Aims and objectives
In order to obtain more information regarding this phenomenon, a scoping review of the literature was undertaken to analyse current research on the recognition of delirium by registered nurses in acute care settings.

Background
Delirium is often manifested as a sign of an underlying undiagnosed condition that requires immediate intervention and is frequently manifested in acute care settings. Unfortunately, registered nurses often do not recognise delirium and its occurrence goes under-reported.

Design/Methods
Based on six inclusion criteria, a search in numerous databases using terms such as delirium detection, recognition and diagnosis by registered nurses was undertaken. Eight quantitative studies were deemed relevant and analysed for this scoping review.

Results
Seven major categories emerged: the fluctuating nature of delirium, the impact of delirium education on its recognition, communication barriers, inadequate use of delirium assessment tools, lack of conceptual understanding of delirium, delirium as a burden and the likeness of delirium and dementia. A brief summary of the findings in each category is reported here.

Conclusions
The scoping review revealed that delirium remains underrecognised by registered nurses, which potentially contributes to reduced quality of nursing care for clients experiencing this condition. Further research on delirium and the processes that registered nurses use to recognise it is timely and will facilitate the development of evidence-based interventions to manage it.

Relevance to clinical practice
While acute care registered nurses have historically reported dramatic changes in cognitive and neuro-biological functions in ill older adults, the literature highlighted in this scoping review revealed the following: (1) the need for further research to validate delirium assessment tools and, (2) the need for education and training for registered nurses on the use of these assessment tools to promote early recognition and thereby decrease the incidence of delirium in older adults.

Factors that contribute to underrecognition of delirium by registered nurses in acute care settings: a scoping review of the literature to explain this phenomenon

Incidence of delirium following total joint replacement in older adults: a meta-analysis

Background
Although detection of delirium using the current tools is excellent in research settings, in routine clinical practice, this is not the case. Together with nursing staff, we developed a screening tool (RADAR) to address certain limitations of existing tools, notably administration time, ease-of-use and generalizability. The purpose of this study was not only to evaluate the validity and reliability of RADAR but also to gauge its acceptability among the nursing staff in two different clinical settings.

/pdf/recognizing-acute-delirium-as-part-of-your-routine-radar-a-34kxzc9622.pdf

Recognizing acute delirium as part of your routine [RADAR]: a validation study

Objectives
To evaluate to what extent delirium experts agree on the diagnosis of delirium when independently assessing exactly the same information and to evaluate the sensitivity of delirium screening tools in routine daily practice of clinical nurses.

Design
Prospective observational longitudinal study.

Setting
Three medical centers in the Netherlands.

Participants
Elderly postoperative adults (n = 167).

Measurements
A researcher examined participants daily (Postoperative Day 1–3) for delirium using a standardized cognitive assessment and interview including the Delirium Rating Scale Revised-98 as global impression without any cut-off values that was recorded on video. Two delirium experts independently evaluated the videos and clinical information from the last 24 hours in the participants’ record and classified each assessment as delirious, possibly delirious, or not delirious. Interrater agreement between the delirium experts was determined using weighted Cohen's kappa. When there was no consensus, a third expert was consulted. Final classification was based on median score and compared with the results of the Confusion Assessment Method for Intensive Care Unit and Delirium Observation Scale that clinical nurses administered.

Results
Four hundred twenty-four postoperative assessments of 167 participants were included. The overall kappa was 0.61 (95% confidence interval = 0.53–0.68). There was no agreement between the experts for 89 (21.0%) assessments and a third delirium expert was needed for the final classification. Delirium screening that nurses performed detected 32% of the assessments that the experts diagnosed as (possibly) delirious.

Conclusion
There was considerable disagreement in classification of delirium by experts who independently assessed exactly the same information, showing the difficulty of delirium diagnosis. Furthermore, the sensitivity of daily delirium screening by clinical nurses was poor. Future research should focus on development of objective instruments to diagnose delirium.

Recognition of Delirium in Postoperative Elderly Patients: A Multicenter Study.

Delirium is a complex neuropsychiatric syndrome which is common in all medical settings. It often goes unrecognized due to difficulties in the detection of its hypoactive variant. This review aims to provide an up-to-date account on recent research on hypoactive delirium (HD). Thirty-eight studies, which were conducted in various clinical settings, including the Intensive Care Unit (ICU), were included in this review. Those studies involved recent research that has been published during the last 6 years. Prevalence of HD was found to vary considerably among different settings. HD seems to be more common in critically ill patients and less common in patients examined by consultation-liaison psychiatric services and in mixed patient populations. The presence of HD in ICU patients was associated with higher short- and long-term mortality and other adverse outcomes, but no such association was reported in other settings. Research on other possible associations of HD with clinical variables and on symptom presentation yielded inconclusive results, although there is some evidence for a possible association of HD with benzodiazepine use. There are several methodological issues that need to be addressed by future research. Future studies should examine HD in the primary care setting; treatment interventions should also be the objective of future research.

/pdf/recent-insights-on-prevalence-and-corelations-of-hypoactive-n76qg5mf51.pdf

Recent Insights on Prevalence and Corelations of Hypoactive Delirium.

Background:Delirium is the most frequent complication associated withhospitalization of older adults, responsible for 17.5 millionadditionalhospitaldaysintheUnitedStateseachyear;yet,nursesfail 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 bycomparing nurse and expert diagnostician ratings for deliriumusing the Confusion Assessment Method (CAM).Method:This study investigated the rate of agreement/disagreementbetween researchers and a convenience sample of 167 nursescaring for 170 medical surgical patients (965 years) indetecting delirium. Paired (nurse vs researcher) CAM ratingswere completed at least every other day until either dischargeor 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 allobservations (. = 0.34). A generalized estimating equationlogistic regression model identified independent predictors ofnurses’ underrecognition of delirium that included increasingage 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 adultwhen using the CAM. Additional research is warrantedregarding the clinical decision-making processes that nursesuse in assessing acute cognitive changes and in identifyingstrategies to improve delirium recognition.KEY WORDS:confusion, delirium, nurse recognition

Michael Knight

Papers

Nurses' recognition of delirium in the hospitalized older adult.