Effect of hospice nonprofessional caregiver barriers to pain management on adherence to analgesic administration recommendations and patient outcomes.

Nonprofessional caregivers frequently experience barriers to using analgesics for pain in patients in home hospice settings, and patients in pain may suffer needlessly. For example, caregiver adherence to the administration of analgesics is lower for as-needed (PRN) regimens than for standard around-the-clock regimens. But little is known about the barriers caregivers experience and the effects of those barriers. Accordingly, we determined caregiver barriers to using analgesics to manage the pain of patients in the home hospice care setting, and how such barriers affected caregiver adherence and patient quality of life. To this end, we measured barriers, caregiver adherence to PRN analgesic regimens, and patient health outcomes (pain, depression, quality of life [QoL]). A 3-day longitudinal design was used. We recruited 46 hospice nonprofessional caregiver-patient dyads from a local community hospice agency. Barriers were measured with the Barrier Questionnaire II. Adherence to the PRN analgesic regimen was obtained with a 3-day pain and medication diary. Patient outcome measures included pain intensity, the Hospital Depression Scale, and the Brief Hospice Inventory for QoL. Barrier scores were moderate to low. Caregivers adhered to PRN analgesic regimens approximately 51% of the time. Higher caregiver adherence to PRN analgesic regimens was associated with lower patient pain intensity and higher patient QoL, but not, surprisingly, with barriers to pain management. Longitudinal studies are now needed to identify factors besides caregiver barriers that may unduly lower caregiver adherence to PRN analgesic regimens.

Sleep in hospitalized elders: a pilot study.

Hospitalized elders frequently experience disturbed sleep related to environmental factors. To determine relationships between sleep and environmental noise and light, a descriptive exploratory study was conducted with 48 hospitalized older adults. Participants aged 70 years or older were monitored for sleep via wrist actigraphy, and noise and light levels were measured the first night of hospitalization. Sleep time was brief (mean, 3.75 hours) and fragmented (mean, 13 awakenings per night). The sleep environment was noisy with a median sound level of 49.65 dB(A). There was an average of 3 periods of elevated light levels (mean, 64 lux) lasting an average of 1.75 hours each night. No significant correlation was found among sleep and age, light, and sound. Recommendations include light and sound reduction measures and dedicated "do not disturb" times to allow for a full 90-minute sleep cycle.

Case studies: is the sleep of hospitalized elders related to delirium?

Four cases are presented to compare sleep, light, and sound levels of patients who developed delirium to patients who did not develop delirium, and to determine the effect of light and sound stimuli upon awakenings from sleep.

The virtual gateway: opening doors in delirium teaching and learning.

Delirium is a common, serious and potentially preventable problem. It is argued here that knowledge and skills for effective assessment and treatment of delirium cannot be considered 'specialist'. Rather, delirium is a problem that requires a healthcare team approach to assessing patients, identifying risks or symptoms and reducing precipitating factors. Research from the preceding decade suggests that the clinical reality is falling short of this ideal with the result that many cases of delirium go undetected and many precipitating factors are not reduced where this is indeed possible. This presents a challenge for the education of nursing and medical students and for the development of qualified staff in practice. The current paper outlines an educational approach, e-learning, which increases access for learners, integrates knowledge and skill development and promotes active, problem-based learning.

Detection of delirium by bedside nurses using the confusion assessment method.

A prospective, descriptive study was used to assess the diagnostic validity of the Confusion Assessment Method (CAM) administered at the bedside by nurses in daily practice. Two different scoring methods of the CAM (the specific (SPEC) and sensitive (SENS) methods) were compared with a criterion standard (CAM completed by trained research nurses). During a 5-month period, all patients consecutively admitted to an acute geriatric ward of the University Hospitals of Leuven (Belgium) were enrolled in the study. The 258 elderly inpatients who were included underwent 641 paired but independent ratings of delirium by bedside and trained research nurses. Delirium was identified in 36 of the 258 patients (14%) or in 42 of the 641 paired observations (6.5%). The SENS method of the CAM algorithm as administered by bedside nurses had the greatest diagnostic accuracy, with 66.7% sensitivity and 90.7% specificity; the SPEC method had 23.8% sensitivity and 97.7% specificity. Bedside nurses had difficulties recognizing the features of acute onset, fluctuation, and altered level of consciousness. For both scoring methods, bedside nurses had difficulties with the identification of elderly patients with delirium but succeeded in diagnosing correctly those patients without delirium in more than 90% of observations. Given these results, additional education about delirium with special attention to guided training of bedside nurses in the use of an assessment strategy such as the CAM for the recognition of delirium symptoms is warranted.

Analysis of measures of functional and cognitive ability for aging adults with cardiac and vascular disease.

Baseline and follow-up assessments of functional and cognitive status are essential for aging patients who survive acute cardiac and vascular disease, as they are faced with new medications and implementing changes in lifestyle. Because declining functional and/or cognitive status will interfere with treatment regimens and taking prescribed medications, it is imperative that healthcare providers develop an understanding of approaches to functional and cognitive assessment that can be used with aging patients, selecting those most appropriate for the venue in which they practice and for their particular patient population.

Cognitive assessment and differentiating the 3 Ds (dementia, depression, delirium).

Differentiation between a diminished or altered cognitive functioning asa consequence of aging and one resulting from serious health problems is critical in the elderly. An unrecognized cognitive disorder or the worsening of the impairment may hamper the effectiveness and appropriateness of care and treatment; therefore, standardized assessment procedures and systematic monitoring of cognition and behavior are important aspects of the nursing care. of older adults. In this article, current notions for accurate and comprehensive cognitive assessment in older persons are delineated. Further, an overview of epidemiological screening and diagnostic dilemmas of dementia, depression, and deliriumare provided.

Intensive Care Unit Nurses' Beliefs About Delirium Assessment and Management.

Delirium, the most frequent complication of hospitalized older adults, particularly in intensive care units (ICUs), can result in increased mortality rates and length of stay. Nurses are neither consistently identifying nor managing delirium in these patients. The purpose of this study was to explore ICU nurses' identification of delirium, actions they would take for patients with signs or symptoms of delirium, and beliefs about delirium assessment and management. In this cross-sectional study using qualitative descriptive methods guided by the theory of planned behavior, 30 ICU nurses' responses to patient vignettes depicting different delirium subtypes were explored. Descriptive and content analyses revealed that nurses did not consistently identify delirium; their actions varied in different vignettes. Nurses believed that they needed adequate staffing, balanced workload, interprofessional collaboration, and established policy and protocols to identify and manage delirium successfully. Research is needed to determine if implementing these changes increases recognition and decreases consequences of delirium.

Psychometric properties of the Flemish translation of the NEECHAM Confusion Scale.

BACKGROUND: Determination of a patient's cognitive status by use of a valid and reliable screening instrument is of major importance as early recognition and accurate diagnosis of delirium is necessary for effective management. This study determined the reliability, validity and diagnostic value of the Flemish translation of the NEECHAM Confusion Scale. METHODS: A sample of 54 elderly hip fracture patients with a mean age of 80.9 years (SD = 7.85) were included. To test the psychometric properties of the NEECHAM Confusion Scale, performance on the NEECHAM was compared to the Confusion Assessment Method (CAM) and the Mini-Mental State Examination (MMSE), by using aggregated data based on 5 data collection measurement points (repeated measures). The CAM and MMSE served as gold standards. RESULTS: The alpha coefficient for the total NEECHAM score was high (0.88). Principal components analysis yielded a two-component solution accounting for 70.8% of the total variance. High correlations were found between the total NEECHAM scores and total MMSE (0.75) and total CAM severity scores (-0.73), respectively. Diagnostic values using the CAM algorithm as gold standard showed 76.9% sensitivity, 64.6% specificity, 13.5% positive and 97.5% negative predictive values, respectively. CONCLUSION: This validation of the Flemish version of the NEECHAM Confusion Scale adds to previous evidence suggesting that this scale holds promise as a valuable screening instrument for delirium in clinical practice. Further validation studies in diverse clinical populations; however, are needed.

The Strain of Care for Delirium Index: a new instrument to assess nurses' strain in caring for patients with delirium.

This study evaluated content validity, internal consistency and construct validity of the Strain of Care for Delirium Index (SCDI), a newly constructed instrument to measure the strain nurses experience in caring for patients with delirium. Content validity, evaluated by eight experts, reduced the initial pool of items from 38 to 28. Using a convenience sample of 190 nurses, Cronbach's alpha for the 28-item version was 0.88. Using non-linear principal components analysis another eight items were eliminated and a four-factor structure was identified. The proportion of variance explained by the remaining 20 items was 61.51%. Preliminary psychometric evaluation of the SCDI supported content validity, internal consistency and construct validity; however additional psychometric evaluation is warranted.

Documentation of delirium in elderly patients with hip fracture.

This study determined the accuracy of diagnosis and documentation of delirium in the medical and nursing records of 55 elderly patients with hip fracture (mean age = 78.4, SD = 8.4). These records were reviewed retrospectively on a patient's discharge for diagnosis of delirium, and for description of clinical indicators or symptoms of delirium. Additionally, all patients were monitored by one of the research members on days 1, 3, 5, 8, and 12 postoperatively for signs of delirium, as measured by the Confusion Assessment Method (CAM). Clinicians were blinded to the purpose of the study. According to the CAM criteria, the incidence of delirium was 14.5% on postoperative Day 1; 9.1% on postoperative Day 3; 10.9% on postoperative Day 5; 7.7% on postoperative Day 8; and 5.6% on postoperative Day 12. For those same days, no formal diagnosis of delirium or a description of clinical indicators was found in the medical records. In the nursing records, a false-positive documentation of 8.5%, 4%, 4.1%, 4.2%, and 5.9%, respectively was noted. False-negative documentation was found in 87.5%, 80%, 66.7%, 75%, and 50% of the cases on the respective days. Documentation of essential symptoms--namely onset and course of the syndrome--and disturbances in consciousness, attention, and cognition, were seldom or never found in the nursing records. However, behaviors of the hyperactive variant of delirium and which are known to interfere with nursing care were documented more often (e.g., 13.4% restless, 10.3% fidget with materials, 7.2% annoying behavior). Both medical and nursing records showed poor documentation and under-diagnosis of delirium. However, a correct diagnosis and early recognition of delirium may enhance the management of this syndrome.

Fatigue in women with type 2 diabetes.

PURPOSE: The purpose of this study was to explore the relationship between fatigue and physiological, psychological, and lifestyle phenomena in women with type 2 diabetes (T2DM) in order to establish the magnitude and correlates of fatigue in women with T2DM and explore the interrelationships between fatigue and specific diabetes-related factors that may be associated with increased levels of fatigue. These factors included physiological factors (glucose control, diabetes symptoms), psychological factors (diabetes emotional distress, depressive symptoms in general), and lifestyle factors (body mass index, physical activity). METHODS: A cross-sectional, descriptive design was used. Women who reported conditions known to cause fatigue were excluded. Physiological measures included fasting blood glucose (FBG), hemoglobin A1C (A1C), glucose variability, and body mass index (BMI). Women completed questionnaires about health, fatigue levels, diabetes symptoms, diabetes emotional distress, depressive symptoms, physical activity, and current diabetes self-care practices. A subset of the women wore a Medtronic Gold CGM sensor for 3 days for assessment of glucose variability. RESULTS: Eighty-three women aged 40 to 65 years with T2DM completed the study. Fatigue was significantly related to diabetes symptoms, diabetes emotional distress, depressive symptoms, higher BMI, and reduced physical activity. There was no relationship between fatigue and FBG or A1C. The strongest explanatory factors for fatigue were diabetes symptoms, depressive symptoms, and BMI, which accounted for 48% of the variance in fatigue scores. Glucose variability was not significantly associated with fatigue in these women. CONCLUSIONS: Fatigue is a persistent clinical complaint among women with T2DM and may signal the presence of physiological, psychological, and lifestyle-related phenomena that could undermine diabetes health outcomes.

Nurses' recognition of delirium in the hospitalized older adult.

BACKGROUND: Delirium is the most frequent complication associated with hospitalization of older adults, responsible for 17.5 million additional hospital days in the United States each year; yet, nurses fail to recognize it more than 30% of the time. OBJECTIVES: The specific aim of the study was to measure staff nurses' recognition of delirium in hospitalized older adults by comparing nurse and expert diagnostician ratings for delirium using the Confusion Assessment Method (CAM). METHOD: This study investigated the rate of agreement/disagreement between researchers and a convenience sample of 167 nurses caring for 170 medical surgical patients (>65 years) in detecting delirium. Paired (nurse vs researcher) CAM ratings were completed at least every other day until either discharge or delirium was detected by the researcher. RESULTS: The researcher detected delirium in 7% (12/170) of patients. Nurses failed to recognize delirium 75% (9/12) of the time, with poor agreement between nurse/researcher for all observations (κ = 0.34). A generalized estimating equation logistic regression model identified independent predictors of nurses' underrecognition of delirium that included increasing age and length of stay, dementia, and hypoactive delirium. DISCUSSION: Findings provide further support for the significance of nurses' underrecognition of delirium in the hospitalized older adult when using the CAM. Additional research is warranted regarding the clinical decision-making processes that nurses use in assessing acute cognitive changes and in identifying strategies to improve delirium recognition.

Model for the First NIH-funded Center of Excellence in End-of-Life Research.

Centers of excellence are widely acknowledged as a mechanism to promote scientific advances in a particular field of science, but until recently there have been no end-of-life or palliative care research centers funded by the National Institutes of Health (NIH). The purpose of this article is to describe aims, framework, and organizational structure of the first NIH-funded Center of Excellence on end-of-life research, the Center for End-of-Life Transition Research (CEoLTR), and the advances in end-of-life research that the CEoLTR will facilitate. The teams of researchers involved in the CEoLTR have grown impressively since it was funded in 2007. Collectively, the teams are on target to accomplish all of the original goals for this five year award.

Delirium, nursing practice and the future.

The preceding papers have outlined the issues of under-recognition of delirium, aspects of assessment to improve this situation and presented an alternative discursive construction of delirious patients. With respect to the understandings from the first two papers, the authors intend to suggest a direction for future practice and research in the area of delirium. The discussion will start with an overview of current international practice. Approaches focussing on the specific care of team members or on multidisciplinary care have been reported as well as approaches that focus on a clinical expert such as a nurse specialist or those that focus care of patients with delirium in a specific identified clinical setting. The literature represents variable evidence of the success, or otherwise, of different initiatives. The authors intend to provoke debate on the care of delirious patients and indicate the priorities for the future management of delirium.

Delirium: a new appraisal of an old problem.

Delirium is a prevalent condition associated with high morbidity and mortality. Studies investigating delirium date back centuries but the subject has received increased attention in the last two decades. This recent attention focuses on, risk factors, early recognition, consequences and management of delirium. The aim of this paper was to provide an updated review of issues concerning the assessment and identification of delirium. Assessment is central to the effective management but delirium continues to be under-recognized by the healthcare team. This review sets the scene for the following papers on practice and the future direction for the management of delirium.