References

Aasmul I, Husebo BS, Sampson EL, Flo E. Advance care planning in nursing homes – improving the communication among patient, family, and staff: results from a cluster randomized controlled trial (COSMOS). Front Psychol. 2018; https://doi.org/10.3389/fpsyg.2018.02284

Ahmed S, Leurent B, Sampson EL. Risk factors for incident delirium among older people in acute hospital medical units: a systematic review and meta-analysis. Age Ageing. 2014; 43:(3)326-333 https://doi.org/10.1093/ageing/afu022

Alagiakrishnan K, Wiens CA. An approach to drug induced delirium in the elderly. Postgrad Med J. 2004; 80:(945)388-393 https://doi.org/10.1136/pgmj.2003.017236

Alam FM, Turner CE, Smith K, Wiles S, Sriskandan S. Inactivation of the CovR/S virulence regulator impairs infection in an improved murine model of Streptococcus pyogenes naso-pharyngeal infection. PLoS One. 2013; 8:(4) https://doi.org/10.1371/journal.pone.0061655

Diagnostic and Statistical Manual of Mental Disorders (DSM–5). 2013; https://doi.org/10.1176/appi.books.9780890425596

Armstrong M J, Weintraub D. The case for antipsychotics in dementia with Lewy bodies. Mov Disord Clin Pract. 2016; 4:(1)32-35 https://doi.org/10.1002/mdc3.12383

Bickley L, Szilagyi PG, Hoffman RM, Soriano RP. Bates' guide to physical examination and history taking, 13th edn. Philadelphia: Wolters Kluwer; 2021

Bharucha AE, Lacy BE. Mechanisms, Evaluation, and Management of Chronic Constipation. Gastroenterology. 2020; 158:(5)1232-1249.e3 https://doi.org/10.1053/j.gastro.2019.12.034

Camilleri M, Lee JS, Viramontes B, Bharucha AE, Tangalos EG. Insights into the pathophysiology and mechanisms of constipation, irritable bowel syndrome, and diverticulosis in older people. J Am Geriatr Soc. 2000; 48:(9)1142-1150 https://doi.org/10.1111/j.1532-5415.2000.tb04793.x

Carey E. Pain assessment and management tool, responsive behaviour care pack. Cherry Orchard Hospital, Dublin South, Kildare, and West Wicklow, Community Healthcare Area.Dublin, Ireland: Health Service Executive (HSE); 2018 mailto:edel.carey@hse.ie

Colomer J, de Vries J. Person-centred dementia care: a reality check in two nursing homes in Ireland. Dementia. 2016; 15:(5)1158-1170 https://doi.org/10.1177/1471301214556132

Dalbeth N, Haskard DO. Mechanisms of inflammation in gout. Rheumatology. 2005; 44:(9)1090-1096 https://doi.org/10.1093/rheumatology/keh640

Dalbeth N, Merriman TR, Stamp LK. Gout. Lancet. 2016; 22:(10055)2039-2052 https://doi.org/10.1016/S0140-6736(16)00346-9

de Jonghe JF, Kalisvaart KJ, Timmers JF, Kat MG, Jackson JC. Delirium-O-Meter: a nurses' rating scale for monitoring delirium severity in geriatric patients. Int J Geriatr Psychiatry. 2005; 20:(12)1158-66 https://doi.org/10.1002/gps.1410

El-Sharkawy AM, Sahota O, Maughan RJ, Lobo DN. The pathophysiology of fluid and electrolyte balance in the older adult surgical patient. Clin Nutr. 2014; 33:(1)6-13 https://doi.org/10.1016/j.clnu.2013.11.010

Fox S, Murphy A, Jennings A, Murphy K, Timmons S. 247 antipsychotic medication in the management of non-cognitive symptoms of dementia: an updated evidence review. Poster presentation, 67th Annual & Scientific Meeting of the Irish Gerontological Society, Innovation, Advances and Excellence in Ageing, Clayton Hotel Silver Springs, Cork. 26–28 September 2019. Age and Ageing. 2019; 48:iii17-iii65 https://doi.org/10.1093/ageing/afz103.151

Gould RL, Coulson MC, Patel N, Highton-Williamson E, Howard RJ. Interventions for reducing benzodiazepine use in older people: meta-analysis of randomised controlled trials. Br J Psychiatry. 2014; 204:(2)98-107 https://doi.org/10.1192/bjp.bp.113.126003

Herron JW, Mitchell A. Depression and antidepressant prescribing in the elderly. Prescriber. 2018; 29:(3)12-17 https://doi.org/10.1002/psb.1654

Hershey LA, Coleman-Jackson R. Pharmacological Management of Dementia with Lewy Bodies. Drugs Aging. 2019; 36:(4)309-319 https://doi.org/10.1007/s40266-018-00636-7

Han JH, Wilson A, Ely EW. Delirium in the older emergency department patient: a quiet epidemic. Emerg Med Clin North Am. 2010; 28:(3)611-631 https://doi.org/10.1016/j.emc.2010.03.005

Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet. 2014; 383:(9920)911-922 https://doi.org/10.1016/S0140-6736(13)60688-1

Iragorri N, Spackman E. Assessing the value of screening tools: reviewing the challenges and opportunities of cost-effectiveness analysis. Public Health Rev. 2018; 39:(1) https://doi.org/10.1186/s40985-018-0093-8

Jablonski AM, DuPen AR, Ersek M. The use of algorithms in assessing and managing persistent pain in older adults. AJN, American Journal of Nursing. 2011; 111:(3)34-43 https://doi.org/10.1097/10.1097/01.NAJ.0000395239.60981.2f

Lindberg G, Hamid SS, Malfertheiner P World Gastroenterology Organisation global guideline: Constipation—a global perspective. J Clin Gastroenterol. 2011; 45:(6)483-487 https://doi.org/10.1097/MCG.0b013e31820fb914

Lorenzl S, Füsgen I, Noachtar S. Acute confusional States in the elderly--diagnosis and treatment. Dtsch Arztebl Int. 2012; 109:(21)391-399

Alcohol withdrawal in the inpatient setting. 2019. https://tinyurl.com/hnvb9taw (accessed 13 January 2022)

Maldonado JR. Delirium pathophysiology: an updated hypothesis of the etiology of acute brain failure. Int J Geriatr Psychiatry. 2018; 33:(11)1428-1457 https://doi.org/10.1002/gps.4823

Martinez F, Tobar C, Hill N. Preventing delirium: should non-pharmacological, multicomponent interventions be used? A systematic review and meta-analysis of the literature. Age Ageing. 2015; 44:(2)196-204 https://doi.org/10.1093/ageing/afu173

Martins S, Fernandes L. Delirium in elderly people: a review. Front Neurol. 2012; 101-112 https://doi.org/10.3389/fneur.2012.00101

Masento NA, Golightly M, Field DT, Butler LT, van Reekum CM. Effects of hydration status on cognitive performance and mood. Br J Nutr. 2014; 111:(10)1841-1852 https://doi.org/10.1017/S0007114513004455

McCaffrey G, Davis TP. Physiology and pathophysiology of the blood-brain barrier: p-glycoprotein and occludin trafficking as therapeutic targets to optimize central nervous system drug delivery. J Investig Med. 2012; 60:(8)1131-1140 https://doi.org/10.2310/JIM.0b013e318276de79

McCusker J, Cole M, Bellavance F, Primeau F. Reliability and validity of a new measure of severity of delirium. Int Psychogeriatr. 1998; 10:(4)421-433 https://doi.org/10.1017/S1041610298005493

National Clinical Programme for Older People. Advanced Nursing Practice Older Persons. Clinical Guidance. 2019. https://tinyurl.com/2s4cwj8n (accessed 13 January 2022)

National Institute for Health and Care Excellence. Urinary tract infections in adults. Quality standard [QS90]. 2015. http://nice.org.uk/guidance/qs90 (accessed 13 January 2022)

National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management. Clinical guideline [CG103]. 2019. https://www.nice.org.uk/guidance/cg103 (accessed 13 January 2022)

Nursing and Midwifery Board of Ireland. Scope of Nursing and Midwifery Practice Framework. 2015. https://cutt.ly/3IsMYav (accessed 13 January 2022)

Nursing and Midwifery Board of Ireland. Advanced practice (nursing) standards and requirements: standard 2. 2017. https://cutt.ly/oIs1wBA (accessed 13 January 2022)

Parish A, Holliday K. Long-term care acquired urinary tract infections' antibiotic resistance patterns and empiric therapy: a pilot study. Geriatr Nurs (Minneap). 2012; 33:(6)473-478 https://doi.org/10.1016/j.gerinurse.2012.05.003

Pendlebury S, Lovett N, Smith S Observational, longitudinal study of delirium in consecutive unselected acute medical admissions: age-specific rates and associated factors, mortality and re-admission. BMJ Open. 2015; 5:(11) https://doi.org/10.1136/bmjopen-2015-007808

Rao SSC, Meduri K. What is necessary to diagnose constipation?. Best Pract Res Clin Gastroenterol. 2011; 25:(1)127-140 https://doi.org/10.1016/j.bpg.2010.11.001

Reinoso H, Bartlett JL, Bennett SL. Teaching differential diagnosis to nurse practitioner students. Journal of Nurse Practitioners. 2018; 14:(10)E207-E212 https://doi.org/10.1016/j.nurpra.2018.08.028

Reisner EG, Reisner HM. Crowley's: an introduction to human disease. Pathology And Pathophysiology Correlations, 10th edn. Burlington (MA): Jones and Bartlett Learning; 2017

Differential diagnosis for the advanced practice nurse, 1st edn. In: Rhoads J, Murphy Jenson M (eds). New York (NY): Springer Publishing Company; 2015

Shenkin SD, Fox C, Godfrey M Protocol for validation of the 4AT, a rapid screening tool for delirium: a multicentre prospective diagnostic test accuracy study. BMJ Open. 2018; 8:(2) https://doi.org/10.1136/bmjopen-2016-015572

Siegel SJ, Weiser JN. Mechanisms of Bacterial Colonization of the Respiratory Tract. Annu Rev Microbiol. 2015; 69:(1)425-444 https://doi.org/10.1146/annurev-micro-091014-104209

Tieges Z, Maclullich AMJ, Anand A Diagnostic accuracy of the 4AT for delirium detection in older adults: systematic review and meta-analysis. Age Ageing. 2021; 50:(3)733-743 https://doi.org/10.1093/ageing/afaa224

van Keulen K, Knol W, Belitser SV Glucose variability during delirium in diabetic and non-diabetic intensive care unit patients: a prospective cohort study. PLoS One. 2018; 13:(11) https://doi.org/10.1371/journal.pone.0205637

van Velthuijsen EL, Zwakhalen SMG, Mulder WJ, Verhey FRJ, Kempen GIJM. Detection and management of hyperactive and hypoactive delirium in older patients during hospitalization: a retrospective cohort study evaluating daily practice. Int J Geriatr Psychiatry. 2018; 33:(11)1521-1529 https://doi.org/10.1002/gps.4690

Varatharaj A, Galea I. The blood-brain barrier in systemic inflammation. Brain Behav Immun. 2017; 60:1-12 https://doi.org/10.1016/j.bbi.2016.03.010

Vazquez Roque M, Bouras EP. Epidemiology and management of chronic constipation in elderly patients. Clin Interv Aging. 2015; 10:919-930 https://doi.org/10.2147/CIA.S54304

Voyer P, Champoux N, Desrosiers J RADAR: a measure of the sixth vital sign?. Clin Nurs Res. 2016; 25:(1)9-29 https://doi.org/10.1177/1054773815603346

Wang HF, Yu JT, Tang SW Efficacy and safety of cholinesterase inhibitors and memantine in cognitive impairment in Parkinson's disease, Parkinson's disease dementia, and dementia with Lewy bodies: systematic review with meta-analysis and trial sequential analysis. J Neurol Neurosurg Psychiatry. 2015; 86:(2)135-143 https://doi.org/10.1136/jnnp-2014-307659

Welch C, McCluskey L Delirium is prevalent in older hospital inpatients and associated with adverse outcomes: results of a prospective multi-centre study on World Delirium Awareness Day. BMC Med. 2019; 17:(1) https://doi.org/10.1186/s12916-019-1458-7

Wilson JE, Mart MF, Cunningham C Publisher Correction: delirium. Nat Rev Dis Primers. 2020; 6:(1) https://doi.org/10.1038/s41572-020-00236-z

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

27 January 2022
19 min read
Volume 31 · Issue 2

Abstract

Delirium is a term used to describe an array of symptoms that indicate a disruption in cerebral metabolism, a condition that is often under-recognised, leading to delayed interventions. The condition is a common cause of older adults presenting in hospital, with significant morbidity and mortality associated with increased length of stay. A case study is used to illustrate the use of a diagnostic algorithm for older adults presenting with delirium to an advanced nurse practitioner (ANP)-led service. The clinical decision pathway provides four differential diagnoses, using the case study to put the decision-making process in context. The article demonstrates the ability of the ANP to practise at a high level of expertise as an autonomous practitioner and shows how the pathway supports the nurse to reach an accurate diagnosis. It shows that prompt and accurate diagnosis of delirium in older adults is crucial to avoiding the complications and cognitive decline associated with the condition.

Research shows that delirium, independent of age, dementia, illness severity and functional status, predicts multiple adverse outcomes for older adults, including morbidity and mortality, alongside increased length of hospital stay (Pendlebury et al, 2015; Welch et al, 2019). For the advanced nurse practitioner (ANP) evidence-based practice (EBP) is paramount to providing the best possible care outcomes for the older adult.

This article sets out a logical approach to obtaining a comprehensive clinical history using the most effective clinical screening tools to provide accurate diagnosis of delirium in the older adult. It presents a short case study that is followed by the application of a diagnostic algorithm, to illustrate the role of the ANP. Algorithms are typically developed from evidence-based clinical guidelines and facilitate the transfer of research to practice, providing nurses with as step-by-step approach to make effective decisions (Jablonski et al, 2011)

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