Why Do Nurses Fail to Recognize Delirium in Hospitalized Elderly Patients?
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Posted about 1 year ago
Delirium is a common but frequently undetected complication in hospitalized elderly patients leading to poor outcomes, prolonged hospital stays, and increased costs of care. Reports indicate that incidence of delirium in elderly patients in acute care settings can be as high as 60%). It has been well documented that prevention and early detection of delirium can significantly improve the outcomes, and decrease mortality and costs of care . However, in spite of the widespread awareness of the importance of early detection, delirium in elderly patients is often not recognized in most nursing care plans. Studies indicate that clinicians often fail to identify individuals at risk, and tend to attribute early signs and symptoms of delirium to other processes, such as age related cognitive changes or underlying psychiatric disease.
According to American Psychiatric Association (APA), diagnosis of delirium consists of four components: (i) altered level of consciousness with decreased focus and inattention, (ii) altered cognition or perceptual disturbances not related to pre-existing condition(s), (iii) acute onset and fluctuating course, and (iv) evidence that the disturbance is caused by the effects of another medical condition
Delirium is further classified on the basis of psychomotor activity into three broad categories: hypoactive-hypoalert, hyperactive-hyperalert and mixed Clinical presentation can vary significantly, which makes early detection and diagnosis more challenging.
Why do nurses and other front line care providers have difficulty identifying individuals at risk and recognizing the early signs of delirium? The two most commonly stated reasons are (i) failure to use standardized screening tools and (ii) concomitant presence of other disorders such as dementia and depression.
A survey conducted
Early detection of delirium seems to pose a particular problem when it is superimposed on another psychiatric condition, most notably dementia and/or depression. Cognitive assessment in individuals with a pre-existing psychiatric condition is dominated by the signs and symptoms of the primary condition, which complicates the isolation and identification of cognitive changes associated with delirium . The overlapping symptoms can interfere with the clinician’s ability to establish baseline and accurately gauge the changes in the patient’s mental status. This is a serious practice issue because studies indicate that patients with dementia who experience delirium during hospitalization are almost twice more likely to die within 12 months following the discharge ). Obviously, the importance of early identification and screening of the individuals at risk cannot be emphasized enough.
What can be done to facilitate timely identification of individuals at risk and early detection of signs and symptoms of delirium? Literature indicates that serial assessment with one of the standardized assessment tools can effectively aid early detection of changes associated with delirium in elderly patients
Clearly, delirium in hospitalized elderly patients is a serious problem with significant impact on the outcomes and costs of care. Nurses are at the frontline of patient care and are in a unique position to improve the outcomes through timely identification of individuals at risk, early detection of signs and symptoms, and prompt intervention. Unfortunately, delirium in hospitalized elderly patients often goes undetected or misdiagnosed in nursing care plans. The lack of studies exploring the nurses’ attitudes and understanding of this complex issue points out the need for further research. Meanwhile, the nurses and other front line clinicians should be encouraged to routinely use standardized screening tools that can facilitate early detection and prevent adverse outcomes associated with this serious but manageable disorder.