Nursing microtheory in the prevention of delirium in older adult in the intensive care unit. / Microteoría de enfermería en la prevención del delirium en personas mayores en la unidad de cuidados intensivos.

OBJECTIVE: to describe a microtheory for nursing care in the prevention of delirium in older adult in the intensive care unit. METHOD: prescriptive theoretical research, based on substruction. Roy's Adaptation Model constructs were deduced and data from the phenomenon of nursing care in the prevention of delirium in older adult in intensive care were induced, based on an integrative literature review. RESULTS: the microtheory has a theoretical and operational system and a model of care. In the theoretical system, Roy's focal and contextual stimulus constructs were used. From them, the concepts of focal and contextual care and the variable adaptive response to prevention were elaborated. From the relational statements, four axioms, two postulates, eight propositions and an epistemic assumption were elaborated. TWO EMPIRICAL INDICATORS WERE ESTABLISHED IN THE OPERATING SYSTEM: the Confusion Assessment Method for Intensive Care Units and the demographic/clinical history of the older adult. Subsequently, two transformational statements, four hypotheses and the model of care represented in figure were produced. CONCLUSION: the microtheory produced prescribes care in the prevention of delirium in older adult in intensive care, through a construct of interest to nursing, and allows interceptions for the development of instruments that guide nursing activities.

Estudio cuasi-experimental sobre intervenciones enfermeras en la valoración, manejo y prevención del síndrome confusional agudo / Quasi-experimental study on nursing interventions in the assessment, management and prevention of acute confusional syndrome

Fundamentos: El síndrome confusional agudo (SCA) es una de las complicaciones con mayor morbimortalidad en las unidades de hospitalización, pero es una situación reversible si se detecta a tiempo, representando un claro desafío para la enfermería. Los objetivos de este estudio fueron valorar previa y posteriormente las intervenciones realizadas por las enfermeras para la identificación y la adopción de las medidas preventivas no farmacológicas aplicadas en el síndrome confusional agudo, así como relacionarlas con los años de experiencia profesional y la formación recibida. Métodos: Se realizó un estudio cuasi experimental, prospectivo y analítico a través de cuestionario estructurado autoadministrado pre-post intervención (extraído de la JBI PACES program-Practical Application of Clinical Evidence System) sobre la identificación y las medidas preventivas aplicadas en el SCA. Se distribuyeron un total de quinientos veinte cuestionarios (valoración pre y post) a enfermeras del servicio de Urgencias y la unidad de medicina interna del Hospital Universitario Miguel Servet de Zaragoza (Aragón, España) de enero de 2021 a abril de 2022. El análisis estadístico se realizó con el programaJamovi® 2.3.13. Resultados: Se recibieron ciento ochenta cuestionarios cumplimentados correctamente (noventa y cuatro pre y ochenta y seis post). Para el 100%, el SCA supuso una carga de trabajo extra y se hallaron diferencias estadísticamente significativas entre la capacidad de manejo de SCA con los años de experiencia profesional (p=<0,028). El 97,2% de las enfermeras aplicaron intervenciones no farmacológicas. Conclusiones: A pesar de percibirse como una carga extra en el trabajo diario, las enfermeras realizan prevenciones no farmacológicas para el manejo del SCA. Es necesario mejorar la formación para proporcionar estrategias de orientación.(AU)

Background: Acute confusional syndrome (ACS) is one of the complications with the highest morbidity and mortality in hospitalization units, but it is a reversible situation if detected early, representing a clear challenge for nursing. The objectives of this studywere to assess the interventions carried out by nurses for the identification and non-pharmacological preventive measures applied inacute confusional syndrome and relate them to the years of professional experience and training received.Methods: A quasi-experimental, prospective and analytical study was carried out through a selfdministered structured questionnaire pre-post intervention (extracted from theJBI PACES program-Practical Application of Clinical Evidence System) on the identificationand preventive measures applied in ACS. A total of 520 questionnaires (pre and post assessment) were distributed to nurses from theemergency department and the internal medicine unit of the Miguel Servet University Hospital in Zaragoza (Aragón, Spain) from January2021 to April 2022. Statistical analysis carried out with the programJamovi®2.3.13.Results: 180 correctly completed questionnaires (94 pre and 86 post) were received. For 100%, the ACS supposed an extra workload and significant differences were found between the ability to manage ACS with the years of professional experience (p=<0.028).97.2% of the nurses applied non-pharmacological interventions.Conclusions: Despite being perceived as an extra burden in daily work, nurses perform nonpharmacological prevention for themanagement of ACS. It is necessary to improve training to provide guidance strategies.(AU)

Cuidados intensivos de enfermagem ao idoso com delirium: um protocolo de revisão de escopo / Intensive nursing care to older adults with delirium: a protocol of scoping review

OBJETIVO: explorar sistematicamente a literatura quanto aos cuidados de enfermagem prestados aos idosos internados com delirium, em unidades de terapia intensiva, sejam eles para prevenção, sejam eles para manejo do delirium. MÉTODO: protocolo de revisão de escopo, estruturado pelas recomendações do Manual do Instituto Joanna Briggs, utilizando as seguintes bases de dados: PubMed via MEDLINE, Scopus, Embase, Web of Science e Google Scholar. A bibliografia encontrada será organizada através do gerenciador EndNote. Após a exclusão dos estudos duplicados, as citações serão transferidas para o software Rayyan. Em seguida, será iniciada a triagem das referências por dois pesquisadores independentes. O processo da seleção de estudos será exibido no fluxograma adaptado do Checklist PRISMA-ScR. Os dados serão extraídos dos estudos através de uma planilha desenvolvida no programa Microsoft Excel pelos próprios autores, avaliando e interpretando as informações de acordo com o objetivo proposto. Os dados serão organizados em tabelas, quadros e fluxogramas, com discussão narrativa.

OBJECTIVE: to systematically explore the literature regarding the nursing care provided to the older adult hospitalized with delirium in intensive care units for the prevention or management of delirium. METHOD: scoping review protocol, structured by the recommendations of the Joanna Briggs Institute manual, utilizing the following database: MEDLINE via PubMed, Scopus, Embase, Web of Science, and Google Scholar. We will organize the citations found through the EndNote manager. After the exclusion of duplicated studies, we will transfer the citations to the Rayyan software. Afterward, two independent researchers will begin the screening of titles / abstracts. We will present the selection process of studies in the Checklist PRISMA-ScR adopted flowchart. The authors will extract the data of the studies through a spreadsheet developed in the Microsoft Excel, evaluating and interpreting the information according to the objective of the study. We will organize the data in charts, tables, and flowcharts with a narrative discussion.

Delirium en ancianos institucionalizados: una epidemia silenciosa / Delirium in institutionalized elderly: a silent epidemic

Introducción: El aumento del envejecimiento, así como de los cuidados sociales y sanitarios que requieren las personas mayores, ha condicionado que se haya incrementado exponencialmente el número de ancianos institucionalizados. En este contexto, el deliriumes una condicion común y muy angustiante, con un gran impacto biopsicosocioeconómico para el residente y su entorno. Pese a ser una entidad potencialmente prevenible, sigue siendo infratratada e infradiagnosticada. Objetivo: Analizar la evidencia científica existente sobre el manejo del delirium en ancianos que se encuentran en centros residenciales de atención a largo plazo. Metodología: Revisión narrativa mediante búsquedas bibliográficas en bases de datos relacionadas con las ciencias de la salud: CINAHL, PubMed, Biblioteca Cochrane, CUIDEN y LILACS, así como en los metabuscadores Dialnet Plus y Google Académico. Resultados: En función de los criterios de inclusión y exclusión se seleccionaron 19 artículos. El análisis de los documentos generó 2 categorías: medidas de control fisiológico y ambiental para la prevención del delirium y estrategias de intervención terapéutica. Como hallazgos, las estrategias multidisciplinares no farmacológicas podrían ser eficaces en la prevención del delirium, así como la identificación temprana de los factores de riesgo y programas educativos dirigidos a las enfermeras que atienden a esta población. De este modo, se estará ejerciendo la medida más eficaz y económica para abordar esta entidad en su fase inicial, la prevención. Conclusión: Se encontraron escasoshallazgos estadísticamente significativos sobre las asociaciones entre las intervenciones y la prevención del delirium en instituciones. Si se quiere optimizar la salud y el bienestar de los residentes deben realizarse investigaciones futuras, específicas y sólidas, y evitar los desafíos que suponen estos entornos (AU)

Introduction: The increase in ageing, as well as the social and health care it requires, has led to an exponential increase in the number of institutionalised residents. In this context, delirium is a common and very distressing condition, with a great bio psycho-social-economic impact on both the patient and his or her environment. Despite being a potentially preventable entity, it continues to be under-treated and under-diagnosed. Objective: To analyze the existing scientific evidence on the management of delirium in elderly people in long-term care residential facilities. Methodology: Narrative review by means of bibliographic searches in databases related to the Health Sciences CINAHL, PubMed, Cochrane Library, CUIDEN and LILACS, as well as in the meta-searches Dialnet Plus and Google Academic. Results: 19 articles were selected according to the inclusion and exclusion criteria. The analysis of the documents generated two categories: physiological and environmental control measures for the prevention of delirium and therapeutic intervention strategies. As findings, non pharmacological multidisciplinary strategies may be effective in preventing delirium, as well as early identification of risk factors and educational programs directed at nurses serving this population. In this way, the most effective and economical measure to address this entity in its initial phase, prevention, will be exercised. Conclusion: There were few statistically significant findings on associations between interventions and delirium prevention in institutions. If the health and well-being of residents is to be optimized, future research must be specific and robust, avoiding the challenges of these environments (AU)

Intervención de enfermería para reducir incidencia y duración del delirium en personas en cuidados intensivos  / Nursing Intervention to Reduce Incidence and Duration of Delirium in Patients in Intensive Care

Objetivo: determinar la efectividad de la intervención de enfermería basada en el Modelo de Síntomas Dinámicos (MSD) y en evidencia científica, frente al cuidado cotidiano, para la reducción de la incidencia y duración del delirium en personas en cuidados intensivos. Método: se emplearon dos fases, diseño y evaluación de la intervención. El diseño siguió las recomendaciones de Sidani desde el enfoque teórico con aplicación del MSD y desde el enfoque empírico con una revisión sistemática. La evaluación de la intervención se realizó con un ensayo clínico aleatorizado de grupos paralelos doble ciego. La muestra fueron 213 personas en UCI. El análisis empleó estadística analítica, paramétrica y no paramétrica. Resultados: se diseñó la intervención denominada Dynamic Delirium (DyDel) con 10 cuidados y 33 actividades. Los cuidados partieron de los componentes fisiológico, psicológico, spiritual y social, ambiental, experiencia y trayectoria del MSD. Las actividades de cada cuidado surgieron de la evidencia científica. Al probar la intervención se halló que la incidencia y duración del delirium fueron significativamente menor en el grupo intervención frente al grupo control (incidencia 5,6% Vs. 14,8%, respectivamente, (p=0.037)) (duración 0.07±0.308 Vs. 0.34±1.28, respectivamente (p=0.016)). El grupo intervención también logró más cantidad de días con dolor leve y sin uso de inmovilizaciones físicas. Conclusión: la intervención DyDel, basada en el MSD y en evidencia científica, fue multicomponente, no farmacológica y vincula a la familia, y fue efectiva para reducir el delirium en personas en UCI. Se comprobó que el conocimiento propio de enfermería mejora la práctica. (AU)

Objective: to determine the effectiveness of a nursing intervention based on the Dynamic Symptom Model (DSM) and scientific evidence, versus daily care, in reducing the incidence and duration of delirium in intensive care patients. Method: two phases were used, design and evaluation of the intervention. The design followed Sidani's recommendations from the theoretical approach with the application of the DSM and the empirical approach with a systematic review. The evaluation of the intervention was carried out with a randomized clinical trial of parallel groups, double-blind. The sample consisted of 213 ICU patients. The analysis used analytical, parametric and nonparametric statistics. Results: the intervention called Dynamic Delirium (Dydel) was designed with ten care and 33 activities. Care was based on the physiological, psychological, spiritual and social, environmental, experience and MSD trajectory components. The activities for each care were derived from scientific evidence. When testing the intervention, it was found that the incidence and duration of delirium were significantly lower in the intervention group versus the control group (incidence 5.6% vs 14.8%, respectively, (p=0.037)) (duration 0.07±0.308 vs 0.34±1.28, respectively (p=0.016)). The intervention group also achieved more days with mild pain and without the use of physical immobilizations. Conclusion: the DyDel intervention, based on the DSM and scientific evidence, was multicomponent, non-pharmacological and linked to the family, and was effective in reducing delirium in ICU patients. It was proven that nursing knowledge improves practice. (AU)

Estudio del síndrome confusional agudo en los registros de enfermería en pacientes geriátricos hospitalizados con interconsulta a psiquiatría / Study of delirium based on nursing records in hospitalized geriatric patients with psychiatric interconsultation

Objetivos: Analizar, a partir de los registros de enfermería, las variables asociadas con la aparición del síndrome confusional agudo (SCA) en pacientes geriátricos de un hospital general.Metodología:Estudio descriptivo transversal y retrospectivo realizado en el Hospital Royo Villanova, de Zaragoza, entre 2011-2014. Población de estudio: N = 881 diagnosticados de SCA (2,2% del total de ingresos); se obtuvo una muestra total de n = 79 pacientes de 60 años o más, con diagnóstico de SCA por psiquiatría de enlace.Resultados:La edad media de los pacientes fue de 82,8 años. La detección de SCA se realizó en los pacientes tras 1,1 a 3,5 días de media desde el ingreso. Las puntuaciones del Índice de Barthel fueron de 40,9 a 60,8. Los fallecimientos durante el episodio de SCA fueron entre el 10,3% y el 15%. El cuadro de SCA fue mayoritariamente de tipo hiperactivo y se inició por la noche y por la tarde. Los síntomas más frecuentes de SCA registrados por enfermería fueron alteraciones motoras (agitación, inquietud) y desorientación.Conclusión:Enfermería registra el SCA antes de la petición de colaboración al servicio de psiquiatría, la cual se da en escaso número. Estos registros son precisos y certeros y coinciden con los términos médicos. Serían necesarios nuevos estudios de investigación que permitan minimizar el infradiagnóstico y no solo detectar SCA del tipo hiperactivo, ya que todos conducen a aumentar la morbimortalidad de nuestros pacientes. (AU)

Objectives: To analyze, from the nursing records, the variables associated with the appearance of Acute Confusional Syndrome (here after SCA) in geriatric patients of a general hospital in the city of Zaragoza.Methodology:Descriptive cross-sectional and retrospective study conducted at the Royo Villanova hospital in Zaragoza between 2011-2014. Study population: N = 881 diagnosed with ACS (2.2% of total income). A total sample of n = 79 was obtained, patients ≥ 60 years, with a diagnosis of ACS by Link Psychiatry.Results:The average age of the patients was 82.8 years. The detection of ACS was performed in patients after 1.1 to 3.5 days on average from admission. Barthel Index scores were 40.9 to 60.8. The exitus during the episode of ACS were 10.3% / 15%. The SCA chart was mostly hyperactive and debuted at night and in the afternoon. The most frequent symptoms of ACS recorded by nursing were motor disorders (agitation, restlessness) and disorientation.Conclusions:Nursing usually register ACS before the request for collaboration to the psychiatry service, which occurs rarely. Besides these records are accurate and match with the medical terms. New research studies are required to minimize underdiagnosis and not only to detect hyperactivity ACS because all types lead to increased morbidity and mortality of our patients. (AU)

Postoperative Cardiovascular Surgery Delirium: Interrater Agreement Between Nurses and Clinical Nurse Specialist and Factors Associated With Prevalence.

PURPOSE: The aims of this study were to examine interrater agreement of delirium between clinical nurses and a clinical nurse specialist, determine delirium subtype prevalence, and examine associated patient, procedure, and hospital factors. DESIGN: A descriptive cross-sectional design and a convenience sample of nurses and patients on progressive care units were used in this study. METHODS: Clinical nurse specialist data were collected on a case report form, and clinician and patient data were obtained from electronic databases. Interrater agreement of delirium prevalence was assessed by κ statistic, and logistic regression models were used to determine patient factors associated with delirium. RESULTS: Of 216 patients, 23 had delirium; clinical nurses identified fewer cases than the clinical nurse specialist: 1.8% versus 10.7%; κ agreement, 0.27 (0.06, 0.49). By delirium subtype, hypoactive delirium was more frequent (n = 10). Factors associated with delirium were history of cerebrovascular disease (odds ratio [95% confidence interval], 2.8 [1.01-7.7]; P = .044), history of mitral valve disease (odds ratio [95% confidence interval], 0.31 [0.09-0.90]; P = .041), and longer perfusion time (odds ratio [95% confidence interval], 1.7 [1.1-2.7]; P = .016). One factor was associated with hypoactive delirium, longer perfusion time (odds ratio [95% confidence interval], 2.2 [1.3-4.2]; P = .008). CONCLUSIONS: Because clinician-clinical nurse specialist delirium agreement was low and hypoactive delirium was common, clinical interventions are needed.

The Impact of Nursing Delirium Preventive Interventions in the ICU: A Multicenter Cluster-randomized Controlled Clinical Trial.

Rationale: Delirium is common in critically ill patients and is associated with deleterious outcomes. Nonpharmacological interventions are recommended in current delirium guidelines, but their effects have not been unequivocally established. Objectives: To determine the effects of a multicomponent nursing intervention program on delirium in the ICU. Methods: A stepped-wedge cluster-randomized controlled trial was conducted in ICUs of 10 centers. Adult critically ill surgical, medical, or trauma patients at high risk of developing delirium were included. A multicomponent nursing intervention program focusing on modifiable risk factors was implemented as standard of care. The primary outcome was the number of delirium-free and coma-free days alive in 28 days after ICU admission. Measurements and Main Results: A total of 1,749 patients were included. Time spent on interventions per 8-hour shift was median (interquartile range) 38 (14-116) minutes in the intervention period and median 32 (13-73) minutes in the control period (P = 0.44). Patients in the intervention period had a median of 23 (4-27) delirium-free and coma-free days alive compared with a median of 23 (5-27) days for patients in the control group (mean difference, -1.21 days; 95% confidence interval, -2.84 to 0.42 d; P = 0.15). In addition, the number of delirium days was similar: median 2 (1-4) days (ratio of medians, 0.90; 95% confidence interval, 0.75 to 1.09; P = 0.27). Conclusions: In this large randomized controlled trial in adult ICU patients, a limited increase in the use of nursing interventions was achieved, and no change in the number of delirium-free and coma-free days alive in 28 days could be determined. Clinical trial registered with www.clinicaltrials.gov (NCT03002701).

Delirium in adult patients in intensive care: nursing interventions.

BACKGROUND: Delirium is a neuropsychiatric syndrome of high incidence in the critically ill patient. It is characterised by changes in acute attention and cognition, has a multifactorial aetiology and has a negative impact on the patient's clinical situation and future quality of life. Prevention of delirium and early identification can reduce associated morbidity and mortality. Consequently, it is vital that intensive care unit (ICU) nurses perform targeted patient monitoring to identify acute cognitive changes. OBJECTIVE: To identify nursing interventions directed at the prevention and management of delirium in adult patients in ICU. METHOD: A scoping review was undertaken based on the principles recommended by the Joanna Briggs Institute. RESULTS: Seven studies were selected for inclusion. Non-pharmacological and pharmacological nursing interventions were identified. CONCLUSION: The interventions identified were predominantly aimed at the prevention of delirium. The training of nurses and wider clinical team in preventing and identifying this syndrome is crucial.

Cuidados para el manejo de delirio en Unidades de Paciente Crítico: una revisión integrativa / Cuidados para o manejo de delirium em Unidades de Pacientes Críticos: uma revisão integrativa / Care management of delirium in Critical Patient Units: an integrative review

Objetivo: analizar en la evidencia bibliográfica los aspectos que influyen en el desarrollo del delirio, manejo, evaluación objetiva para su pesquisa y los cuidados relacionados a la promoción y prevención de éste en los usuarios hospitalizados en unidades críticas. Metodología: Se realizó una revisión integrativa, en bases de datos CINAHL; SCOPUS y Scielo. Fueron seleccionados 19 artículos limitados por año (2016-2017). Resultado: Se identificaron cuatro factores que impactan en el delirio: la fisiopatología/factores de riesgo, la prevención y promoción, la evaluación objetiva y el manejo en unidades críticas. Conclusión: La Gestión del Cuidado se encuentra a cargo de Enfermería, por ende, es fundamental no dejar esta temática de lado debido a que su incidencia aumentará los días de hospitalización, días de ventilación mecánica y mortalidad, impactando negativamente en la calidad de los cuidados.(AU)

Aim: To identify aspects thatinfluence the development of delirium, itsmanagement, evaluation and care in relationto the promotion and the prevention ofdelirium. Methodology: An integrativereview was carried out in the followingdatabases; CINHAL, SCOPUS and Scielo.19 articles were selected, limited by year(2016-2017). Result: Four factors that havean impact on delirium were identified:pathophysiology / risk factors, preventionand promotion, objective evaluation andmanagement in critical units. Conclusion:Nursing is in charge of care management,therefore, it is essential not to leave this issue aside because its incidence will increase thedays of hospitalization, days of mechanicalventilation and mortality, negativelyimpacting the quality of care.(AU)

Objetivo: Identificar aspectos queinfluenciam o desenvolvimento do delirium,seu manejo, avaliação objetiva para suapesquisa e cuidados relacionados àpromoção e prevenção deste. Metodologia:Uma revisão integrativa foi realizada nasbases de dados da CINAHL; SCOPUS eScielo. Foram selccionados 19 artigoslimitados por ano (2016-2017). Resultado:Foram identificados quatro fatores que têmimpacto no delirium: fisiopatologia / fatoresde risco, prevenção e promoção, avaliaçãoobjetiva e manejo em unidades críticas.Conclusão: A gerência do cuidado éresponsável pela enfermagem, portanto, éimprescindível não deixar de lado essaquestão, pois sua incidência aumentará osdias de internação, dias de ventilaçãomecânica e mortalidade, impactandonegativamente na qualidade do cuidado.(AU)

A narrative review of preventive measures for postoperative delirium in older adults.

Postoperative delirium (POD) is an acute neurological condition associated with changes in cognition and attention and disorganised thinking. Although delirium can affect patients from any age group, it is common in older patients and could lead to a longer hospital stay and a higher risks of mortality. This article presents findings from a literature review that identifies various strategies used by health professionals globally to prevent POD. A database search resulted in 25 articles that met the inclusion criteria. Thematic analysis and coding were used to combine recurrent ideas that emerged from the literature. Three themes were identified: early identification and screening, modifiable risk factors, and preventive interventions. Further research focusing on education and improving awareness about POD among nurses is essential.

Preventing, identifying and managing delirium in nursing homes and acute settings.

Older people, particularly those in nursing homes, are vulnerable to delirium, which is a condition characterised by confusion. This article outlines the risk factors, prevention, identification and management of delirium in older people in nursing homes and acute settings. It uses a case study approach to encourage nurses to consider the challenges faced in these settings and how they could address delirium. The article also details the multicomponent interventions that can be used for prevention, as well as the available delirium assessment tools, with a focus on selecting tools based on the person's health status and the healthcare setting.

Intensive Care Unit Nursing Priorities in the United States.

This integrative review presents the most recent and relevant critical care nursing research publications in the United States. A comprehensive search identified publications on the topics of delirium; early mobility; communication; palliative care; tele-intensive care unit; care bundle implementation; and prevention, detection, and early management of infection. The evidence is summarized for each of these topics, as well as other research, with suggestions and guidance for end users.

Implementing a Rapid, Two-Step Delirium Screening Protocol in Acute Care: Barriers and Facilitators.

BACKGROUND/OBJECTIVES: An effective and efficient protocol for delirium identification is needed to improve health outcomes for older adults and reduce healthcare costs. This study describes the barriers and facilitators related to the implementation of the ultra-brief confusion assessment method (UB-CAM), a rapid two-step delirium identification protocol (ultra-brief screen, followed by CAM in positives), field tested with hospitalized older adults (70+). DESIGN: A qualitative descriptive design using observational data collection and brief semi-structured interviews. SETTINGS: An urban academic medical center and a community teaching hospital. PARTICIPANTS: Participants included 50 physician hospitalists, 189 registered nurses, and 83 nursing assistants (NAs). MEASUREMENTS: Field researchers guided by a modified multi-level implementation framework, collected observational data as participants administered the UB-CAM (n = 767). Thematic analysis was conducted on five observational categories: structural, organizational, patient, clinician, and innovation. Field notes and brief semi-structured interviews (n = 231) with clinicians, explored the utility, acceptability, and feasibility of the protocol, and supplemented the observations. RESULTS: The UB-CAM was generally positively received by all three clinician types. Six themes describe barriers and/or facilitators to implementing the UB-CAM: (1) physical setting and milieu; (2) practice environment; (3) integrating into role; (4) adaptive techniques; (5) patient responses; and (6) systematic assessment. The composition and interaction of the six themes determined if the theme was expressed as a barrier or facilitator, affirming the importance of context when implementing system-level delirium screening. CONCLUSION: This is one of the first studies to test a two-step process for delirium identification, and to involve NAs in screening, and the findings demonstrate overall support from clinicians for delirium identification, and describe the need for a multifaceted, contextualized, and systemic approach to implementation and evaluation of delirium screening.

Developing a dementia care leaders' toolkit for older patients with cognitive impairment.

A recent review of the progress that has been made in meeting the government's Challenge on Dementia 2020 detailed the variability, and in some cases suboptimal quality, of hospital care for people with dementia. The review also identified the need for improvements in assessing the individual needs of people with dementia while in hospital, including their emotional and social needs. This article focuses on the development and implementation of an evidence-based toolkit to improve the hospital care of older patients with cognitive impairment, including dementia and/or delirium. The toolkit's focus is on optimising the patient experience of people with cognitive impairment who have been admitted to hospital. The toolkit also promotes the importance of person-centred care and communication skills.

Are common delirium assessment tools appropriate for evaluating delirium at the end of life in cancer patients?

OBJECTIVES: The objectives of this study are to investigate how many advanced cancer patients became unconscious or non-communicative after pharmacological treatment for delirium, and to explore whether existing delirium assessment tools can successfully evaluate its severity at the end of life. METHODS: This was a secondary analysis of a registry study that examined the efficacy and safety of antipsychotics for advanced cancer patients with delirium. A total of 818 patients were recruited from 39 specialized palliative care services in Japan. The severity of delirium was measured using the Richmond Agitation-Sedation Scale-Palliative care version, the Delirium Rating Scale-Revised-98 (DRS-R-98), and the Nursing Delirium Screening Scale (Nu-DESC) on Day 3. Data from 302 patients with motor anxiety with an Agitation Distress Scale score ≥2 on Day 0 were analyzed for this study. The patients were categorized into four treatment response groups: complete response (CR: no agitation and fully communicative), partial response (PR: no/mild agitation and partially communicative), unconscious/non-communicative (UC), and no change (NC). RESULTS: On Day 3, 29 (10%; 95% confidence intervals [CI], 7-13) and 2 (1%; 95% CI, 0-2) patients became unconscious and non-communicative, respectively. Forty-four patients were categorized as CR, 97 as PR, 31 as UC, and 96 as NC. The scores of the DRS-R-98 and Nu-DESC in the UC group were rated higher than patients in the NC group were. CONCLUSIONS: A considerable number of cancer patients with delirium became unconscious or non-communicative. Existing delirium assessment tools may be inappropriate for measuring the severity of delirium in end-of-life.