Beruflich Dokumente
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Guest Editorial
Recently I gave a talk entitled Clinical care of delirium: where are we now
and where are we going? at the British Geriatrics Society (Scotland
Division) conference. I included a timeline of some of the landmarks in the
expansion of the field thinking in particular of tangible effects on clinical
practice in the UK. These landmarks included delirium appearing in
DSM-III, the publication of specific delirium assessment scales, several key
papers on risk factors and prevention, the Who Cares Wins report in
2005, the founding of the European Delirium Association in 2006, and key
UK National Institute of Health and Clinical Excellence (NICE) documents
on delirium: the Guidelines (2010) and Quality Standards (2014). In
Scotland we have also had additional national impact from both the
Scottish Delirium Association (founded 2011), a group of clinicians
focused on providing pragmatic resources, and strategic government
involvement from Healthcare Improvement Scotland since 2012. These
and many other developments are now clearly having positive effects on
the quality of routine care of delirium. We can be encouraged that
delirium is now no longer generally overlooked, and is now coming to be
recognised as a major problem in modern healthcare.
Ongoing improvements in delirium care will come from activity in many
domains. Working to increase awareness of delirium among professionals,
policy-makers and the public remains a priority because it is essential to
producing mainstream change. As an example, in the UK the decision by
the governmental bodies NICE and Healthcare Improvement Scotland to
make delirium a focus of activity was strongly influenced by the
engagement of a relatively small number of professionals (several
The EDA is active in all the above domains, and the programme of our
forthcoming meeting in Cremona reflects this. Alessandro Morandi
(Chair), Giuseppe Bellelli and other members of the scientific committee
have put together a strong, highly varied and exciting programme with
multiple international speakers and workshops. We also have even more
space dedicated to new research presentations: this year we have had the
largest ever number of abstract submissions for oral presentations and
posters. Full details of the programme can be seen here:
http://www.overgroup.eu/eda2014/. It is great to see the enormous
achievements and rapid expansion of the American Delirium Society. This
year also marked the inaugural meeting of the Australian Delirium
Society, which was another huge success. We look forward to ongoing
productive work with our sister international organisations, and hopefully
many collaborative visits to our respective continents!
Please do promote the work of EDA our forthcoming meetings in
Cremona and London (2015) as well as our website. Look out for an
expansion of the website in 2015 (led by Stefan Kreisel and Daniel Davis),
as we aim to put together a major centralised source of materials for
delirium awareness-raising, education, clinical implementation, and
science.
Resources and links referred to above can be found at:
www.scottishdeliriumassociation.com
NICE Delirium Guidelines: https://www.nice.org.uk/guidance/cg103
NICE Delirium Quality Standards: http://www.nice.org.uk/guidance/qs63
Alasdair MacLullich
Professor of Geriatric Medicine
University of Edinburgh, and
President of the European Delirium Association
Aim
Results
Conceptual framework
Knowledge translation (KT) is the conceptual framework underpinning
this doctoral research project. Knowledge translation is defined as a
dynamic and systematic process by which knowledge moves more rapidly
into practice, strengthens the health system and improves peoples health.
[10] This conceptual framework was selected because it acknowledges the
challenges of translating evidence into practice, and allows for a better
understanding local health care context and the factors that impact on
specialist palliative care service and nurse capacity to integrate delirium
evidence into practice.
Setting
This research was conducted in Australia, where specialist palliative care
inpatient units admit patients with complex needs related to life limiting
illness, for the purposes of symptom management, respite and/or
terminal care [11]. Despite the call for palliative care to broaden its remit
to non-malignant life limiting illness, the majority of Australian inpatient
units continue to serve a predominately advanced cancer population [12].
Methods
The DePAC Project is a three-phase sequential transformative mixed
method design, composed of a series of sub-studies (Figure 1).[13] These
studies have been configured to allow examination of delirium recognition
and assessment in palliative care units from a multifaceted perspective,
using a variety of qualitative and quantitative methodologies.
Study 6: A Quality Improvement Initiative adopted a Plan-Do-StudyAct [22, 23] approach, to identify and test small steps to develop
palliative care interdisciplinary practice and systems in delirium
recognition and assessment in one palliative care unit. These steps
included: 1) implementation of the NuDESC; 2) addition of tick-box
prompts for nurses to document and communicate a positive
NuDESC score to the doctor and nurse in charge; 3) bedside guidance
on delirium assessment, communication and non-pharmacological
intervention. Testing of change revealed that while nursing staff
achieved a high rate of completion of the NuDESC, a positive NuDESC
score did not consistently lead to documentation of interdisciplinary
communication, delirium assessment, delirium diagnosis nor care
planning for patients.
Final steps
This program of research is in the final stages of data analysis and writing
up. These data will inform the development of a model to guide future
practice development and research initiatives related to delirium care of
patients receiving palliative care, which will be disseminated widely.
Conclusions
The DePAC project has provided important insights into the barriers and
enablers shaping palliative care nurses delirium screening and
assessment practices. Better understanding of the impetus for practice
change, as well as the context in which nurses practice, will enable the
development of more tailored interventions to address the barriers and
harness the enablers that will change individual and organisational
practices in delirium recognition and assessment within palliative care
inpatient settings.
6.
Acknowledgements
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5.
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Figure 1
Introduction
In light of the prevalence of delirium (Bruce, Ritchie, Blizard, Lai, & Raven,
2007; Siddiqi, House, & Holmes, 2006), and by virtue of love, a sense of
duty, roles or responsibilities, family members of older people are likely to
encounter delirium and the changes to their loved ones demeanour that
ensue. Family members also become involved in their loved ones care
during delirium in order to assist nursing staff to manage their loved ones
disruptive behaviours, the increased workload, safety issues and general
ward disruption (Dahlke & Phinney, 2008; Hallberg, 1999; Rogers &
Gibson, 2002; Segatore & Adams, 2001). Family member involvement is
also suggested in clinical guidelines and research as an important way of
improving the therapeutic environment for the older person, and
preventing, detecting, monitoring or managing delirium (Harding, 2006;
Rapp, 2001). Care involvement is, however, despite little being known
about the experiences of family members at this time.
During delirium the womens attention was focused on their older loved
one; the person they expected to meet and depicted in their family
portraits. However, delirium suddenly and markedly altered the very
nature of the person the women were with, changing who they
experienced as present, or in-person. Delirium was lived as a sudden,
imposed and traumatic absence of their mother, father or husband, whilst
the unfamiliar and bizarre ways the person behaved redefined their loved
one as a stranger. Though immersed in absence they were called on to be
with, and support, a stranger.
Certain qualities characterised the nature of the absence experienced by
the women; it was unexpected, distressing and pervasive. Unlike other
losses some women had experienced during their loved ones dementia,
experiencing absence during delirium was a shock; it was unforeseen
rather than anticipated, sudden rather than insidious, unpredictable
rather than predicable. Their older loved ones absence came quickly and
without explanation and was incongruous with their loved ones
continued corporeal presence. No matter if their loved ones delirium
lasted for a short time or persisted, absence was difficult for the women to
comprehend; their loved ones absence was unrelated to their loved ones
physical death and seemed to break the unity of their older loved ones
corporeal presence and self.
The second theme and sub-themes add further insights into the womens
experience of existential absence:Living life holding on:
In the dark,
Keeping secrets.
The women experienced having little control over what was happening
and lived life holding on to their memories of their loved one and, filled
with uncertainty, they waited and hoped for their loved ones return.
Waiting, the women felt isolated and yet central to their loved ones care.
Consigned to being an onlooker through the staffs relationship with them,
the women watched on and felt helpless to control the stranger they were
with. Rather than finding reassurance and relief in the presence of
References
Bruce, A., Ritchie, C., Blizard, R., Lai, R., & Raven, P. (2007). The incidence
of delirium associated with orthopedic surgery: A meta-analytic
review. International Psychogeriatrics, 19(2), 197-214. doi:
10.1017/S104161020600425X
Cohen, M., Kahn, D., & Steeves, R. (2000). Hermeneutic phenomenological
research: A practical guide for nurse researchers. California: Sage.
Dahlke, S., & Phinney, A. (2008). Caring for hospitalised older adults at risk
for delirium: The silent, unspoken piece of nursing practice. Journal of
Gerontological Nursing, 34(6), 41-47.
Hallberg, I. (1999). Impact of delirium on professionals. Dementia and
Geriatric Cognitive Disorders, 10(5), 420-425.
Harding, S. (2006). Delirium in older people: An Australian government
initiative. Candberra: Australian Department of Health and Ageing,
Commonwealth of Australia.
Merleau-Ponty, M. (1945/2002). Phenomenology of perception (C. Smith,
Trans.). London: Routledge.
Rapp, C.G. (2001). Acute confusion/delirium protocol. Journal of
Gerontological Nursing, 27(4), 21-33.
Rogers, A., & Gibson, C. (2002). Experiences of orthopaedic nurses caring
for elderly patients with acute confusion. Journal of Orthopaedic
Nursing, 6(1), 9-17. doi: 10.1054/joon.2001.0210
Sartre, J.P. (1943/2003). Being and nothingness: A phenomenological
ontology (H. E. Barnes, Trans.). New York: Routledge.
Segatore, M., & Adams, D. (2001). Managing delirium and agitation in
elderly hospitalised orthopaedic patients: Part 2 - interventions.
Orthopaedic Nursing, 20(2), 61-75.
Siddiqi, N., House, A., & Holmes, J. (2006). Occurrence and outcome of
delirium in medical in-patients: A systematic literature review. Age
and Ageing, 35(4), 350-365. doi: 10.1093/ageing/afl005
10
2)
Delirium awareness should be part of post-diagnostic counselling
for PWD and their carers. Our local 3rd sector providers for dementia
support have included delirium in their programmes.
3)
Delirium training should be part of nursing undergraduate courses
in Mental Health. This has been achieved at the University of Derby.
4)
Initiation and regular refreshment of delirium training for Old Age
Psychiatry staff. Liaison Psychiatry staff have already commenced this
programme within the general hospital but we aim to appoint a Band 8
delirium practitioner to pump-prime the Mental Health Trust.
5)
Nurses within CMHTEs should have attachments to the Liaison
Team at the general hospital to embed awareness of the diagnostic
challenges presented by delirium and the deliriogenic potential of the
general hospital environment. Carefully considered, therapeutic risktaking is crucial here the benefits of discharge back to a familiar setting
may outweigh the safeguards provided by an institutional setting.
6)
Under the auspices of the Delirium Practitioner, delirium training
for primary care staff is to run alongside that for dementia.
Research questions
1)
What factors lead to patients with dementia who have been
referred to mental health services attending hospital for reasons other
than discrete pathology such as hip fracture? The Liaison Team is
providing daily screening the Medical Assessment Unit at the general
hospital for those patients who are known or have been referred to
mental health services (usually because of suspected dementia) to provide
information to general hospital staff and identify lacunae in services that
might have avoided the crisis.
2)
We have audited admissions to the general hospital of patients
initially noted to have both delirium and urinary tract infection (UTI) and
found that undiagnosed dementia is commonly unmasked by delirium.
UTI was not substantiated in over 50% of cases and 60% died or were
readmitted within 6 months. 50% were referred to memory services
because of a suspected underlying dementia. More research on the factors
that lead to this sort of presentation is required. Would earlier diagnosis
of dementia or better assessment of the potential for delirium within
primary care have avoided the acute presentation?
3)
Is DP an acceptable way of selling cognitive assessment to older
people who are reluctant to be referred for memory services?
4)
Is delirium-risk best assessed within primary care thereby
avoiding burdensome memory clinic appointments for frail elderly
people? For many of these, dementia can be considered as a geriatric
syndrome and a risk factor (for delirium) rather than a disease in need of
extensive high-tech investigation. This model has parallels with the
Gnosall model of primary care memory services and merits further
investigation.15
5)
Community mental health team work is focused on BPSD but a
simultaneous focus on DP and BPSD might increase the credibility and
acceptability of DP by spotlighting the potential acuity of decompensation
within dementia. Again further investigation of this approach is
warranted.
Summary
The prevention of delirium attenuates morbidity within dementia and
may even have a preventive role against dementia. Psychiatry in the
United Kingdom now has a firm grasp of the dementia agenda. The skills
of psychiatric teams within general hospitals and thenceforth in the
community can help realise the potential to stop delirium in some of our
most vulnerable elders.
11
(doi: 10.1016/j.jagp.2013.04.007).
References
1. Living well with dementia: A National Dementia Strategy. Department
of Health 2009.
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en
/documents/digitalasset/dh_094051.pdf
11. Monitor. Enabling Integrated Care in the NHS. Last updated 8th
September 2014. https://www.gov.uk/enabling-integrated-care-inthe-nhs
12. Donnelley, P. We fear dementia more than cancer. Daily Mail 4th
August 2014. http://www.dailymail.co.uk/health/article2715049/We-fear-dementia-cancer-Two-thirds-50s-fear-braincondition.html
13. Prakash A, Thacker S. The audacity of hope tyranny or liberation in
dementia care. Geriatric Medicine 2014
http://www.gmjournal.co.uk/the_audacity_of_hope_tyranny_or_libera
tion_in_dementia_care_25769811827.aspx
14. Siddiqi N, Young J, Cheater FM, Harding RA. Educating staff working in
long-term care about delirium: The Trojan horse for improving quality
of care? Journal of Psychosomatic Research 2008; 65:261-6.
7. Inouye, Help Hope article Inouye SK, Bogardus ST, Jr., Charpentier PA,
Leo-Summers L, Acampora D, Holford TR, et al. A multicomponent
intervention to prevent delirium in hospitalized older patients. New
England Journal of Medicine 1999; 340(9):669-76.
8. Davis DH, Kreisel SH, Muniz Terrera G, Hall AJ, Morandi A, Boustani M,
Neufeld KJ, Lee HB, Maclullich AM, Brayne C. The epidemiology of
delirium: challenges and opportunities for population studies. Am J
Geriatr Psychiatry 2013;21(12):1173-89
12
3 Nursing
Introduction
For several decades patients in Intensive Care Units (ICU) were assumed
to benefit from bed rest and deep sedation. Mental and physical
immobilisation was supposed to protect patients and reduce their risks
for complications1. During the last decade, though, bed rest has been
shown to be associated with a higher risk for several undesirable effects.
Prolonged immobility increases the risk for an extended rehabilitation
process and many secondary complications in ICU patients, including
muscle wasting, insulin resistance, orthostatic intolerance, pressure sores,
contractures, pneumonia, prolonged weaning from ventilator etc. These
conditions result in serious consequences like ICU acquired weakness and
neurological as well as psychological complications: delirium, anxiety,
depression and posttraumatic stress disorder2-4. Hence, to reduce the
consequences of prolonged bed rest, early rehabilitation and mobilisation
is now recommended for the treatment of mechanically ventilated ICU
patients4.
Early mobilisation is a stepwise, interdisciplinary approach, starting after
initial stabilisation. Patients are mobilised in a sitting position, sit on the
edge of the bed or in a chair, are standing, marching, walking with
mechanical ventilation. Example videos can be seen on www.mobilization-
13
Feasibility
Despite of the latter evidence based recommendations, clinicians may see
limited feasibility to facilitate early mobilisation in hospitalised delirious
patients, in particular in the group of critically ill patients19. Evidence
based protocols and safety criteria can be adapted to the culture and
sample of patients of different ICUs5,20,21. Common concerns of clinicians
are safety of early mobilisation of delirious patients, lack of staff and
others. In general, early mobilisation is safe with a low rate of
complications. In a current systematic review including 453 mechanically
ventilated patients who were mobilized for 3613 times out-of-bed, the
rate of unplanned pulling out of tubes or lines was 0.3% (n=10)22, but
presence and in- or exclusion of delirium was not consistently
demonstrated in the included studies. Clinicians may fear the safety of
tubes and lines, when mobilising delirious patients, especially in the case
of a hyperactive delirium. Based on our clinical experiences, patients with
a hyperactive delirium often improved after being mobilised out of bed.
Besides an anticipatory planning, individual safety and risk assessment
and interdisciplinary collaboration, a trustful and understandable
communication with the hyperactive delirious patient is essential.
In the context of safety issues the question arises how many personnel are
needed to safely mobilise a critically ill patient, for example suffering from
a hyperactive delirious episode? Has a nurse patient ratio, or the presence
of a 7-days-a-week physical therapist (PT), an influence on the
frequency or quality of a targeted early mobilisation? Morris et al.
(2008)21 were able to present results whereupon a mobility team could
significantly reduce the ICU stay (p= 0,027) respectively the length of
hospital stay (p=0,006) in the investigated sample. The economical benefit
of additional staff for early mobilization has been proven7,21,23. Outside the
setting of early mobilisation with specifically trained teams, the discussion
remains controversial. In a one day point prevalence study in Germany,
including 116 ICUs and 783 patients, no relationship between staffpatient-ratio and out-of-bed mobilisation was found10. In contrast, another
study from Germany24, exploring consequences of reduced staffing in
14
Recommendations/Conclusions
Early mobilisation is recommended for the rehabilitation, prevention and
management of delirium in critically ill patients. The impact of early
mobilisation on the delirious brain cannot be explained in detail, yet. The
approach is safe and reduces the delirium rate. Further research is needed
to evaluate the participation of next of kin and to prove the impact of early
mobilisation during the night on hyperactive, delirious patients.
References
1. Kress, J.P. (2013). Sedation and Mobility: Changing the Paradigm. Crit
Care Clin. 29 (1): 67-75.
2. Brower, R.G. (2009).Consequences of bed rest. Crit Care Med 37 (10):
422-428.
3. Desai, S. V., Law, T. J. & Needham D. M. (2011). Long-term
complications of critical care. Crit Care Med (39) 2: 371-379.
15
4. Needham, D.M., Davidson, J., Cohen, H., et al. (2012). Improving longterm outcomes after discharge from intensive care unit: report from a
stakeholders' conference. Crit Care Med. 40 (2): 502-9.
13. Swain RA, Harris AB, Wiener EC et al. (2003). Prolonged exercise
induces angiogenesis and increases cerebral blood volume in primary
motor cortex of the rat. Neuroscience 117:1037-1046.
5. Bailey, P., Thomsen, G.E., Spuhler, V.J., et al. (2007). Early activity is
feasible and safe in respiratory failure patients. Crit Care Med. 35 (1):
139-45.
14. Rhyu IJ, Bytheway JA, Kohler SJ et al. (2010). Effects of aerobic
exercise training on cognitive function and cortical vascularity in
monkeys. Neuroscience 167:12391248.
6. Morris, P.E., Goad, A., Thompson, C., et al. (2008). Early intensive care
unit mobility therapy in the treatment of acute respiratory failure. Crit
Care Med.: 36 (8): 2238-43.
7. Needham, D.M., Korupolu, R., Zanni, J.M., et al. (2010). Early physical
medicine and rehabilitation for patients with acute respiratory failure:
A quality improvement project. Arch Phys Med Rehabil 91:536-542.
8. Schweickert, W.D., Pohlman, M.C., Pohlman, A.S., et al. (2009). Early
physical and occupational therapy in mechanically ventilated, critically
ill patients: a randomised controlled trial. Lancet 30; 373 (9678):
1874-82.
9. Page, V.J., Casarin, A. (2014). Missing link or not, mobilise against
delirium. Crit Care. 31; 18 (1): 105.
10. Nydahl, P., Bartoszek, G., Ruhl, P.A. et al. (2014). Early Mobilization of
Mechanically Ventilated Patients: A One-Day Point Prevalence Study in
Germany. Crit Care Med 42: 1178-1186.
11. Balas, M.C., Vasilevskis, E.E., Olsen, K.M. et al. (2014). Effectiveness and
safety of the awakening and breathing coordination, delirium
monitoring/management, and early exercise/mobility bundle. Crit
Care Med. 42 (5): 1024-36.
12. Hopkins RO, Suchyta MR, Farrer TJ et al. (2012). Improving postintensive care unit neuropsychiatric outcomes: understanding
cognitive effects of physical activity. Am J Respir Crit Care Med.
186(12):1220-8.
16. Laurin D, Verreault R, Lindsay J et al. (2001). Physical activity and risk
of cognitive impairment and dementia in elderly persons. Arch Neurol
58:498504.
17. Heyn P, Abreu BC, Ottenbacher KJ (2004). The effects of exercise
training on elderly persons with cognitive impairment and dementia: a
meta-analysis. Arch Phys Med Rehabil 85:1694-1704.
18. Brummel NE, Girard TD, Ely EW et al. (2014). Feasibility and safety of
early combined cognitive and physical therapy for critically ill medical
and surgical patients: the Activity and Cognitive Therapy in ICU (ACTICU) trial. Intensive Care Med. 2014 Mar;40(3):370-9.
19. Devlin, JW, Pohlman, AS (2014). Everybody, Every Day: An
Awakening and Breathing Coordination, Delirium Monitoring/
Management, and Early Exercise/Mobility Culture Is Feasible in Your
ICU. Critical Care Medicine 42 (5): 1280-1281.
20. Stiller, K. & Phillips, A. (2003). Safety aspects of mobilising acutely ill
inpatients. Physiotherapy Theory & Practice 19 (4): 239-57.
21. Morris, PE. Goad, A., Thompson, C. et al. (2008). Early intensive care
unit mobility therapy in the treatment of acute respiratory failure. Crit
Care Med.36(8): 223843.
22. Nydahl, P., Ewers, A., Brodda, D. (2014). Complications related to early
mobilisation of mechanically ventilated patients on Intensive Care
Units. Nursing in Critical Care, in press.
16
23. Lord RK, Mayhew CR, Korupolu R. (2013). ICU early physical
rehabilitation programs: financial modeling of cost savings. Critical
Care Medicine 41(3):717-24.
24. Isfort, M., Weidner, F., Gehlen, D. (2012). Nursing-Thermometer 2012
(German: Pflege-Thermometer 2012). www.dip.de, 12.8.2014
25. Thomsen, G.E., Snow, G.L., Rodriguez, L. et al. (2008). Patients with
respiratory failure increase ambulation after transfer to an intensive
care unit where early ac- tivity is a priority. Crit Care Med 36 (4):
1119-24.
26. Engel, H.J., Needham, D.M., Morris, P.E. et al. (2013). ICU Early
Mobilization: From Recommendation to Implementation at Three
Medical Centers. Crit Care Med 41:S69-S80.
27. Kamdar BB, Yang J, King LM, et al. (2013). Developing, Implementing,
and Evaluating a Multifaceted Quality Improvement Intervention to
Promote Sleep in an ICU. Crit Care Med 41:800809.
28. Rosenbloom-Brunton, DA, Henneman, EA, Inouye SK. (2010).
Feasibility of Family Participation in a Delirium Prevention Program
For The Older Hospitalized Adult. Gerontol Nurs. 36(9): 2235.
29. Balas, MC. et al. (2013). Implementing the ABCDE Bundle into
Everyday Care: Opportunities, Challenges and Lessons Learned
for,Implementing the ICU Pain, Agitation and Delirium
(PAD),Guidelines. Critical Care Medicine. 41(901): S116S127.
30. Carrothers, KM. et al. (2013). Contextual Issues Influencing
Implementation and Outcomes Associated With an Integrated
Approach to Managing Pain, Agitation, and Delirium in Adult ICUs.
Critical Care Medicine. 41 ( 9) (Suppl.): S129.
17
Thomas Jackson
On behalf of delegates:
Leonna Bannon
Emma Cunningham
Daniel Davis
Roanna Hall
John Hazeldine
Kirsty Hendry
Daisy Moran
Sarah Richardson
Liz Sapey
Alina Schwarz
Joyce Yeung
18
Key dates:
November 24, 2014: Deadline for Submission of Oral Presentation
Abstracts
December 15, 2014: Email Notification of Status Sent to Abstract
Submitters
March 2, 2015: Deadline for Poster Abstract Submissions
April 15, 2015: Early Registration Deadline (Presenters must register by
this date)
May 31 - June 2- 2015: American Delirium Societys 5th Annual Meeting
Baltimore, MD
____________________________________________________________________________________
19
ADVANCE NOTICE
________________________________________________
EDA 2015
10th Scientific Conference
Dates: 2nd 4th September 2015
Venue: Guys Campus of Kings College London
We will be hosting the conference in conjunction with the British
Geriatrics Society Dementia and related disorders Specialist Interest
Group (BGS Dementia SIG).
20