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Annals of Delirium Care

Volume 14, October 2014

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

involved in the EDA) with an interest in delirium. The resources and


implementation expertise of such policy-makers massively amplifies the
adoption of good practice recommendations from expert groups in the
field. Positive effects are now being seen in mainstream healthcare in the
UK. Continued efforts at raising awareness, such as distributing the
Scottish Delirium Associations Factsheet for Hospital Managers (see
www.scottishdeliriumassociation.com), will likely yield large dividends.
Education of healthcare practitioners is another domain where harnessing
the scale and authority of major providers is essential. Through
engagement with relevant policy-makers, delirium is now featuring more
prominently in curricula and in online training programmes. This
required not only that the educational resources were produced, but also
that national providers were approached about disseminating these
resources. So our efforts in delirium education, tackling attitudes, skills,
and knowledge, should not only be made in local and national educational
events but also at the level where we can reach those not attending such
events.
Implementation is a domain of healthcare which is rapidly developing,
especially as proven improvement methodologies become more
commonly employed. It is pleasing to see that several delirium meetings
now include reports of the use of such methodologies in delirium; indeed
there is a workshop on this in the EDAs next annual meeting in Cremona,
Italy. Work on how we join up research findings with pragmatic
implementation strategies will likely be an important growing area in the
field.
Alongside raising awareness, providing education, and implementing
what we know to be best practice, the field also needs an expanding
programme of high quality research. There are too many issues to list
here, but examples are the mechanisms underpinning delirium, the
detailed epidemiology (especially addressing long-term outcomes),
further development of measurement tools, and clinical trials of
prevention and treatment strategies.

European Delirium Association 2014 www.europeandeliriumassociation.com

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

Developing delirium recognition and assessment in palliative


care: an update on the DePAC project
Annmarie Hosie
The University of Notre Dame Australia
Correspondence to: annmarie.hosie1@my.nd.edu.au
Introduction
Delirium is an acute neurocognitive condition [1] that is prevalent,
distressing and debilitating for hospitalised patients, yet frequently
under-recognised and under-prioritised in many clinical practice settings
[2], including inpatient palliative care. [3] Fortunately, there is growing
awareness of the need to build the palliative care delirium evidence-base
and better align medical and nursing care with emerging evidence. [4]
Nurses are integral to optimal recognition and assessment of delirium by
virtue of their 24-hour presence at the bedside and professional
responsibilities. [5] However, nurses have variable delirium recognition
capabilities. [6, 7] Various strategies have been recommended to engage
nurses in better delirium recognition and assessment practices across
care settings, including: use of validated tools, building their delirium
capabilities using an array of educational approaches, and integration of
cognitive and delirium assessment into ward rounds, routine
documentation and patient handovers. [6-9] In order to better target
strategies to enhance palliative care nurses delirium practices first
requires exploration of: 1) impetus for change; 2) contextual factors that
influence nurses delirium capabilities; 3) nurses perspectives of their
experiences in delirium care; and 4) the barriers and enablers to changing
individual and organisational practices.
This paper provides a brief overview of a research project exploring these
factors in Australia.

European Delirium Association 2014 www.europeandeliriumassociation.com

Aim

Results

The Delirium in Palliative Care Project (The DePAC Project) aims to


determine how nurses can better recognise, assess and respond to
patients delirium symptoms within palliative care inpatient settings.

Phase 1 - Scoping the problem

Study 1: A systematic review of delirium prevalence, incidence and


implications for screening in palliative care inpatient settings
identified eight studies (1996 -2008) of predominately advanced
cancer populations (98.9%). [14] Studies screening patients at least
daily for delirium reported higher incidence (32.8%45%), while
delirium prevalence was 13.3%42.3% at admission, 26%62%
during admission, and 58.8%88% in the weeks or hours preceding
death. The conclusions emerging from this systematic review found
that delirium occurrence rates in palliative care inpatient settings
support the need for routine screening in clinical practice. However, to
support this practice change there is a need to establish which
delirium tools and processes are most feasible, valid and acceptable
for palliative care patients and their families. [14]

Study 2: A cross sectional study prospectively measured 24-hour


delirium point prevalence in inpatients (n=47) of two palliative care
units, using the Nursing Delirium Screening Scale (NuDESC) [15],
Memorial Delirium Assessment Scale (MDAS) [16] and the American
Psychiatric Association (APA) Diagnostic and Statistical Manual of
Mental Disorders, Fifth edition (DSM-5) [1] diagnostic criteria for
delirium. Results revealed that this cohort was primarily an older
(mean age 74 years (SD +10) and advanced cancer population (96%),
with only two patients (4%) considered by clinicians to be in their last
days or hours of life. [17] Sixteen patients (34%) screened positive for
delirium, with a fifth (19%) meeting the full DSM-5 diagnostic criteria
for delirium (n=9). These results are similar to that reported in the
systematic review [14] and support the need for routine processes for
delirium recognition and assessment within Australian inpatient
palliative care services.

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.

European Delirium Association 2014 www.europeandeliriumassociation.com

Study 3: An environmental scan examining organisational capacity to


recognise and assess delirium in palliative care inpatient settings is
currently underway, with initial data obtained through structured
group interviews with key personnel of three metropolitan palliative
care inpatient units. Preliminary data indicate that policies and
procedures guiding delirium practice and routine screening and
assessment processes are absent within this setting. However, there
are opportunities for future practice change strategies to be
incorporated into existing systems; for example: through routine daily
delirium symptom screening [18] and structured clinical handover
using ISBAR (Identify, Situation, Background, Assessment and
Recommendation), a mnemonic designed to improve safety and
consistency in the transfer of patient information. [19]

Phase 2 Exploring palliative nurses delirium experiences,


perceptions and capabilities

Study 4: A series of semi-structured interviews using the critical


incident technique explored inpatient palliative care nurses:
a. delirium recognition and assessment capabilities; [20] and
b. perceptions of the barriers and enablers to delirium
recognition and assessment for palliative care inpatients. [21]
In brief, palliative care nurses experience a range of emotions when
caring for patients with delirium symptoms, including empathy,
puzzlement and distress. These nurses acknowledged the need to
improve their delirium knowledge and expressed a preference for
locally delivered education that is relevant to the palliative care
context. They believed that integrating delirium guidance, routine
systems and screening tools would better support their practice.
Ambiguous terminology, such as terminal agitation or terminal
restlessness, impeded nurses understanding, communication and
assessment of delirium. Findings revealed a need for team
communication that is more consistently respectful, structured and
explicitly focused on patients delirium status. [20, 21]

Study 5: A mixed methods study exploring the feasibility and


acceptability of the NUDESC in the palliative care inpatient setting
resulted in bedside nurses applying the tool for 100% of inpatients at
two palliative care inpatient units at least once during eight 24-hour
periods. Per shift, a 97% completion rate was achieved. Additionally,
the perspectives of nurses who had used the NuDESC (n=19) were
obtained through rapid focus groups, with thematic content analysis
and integration of data soon to be finalised and reported.

Phase 3: Narrowing the evidence-practice gap

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

European Delirium Association 2014 www.europeandeliriumassociation.com

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

8.

The author gratefully acknowledges the contribution of Professor Jane


Phillips, Professor Patricia Davidson, Associate Professor Meera Agar and
Professor Elizabeth Lobb in The DePAC Project design, conduct and
dissemination, and all managers and nurses who have supported and
participated in this research.
References
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2.

3.
4.

5.

American Psychiatric Association, Diagnostic and Statistical Manual


of Mental Disorders, Fifth Edition (DSM-5)2013, Arlington, VA:
American Psychiatric Publisher.
National Clinical Guideline Centre for Acute and Chronic Conditions,
Delirium: diagnosis, prevention and management, NICE Clinical
Guideline 103, 2010, National Institute for Health and Clinical
Excellence: London.
Fang, C.K., et al., Prevalence, detection and treatment of delirium in
terminal cancer inpatients: A prospective survey. Japanese Journal of
Clinical Oncology, 2008. 38(1): p. 56-63.
Lawlor, P.G., et al., An Analytic Framework for Delirium Research in
Palliative Care Settings: Integrated Epidemiological, ClinicianResearcher and Knowledge User Perspectives. Journal of Pain and
Symptom Management, 2014(0).
Nursing and Midwifery Board of Australia, National Competency
Standards for the Registered Nurse, 2006, Nursing and Midwifery
Board of Australia: Melbourne.

7.

9.

10.
11.
12.

13.
14.
15.

Steis, M.R. and D.M. Fick, Are nurses recognizing delirium? A


systematic review. Journal of Gerontological Nursing, 2008. 34(9): p.
40-49.
Agar, M., et al., Making decisions about delirium: A qualitative
comparison of decision making between nurses working in palliative
care, aged care, aged care psychiatry, and oncology. Palliative
Medicine, 2012. 26(7): p. 887-96.
Brummel, N.E., et al., Implementing delirium screening in the ICU:
Secrets to success. Critical Care Medicine, 2013. 41(9): p. 2196-2208.
Registered Nurses Association of Ontario, Caregiving Strategies for
Older Adults with Delirium, Dementia and Depression (With revised
2010 supplement), 2004, Registered Nurses Association of Ontario:
Toronto.
World Health Organisation, Bridging the KnowDo Gap Meeting on
Knowledge Translation in Global Health WHO, Editor 2005: Geneva,
Switzerland.
Palliative Care Australia, A Guide to Palliative Care Service
Development: A population based approach, 2005, p.7, Palliative Care
Australia: Deakin West.
Palliative Care Outcomes Collaborative, National Report on Patient
Outcomes in Palliative Care in Australia, 2013, Centre for Health
Service Development, University of Wollongong PCOC Central
Cancer and Palliative Care Research and Evaluation Unit, University
of Western Australia PCOC West Department of Palliative and
Supportive Services, Flinders University of South Australia PCOC
South Institute of Health and Biomedical Innovation, Queensland
University of Technology - PCOC North.
Creswell, J.W., & Plano-Clarke, V. , Designing and conducting mixed
methods research2006, Thousand Oaks, California: Sage Publications.
Hosie, A., et al., Delirium prevalence, incidence, and implications for
screening in specialist palliative care inpatient settings: A systematic
review. Palliative Medicine, 2013. 27(6): p. 486-498.
Gaudreau, J.D., et al., Fast, systematic, and continuous delirium
assessment in hospitalized patients: the nursing delirium screening

European Delirium Association 2014 www.europeandeliriumassociation.com

16.
17.

18.
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21.

22.
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scale. Journal of Pain and Symptom Management, 2005. 29(4): p.


368-375.
Breitbart, W., et al., The memorial delirium assessment scale. Journal
of Pain and Symptom Management, 1997. 13(3): p. 128-137.
Palliative Care Clinical Outcomes Collabrative. Clinical Reference
Manual
Version
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Dataset.
2012;
Available
from:
http://ahsri.uow.edu.au/content/groups/public/@web/@chsd/@p
coc/documents/doc/uow137241.pdf.
Eagar, K., The Australian Palliative Care Outcomes Collaboration
(PCOC) - Measuring the quality and outcomes of palliative care on a
routine basis. Australian Health Review, 2010. 34(2): p. 186-192.
SA Health. Clinical handover. 2012 September 29 2014]; Available
from:
http://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/
sa+health+internet/clinical+resources/safety+and+quality/clinical+
handover.
Hosie, A., et al., Palliative care nurses' recognition and assessment of
patients with delirium symptoms: A qualitative study using critical
incident technique. International Journal of Nursing Studies, 2014.
http://dx.doi.org/10.1016/j.ijnurstu.2014.02.005.
Hosie, A., et al., Identifying the Barriers and Enablers to Palliative Care
Nurses' Recognition and Assessment of Delirium Symptoms: A
Qualitative Study. Journal of Pain and Symptom Management, 2014.
http://dx.doi.org/10.1016/j.jpainsymman.2014.01.008.
NSW Ministry of Health. Plan, Do, Study, Act cycle. 2013; Available
from: http://www.health.nsw.gov.au/pfs/Pages/PDSA.aspx.
Clinical Excellence Commission. Clinical Practice Improvement. 2014;
Available from:
http://www.cec.health.nsw.gov.au/programs/clinical-practice.

Figure 1

European Delirium Association 2014 www.europeandeliriumassociation.com

Older loved ones and delirium: The experiences of family


members in Australia
Dr Jenny Day & Professor Isabel Higgins
School of Nursing and Midwifery, University of Newcastle, Australia
Correspondence to: jenny.day@newcastle.edu.au

In this Annals item we provide a summary of research undertaken by the


first author for her doctoral studies. Whilst a full report is under review
for publication, our aim is to bring the thesis findings to the attention of
researchers and clinicians committed to understanding delirium from the
perspective of family.

Approach & Methods


Guided by phenomenology, the aim of this study was to describe the
experiences of family members during their older loved ones delirium.
There were 14 family members in this study; twelve daughters and two
wives who cared for their loved ones at home, in residential aged care
and/or while hospitalised. The older people included 8 mothers, 2 fathers
and 2 husbands (n=12) aged 69-100 yrs. Seven had pre-existing
early/moderate dementia. Delirium was determined by diagnosis or
participant description concordance with recognised delirium
identification/diagnosis criteria. Data from in-depth interviews over 19
months, field notes and reflections, and media depictions were analysed.
Data interpretation was thematic, informed by the phenomenologies of
Merleau-Ponty (1945/2002) and Sartre (1943/2003).
Findings

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.

Changing family portraits: Sudden existential absence during delirium


depicts the womens experiences during their older loved ones delirium.
The notion of existential absence reveals how the women suddenly lost
the familiar and taken-for-granted presence of their loved one, and
experienced the presence of a stranger. The meaning of existential
absence for the women is described further by the following theme and
sub-themes:
Living the fragility of a loved ones presence:

Facing a loved one's existential absence, and

Living with a stranger.

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

European Delirium Association 2014 www.europeandeliriumassociation.com

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:

Waiting for a loved one,

In the dark,

On the fringe but centre stage,

On thin ice, and

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

healthcare staff, the women were distressed, troubled and frustrated.


Their experience of the stranger was theirs alone; it was hidden and went
unacknowledged by health care staff. The women yearned for the loved
one they knew; the one depicted in their family portraits and recalled
from their memories.
The women sought explanations that would help them to come to grips
with their loved ones absence and the strangers presence, particularly
how long they would need to endure the strangers presence. Lived was
the inadequacy of medical categories in explaining their experiences. Like
being left In the dark, not understanding their experience added to the
uncertainty which permeated the womens experiences and made it
harder for them to know what to do and maintain hope for their loved
ones return.
The women who experienced an end to an episode of delirium also
experienced the ever-present possibility their loved one would suddenly
transform and be absent once more, this possibility engendering
apprehension. When their loved one was well the possibility of deliriums
return kept the women wary, watchful and on guard. Like living On thin
ice, these women were never sure when their loved one would suddenly
leave again. These women also endured Keeping secrets. Though all
women experience the stranger, some find the stranger is not recalled by
their loved one after delirium passes. They realise they hold privileged
knowledge of a time when their loved one was a stranger. Keeping the
stranger a secret shields their loved one from the likely distress of
knowing they were not themselves; that their behaviour was out of control
and at times unspeakable. Keeping secrets reveals the close ties between
family members but they are also a burden the women bear.
Conclusion
The analysis and interpretation of experiences shared by the women in
this study reveals that their experiences were profound; distressingly
dominated by the existential absence (Sartre, 1943/2003) of their older

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loved one. It reveals that reaching beyond knowledge of delirium as a


condition to its existential meaning for family members enriches our
understanding of human experiences during this condition. Based on
Cohen et al.s (2000) argument that understanding the meaning of
experiences for several people provides a sensitive basis upon which a
caring relationship can be built, it is hoped that these findings invite
readers to appreciate what delirium is like for family members and to
respond with compassion and sensitivity.
Implications for Practice
Understanding family member experiences of absence and their feelings
of distress invites healthcare staff to provide meaningful support and
appropriately include family members in their older loved ones care. For
example, opportunities for family members to express feelings or
concerns, providing information or explanations and talking about how
they are coping with the changes they perceive may be interventions
which are supportive and of benefit. Together with information about
delirium, it may be beneficial to include explanations about what family
members experience and how to cope or respond during care. Better
understanding of the impact of delirium on family members can assist in
acknowledging and ensuring the wellbeing of family members during an
older loved ones delirium.
Acknowledgement
Sincere thanks to John Young and the Editors for permission to use the
poem titled My Fathers Delirium, published in the March 2012 Annals, in
my thesis.

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
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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

European Delirium Association 2014 www.europeandeliriumassociation.com

Delirium Prevention in Psychiatry a new Paradigm


Dr Simon Thacker
Derbyshire Healthcare NHS Foundation Trust
Correspondence to: simon.thacker@derbyshcft.nhs.uk
Dementia is the heartland of Old Age Psychiatry and has achieved a high
national profile in the UK.1 In contrast, delirium barely enters public
discourse. The prevalence of delirium in hospitals and care homes is
remarkable and of the same order of magnitude as dementia
unsurprising given that age and a pre-existing dementia are the largest
risk factors for delirium.2,3 The publication of NICE Delirium Guidelines
has been a major advance in the promotion of delirium management4 but
evidence is lacking that specific programmes of delirium-care improve
outcomes.5 Conversely, there is some limited evidence that
multicomponent interventions aimed at preventing delirium reduce its
incidence and improve outcomes.6,7
Why is Delirium Prevention not taken more seriously in
Community Psychiatry?
Prevalence studies of delirium in any setting are fraught by the problem of
distinguishing delirium from dementia.8 A Swedish epidemiological study
of very elderly people found that 52% of PWD had experienced delirium
within the previous month compared to 5% of those without dementia.9
Moreover, there is evidence from cohort follow-up that delirium in the
very elderly increases the risk of subsequent dementia by 9-fold. 10
People with dementia (PWD) who are living in their own homes and in
receipt of care from community mental health teams are also likely to be
at high risk of delirium. Behavioural and psychological symptoms in
dementia (BPSD) create obstacles to care that render the patient
vulnerable to comorbidities that contribute to delirium such as falls,

nutritional deficits and polypharmacy. Conversely, delirium can plausibly


generate non-cognitive features that become chronic and constitute BPSD.
Delirium is often triggered by acute physical events and rightly remains
the domain of primary care and geriatricians but unless psychiatry coowns the delirium agenda, the cross-over of skills from the management
of BPSD will fail to influence Delirium Prevention (DP).
Integrated Care for the Frail Elderly
Community care of the frail elderly must embrace both delirium and
dementia by recognising their reciprocity. Unfortunately, the requirement
for dual skills and current organisational divisions are at odds.
Transformational change into Integrated Care is an NHS driver aimed at
healing the schism but clear ideas of the mechanism for this are lacking.11
Is raising the profile of delirium a way to bridge the divide between
mental health and physical health approaches to the care of the elderly?
Facing the Fear
Dementia has become the most feared disease of later life.12 The thrust
towards early diagnosis is creating an expectation that services will exist
to support PWD but these interventions are predominantly social and can
leave many people feeling short-changed that medical carers have
abandoned them.13 DP constitutes a multicomponent medical paradigm
that seeks to engage and empower carers by providing a formulation of
dementia as a risk factor for a greater catastrophe i.e delirium. 14
The Derbyshire Ambition
1)
Delirium prevention should be an explicit part of all care plans for
people with dementia on the wards and within community mental health
teams for the elderly (CMHTEs). A simple checklist is necessary but
insufficient without raising the profile of delirium through training and
education.

European Delirium Association 2014 www.europeandeliriumassociation.com

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.

European Delirium Association 2014 www.europeandeliriumassociation.com

11

(doi: 10.1016/j.jagp.2013.04.007).

References
1. Living well with dementia: A National Dementia Strategy. Department
of Health 2009.

9. Mathillas et al. Thirty-day prevalence of delirium among very old


people: A population-based study of very old people living at home
and in institutions . Archives of Gerontology and Geriatrics 2013;
57:298304.

2. Ryan D, O'Regan N, O Caoimh R, et al. Delirium in an adult acute


hospital population: predictors, prevalence and detection. BMJ Open
2013; 3:e001772 (doi:10.1136/bmjopen-2012-001772)

10. Davis DH, Muniz Terrera G, Keage H, Rahkonen T, Oinas M, Matthews


FE, Cunningham C, Polvikoski T, Sulkava R, MacLullich AM, Brayne C.
Delirium is a strong risk factor for dementia in the oldest-old: a
population-based cohort study. Brain 2012 135(Pt 9):2809-16.

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en
/documents/digitalasset/dh_094051.pdf

3. Siddiqi N, Clegg A, Young J. Delirium in care homes. Reviews in Clinical


Gerontology 2009; 19(4):309-16.
4. NICE clinical guidelines. Delirium: diagnosis, prevention and
management. Updated July 2010.
www.nice.org.uk/guidance/CG103/PublicInfo
5. Goldberg SE, Bradshaw SE, Kearney F, Russell C, Whittamore K, Foster
PER, Mamza J, Gladman JRF, Jones RG, Lewis SA, Porock, D, Harwood
RH on behalf of the Medical Crises in Older People study group. Care in
specialist medical and mental health unit compared with standard
care for older people with cognitive impairment admitted to general
hospital: randomised controlled trial (NIHR TEAM trial). BMJ
2013;347:

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

6. Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing


delirium after hip fracture: a randomized trial. Journal of the American
Geriatrics Society 2001; 49(5):516-22.

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.

15. Jolley D, Greaves I, Greaves N, Greening L. Three tiers for a


comprehensive regional memory service. Journal of Dementia Care
2010; 18(1):26-9.

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

European Delirium Association 2014 www.europeandeliriumassociation.com

12

Delirium and early Mobilisation


Nydahl, P., RN BScN,1 Guenther, U., MD DESA EDIC,2 Krotsetis, S., RN CCRN
MSc 3
1 Nursing

Research, University Hospital of Schleswig-Holstein, Kiel

Consultant Anaesthesiologist, Clinic of Anesthesiology & Intensive Care


Medicine, Bonn University Medical Centre, Bonn, Germany.
2

3 Nursing

network.org. Early mobilisation of mechanically ventilated patients has


been shown to be safe, even with an endotracheal tube in place5, and was
associated with reduced length of stay and ventilator days6,7; moreover, it
improves physical outcome8. Early mobilisation is also recommended for
the treatment of delirious patients9, while at the same time, delirium is
seen as a barrier to mobilisation by clinicians10. Hence, questions arise
about the impact and feasibility of early mobilisation on delirious patients.

Research, University Hospital of Schleswig-Holstein, Lbeck

Correspondence to: peter@nydahl.de

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-

Early mobilisation and delirium: evidence


Early mobilisation has got an impact on delirium of mechanically
ventilated ICU patients. proved In a randomized controlled trial with
medical, mechanically ventilated patients Schweickert et al.8 showed the
effects of early mobilisation within the first 72h compared to usual care.
The intervention was conducted by additional occupational Therapists
and physiotherapists during daily wake up and spontaneous breathing
trial - the control grouponly receiving daily wake up & breathing trials.
The intervention group (n=49) showed significant better self-care
competencies, shorter time of mechanical ventilation and shorter length of
stay in the ICU than the control group (n=55). Patients in the intervention
group had shorter time of delirium than control (2d vs 4d, p=0.02).
Delirious days on ICU were 33% vs. 55% (p=0.02), assessed with the
CAM-ICU.
Needham et al.7 conducted a quality improvement project to reduce
sedation and improve mobility of medical ICU patients. Compared to the
4-month pre-project period (n=29), patients in the project group (n=30)
had significantly more physical therapy (93% vs 59%, p = 0.004), were
more out of bed (sitting or more: 78% vs 56%, p = 0.03), had a reduced
length of stay in the ICU (4.9 vs 7.0 days, p = 0.02) and had more delirium
free days on the ICU (53% vs 21%, p = 0.003), detected with the CAM-ICU.
Balas et al.11 implemented the ABCDE approach (daily wake up trial, daily
spontaneous breathing trial, delirium assessment and early mobilisation).

European Delirium Association 2014 www.europeandeliriumassociation.com

13

In a before/after cohort study on a medical and surgical ICU (before:


n=146, after: n=150), after adjustment of co-factors the approach lead to a
significant reduction in ventilator days (24d vs 21d, p=0.04), doubled the
odd of being mobilised out of bed (OR 2.11, 95%CI 1.29-3.45, p=0.003)
and reduced the odd of delirium by half (OR 0.55, 95% CI 0.33-0.93,
p=0.03).
These well done studies with a low risk of bias proved the impact of early
mobilisation on delirium, despite being critically ill or being mechanically
ventilated. How can this effect be explained?

Early mobilisation and the brain


As Hopkins et al.12 discussed, the impact of early mobilisation on the
delirious brain is not fully explained nor proven, but one can use hints
from other studies. Animal studies13,14 found that physical activity
promoted new blood vessel formation and neurogenesis. In elderly
humans, physical exercise has been shown to be associated with increased
cerebral blood flow, oxygen extraction and glucose metabolisation15. In
patients suffering from dementia, a prospective study following more than
4000 healthy elderly people for 5 years demonstrated that physical
activity was associated with lower incidence of cognitive decline and
dementia16. In patients already presenting with dementia, physical
exercise was confirmed by a meta-analysis to still have moderate
beneficial effects on cognition17. Recent data suggest that physical exercise
also prevents physical impairment and cognitive decline in ICU patients8,
but further and well powered studies are needed to prove the impact18.
According to Hopkins et al.12, early mobilisation increase resistance to
brain injury by facilitation of synaptic transmission and promotion of
neurogenesis and angiogenesis. Early mobilisation thereby preserves
cognitive function and decreases depression and anxiety12.

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

European Delirium Association 2014 www.europeandeliriumassociation.com

14

German ICUs, reported reduced mobilisation on 532 ICUs, if less nurses


were present. These contrary results can be explained with a sample bias
within the studies (only those ICUs with enough or spare staff
participated). On the other hand, Thomsen25 proved that patients are
more mobilised if they are transferred to an ICU where early mobility has
a high priority. Attitude, knowledge and cooperation seem to be important
factors to overcome the barriers to early mobilisation26.
Another important issue is early mobilisation during the night. Sufficient
sleep quality reduces the incidence of delirium27 and early mobilisation
may be reduced to daytime activities. Delirious patients have a disturbed
sleep rhythm. One can argue that early mobilisation may also happen
during the night, if a patient is restless and cannot sleep, e.g. sitting on the
edge of the bed for a couple of minutes. Clinicians expect patients to sleep
at night, but one has to know that (in Germany) one in three suffers from
sleep disorders (Fed. Bureau of Statistics, 2013). At home, these persons
would stand up, walk around, watch tv or the like: for those persons it is
common to get up during the night. If early mobilisation reduces incidence
of delirium, one can conclude that mobilisation during the night might
help (one third of) delirious patients to reduce the tension, particularly
those patients suffering of a hyperactive delirium. It may help patients to
re-orientate and to get back to a regular wake-sleep-cycle. Future research
may focus on the hypothesis of early mobilisation during the night,
whether it has an influence on sleeping quality and delirium, subsequent
use of benzodiazepines and restraints.
A trustful, understandable interaction, and possible presence of relatives
may be important factors. The approach of early mobilisation, which
combines the need of family members to be integrated into the care of
their critically ill relatives26 and to provide a more familiar surrounding
for the delirious patient requires participation of families or friends into a
mobilisation procedure. Rosenbloom-Brunton et al. (2010)28 conducted a
study regarding the feasibility of family participation in a delirium
prevention in elderly hospitalised patients. The researchers evaluated that
57% of the interviewed relatives (n=15) estimated the participation in an

early mobilisation protocol as moderately difficult to perform. Of course,


families need detailed teaching and constant monitoring.
In order to support patients and family members and to promote a culture
of willingness to implement tools of a successful delirium management,
such as an early mobility approach, into daily practice, the entire
therapeutic team needs a valid knowledge regarding the clinical picture,
prevention and management of delirium29. Furthermore institutional
engagement and support of the therapeutic team seems crucial to
constitute a structural framework30.

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.

European Delirium Association 2014 www.europeandeliriumassociation.com

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.

15. Churchill JD, Galvez R, Colcombe S et al. (2002). Exercise, experience


and the aging brain. Neurobiol Aging 23:941955.

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.

European Delirium Association 2014 www.europeandeliriumassociation.com

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.

EDA and ADS working together


Following the publication of the DSM-5 criteria the EDA and American
Delirium Society collaborated on an opinion piece, which was recently
published in Current Controversies in Psychiatry. The paper comments in
the particular on the loss of the term consciousness i.e. the change from
DSM-4, which described delirium as a disturbance in consciousness and
attention, to DSM-5, to a disturbance in attention and awareness.
Furthermore DSM-5 adds the statement that the disturbance does not
occur in the context of a severely reduced level of arousal such as coma.
The concern is that The risk of misinterpreting these revised criteria
is that clinicians may focus inappropriately on inattention and
testability, erroneously overlooking the de facto disturbance in
consciousness (that is, delirium) that comes with altered arousal.
The emphasis in DSM-V is in the detection of inattention. A substantial
proportion of patients present with reduced levels of arousal severe
enough to affect their ability to be tested for inattention. Those patients,
rather than being correctly identified as delirious, may be classed as
obtunded or stuporose. Reduced arousal may indeed be a result of
delirium. Separating reduced arousal, short of coma, into those patients
who can be demonstrated to have inattention and those who cannot be
tested due to their lack of response is not clinically useful and given the
degree of fluctuation in delirium, impractical.
The summary states that patients who have impaired arousal such that
they cannot engage in cognitive testing or interview must be understood
to effectively have inattention. This is consistent with the current
evidence base and the realities of clinical practice. This unique opinion
piece is freely available to read in its entirety on open access.
http://www.biomedcentral.com/1741-7015/12/141
Valerie Page
Editor

European Delirium Association 2014 www.europeandeliriumassociation.com

17

Young Delirium Researchers Meeting


On 11th and 12th of September this year 15 researchers in delirium met in
Birmingham, UK. The meeting had the intention of bringing together early
career researchers working in the field of delirium in an informal yet
constructive way. By presenting current and future projects to peers we
were able to highlight challenges as well as a good practice in delirium
research. These included recently funded work looking at anaesthetic
type and delirium in hip fractures, ongoing work in screening for delirium
using different tools and potential projects looking at cognitive outcomes
in delirium in population based cohorts. Delegates included medical
students, neuropsychologists, nurses and both doctoral students and early
post-doctoral researchers. Updates in biomarker work, animal studies,
assessment scales and cognitive outcomes were presented as well as a
presentation on inflammageing as a possible driver of delirium. This was
all done through seminar style presentations and importantly over drinks
and a meal later on. By meeting as a group of peers, without the
potentially intimidating presence of senior researchers, it allowed
perhaps more unguarded questioning and discussion which was very
constructive.

2) Describe the natural history of delirium with respect to cognitive,


functional and inflammatory outcomes- from community settings through
all care settings, especially hospitals and care homes. This will need
collaboration with other disciplines including epidemiology and health
economics.
3) Embed basic and translational research alongside clinical research
projects to improve understanding of the pathophysiology and
understanding of any conclusions seen
4) Improve collaboration with all clinical disciplines including, but not
exclusively nursing, physiotherapy, occupational therapy and speech
therapy.
People left the meeting feeling refreshed and enthusiastic about the future
with new project ideas and collaborations in the pipeline; so its main aim
was met.

One of the difficulties in organising the meeting was attempting to identify


everyone who may have liked to come, and future meeting would hope to
ensure we include as many people as possible. In a relatively small but
emerging field this collaboration provides a good peer level support
network.
From our meeting the group identified 4 research priorities:
1) Clarify and operationalise measures for assessing delirium severity and
the core symptoms of arousal and inattention.

European Delirium Association 2014 www.europeandeliriumassociation.com

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

9th Annual Meeting of the European Delirium Association


November 6th - 7th, 2014 Cremona (Italy)
http://www.overgroup.eu/eda2014/

The Conference Planning Committee of the


American Delirium Society
invites you to submit proposals for presentation at ADS 5th Annual
Meeting, May 31 - June 2, 2015.
Follow this link to the Call for Proposals page on our website:
https://www.americandeliriumsociety.org/conference-events/call-forproposals
Click here to go directly to the downloadable form:
https://www.americandeliriumsociety.org/files/Call_for_Proposals_2015
_v1.pdf

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
____________________________________________________________________________________

European Delirium Association 2014 www.europeandeliriumassociation.com

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).

Guidelines for authors


Annals of Delirium Care is a publication of the European Delirium
Association which seeks to advance knowledge in the field of delirium. It
is published three times a year (March, July, November). We especially
welcome opinion pieces, reviews and research articles in the field.
Please send your ideas for contributions to the next Annals to
valerie.page@whht.nhs.uk, andrew.teodorczuk@newcastle.ac.uk or
m.dewes@web.de .

Contact for further information: daniel.davis@ucl.ac.uk


_______________________________________________________________________________
Production Manager: Anne Maule, Newcastle upon Tyne, UK

European Delirium Association 2014 www.europeandeliriumassociation.com

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