consciousness with inattention as the key feature and can be a mix of the hypoactive and hyperactive types. It is well established that delirium's adverse consequences include functional decline 1, increased likelihood of falls2,3, (3) longer hospital length of stay3, (4) hospital readmissions4, (5) greater likelihood of nursing home placement1,5, (6) increased risk for subsequent development of dementia or cognitive impairment6, and (7) higher morbidity and mortality7. Evidence-based management of delirium requires an individualized, multi-component approach. An interdisciplinary approach to prevent, manage, and treat delirium is essential. This website has been created for the practitioner to be able to access high quality, evidence-based resources. It is our hope that the user will apply this information to improve the quality of care and the quality of life of those affected.

References:

1 Dasgupta, M., & Brymer, C. (2014). Prognosis of delirium in hospitalized elderly: Worse than we thought. International Journal of Geriatric Psychiatry, 29(5), 497-505. doi: 10.1002/gps.4032.

2 Lakatos, B. E., Capasso, V., Mitchell, M. T., Kilroy, S. M., Lussier-Cushing, M., Sumner, L., Repper-Delisi, J., Kelleher, E. P., Delisle, L. A., Cruz, C., & Stern, T. A. (2009). Falls in the general hospital: Association with delirium, advanced age, and specific surgical procedures. Psychosomatics, 50(3), 218-226. doi: 10.1176/appi.psy.50.3.218.

3 Mangusan, R. F., Hooper, V., Denslow, S. A. & Travis, L. (2015). Outcomes associated with postoperative delirium after cardiac surgery. American Journal of Critical Care, 24(2), 156-163. doi: 10.4037/ajcc2015137.

4 Koster, S., Hensons, A. G. Schuurmans, M. J., & van der Palen, J. (2012). Consequences of delirium after cardiac operations. Annals of Thoracic Surgery, 93(3), 705-711. doi: 10.1016/j.athoracsur.2011.07.006.

5 Krogseth, M., Wyller, T. B., Engedal, K. & Juliebø, V. (2014). Delirium is a risk factor for institutionalization and functional decline in older hip fracture patients. Journal of Psychosomatic Research, 76(1), 68-74. doi: 10.1016/j.jpsychores.2013.10.006.

6 Krogseth, M., Watne, L. O., Juliebø, V., Skovlund, E., Engedal, K., Frihagen, F. & Wyller, T. B. (2016). Delirium is a risk factor for further cognitive decline in cognitively impaired hip fracture patients. Archives of Gerontology and Geriatrics, 64, 38-44. doi: 10.1016/j.archger.2015.12.004.

7 Pauley, E., Lishmanov, A., Schumann, S., Gala, G. J., van Diepen, S. & Katz, J. N. (2015). Delirium is a robust predictor of morbidity and mortality among critically ill patients treated in the cardiac intensive care unit. American Heart Journal, 170(1), 79-86, 86e1. doi: 10.1016/j.ahj.2015.04.013.
 

Landing Page “Did You Know” Statistics References:

1 Rudolph, J. L., Archambault, E., Kelly, B. & VA Boston Delirium Task Force. (2014). A delirium risk modification program is associated with hospital outcomes. Journal of American Medical Directors Association, 15(12), 957e7-957e11.

2 Agarwal, V., O’Neil, P. J., Cotton, B. A., Pun, B. T., Haney, S., Thompson, J., Kassebaum, N., Shintani, A., Guy, J., Ely, E. W., & Pandharipande, P. (2010). Prevalence and risk factors for development of delirium in burn intensive care unit patients. Journal of Burn Care and Research, 31(5), 706-15. doi: 10.1097/BCR.0b013e3181eebee9.

3 Zhang, H., Lu, Y., Liu, M., Zou, Z., Wang, L., Xu, F. Y., & Shi, X. Y. (2013). Strategies for prevention of postoperative delirium: A systematic review and meta-analysis of randomized trials. Critical Care, 17(2), 1-21.

4 Kolanowski, A., Fick, D., Clare L., Therrien, B., & Gill, D. (2010). An intervention for delirium superimposed on dementia based on cognitive reserve. Aging & Mental Health, 14(2), 232-242. doi: 101080/136907860903167853

5 Martinez, F., Tobar, C., & Hill, N. (2015). Preventing delirium: should non-pharmacological, multicomponent interventions be used? A systematic review and meta-analysis of the literature. Age and Ageing, 44(2), 196-204. doi: 101093/ageing/aful73

6 Rivosecchi, R. M., Smithburger, P. L., Svec, S., Campbell, S., & Kane-Gill, S. L. (2015). Non-pharmacological interventions to prevent delirium: An evidence-based systematic review. Critical Care Nurse, 35(1), 39-51.

Select Delirium Resources

For a comprehensive overview of delirium as well as multiple resources, please visit the American Delirium Society’s website:https://www.americandeliriumsociety.org/
 

Media Type

Year

Name

Webpage

Description

Family Education

Family Education

Professional Education

💻 Website
👓 Article/Book

2016

Australian Delirium Association

Healthcare Professionals

http://delirium.
org.au/

Website for community and healthcare professionals with information on delirium

  • Bi-annual Newsletter (Events/Updates)
  • Delirium facts, definition, risk factors/causes, prevention, early identification, accurate diagnosis, management and impact
  • Links to other websites for delirium education
  • Journal Articles and Reviews

Family Education

Professional Education

💻 Website
📄 Handouts
☉ CD/DVD/     Video

2016

ICU-Delirium and Cognitive Impairment Study Group

http://www.icu
delirium.org/

http://www.icu
delirium.org/
patients.html

ICU Delirium and Cognitive Impairment Study Group: Vanderbilt University, Monroe Carell Jr. Children’s Hospital at Vanderbilt, & US Dept of Veteran Affairs (VA). Website for healthcare professionals and family about delirium, which includes patients of all ages and populations

  • Delirium facts, terminology and learning mnemonics
  • ABCDEF Bundle for delirium prevention
  • Assessment
  • Patient testimonials
  • References/Research Studies/Articles
  • Learning tools for healthcare professionals/Videos/Handouts/Charts
  • Learning Tools for families/Brochures/Videos/Handouts

Family Education

Professional Education

Patient Education

💻 Website
📄 Handouts
☉ CD/DVD/     Video

2016

Hospital Elder Life Program (HELP)

Family, Healthcare Professionals

www.hospital
elderlife
program.org

The Hospital Elder Life Program (HELP) is an informative website that provides

  • Access to various versions of the Confusion Assessment Method (CAM) delirium assessment tools for healthcare professionals.
  • Family members and patients access to information on delirium.
  • A newsletter with current information
  • Upcoming conference Information
  • New research findings
  • Journal articles and resource links
  • Patient and family resources and websites
  • Delirium assessment tools with user information (Long CAM, Short CAM, CAM-S Severity, FAM CAM, 3D- CAM, Chart Del)

Family Education

📄 Handouts

2016

Delirium

http://www.
upmc.com/
patients-visitors/
education/
behavioral-
health/pages/
delirium.aspx

University of Pennsylvania Medical Center patient and family delirium education information page on delirium.

Family Education

☉ CD/DVD/     Video

2012

Dept. of VA

Delirium Quiet & Excited

https://www.
youtube.com/
watch?v=
M4wsPTtGeIc

Barbara Kamholz, MD developed the video, as a federal employee, to assist those who care for persons in delirium. This video helps families understand the beginning of delirium and its intervention.

Family Education

2010

In the Intensive Care Unit Delirium

http://www.icu
delirium.org/
docs/delirium_
education_
brochure.pdf

ICU Delirium & Cognitive Impairment Study Group. Educational brochure for family members of patients who experience delirium.

General Education

Professional Education

☉ CD/DVD/     Video

2016

Delirium: Hidden Dangers and Beyond

https://www.
youtube.com/
watch?v=
r6mgBwiz6yE

American Association of Critical Care Nurses, Houston Gulf Coast Chapter created an educational video to raise delirium awareness and provide an introduction to the Grami-Smith Delirium Prevention Bundle© as a delirium prevention strategy.

Target Audience: All
Time: 12.08 minutes.

Professional Education

💻 Website

2016

iDelirium

http://www.
idelirium.org/

iDelirium is a collaboration of three delirium organizations working with patients, caregivers, professionals, and policymakers to promote delirium science.

Professional Education

☉ CD/DVD/     Video

2015

Delirium in Healthcare Thriller Style

https://m.
youtube.com/
watch?feature=
youtu.be&v=
dKCqdOoYb38

American Association of Critical Care Nurses, Houston Gulf Coast Chapter created a short Michael Jackson “Thriller” style video to raise delirium awareness and provide introduction to staff nurses on delirium prevention using the Grami-Smith Delirium Prevention Bundle© as a prevention strategy.

Target Audience: Healthcare Professionals
Time: 5:58 minutes.

Professional Education

👓 Article/Book
📄 Handouts

2015

Delirium Resources

http://www.viha.
ca/mhas/
resources/
delirium/
tools.htm

Vancouver Island Health Authority. Website of delirium resources for families and health care professionals including quick reference tools and quizzes.

Professional Education

💻 Website
👓 Article/Book

2016

American Association of Critical-Care Nurses

Delirium Assessment and Management

www.aacn.org

http://www.
aacn.org/wd/
practice/content/
practicealerts/
delirium-
practice-
alert.pcms?
menu=practice

Website for healthcare professionals about delirium in patients of all ages and populations

  • References, research studies, articles
  • Practice guidelines and Best Practice Alerts

Professional Education

💻 Website

2016

European Delirium Association

http://www.
european
delirium
association.com/

Website for healthcare professionals and other interested parties on delirium. Includes videos and other resources.

Professional Education

💻 Website
📄 Handouts
☉ CD/DVD/     Video

2016

ICU Delirium and Cognitive Impairment Study Group

www.icudelirium
.org/resources.
html

Webpage of resources for healthcare professionals related to screening and assessment of delirium, and management using The ABCDEF Bundle. Webpage includes a variety of education slides in addition to other materials.

Social Media

Professional Education

2016

American Delirium Society Facebook

https://www.
facebook.com/
theamerican
deliriumsociety

 

Professional Education

2016

American Delirium Society Twitter

@AmerDelirium

 

Professional Education

2016

Delirium Care Network Twitter

@DeliriumCare

 

Professional Education

2016

European Delirium Association Facebook

https://www.
facebook.com/
EDA.delirium/
?fref=ts

 

Palliative Care

Professional Education

☉ CD/DVD/     Video

2011

Delirium – presentation, issues and management in Palliative Care

https://www.
youtube.com/
watch?v=pkVia
_NIc-k

Uploaded on April 3, 2011.

Dr. Ted Braun, Alberta Health Services, provided the plenary at the annual conference of the Saskatchewan Hospice Palliative Care Association (SHPCA). The one-hour video addresses delirium in the home health and inpatient settings for the palliative care population. It includes case study reviews, subtypes of delirium, signs and symptoms, delirium assessment tools, and delirium management suggestions.

Older Adults

Professional Education

☉ CD/DVD/     Video

2012

Dept. of VA, Geriatric Research Education & Clinical Centers (GRECC)

Agitated Behaviors Among Older Hospitalized Patients

https://www.
youtube.com/
watch?v=
GrJypBgHUxk

This video includes common vignettes of older hospitalized patients who appear agitated. For each vignette, viewers will see how staff try to handle the situation, first in a traditional way which is not very effective; then, in a more successful way that demonstrates the T-A-DA method (Tolerate, Anticipate, Don't Agitate).

Professional Education

☉ CD/DVD/     Video

2012

Dept. of VA, GRECC

Agitated Behaviors Among Older Nursing Home Residents

https://www.
youtube.com/
watch?v=
iORtNxwMK6o

This video includes common vignettes of older patients living in a nursing home who either become agitated or are agitated. For each vignette, viewers will see how staff try to handle the situation, first in a traditional way which is not very effective; then, in a more successful way that demonstrates the T-A-DA method (Tolerate, Anticipate, Don't Agitate).

Pediatric Assessment Tools

💻 Website

2016

ICU Delirium and Cognitive Impairment Study Group

pCAM-ICU

http://www.icu
delirium.org/
pediatric.html

The pCAM-ICU was adapted from the Confusion Method for the ICU (CAM-ICU) for use in intubated or non-intubated children who are at least 5 years of age and who do not demonstrate significant developmental delay. The webpage provides pocket cards for delirium monitoring using the pCAM-ICU and either the RASS or SBS on the webpage.

💻 Website

2016

ICU Delirium and Cognitive Impairment Study Group

psCAM-ICU

http://www.icu
delirium.org/
pediatric.html

Recently developed delirium assessment tool which is used in infants at least 6 months of age. Validation studies are in progress. Patients may be critically ill, intubated or non-intubated.

Adult Assessment Tools

💻 Website

2015

American Geriatrics Society 2015 updated Beers Criteria for potentially inappropriate medication use in older adults

https://www.
guideline.gov/
summaries/
summary/49933

List of drugs that may be inappropriate for use in older adults including the rationale, recommendation, quality of the evidence, and the strength of the recommendation.

☉ CD/DVD/     Video

2016

ConsultGeri

https://consult
geri.org/

A clinical website of The Hartford Institute for Geriatric Nursing. Classic assessment tools commonly used in the geriatric population. Includes delirium screening tools and links as well as sections dedicated to specialty nursing and/or caring for persons with dementia.

👓 Article/Book
☉ CD/DVD/     Video

2011

Delirium: The under-recognized medical emergency “How to Try This” Video.

http://journals.
lww.com/
ajnonline/
Fulltext/2007/
12000/How_to_
Try_This__
Detecting_
Delirium.
27.aspx

American Journal of Nursing. Provides access to article and training video. This video guides viewers through the utilization of two tools: the Confusion Assessment Method (CAM) and Assessing and Managing Delirium in Older Adults with Dementia. In this five chapter program, two patients are presented and assessed for delirium using the CAM: one with delirium and one with a delirium superimposed on an underlying dementia. Once identified, further assessment and treatment of the underlying etiology and safe management of care is shown using the Delirium Superimposed on Dementia Algorithm.

Time: 51.19 minutes.

👓 Article/Book

Rev. 2012

The Geriatric Depression Scale (GDS)

https://consult
geri.org
/try-this
/general-
assessment/
issue-4.pdf

From the Hartford Institute for Geriatric Nursing, New York University College of Nursing, this article outlines the strengths, limitations, and validity and reliability of the GDS, as well as its target population. It also includes the short form of the GDS.

👓 Article/Book
💻 Website

 

Nursing Home Toolkit

www.nursing
hometoolkit.
com

Prepared for the Commonwealth Fund in collaboration with The John A. Hartford Foundation with A. Kolanowski & K. Van Haitsma as expert panel coordinators. Nursing Home Toolkit focuses on behavioral health of nursing home residents, although the information is pertinent to hospitalized patients as well. Primary focus of webpage is dementia. A small amount of information about delirium is found under the heading, Toolkit. In the Assessment section, pay particular attention to the NOTE in the middle of the page and the two citations listed. In the heading, Urgent and Unresolved Behaviors, explore the section, Managing Specific Behaviors. In the second row of topics explore the topic, Delirium /Acute Confusion.

☉ CD/DVD/     Video
📄 Handouts
💻 Website

2014

RADAR Training materials, poster, research results, videos, and validation results

http://radar.
fsi.ulaval.ca/
?page_id=54

Phillip Voyeur et al. The first presentation focuses on the proper use of the R.A.D.A.R. delirium assessment tool. The presentation focuses on the proper use of the RADAR delirium assessment tool for nurses. Effectively uses cases studies as teaching tools. Does not include information about scoring the results.

Time: 26:28 minutes.

Definitions of different types of delirium that are found in the DSM are discussed. The second video presents validation statistics of the RADAR tool, which is intended for nurses to assess patients for delirium.

Time: 20:47 minutes.

👓 Article/Book

2015

American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 5th | DSM-5

dsm.psychiatry
online.org

The DSM-5 is a resource for all healthcare professionals. It is a resource with current information to help guide clinical practice in the treatment of mental health issues in various healthcare settings. Delirium diagnosis and management is discussed. Links to numerous articles and research studies on delirium.

📄 Handouts
☉ CD/DVD/     Video
💻 Website

2016

Adult Non-ICU Care: Monitoring Delirium

http://www.icu
delirium.org/
non-icu.html

The ICU Delirium and Cognitive Impairment Study Group provides a rich source of delirium assessment tools for use in hospital areas outside of the ICU. The following tools are highlighted: The Delirium Triage Screen (DTS); The Brief Confusion Assessment Method (bCAM); The Confusion Assessment Method (CAM); The 3D CAM for elders takes approximately 3 minutes; and the 4 ‘A’s Test (4AT), which is used commonly internationally and takes approximately 2 minutes to complete. Instructions, flow sheets, articles, and links are located on the webpage.

☉ CD/DVD/     Video
💻 Website
📄 Handouts

2016

Hospital Elder Life Program

Long CAM Instrument

Confusion Assessment Method (Short CAM)

http://www.
hospitalelder
lifeprogram.org/
delirium-
instruments/
confusion-
assessment-
method-long-
cam/

http://www.
hospitalelder
lifeprogram.org/
delirium-
instruments/
short-cam/

The Confusion Assessment Method (CAM) was developed to improve the recognition of delirium by non-psychiatrists. Confusion Assessment Method (CAM) is the most widely studied and used assessment tool for non-ICU delirium.

The Long CAM is a very comprehensive tool, however the Short CAM is used more often because it has been validated in research studies and can be completed in five minutes.

💻 Website
📄 Handouts

2016

Hospital Elder Life Program

FAM-CAM (Family CAM)

http://www.
hospitalelder
lifeprogram.org/
delirium-
instruments/
fam-cam/

The Family-CAM (FAM-CAM) was developed from the CAM and aids the healthcare team in the detection of delirium based on feedback from the family. The tool was developed to assist the clinician in early detection and must be used with another reliable validated tool to diagnose delirium.

💻 Website
📄 Handouts
👓 Article/Book

2016

4AT

http://www.
the4at.com/

This validated tool was designed for the rapid assessment of delirium and cognitive impairment at first patient contact by any health professional. It is widely used in clinical practice in the UK and internationally.

👓 Article/Book

2013

ICU Delirium and Cognitive

http://www.
icudelirium.org/
resources.html

This website link provides a multitude of delirium assessment tools, complete with training manuals, flow and worksheets, and FAQs.

Guidelines

Best Practice Guidelines

👓 Article/Book

2010

NICE

National Institute for Health and Care Excellence

https://www.
nice.org.uk/
guidance/cg103/
chapter/
1-Guidance

Website addresses delirium in the adult population and discusses diagnosis, prevention and management in various clinical settings. It is well-recognized evidence-based guidance that sets the standard of quality of delirium care in hospitals and long term care settings.

Best Practice Guidelines

👓 Article/Book

2016

Canadian Agency for Drugs and Technologies in Health

http://www.ncbi.
nlm.nih.gov/
pubmedhealth/
PMH0084861/

Fully downloadable report on the Treatment of Older Adults with Insomnia, Agitation, or Delirium with Benzodiazepines: A Review of Clinical Effectiveness and Guidelines.

Best Practice Guidelines

👓 Article/Book

2014

American Geriatrics Society (AGS) Expert Panel on Postoperative Delirium in Older Adults.

http://
geriatricscare
online.org/
ProductAbstract/
american-
geriatrics-
society-clinical
-practice-
guideline-for-
postoperative-
delirium-in-
older-adults/
CL018/

This American Geriatrics Society (AGS) clinical practice guideline was developed to identify evidence-based pharmacological and non-pharmacological strategies that should be implemented in the perioperative period for the prevention and treatment of postoperative delirium in older patients who are identified as at risk for delirium with delirium risk prediction models. Guideline development was based upon the AGS framework, with a standardized process for literature review, and rating the quality and strength of the recommendations. The nonpharmacological recommendations address (1) health professionals' education about delirium, (2) multicomponent interventions performed by an interdisciplinary team for delirium prevention and management, (3) identification and management of delirium's causes and (4) specialized hospital units. Pharmacological interventions address (1) anesthesia depth, (2) regional anesthesia, (3) analgesia, (4) avoidance of inappropriate medications, (4) medications including antipsychotics, cholinesterase inhibitors, benzodiazepines and medications for severe agitation, and (5) pharmacological management of hypoactive delirium.

Please note that you must register for this article, but it is free.

Miscellaneous

Best Practice Guidelines

📄 Handout

2016
Updated

Delirium & Acute Encephal-
opathy Care Pathway

ADAPT
(Actions for Delirium Assessment Prevent & Treatment), Hartford Hospital

Not available
at this time

See brochure
here

Brochure sponsored by ADAPT (Actions for Delirium Assessment Prevent & Treatment), Hartford Hospital. This brochure outlines drugs to limit and/or avoid, possible etiologies, various assessment methods, and several actions and assessments for the health care providers and patients.

Professional Education

💻 Website

2017

American Nurses
Association

Safe Patient
Handling and Mobility

Handle with Care

This website contains tools, videos, and other resources that describe safe patient handling and mobility practices that can assist with early mobility. Early mobility can be beneficial in preventing and treating delirium.

 

Last edited 7/27/2017

References

General

De, J., & Wand, A. F. (2015). Delirium screening: A systematic review of delirium screening tools in hospitalized patientsThe Gerontologist, 55(6), 1079-1099. doi:10.1093/geront/gnv100

This review aimed to identify, compare, and evaluate delirium screening tools used in non-critically ill hospitalized patients and to provide guidance on using the tools in different patient populations. A search of MEDLINE, CINAHL, and PsychInfo databases identified 31 studies of 21 delirium screening tools. Most studies were conducted in mixed populations of older hospitalized patients. Others were conducted in surgical, emergency department, oncology, and palliative care patients exclusively. The Confusion Assessment Method (CAM) was the most widely studied tool. Considerations for selecting a delirium screening tool and suggestions for using specific tools in different populations are provided.

Hshieh, T. T., Yue, J., Oh, E., Puelle, M., Dowal, S., Travison, T., & Inouye, S. K. (2015). Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysisJAMA Internal Medicine, 175(4), 512-520. doi:10.1001/jamainternmed.2014.7779

This study drew articles from PubMed, Google Scholar, ScienceDirect, and the Cochrane Database of Systematic Reviews and specifically looked at 14 studies for the impact of 12 unique nonpharmacological interventions on delirium incidence, falls, length of stay, rate of discharge to a long term institutionalization, and change in status (functional or cognitive). Interventions were based on Hospital Elder Life Program (HELP) protocols. Meta-analysis was performed only for outcomes of delirium incidence, falls, length of stay, and institutionalization. Authors summarize that non-pharmacologic interventions have shown to decrease not only delirium incidence but preventing falls, an outcome that has not been as well investigated as other outcomes.

Inouye, S. K., Westendorp, R. J., & Saczynski, J. S. (2014). Delirium in elderly peopleLancet, 383(9920), 911-922. doi:10.1016/S0140-6736(13)60688-1

A review was performed of original articles on delirium occurring in those aged 65 and older. Utilizing the data bases of Medline, PubMed, article reference lists, and other reviews, articles published between 1990-2012 were selected. The epidemiology, diagnosis, etiology, pathophysiology, evaluation, prevention and treatment methods, controversies, and recommendations for research regarding delirium in the elderly were summarized. Findings for elderly patients with delirium were listed. These included: use cognitive screening and the CAM on all elderly hospitalized patients for delirium; evaluate the necessity of medications prescribed; use nonpharmacological approaches when appropriate; involve the patient’s family; encourage movement; involve patient in care and self-care; ensure availability of assistive devices; and keep patients informed of their schedule.

Kalish, V. B., Gillham, J. E., & Unwin, B. K. (2014). Delirium in older persons: evaluation and managementAmerican Family Physician, 90(3), 150-158.

This article provides a concise yet comprehensive overview of best practices in evaluation and management of delirium in diverse settings. After presenting a case study, the article summarizes the definition, diagnostic criteria, incidence, prevalence and risk factors for delirium. Methods to identify delirium are provided, including the Confusion Assessment Method (CAM) and recommendations are given for appropriate evaluation of associated symptoms to identify underlying illnesses. The article reviews non-pharmacologic and pharmacologic interventions and best practices. This is a useful resource for nurses and advanced practice nurses working in all settings including ICU, acute care, long-term care, community and hospice. CME credits offered.

Maldonado, J. R. (2013). Neuropathogenesis of delirium: Review of current etiologic theories and common pathwaysAmerican Journal of Geriatric Psychiatry, 21(12), 1190-1222. doi:10.1016/j.jagp.2013.09.005

This article is a review of the literature and summary of the seven proposed theories that attempts to explain what happens on a neuronal level during illness leading to the cognitive and behavioral changes seen in delirium. These theories include: Neuroinflammatory, Neuronal Aging, Oxidative, Neurotransmitter, Neuroendocrine and Network Disconnectivity Hypotheses. The article further discusses how these theories complement each other and the intersections and reciprocal influences they share.

Martinez, F., Tobar, C., & Hill, N. (2015). Preventing delirium: should non-pharmacological, multicomponent interventions be used? A systematic review and meta-analysis of the literatureAge and Ageing, 44(2), 196-204. doi:ageing/afu173

This study obtained articles from 7 data bases including PubMed/MEDLINE, EMBASE, PsychInfo, CINAHL, Cochrane Library, Cochrane Register Controlled Trials (CENTRAL), LILACS, ScieELO, and grey literature repositories. A systematic review of randomized trials included 7 studies exploring multicomponent interventions to reduce delirium incident and accidental falls during hospitalization. A non-significant reduction in delirium duration, hospital stay and mortality were also discovered. Authors summarized the systematic review and meta-analysis, thus concluding that multicomponent interventions were effective in reducing incident of delirium and reducing accidental falls. The effects did not differ according to clinical setting and should be standard of care for elderly inpatients.

Yue, J., Tabloski, P., Dowal, S. L., Puelle, M. R., Nandan, R., & Inouye, S. K. (2014). NICE to HELP: Operationalizing National Institute for Health and Clinical Excellence Guidelines to improve clinical practiceJournal of the American Geriatrics Society, 62(4), 754-761. doi:10.1111/jgs.12768

The purpose of the article was to share results of a rigorous process to align intervention protocols of the HELP program with the NICE guidelines. The authors conducted a systematic review of all English language articles that were accessed through the PubMed and CINAHL databases from January 1, 2008 through December 31, 2012 on the topics of hypoxia, infection, and pain, which were part of the NICE guidelines, but were not included in the HELP program. Likewise, they explored the same literature to expand the existing dehydration protocol in the HELP program so as to include constipation as one of the target areas. As a result, the NICE guidelines for delirium prevention were fully operationalized and align with the HELP program.

Surgical

American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults. (2015). American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults. (2015). Journal of the American Geriatrics Society, 63(1), 142-150. doi:10.1111/jgs.1328

This American Geriatrics Society (AGS) clinical practice guideline was developed to identify evidence-based pharmacological and non-pharmacological strategies that should be implemented in the perioperative period for the prevention and treatment of postoperative delirium in older patients who are identified as at risk for delirium with delirium risk prediction models. Guideline development was based upon the AGS framework, with a standardized process for literature review, and rating the quality and strength of the recommendations. The nonpharmacological recommendations address (1) health professionals’ education about delirium, (2) multicomponent interventions performed by an interdisciplinary team for delirium prevention and management, (3) identification and management of delirium’s causes and (4) specialized hospital units. Pharmacological interventions address (1) anesthesia depth, (2) regional anesthesia, (3) analgesia, (4) avoidance of inappropriate medications, (5) medications including antipsychotics, cholinesterase inhibitors, benzodiazepines and medications for severe agitation, and (6) pharmacological management of hypoactive delirium.

ICU

Balas, M. C., Vasilevskis, E. E., Burke, W. J., Boehm, L., Pun, B. T., Olsen, K. M., Peitz, G. J., & Ely, E. W. (2012). Critical care nurses' role in implementing the "ABCDE bundle" into practiceCritical Care Nurse, 32(2), 35-38, 40-47; quiz, 48. doi:10.4037/ccn2012229

This article focuses on the implementation of the “ABCDE Bundle” as an evidenced based strategy to decrease the incidence an duration of delirium in the ICU setting. Awakening and breathing, delirium monitoring and early mobilization are strategies that are proven to help lessen the negative effects of an ICU admission. The article reviews the evidence, the importance of the inter-professional team as well as the importance of consistent adherence to the bedside routines to create successful implementation. A strength of the article is a real time “walk through” of how the bundle is implemented in the clinical setting. It includes many useful charts and work flow diagrams which make this article highly appealing for bedside providers.

Barr, J., Fraser, G. L., Puntillo, K., Ely, E. W., Gelinas, C., Dasta, J. F., Davidson, J., E., Devlin, J. W., Kress, J. P., Joffe, A. M., Coursin, D. B., Herr, D. L., Tung, A., Robinson, B. R. H., Fontaine, D. K., Ramsay, M. A., Riker, R. R., Sessler, C. N., Pun, B., Skrobik, Y., & Jaeschke, R. (2013). Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Critical Care Medicine41(1), 263-306. Doi: 10.1097/CCM.0b013e3182783b72

The article updates and includes evidence-based guidelines and recommendations for healthcare professionals for the prevention and management of delirium in the critical care setting. This was done by an interdisciplinary task force of twenty individuals over a six year period.

Trogrlic, Z., van der Jagt, M., Bakker, J., Balas, M. C., Ely, E. W., van der Voort, P. H., & Ista, E. (2015). A systematic review of implementation strategies for assessment, prevention, and management of ICU delirium and their effect on clinical outcomesCritical Care, 19(1), 157-157. doi:10.1186/s13054-015-0886-9

This study was a systematic review of 21 articles pulled from 5 different databases (PubMed, Embase, PsychINFO, Cochrane and CINAHL) that analyzed the implementation strategies for assessment, prevention and management of ICU delirium. All of the studies reviewed included process measures and nine of the studies used both process measures and clinical outcomes. Results from the study showed that implementation of successful interventions often changed process measures but strong data supporting outcome measures was not evident. The study’s findings indicated that implementing multi-component programs with more strategies that targeted ICU delirium assessment; prevention and treatment are more likely to improve clinical outcomes when combined with pain agitation and delirium (PAD) or awakening, breathing coordination, choice of sedative, delirium monitoring and early mobility (ABCDE) bundles.

Cancer

Lawlor, P. G., & Bush, S. H. (2015). Delirium in patients with cancer: assessment, impact, mechanisms and management. Nature Reviews Clinical Oncology12(2), 77-92. doi:10.1038/nrclinonc.2014.147

This comprehensive review looks at delirium in patients with cancer. The authors searched MEDLINE and Scopus databases for articles between January 1990 and October 2013. It acknowledges that delirium is common with rates up to 90% with advanced cancer. The authors review validated assessment tools available for screening, and monitoring the severity of Delirium. They also discuss predisposing and precipitating factors, reversibility of delirium, and pathophysiology of delirium in the cancer population. Lastly, the article discusses non-pharmacological and pharmacological interventions to treat delirium and refractory delirium.

Palliative

Hosie, A., Davidson, P. M., Agar, M., Sanderson, C. R., & Phillips, J. (2013). Delirium prevalence, incidence, and implications for screening in specialist palliative care inpatient settings: a systematic reviewPalliative Medicine, 27(6), 486-498. doi:10.1177/026921631245721

The purpose of this article was to look at how delirium occurrence was measured in inpatient palliative or hospice settings and to also report on the overall quality and results of that research. A total of eight articles published from 1980 until now were included in this systematic review across the CINAHL and Medline databases. The authors found that the majority of research included both delirium screening and formal assessment, typically diagnosed using DSM criteria. Eight different screening and assessment tools were used across the studies, including delirium tools (i.e., CAM or DRS) and cognition tools (i.e., MMSE). Overall results found that delirium occurrence was lowest upon admission and increased closer to the time of death, with rates as high as 88%. Hypoactive delirium was also found to be the most predominant subtype in this population.

Delirium & Dementia

Fong, T. G., Davis, D., Growdon, M. E., Albuquerque, A., & Inouye, S. K. (2015). The interface between delirium and dementia in elderly adults. The Lancet Neurology14(8), 823-832.

This paper reviews scientific evidence from laboratory and clinical studies that support a link between delirium and dementia. The paper describes evidence that supports the role of dementia as an independent risk factor for delirium; delirium as an independent risk factor for dementia; and evidence from clinicopathological, neuroimaging and biomarker studies that suggest both shared and distinct mechanisms of neuronal injury. The role of delirium as a marker of brain vulnerability, mediator of noxious insults and/or contributor to neuronal damage is described. This paper is useful for nurses seeking deeper understanding of the relationship between acute and chronic cognitive impairment.

Family

Halloway, S. (2014). A family approach to delirium: a review of the literature. Aging & Mental Health, 18(2), 129-139. doi:10.1080/13607863.2013.814102

This article reviews studies that explore a family approach to the prevention and management of delirium. It explores the current state of research related to delirium identification and treatment through the lens of family involvement. The review exposes a need for much further exploration and research on the use of family in the management of delirium, especially for the at risk elder patient. The majority of studies reviewed were lower level evidence but two high quality studies, one multi-component intervention and one bedside intervention improved delirium outcomes significantly. Eleven articles met criteria for the review, which demonstrated a need to further explore this understudied topic.

Pediatrics

Kelly P. & Frosch E. (2012). Recognition of delirium on pediatric hospital services. Psychosomatics53(5), 446-51. doi: 10.1016/j.psym.2012.04.012.

A retrospective chart review noting that out of 515 pediatric patients in which psychiatry was consulted; only 6 of the consults were delirium noted by the medical team. An additional 47 were diagnosed with delirium by psychiatry, which means the medical team missed 88%. The article brings to light not only the need for the use of bedside tools to detect delirium by the medical staff but also the importance of the psychiatry team.

Williams, S. R. (2016). How to recognize delirium in pediatric patients. American Nurse Today11(5), 8-11.

This article provides nurses an overview on how to identify delirium in the pediatric patient. It gives detailed information on commonly used delirium assessment tools used specifically for the pediatric population. Each description includes the tool’s background, sensitivity/specificity, and age range. Nursing actions are then listed with the appropriate reasoning behind the action, as well as suggestions for care in specific circumstances.

Early Mobility

Balas, M. C., Vasilevskis, E. E., Olsen, K. M., Schmid, K. K., Shostrom, V., Cohen, M. Z., Peitz, G., Gannon, D. E., Sisson, J., Sullivan, J., Stothert, J., C., Lazure, J., Nuss, S. L., Jawa, R., S., Freihaut, F., Ely, E. W., & Burke, W. J. (2014). Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Critical Care Management42(5), 1024-36. DOI: 10.1097/CCM.0000000000000129

This article evaluates the effectiveness as well as the safety of implementing the Awakening, Breathing, Coordination, Delirium monitoring/management and Early Exercise mobility (ABCDE) bundle into everyday practice. Following 296 patients this study was an eighteen-month prospective, cohort, before-after study. Regression models were used to quantify relationships between the ABCDE bundle and prevalence/duration of delirium and coma, early mobilization, mortality, time to discharge and change in residence. Results of the study showed that critically ill patients who were managed with the ABCDE bundle spent three more days breathing without assistance, were more likely to be up and mobile during their ICU stay and experienced less delirium than patients who were treated with usual care not including the ABCDE bundle.

Balas, M. C., Burke, W. J., Gannon, D., Cohen, M., Z., Colburn, L., Bevil, C., Franz, D., Olsen, K., M., Ely, E. W., & Vasilevskis, E. E. (2013). Implementing the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle into everyday care: Opportunities, challenges, and lessons learned for implementing the ICU pain, agitation and delirium guidelines. Critical Care Management41(9), S116-S127. DOI: 10.1097/CCM.0b013e3182a17064

The purpose of this was to examine what worked and what did not when implementing the ABCDE bundle in a prospective study in multiple units in an academic medical center. The 18 month project focused on barriers and facilitators for interdisciplinary staff implementing the bundle. Four factors were identified that helped implementation (e.g. daily rounds of interdisciplinary team, commitment of operational leaders) and five barriers were noted (treatment issues like timing of interventions, workload). Both survey and focus groups with the participants revealed they felt the bundle caused an improvement in practice.

You are now leaving the American Nurses Foundation

The American Nurses Foundation is a separate charitable organization under Section 501(c)(3) of the Internal Revenue Code. The Foundation does not engage in political campaign activities or communications.

The Foundation expressly disclaims any political views or communications published on or accessible from this website.

Continue Cancel

Item(s) added to cart

Go to cart Continue Shopping