Differentiation of delirium, dementia and delirium superimposed on dementia in the older person.

Delirium is an acute clinical emergency that requires prompt clinical intervention. A predisposing factor for delirium is dementia, and delirium may highlight the vulnerability of a patient to developing dementia. However, delirium also occurs during an acute illness in patients diagnosed with dementia; this is classified as delirium superimposed on dementia. This complex interplay of both dementia syndromes and the condition of delirium has been extensively studied. However, delirium continues to be under-recognised in the acute setting, which impacts negatively on patient outcomes. Nurses are the health professionals best placed to recognise a change in a patient's cognitive symptoms, but nurses caring for the older person have suggested the identification of and differentiation between delirium, dementia and delirium superimposed on dementia remains very confusing. A need for further education with supportive guidelines and protocols is required to empower nurses caring for an older person to verbalise changes in patients' cognitive status in a reliable, robust and systematic manner.

Safety incidents involving confused and forgetful older patients in a specialised care setting--analysis of the safety incidents reported to the HaiPro reporting system.

AIMS AND OBJECTIVES: To describe the safety incidents involving confused and forgetful older patients in a specialised care setting entered in the HaiPro reporting system. BACKGROUND: About 10% of patients experience a safety incident during hospitalisation, which causes or could cause them harm. The possibility of a safety incident during hospitalisation increases significantly with age. A mild or moderate memory disorder and acute confusion are often present in the safety incidents originating with an older patient. DESIGN: The design of the study was action research with this study using findings from one of the first-phase studies, which included qualitative and quantitative analysed data. METHODS: Data were collected from the reporting system for safety incidents (HaiPro) in a university hospital in Finland. There were 672 reported safety incidents from four acute medical wards during the years 2009-2011, which were scrutinised. Seventy-five of them were linked to a confused patient and were analysed. RESULTS: The majority of the safety incidents analysed involved patient-related accidents. In addition to challenging behaviour, contributing factors included ward routines, shortage of nursing staff, environmental factors and staff knowledge and skills. Nurses tried to secure the patient safety in many different ways, but the modes of actions were insufficient. CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE: Nursing staff need evidence-based information on how to assess the cognitive status of a confused patient and how to encounter such patients. The number of nursing staff and ward routines should be examined critically and put in proportion to the care intensity demands caused by the patient's confused state. The findings can be used as a starting point in the prevention of safety incidents and in improving the care of older patients.

A new tool to asses risk of wandering in hospitalized patients.

This article describes the development and implementation of a wandering screening and intervention program based on identifying hospitalized patients with impaired cognition and mobility. A wandering screening tool developed by a multidisciplinary team was linked to appropriate levels of interventions available in the electronic health record. Advanced practice nurses (APNs) confirmed the accuracy of screening and interventions by bedside nurses for all patients who screened positive. Of 1,528 patients hospitalized during a 3-week period, 48 (3.1%) screened positive for wandering. At-risk patients were older (age ≥ 65) (66.7%), those admitted to surgical units (41.7%), Caucasian (89.6%), and men (58.3%). Thirteen (27.1%) had dementia and 45 (93.8%) had impaired cognition. Of those patients who screened positive for wandering, the APNs agreed with the bedside nurses' assessment in 79.2% of cases (38/48) about wandering risk and 89.5% (34/38 true positives) for the interventions. A two-item wandering screening tool and intervention was feasible for use by bedside nurses. Further studies are needed to determine whether this tool is effective in preventing wandering.

Management of acute confusion in patients with CNS infections.

This article discusses the management of acute confusion and aggression in patients with infections of the central nervous system (CNS). The issues discussed are applicable to the management of acute confusion of any cause and the principles of care apply to all confused patients. The article addresses many of the challenges encountered by nurses caring for confused patients, including the recognition of acute confusion, use of screening tools, and the management and treatment of these patients.

[The confused elderly patient]. / Le sujet âgé confus.

Mental confusion has long-time been likened to dementia, while it is in fact an acute disturbance of a person's alertness and attention capacities. Generally reversible and temporary, it is brought on by high levels of stress. Nursing care is an essential element of its treatment.

Using Diffusion of Innovations Theory to implement the confusion assessment method for the intensive care unit.

Routine screening of mechanically ventilated patients for delirium is essential for prompt recognition and management; however, this represents a change in practice. Rogers' Diffusion of Innovations Theory can be useful as a strategy to facilitate adoption of a practice change. This case study describes the effectiveness of identifying barriers to a change in practice and developing strategies, specific to Rogers' innovation decision process, for implementing the Confusion Assessment Method for the intensive care unit.

Toward the development of a nursing practice for older persons with acute confusional state (ACS).

Surgery unit nurses often deal with older people in an acute confusional state (ACS). To care for them, nurses must resort to different patterns of knowing, including empirical, esthetic, ethical, personal and emancipatory. According to Chinn and Kramer (2008), it is by consciously and deliberately asking themselves critical questions about specific clinical situations that nurses can enhance their knowledge and improve practice. In this regard, narrative pedagogy developed by Diekelmann (2001), which encourages sharing lived experiences and seeking other possibilities for the future, seems a well suited approach. This article presents the theoretical bases of narrative pedagogy and the grounds for an intervention inspired by this approach and intended for nurses who must care for hospitalized older people in an ACS. This innovative pedagogical intervention, which encourages nurses to participate actively in their learning, is consistent with recent empirical works on continuing education of health professionals.

[Research study regarding the benefits of nursing care in the twilight syndrome]. / Studio di ricerca sui benefici dell'assistenza infermieristica nell'insorgenza della sindrome del tramonto.

The twilight syndrome manifests with the appearance of a severe confusional state which damages the patient's cognitive potential. The aim of this study was to evaluate whether nursing care focused on the patient's space-time orientation could reduce or even prevent the onset of this syndrome. The study comprised 48 patients, 17 in the action group and 31 in the control group. The results of the study showed that the nursing strategies implemented, aimed at maintaining the patient's cognitive, perceptive and orientation functions, not only slowed down the progression of the syndrome but also made early recognition possible.

Drug safety in pregnancy--monitoring congenital anomalies.

AIM: This paper outlines research into the causes of congenital anomalies, and introduces a pan-European study. The potential roles of nurses and midwives in this area are illustrated by a case report. BACKGROUND: Since the thalidomide disaster, use of drugs in pregnancy has been carefully monitored to prevent anything similar happening again. However, monitoring is incomplete and questions remain unanswered. KEY ISSUES: Many medicines are essential for the health of pregnant women. However, drug use in pregnancy requires surveillance. Methods include spontaneous reporting of adverse events, cohort studies and case control studies. It is hoped that a Europe-wide study, combining data from several congenital anomaly registers, will provide a sufficiently large population to assess the impact of selected drugs on congenital anomalies. However, this work depends on the consistency of reporting by nurses and midwives. CONCLUSION: Drug safety in pregnancy remains undetermined. Collaboration across Europe has the potential to provide a framework for safety evaluation. IMPLICATIONS FOR NURSING MANAGEMENT: Prescribers should consider the possibility of pregnancy in women of child-bearing age. Careful review of maternal drug use in early pregnancy is essential. Midwives and nurses should be aware of adverse event drug reporting systems, including congenital anomaly registers.

Function-focused care and changes in physical function in Chinese American and non-Chinese American hospitalized older adults.

Function-focused care (FFC) is a rehabilitative philosophy of care with which nurses help patients engage in activities of daily living and physical activity with the goal of preventing avoidable functional decline. This prospective, observational study described the degree of FFC provided by nursing staff to Chinese American (n = 32) and non-Chinese American (n = 43) older adults in medical-surgical units of an urban hospital. In both groups, only a few ADLs were a focus of FFC. Loss of physical function occurred, and physical function did not return to baseline by discharge in both groups; however, FFC was associated with less decline. Results suggest that hospitalized elders, both Chinese American and non-Chinese American, can benefit from nurse-led FFC. FFC may help minimize functional decline and decrease the use of postacute care rehabilitation. The gerontological rehabilitation nurse can play an essential role, guiding a function-focused approach throughout the hospital stay, including with the transitional care plan.

What are we asking for when requesting "Specialling" for the confused hospitalised older person? A concept analysis.

BACKGROUND AND/OR RATIONALE: "Specialling" is a common nursing practice in hospitals which entails the allocation of extra staff to be with an older person who is confused to maintain safety. Despite ongoing use, this practice has little evidence of effectiveness. To facilitate further investigation, a concept analysis of "specialling" was undertaken. AIMS: The aim of this paper was to report on a concept analysis on the practice of "specialling" pertaining to older people who have cognitive impairment when in hospital. METHODS: This study used Rodgers evolutionary approach to concept analysis to clarify the attributes, antecedents and consequences of the concept to determine a definition of "specialling." Web of Science (Core Collection and Web of Science Medline), CINAHL and SCOPUS databases were searched to identify relevant literature. Due to the scarcity of papers, the search was broadened to include all sources that could add understanding. FINDINGS: A total of (n = 43) sources were identified. The attributes were themed to 5 categories: Labels and descriptions; the "Special" role; Patient safety; Patient care; and Communication. The antecedents to 2 themes: Patient characteristics; and Organisational risk. The consequences of "specialling" were diverse with 6 themes: the "Special" role; the Older persons experience; Costly; "Special" use and nursing beliefs; Safety outcomes; and Opportunities. DISCUSSION: The process of concept analysis provided a means to identify knowledge gaps and practice challenges. The definition determined from this analysis has provided a reflective opportunity for clinicians and researchers to consider when implementing care initiatives to support older people in hospital. Important is the lack of person-centred approaches and the opportunities in developing nurse leadership through empowerment. The findings from this analysis will inform a PhD study. IMPLICATIONS FOR PRACTICE: Nurses have an opportunity to lead care improvements by ensuring person-centred approaches in the care of older people with cognitive impairment.

Factors determining nurses' clinical judgments about hospitalized elderly patients with acute confusion.

Acute confusion(AC)/delirium is a common clinical phenomenon in hospitalized elders that is often overlooked or misdiagnosed by nurses of various cultural backgrounds. The aim of this study was to better understand factors affecting nurses' clinical judgments regarding the detection of AC in elderly Taiwanese patients. Nurses from two hospitals in Taiwan (n = 654, response rate = 71.3%) participated in the study. A two-level hierarchical linear model analysis was used to examine the data. The characteristics of patients explained the most variance of the model (86.2%), with characteristics of nurse participants and their health organizations accounting for 13.8% of the variance. Patient characteristics of age, infection, hydration, and hypoactive subtypes of AC, as well as a nurse's strong belief in traditional Chinese values, such as respect for elders, hard work, modesty, noncompetitiveness, and respect for tradition, were positively associated with difficulty detecting acute confusion. Findings of this study indicated that the accuracy of nurses' clinical judgments in detecting AC were most related to characteristics of patients.

Older adult surgical patients: presentation and challenges.

The age of the population is increasing dramatically, and the age of the surgical population parallels that of the general population. This is occurring at a time when there are fewer health care providers with geriatric expertise in all disciplines. All health care providers must be knowledgeable about the normal changes of aging and must understand communication challenges with older adult patients. Health care providers must understand the specific risks and benefits of surgery and perform a complete individualized preoperative assessment to improve older adult patients' outcomes.

The challenge of care--managing a confused patient in an inpatient setting.

This article looks at the issues around capacity and consent, focusing particularly on how nurses should assess the capacity of confused patients to make decisions about their treatments. It covers the legal framework, including the Mental Capacity Act, within which nurses must care for patients who, due to illness or incapacity, are unable to understand, consent to or cooperate with treatment. It emphasises the importance of training to give nurses the knowledge to assess risk and document it correctly, and have the confidence to be able to justify their actions if necessary.

The older patient's experience of encountering professional carers and close relatives during an acute confusional state: an interview study.

BACKGROUND: Acute confusional state (ACS) is a common and difficult condition among older patients with a variety of opinions about how to act when encountering patients with ACS. Few studies to our knowledge have been found exploring the encounter from the perspective of older patients and their experiences. OBJECTIVES: The aim of this study was to understand the experiences of older patients with ACS when encountering professional carers and close relatives. DESIGN: In order to understand older patients' experiences of encounters during their ACS a latent qualitative content analysis was used. SETTINGS: The data collection took place at two geriatric wards in an emergency hospital in a metropolitan area. PARTICIPANTS: The inclusion criteria included being aged 65 years or older and having suffered from ACS, according to the DSM-IV criteria, and having regained lucidity. Participants were being cared for at one of two geriatric wards. Patients diagnosed with dementia were excluded. About 150 patients were screened, 67 patients fulfilled the inclusion criteria and seven patients were included in the study, four females and three males, aged between 78 and 98 years. METHODS: Data were collected by interviews. RESULTS: Three themes were found, namely; 'Feeling lonely within the perceived reality of ACS', with three sub-themes: the unequal encounter, keeping a distance and being an outsider; 'striving towards understanding' with two sub-themes: searching for answers and it takes time to understand; and 'feelings of participation in the encounter' with two sub-themes: a mutual understanding and feeling safe and supported. CONCLUSIONS: Within the encounter the older patients with ACS are searching for answers to what is happening and why. The patients feel dependent on the persons they encounter and their willingness to understand and communicate. The patients also feel lonely, unnecessarily questioned and untrustworthy; but they can also feel safe, trusted and understood.

Use of the acute confusion protocol: a research utilization project.

This evidence-based project was undertaken to implement research-based preventive protocols to decrease the negative outcomes associated with delirium/acute confusion. After implementation, the medical-surgical unit experienced a 62% reduction in falls and a 100% decrease in sitter usage the first year. The use of medications known to cause acute confusion was decreased by more than 50%. Since implementation, the fall rate as well as the use of restraints has decreased by 25%.

Delegation of medication administration: an exploratory study.

AIM: To examine the delegation of medication administration, including the frequency of delegation, whether delegation was to a care worker or a registered nurse (RN) and whether care workers were directly supervised when administering medication. METHOD: Administration of 1313 medication doses was observed on two inpatient psychiatric wards for older people. RESULTS: Administration was delegated by the nurse preparing the medication for four out of every five doses, usually to another registered nurse (78% of delegated doses), but also to care workers (22%). Care workers were more likely to administer medications to confused and aggressive patients than were registered nurses. CONCLUSION: Care workers who undertake delegated medication administration should receive regular training to ensure safety. Nurses remain accountable for delegated medication administration.