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Guideline Summary
Guideline Title
Delirium. In: Evidence-based geriatric nursing protocols for best practice.
Bibliographic Source(s)
Tullmann DF, Mion LC, Fletcher K, Foreman MD. Delirium. In: Boltz M, Capezuti E, Fulmer T, Zwicker D, editor(s). Evidence-based geriatric nursing protocols for best practice. 4th ed. New York (NY): Springer Publishing Company; 2012. p. 186-99.
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Tullmann DF, Mion LC, Fletcher K, Foreman MD. Delirium: prevention, early recognition, and treatment. In: Capezuti E, Zwicker D, Mezey M, Fulmer T, editor(s). Evidence-based geriatric nursing protocols for best practice. 3rd ed. New York (NY): Springer Publishing Company; 2008 Jan. p. 111-25.

Scope

Disease/Condition(s)

Delirium

Guideline Category
Evaluation
Management
Prevention
Risk Assessment
Treatment
Clinical Specialty
Critical Care
Family Practice
Geriatrics
Nursing
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Hospitals
Nurses
Physician Assistants
Physicians
Guideline Objective(s)

To provide a standard of practice protocol to reduce the incidence of delirium in hospitalized older adults

Target Population

Hospitalized older adults

Interventions and Practices Considered

Assessment/Evaluation

  1. Assessment for risk factors for delirium
  2. Assessment of features of delirium

Management/Treatment

  1. Obtaining geriatric consultation
  2. Elimination or minimization of risk factors
  3. Provision of therapeutic environment
Major Outcomes Considered
  • Presence or absence of delirium
  • Cognitive status
  • Functional status
  • Destination at discharge
  • Patient, family, and caregiver satisfaction with care
  • Morbidity and mortality
  • Length of stay

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Although the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument (described in Chapter 1 of the original guideline document, Evidence-based Geriatric Nursing Protocols for Best Practice, 4th ed.) was created to critically appraise clinical practice guidelines, the process and criteria can also be applied to the development and evaluation of clinical practice protocols. Thus, the AGREE instrument has been expanded (i.e., AGREE II) for that purpose to standardize the creation and revision of the geriatric nursing practice guidelines.

The Search for Evidence Process

Locating the best evidence in the published research is dependent on framing a focused, searchable clinical question. The PICO format—an acronym for population, intervention (or occurrence or risk factor), comparison (or control), and outcome—can frame an effective literature search. The editors enlisted the assistance of the New York University Health Sciences librarian to ensure a standardized and efficient approach to collecting evidence on clinical topics. A literature search was conducted to find the best available evidence for each clinical question addressed. The results were rated for level of evidence and sent to the respective chapter author(s) to provide possible substantiation for the nursing practice protocol being developed.

In addition to rating each literature citation as to its level of evidence, each citation was given a general classification, coded as "Risks," "Assessment," "Prevention," "Management," "Evaluation/Follow-up," or "Comprehensive." The citations were organized in a searchable database for later retrieval and output to chapter authors. All authors had to review the evidence and decide on its quality and relevance for inclusion in their chapter or protocol. They had the option, of course, to reject or not use the evidence provided as a result of the search or to dispute the applied level of evidence.

Developing a Search Strategy

Development of a search strategy to capture best evidence begins with database selection and translation of search terms into the controlled vocabulary of the database, if possible. In descending order of importance, the three major databases for finding the best primary evidence for most clinical nursing questions are the Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Medline or PubMed. In addition, the PsycINFO database was used to ensure capture of relevant evidence in the psychology and behavioral sciences literature for many of the topics. Synthesis sources such as UpToDate® and British Medical Journal (BMJ) Clinical Evidence and abstract journals such as Evidence Based Nursing supplemented the initial searches. Searching of other specialty databases may have to be warranted depending on the clinical question.

It bears noting that the database architecture can be exploited to limit the search to articles tagged with the publication type "meta-analysis" in Medline or "systematic review" in CINAHL. Filtering by standard age groups such as "65 and over" is another standard categorical limit for narrowing for relevance. A literature search retrieves the initial citations that begin to provide evidence. Appraisal of the initial literature retrieved may lead the searcher to other cited articles, triggering new ideas for expanding or narrowing the literature search with related descriptors or terms in the article abstract.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence

Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)

Level II: Single experimental study (randomized controlled trials [RCTs])

Level III: Quasi-experimental studies

Level IV: Non-experimental studies

Level V: Care report/program evaluation/narrative literature reviews

Level VI: Opinions of respected authorities/consensus panels

AGREE Next Steps Consortium (2009). Appraisal of guidelines for research & evaluation II. Retrieved from http://www.agreetrust.org/?o=1397 External Web Site Policy.

Adapted from: Melnyck, B. M. & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & health care: A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins and Stetler, C.B., Morsi, D., Rucki, S., Broughton, S., Corrigan, B., Fitzgerald, J., et al. (1998). Utilization-focused integrative reviews in a nursing service. Applied Nursing Research, 11(4) 195-206.

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

Not stated

Recommendations

Major Recommendations

Levels of evidence (I–VI) are defined at the end of the "Major Recommendations" field.

Parameters of Assessment

Assess for Risk Factors (Michaud et al., 2007 [Level V])

  • Baseline or pre-morbid cognitive impairment (see the National Guideline Clearinghouse [NGC] summary of the Hartford Institute for Geriatric Nursing guideline Assessing cognitive functioning)
  • Medications review (see the NGC summary of the Hartford Institute for Geriatric Nursing guideline Reducing adverse drug events in older adults)
  • Pain (see the NGC summary of the Hartford Institute for Geriatric Nursing guideline Pain management in older adults).
  • Metabolic disturbances (hypoglycemia, hypercalcemia, hyponatremia, hypokalemia)
  • Hypoperfusion/hypoxemia (blood pressure, capillary refill, pulse oxygen saturation [SpO2])
  • Dehydration (physical signs/symptoms, intake/output, sodium [Na+], blood urea nitrogen/creatinine ratio [BUN/Cr])
  • Infection (fever, white blood cells [WBCs] with differential, cultures)
  • Environment (sensory overload or deprivation, restraints)
  • Impaired mobility
  • Sensory impairment (vision, hearing)

Features of Delirium (American Psychiatric Association, 2000 [Level I]; Inouye et al., 1990 [Level IV])

Assess every shift (see www.ConsultGeriRN.org External Web Site Policy for resources for validated instruments).

  • Acute onset; evidence of underlying medical condition
  • Alertness: fluctuates from stuporous to hypervigilant
  • Attention: inattentive, easily distractible, and may have difficulty shifting attention from one focus to another; has difficulty keeping track of what is being said
  • Orientation: disoriented to time and place; should not be disoriented to person
  • Memory: inability to recall events of hospitalization and current illness; unable to remember instructions; forgetful of names, events, activities, current news, and so forth
  • Thinking: disorganized thinking; rambling, irrelevant, incoherent conversation; unclear or illogical flow of ideas; or unpredictable switching from topic to topic; difficulty in expressing needs and concerns; speech may be garbled
  • Perception: perceptual disturbances such as illusions and visual or auditory hallucinations and misperceptions such as calling a stranger by a relative's name
  • Psychomotor activity: may fluctuate between hypoactive, hyperactive, and mixed subtypes

Nursing Care Strategies

Based on protocols in multicomponent delirium prevention studies (Inouye et al., 1999 [Level II]; Lundström et al., 2007 [Level II]; Marcantonio et al., 2001 [Level II])

  • Obtain geriatric consultation.
  • Eliminate or minimize risk factors.
    • Administer medications judiciously; avoid high-risk medications (see the NGC summary of the Hartford Institute for Geriatric Nursing guideline Reducing adverse drug events in older adults).
    • Prevent/promptly and appropriately treat infections.
    • Prevent/promptly treat dehydration and electrolyte disturbances.
    • Provide adequate pain control (see the NGC summary of the Hartford Institute for Geriatric Nursing guideline Pain management in older adults).
    • Maximize oxygen delivery (supplemental oxygen, blood, and blood pressure support as needed).
    • Use sensory aids as appropriate.
    • Regulate bowel/bladder function.
    • Provide adequate nutrition (see the NGC summary of the Hartford Institute for Geriatric Nursing guideline Nutrition in Aging).
  • Provide a therapeutic environment.
    • Foster orientation: frequently reassure and reorient patient (unless patient becomes agitated); use easily visible calendars, clocks, caregiver identification; carefully explain all activities; communicate clearly.
    • Provide appropriate sensory stimulation: quiet room, adequate light, one task at a time, noise reduction strategies.
    • Facilitate sleep: back massage, warm milk or herbal tea at bedtime, relaxation music/tapes, noise reduction measures, avoid awakening patient.
    • Foster familiarity: encourage family/friends to stay at bedside, bring familiar objects from home, maintain consistency of caregivers, minimize relocations.
    • Maximize mobility: avoid restraints (see NGC summary of the Hartford Institute for Geriatric Nursing guideline Physical restraints and side rails in acute and critical care settings) and urinary catheters, ambulate or active range of motion (ROM) three times daily.
    • Communicate clearly, provide explanations.
    • Reassure and educate family (see the NGC summary of the Hartford Institute for Geriatric Nursing guideline Family caregiving).
    • Minimize invasive interventions.
    • Consider psychotropic medication as a last resort for agitation.

Follow-up Monitoring of Condition

  • Decreased delirium to become a measure of quality care
  • Incidence of delirium to decrease
  • Patient's days with delirium to decrease
  • Staff competence in recognition and treatment of acute confusion/delirium
  • Documentation of a variety of interventions for acute confusion/delirium

Definitions:

Levels of Evidence

Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)

Level II: Single experimental study (randomized controlled trials [RCTs])

Level III: Quasi-experimental studies

Level IV: Non-experimental studies

Level V: Care report/program evaluation/narrative literature reviews

Level VI: Opinions of respected authorities/consensus panels

AGREE Next Steps Consortium (2009). Appraisal of guidelines for research & evaluation II. Retrieved from http://www.agreetrust.org/?o=1397 External Web Site Policy.

Adapted from: Melnyck, B. M. & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & health care: A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins and Stetler, C.B., Morsi, D., Rucki, S., Broughton, S., Corrigan, B., Fitzgerald, J., et al. (1998). Utilization-focused integrative reviews in a nursing service. Applied Nursing Research, 11(4) 195-206.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for selected recommendations (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Patient

  • Absence of delirium or cognitive and functional status returned to baseline
  • Discharge to same destination as prehospitalization

Health Care Provider

  • Regular use of delirium screening tool
  • Increased detection of delirium
  • Implementation of appropriate interventions to prevent/treat delirium
  • Decreased use of physical restraints and anti-psychotic medications
  • Increased satisfaction in care of hospitalized older adults

Institution

  • Improved staff education and interprofessional care planning
  • Implementation of standardized delirium screening protocol
  • Decreased overall cost
  • Decreased length of stays
  • Decreased morbidity and mortality
  • Increased referrals and consultation to above-specified specialists
  • Improved satisfaction of patients, families, and nursing staff
Potential Harms

Not stated

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Chart Documentation/Checklists/Forms
Mobile Device Resources
Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Tullmann DF, Mion LC, Fletcher K, Foreman MD. Delirium. In: Boltz M, Capezuti E, Fulmer T, Zwicker D, editor(s). Evidence-based geriatric nursing protocols for best practice. 4th ed. New York (NY): Springer Publishing Company; 2012. p. 186-99.
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2003 (revised 2012)
Guideline Developer(s)
Hartford Institute for Geriatric Nursing - Academic Institution
Guideline Developer Comment

The guidelines were developed by a group of nursing experts from across the country as part of the Nurses Improving Care for Health System Elders (NICHE) project, under sponsorship of the Hartford Institute for Geriatric Nursing, New York University, College of Nursing.

Source(s) of Funding

Hartford Institute for Geriatric Nursing

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Primary Authors: Dorothy F. Tullmann, PhD, RN, Assistant Professor, University of Virginia, School of Nursing, Charlottesville, VA; Lorraine C. Mion, PhD, RN, FAAN, Independence Foundation Professor of Nursing, Vanderbilt University, Nashville, TN; Kathleen Fletcher, RN, MSN, APRN-BC, GNP, FAAN, Administrator of Senior Services, University of Virginia Health System, Charlottesville, Virginia; Marquis D. Foreman, PhD, RN, FAAN, Professor and Chairperson, Rush University, Chicago, IL

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Tullmann DF, Mion LC, Fletcher K, Foreman MD. Delirium: prevention, early recognition, and treatment. In: Capezuti E, Zwicker D, Mezey M, Fulmer T, editor(s). Evidence-based geriatric nursing protocols for best practice. 3rd ed. New York (NY): Springer Publishing Company; 2008 Jan. p. 111-25.

Guideline Availability

Electronic copies: Available from the Hartford Institute for Geriatric Nursing Web site External Web Site Policy.

Copies of the book Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th edition: Available from Springer Publishing Company, 536 Broadway, New York, NY 10012; Phone: (212) 431-4370; Fax: (212) 941-7842; Web: www.springerpub.com External Web Site Policy.

Availability of Companion Documents

The following are available:

The ConsultGeriRN app for mobile devices is available from the Hartford Institute for Geriatric Nursing Web site External Web Site Policy.

Patient Resources

None available

NGC Status

This summary was completed by ECRI on February 2, 2004. The information was verified by the guideline developer on March 15, 2004. This summary was updated by ECRI Institute on June 19, 2008. The updated information was verified by the guideline developer on August 4, 2008. This NGC summary was updated by ECRI Institute on June 24, 2013. The updated information was verified by the guideline developer on August 6, 2013.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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