¶ … Recognition of Delirium: Literature Review The objective of this study is to conduct a review of the literature on the assessment and recognition of delirium. The study, which follows reviews literature, related to the recognition of delirium in older patients by nurses and examines the variations of recognition of delirium by nurses as it relates to their own personal views of age and aging related symptoms.

Devline et al. (2013)

There are few data in existence relating to the current assessment practices used by nurses for delirium. (Devline, et al., 2013, p.555) Delirium is reported to be characterized by "an acutely changing or fluctuating mental status, inattention, disorganized thinking and altered level of consciousness." (Devline, et al., 2013, p.556) Devline et al. (2013) additionally reports that while it is believed by many that patients with delirium are hyperactive they are in fact more likely to be hypoactive or have a mixed pattern. (Devline, et al., 2013, p.556) Delirium in the ICU is reported to be associated "with higher mortality, prolonged stay, and greater health care costs." (Devline, et al., 2013, p.556) Preexisting cognitive impairment is reported as the primary risk factor for delirium as well as are factors of "higher age, the presence of acute systematic illnesses or medical comorbid diseases, and the use of certain medications." (Devline, et al., 2013, p.556)

Ramaswamy et al. (1993)

The work of Ramaswamy, et al. (1993) reports a study that involved a "comprehensive and sequential intervention (CSI) aiming to effect change in clinician behavior by improving knowledge about delirium. The study design and methods reported include "a 2-day CSI program that consisted of progressive 4-part didactic series, including evidence-based reviews of delirium recognition, prevention and management, interspersed with interactive and small group sessions and practical case conferences " which were reported to have been "conceptualized in a consultation with a leading expert on delirium." (Ramaswamy, et al., 1993, p.122) It is reported that the design of pre- and post-tests were focused on testing the participants in their knowledge and confidence around delirium identification. Study results state that there were an average attendance of 71 individuals at each didactic session. Specifically reported is "…Among all responses, 50 pretests and posttests were matched based on numeric coding (6 MD/DOs, 34 RNs, and 10 others). Mean pretest and posttest scores were 7.9 and 10.8 points, respectively (maximum: 17), showing a positive change in knowledge scores after the intervention (2.9 points, p < .001). Improvement in knowledge scores was higher in the cohort attending 2 or more lectures (3.8 points, p < .001)." (Ramaswamy, et al., 1993, p.122)

Tabet et al. (2005)

The work of Tabet, et al. (2005) reports a study that examined an educational intervention for preventing delirium on acute medical wards and states that delirium is a common disorder is older people who are hospitalized and that intervention may not improve such cases. The study reports the objective of testing the hypothesis "that an educational package for medical and nursing staff would both reduce the number of incident cases of delirium and increase recognition of cases of delirium within an acute medical admissions ward." (p.152) The study reported was a single-blind case control study in two acute admissions wards in a busy inner-city teaching hospital involving 250 participants over the age of 70 years of age. The state methodology was use of an educational package for staff on one ward of the hospital comprised by a one-hour presentation that was formal in nature accompanied by a group discussion, written management guidelines, and follow-up sessions. It is reported that the follow-up sessions "were based on one-to-one and group" and had the objective of making the provision of "continuous support of staff through emphasizing learning and testing knowledge. Diagnosis and management of some discharged delirium patients were also discussed to allow staff to learn from previous experience. The main outcome measures are point prevalence of delirium established by researchers, and recognition and case-note documentation of delirium by clinical staff." (Tabet, et al., 2005, p.152) Study results state that the point prevalence of delirium "…was significantly reduced on the intervention compared to the control ward (9.8% versus 19.5%, P < 0.05) and clinical staff recognized significantly more delirium cases that had been detected by research staff on the ward where the educational package had been delivered." (Tabet, et al., 2005, p.152)

Inoyue et al. (2001)

The work of Inouye et al. (2001) reports that nurses "play a key role in recognition of delirium, yet delirium is often unrecognized by nurses." (p.2467) Inouye (2004) reports a prospective study involving 797 patients ages 70 and older who underwent 2721 paired delirium rating...

It is reported that patient-related factors associated with underrecognition by delirium nurses were examined. The study results stated that delirium "occurred in 249 (9%) of 2721 observations or 131 (16%) of 696 patients." (Inouye, 2001, p.2467) Only 19% of observations involved the identification of delirium by nurses and 31% of patients compared with researchers. It is reported that sensitivities of nurses' rating for delirium and its key features "were generally low (15-31%); however specificities were high (91-99%). Nearly all disagreements between nurse and researcher ratings were because of underrecognition of delirium by the nurses. Four independent risk factors for underrecognition by nurses were identified: (1) hypoactive delirium; (2) vision impairments; (3) age 80 years or older; and (4) dementia. (Inouye, 2004, p.2467) The risk of underrecognition by nurse is reported to have increased the number of risk factors present from 2% to 6%. (Inouye, 2001, p.2467) Patients with three to four risk factors were reported to have had "a 20-fold risk for underrecognition of delirium by nurses." (Inouye, 2001, p.2467) The study concluded that delirium is often missed by nurses when present but that delirium when absent was rarely identified. Specifically it is reported that "recognition of delirium can be enhanced with education of nurses on delirium features, cognitive assessment, and factors associated with poor recognition." (Inouye, 2001, p.2467)
McCarthy (2003)

The study reported by McCarthy (2003) entitled "Detecting Acute Confusion in Older Adults: Comparing Clinical Reasoning of Nurses" states the purpose of presenting the results from a study conducting "to challenge and refine the theory of situated clinical reasoning generated from an earlier dimensional analysis investigation." (p.203) The study sought to examine how nurses reason and make decisions "in the context of caring for older patients who demonstrate acute confusion in the hospital setting." (McCarthy, 2003, p.203) The study investigated the nursing care environment including acute care, long-term care, and home care settings in order to discover "whether care environment might serve as a factor that could either assist or prevent nurses from making accurate clinical decisions." (McCarthy, 2003, p.203) According to McCarthy, "The theory of situated clinical reasoning explains why nurses often fail to recognize acute confusion or differentiate it from dementia in their older patients who demonstrate cognitive impairment during hospitalization. Moreover, it describes and explains the differences in nurses' abilities to appreciate the importance of confusion and illuminates how nurses' perspectives toward health in aging affect the ways they regard older people and ultimately the ways nurses deal with the elderly in clinical situations." (2003, p.204) McCarthy reports that analysis "undertaken in the original dimensional analysis study yielded a grounded theory that addresses the failure of nurses to differentiate acute confusion from dementia in hospitalized older patients." (2003, p.204) The theory of clinical reasoning holds that nurses "embrace different philosophical perspectives regarding aging and the aged that represent personal postures or sets of beliefs. These beliefs can influence nurses, directing them to "figure out" clinical situations and act in particular ways. The theory proposes that nurses apply these perspectives by using different reasoning approaches when caring for older patients who demonstrate confusion behavior. Rather than follow an invariable scheme of clinical reasoning nurses tend to demonstrate wide variation in the nature of the observations they make, in their ability to accurately interpret observations, and in the efficacy and appropriateness of subsequent actions they take while providing care." (McCarthy, 2003, p.204) The explanation for the variations among clinical reasoning patterns of nurses in the context of caring for older patients demonstrating symptoms of confusion "can be linked to the 'overarching philosophy" of aging that they embrace and operationalize in particular clinical situations. These overarching philosophies serve as perspectives that condition the ways in which nurses judge and ultimately deal with older patients experiencing acute confusion." (McCarthy, 2003, p.205) Three distinct overarching philosophies in the theory of situated clinical reasoning were identified upon the basis of previous research including: (1) the decline perspective (DP); (2) the vulnerable perspective (VP); and (3) the healthful perspective (HP). (McCarthy, 2003, p.205) Findings reported by McCarthy include: "Analysis of these new data showed that regardless of setting, the ability of nurses to recognize acute confusion and to distinguish it from dementia among older patients varied." (2003, p.209) There are reported to be four strategies to enhance the nursing practice including: (1) determination of nurses' perspectives on aging before they care for populations of older…