Evidenced-Based Practice Change Presentation

PICOT Statement

State your PICOT statement from Week 2 in the standard format and label each element ( e.g., P, I, C, O, T).

In hospitalized older adult patients (P) , how does identification of delirium (I) compared to not identifying (C) affect prevention or management of delirium and its effect (O) within 3 month’s time (T)?

Original Research Articles

Full reference for article (APA Format) and Chamberlain University hyperlink

Oliven, R., Rotfeld, M., Gino-Moor, S., Schiff, E., Odeh, M., & Gil, E. (2021). Early Detection and Intervention for Patients with Delirium Admitted to the Department of Internal Medicine: Lessons from a Pilot Initiative.
Dementia and Geriatric Cognitive Disorders Extra,
11(2), 134–139.
https://doi.org/10.1159/000515958

Link:
https://chamberlain.primo.exlibrisgroup.com/discovery/search?vid=01CUCON_INST:DEFAULT&tab=Everything&search_scope=MyInst_and_CI&lang=en&query=any,contains,Early%20Detection%20and%20Intervention%20for%20Patients%20with%20Delirium%20Admitted%20to%20the%20Department%20of%20Internal%20Medicine:%20Lessons%20from%20a%20Pilot%20Initiative.%20Dementia%20and%20geriatric%20cognitive%20disorders%20extra

Purpose and Type of Research

The article aims to assess the effectiveness of early detection and management strategies for delirium through tools such as the 4AT assessment and early mobilization protocols. This study would, therefore, seek to enhance patient outcomes through the proactive handling of delirium. The research is an original research article in that it reports findings from a pilot initiative implemented in the internal medicine department of a hospital. It does not test a theoretical framework but investigates practical applications of delirium detection and management.

Methods

Methods

This was a pilot initiative that consisted of a study design using the implementation of the 4AT tool for screening for delirium and introducing structured early mobilization as an intervention. Feasibility data for the above practices were collected regarding the impact on patients admitted to the internal medicine department. Changes in the incidence of delirium were recorded, with observed effectiveness of strategies documented via observational data and outcome monitoring.

Sample and Participants

The study involved patients admitted to the Department of Internal Medicine in one health facility. Participants targeted were adults who were at risk of developing delirium, although specific criteria for inclusion and exclusion were not stated. The sample size was small, as this initiative was a pilot to try the feasibility and effectiveness of interventions within a controlled scope.

Study Findings

These results showed that the use of the 4AT as a screening tool for early detection of delirium and structured early mobilization could reduce the severity and duration of the condition. The feasibility of these strategies in routine clinical practice to improve patient outcomes was evident in this pilot initiative. Moreover, the study pointed out the importance of a multidisciplinary approach in managing delirium.

Limitations of the Study

Limitations to the study were multiple and largely related to its pilot nature. The sample size was small, limiting the generalizability of the findings. It was conducted in a single healthcare setting, reducing the applicability of results across diverse populations or facilities. In addition, there was no control group for this study, which can be considered a limitation since outcomes could not be wholly attributed to the interventions being tested.

Relevance to Practice Issue or Proposed Intervention

The study is highly pertinent to this practice issue of improving patient outcomes for those at risk of delirium through timely detection and intervention. This is especially important in hospitalized patients, where delirium has been shown to be associated with worse outcomes, such as prolonged hospital stay, increased mortality, and long-term cognitive decline. It has provided evidence-based, practical approaches that will fit easily into routine care by demonstrating the feasibility and efficacy of the 4AT screening tool and structured early mobilization protocols. This finding informs action on current interventions that will result in proactive management of delirium and complements goals of increasing patient safety with decreasing complication rates and improving overall quality of care. The finding also has implications for collaborative interaction in multidisciplinary teamwork for the actualization of such interventions, thus becoming more relevant in clinical settings for resource optimization and patient-centered care.

Meged-Book, T., Frenkel, R., Nikonov, A., Zeldetz, V., Kosto, A., Schwarzfuchs, D., Freud, T., & Press, Y. (2024). Delirium screening in the emergency department: evaluation and intervention.
Israel Journal of Health Policy Research,
13(1), 16–19. https://doi.org/10.1186/s13584-024-00603-1

Link:
https://chamberlain.primo.exlibrisgroup.com/discovery/search?query=any,contains,Delirium%20screening%20in%20the%20emergency%20department:%20evaluation%20and%20intervention&tab=Everything&search_scope=MyInst_and_CI&vid=01CUCON_INST:DEFAULT&lang=en&offset=0

This study aimed to assess the effectiveness of a delirium screening conducted in the ED, where the main focus was on investigating the effectiveness of a specific delirium screening protocol in which there was a dedicated evaluator. The current study prospectively compared the outcomes for screened and unscreened patients, with a special focus on the recognition of delirium and related factors like age, comorbidities, and living status. This is a quantitative, observational study aimed at determining the prevalence of delirium among elderly patients in the ED and the effectiveness of interventions to improve diagnosis.

This was a pre-and post-intervention study; data collection occurred in two phases. The initial period, T1, consisted of raising awareness about delirium among ED staff. In the second phase, T2, active screening was conducted by a delirium evaluator. The main outcomes measured included the rate of delirium diagnosis, rates of hospitalization, and the influence of various patient factors on diagnosis. Delirium screening was done by utilizing tools such as the 4AT delirium assessment tool; data was gathered from direct observations and clinical assessments of the patient and the patient’s medical records.

The sample size was 5,174 patients; of those, 451 patients were screened for delirium in the second phase, 780 were admitted without a delirium evaluator, and 4,943 were unscreened. The mean age of the participants was 77.6 years, and 51.9% of the patients were female. This is an older adult population in which most of the sample had comorbid conditions that could affect the presence of delirium.

Out of the patients screened, delirium was diagnosed in 14.9%, while only 1.9% were diagnosed when compared to those not screened in the absence of delirium evaluators. The diagnosis was significantly higher in the screened population, which showed that having a dedicated delirium evaluator enhanced the identification of that condition. Additionally, patients diagnosed with delirium were older, had higher rates of comorbidities (demented especially), and were more likely to be admitted to a hospital. This study established that moreover delirium was associated with those cases reported higher rates of confusion by ED staff, lower family status, and a higher Charlson comorbidity score. There were also significant differences in vital signs between these patients like abnormal temperatures, blood pressures, and oxygen saturations, all indicating higher instability clinically. The findings indicated the importance of screening for delirium in achieving better diagnoses and treatment outcomes in the ED.

Several limitations were declared in the study. First, only 36.6% of eligible patients were screened, with no rationale provided for exclusions, which may be subject to selection bias. Secondly, the Charlson Comorbidity Index is used to assess comorbidities without accounting for the individual conditions’ severity, which might affect the risk of developing delirium. Another limitation was the lack of post-hospitalization follow-up, meaning the study could not track the resolution of delirium or long-term outcomes such as mortality beyond 90 days. Finally, the focus of the study on the immediate impact of the delirium screening interventions did not address the long-term sustainability of improvements in the recognition of delirium.

The results of this study are very relevant to clinical practice, especially in enhancing the management of delirium in the ED. This study emphasizes the implementation of compulsory delirium screening at triage for older adults since early diagnosis is vital in minimizing the morbidity and mortality rates related to delirium. Given the high impact of delirium on patient outcomes, this study recommends the integration of delirium screening into routine triage for all patients aged 65 years and above. It is also suggested that electronic medical record alerts and automated screening tools be adopted; these interventions may lead to earlier recognition and, thus earlier management of delirium, improving patient outcomes. The study adds weight to the fact that only such systematic approaches, including compulsory screening and electronic reminders, will help to improve the detection and management of delirium in ED.

Synthesis Articles

Full reference for article (APA Format)

Tieges, Z., Maclullich, A. M. J., Anand, A., Brookes, C., Cassarino, M., O’connor, M., Ryan, D., Saller, T., Arora, R. C., Chang, Y., Agarwal, K., Taffet, G., Quinn, T., Shenkin, S. D., & Galvin, R. (2021). Diagnostic accuracy of the 4AT for delirium detection in older adults: systematic review and meta-analysis.
Age and Ageing,
50(3), 733–743.
https://doi.org/10.1093/ageing/afaa224

Link:
https://chamberlain.primo.exlibrisgroup.com/discovery/search?query=any,contains,Diagnostic%20accuracy%20of%20the%204AT%20for%20delirium:%20A%20systematic%20review%20and%20meta-analysis&tab=Everything&search_scope=MyInst_and_CI&vid=01CUCON_INST:DEFAULT&lang=en&offset=0

This systematic review and meta-analysis aimed to determine the diagnostic accuracy of the 4AT tool for detecting delirium among older patients in various clinical settings. Delirium is a common condition among the elderly that, despite its high morbidity and mortality, often goes undiagnosed. The study seems to ascertain whether the 4AT represents an effective brief delirium screening tool in the diagnosis of delirium and inform clinical practice. This study is diagnostic in nature and is focused on assessing the accuracy of a particular clinical tool.

Search strategy

They carried out a systematic search through the four major databases: PubMed, Web of Science, PsycINFO, and EMBASE. Such data include studies published from inception until April 2020 and updated in January 2022. Keywords related to delirium and the 4AT screening tool were used. Lastly, relevant systematic reviews and meta-analyses were reviewed to see whether there were any additional studies meeting the inclusion criteria. The search strategy adhered to the PRISMA guidelines.

Discussion of Inclusion Criteria

Thus, the studies that were included in this review were those that met some criteria. They included studies that examined the use of the 4AT for delirium detection in adult patients of 18 years and over. They needed to provide diagnostic accuracy data for the 4AT, such as sensitivity, specificity, and so on. They had to be published in peer-reviewed journals in English, focusing on environments where there is a higher prevalence of delirium in older adults, such as hospitals, emergency departments, and intensive care units.

This meta-analysis includes studies in which a total of 2,789 persons were involved. The pooled sensitivity of the 4AT was 0.87, and its pooled specificity was also found to be 0.87, meaning that the instrument is excellent for diagnosing delirium. With a positive likelihood ratio of 6.66, the positive 4AT result indicates a high chance of having acquired delirium, while the negative likelihood ratio of 0.15 implies that a not positive result clearly rules out the diagnosis. Furthermore, the study indicated that variables like patient selection, clinical setting, and timing affect the accuracy of the 4AT tool.

This meta-analysis has a number of limitations. Firstly, while this may be a large sample size, the studies differ in terms of clinical settings and patients under study, which may affect the applicability of findings. Apart from that, the 4AT tool’s performance may differ in accordance with the definition and diagnosis of delirium in individual settings. Another limitation of this analysis was to include published studies that may pose a risk of introducing publication bias. Furthermore, the studies did not evaluate the long-term outcomes of delirium diagnosis, using the 4AT, on patient prognosis or healthcare costs.

The results of this study are very relevant to clinical practice, especially for healthcare professionals working with older patients. It has an easy and fast method of screening for delirium, hence very applicable, especially in the time-constrained setting of an ED or even an ICU. Since many cases of delirium are not recognized clinically, this may lead to earlier identification and treatment using the 4AT. This can lead to improvements in patient outcomes by potentially avoiding complications related to the course of delirium. Additionally, the ease of use of the tool and the very minimal training required make it accessible to a broad range of healthcare providers. This study supports the wider use of the 4AT tool in routine clinical practice for the early detection and management of delirium in older adults.

Lauretani, F., Bellelli, G., Pelà, G., Morganti, S., Tagliaferri, S., & Maggio, M. (2020). Treatment of Delirium in Older Persons: What We Should Not Do.
International Journal of Molecular Sciences,
21(7), 2397-. https://doi.org/10.3390/ijms21072397

Links:
https://chamberlain.primo.exlibrisgroup.com/discovery/search?query=any,contains,Treatment%20of%20Delirium%20in%20Older%20Persons:%20What%20We%20Should%20Not%20Do!&tab=Everything&search_scope=MyInst_and_CI&vid=01CUCON_INST:DEFAULT&lang=en&offset=0

This review aimed to evaluate the treatment options for hyperactive delirium, with a particular focus on the effects of drug use in patients with acute delirium. The review was based on an unstructured bibliographic search that examined studies relevant to the literature reviewed. Studies were categorized based on design and quality, ranging from animal and in vitro studies to meta-analyses and systematic reviews, and the level of evidence for each study was assessed using a star rating system.

Search strategy. The search strategy consisted of an unstructured bibliography, in which relevant studies were identified from the reviewed literature and selected based on their relevance to the topic of ADHD and pharmacotherapy. Many studies were reviewed, and the search resulted in clinical trials and studies that provided high-quality evidence. Studies were categorized according to an evidence-based pyramid, with each study quality indicated by an asterisk, ranging from low-quality animal studies to high-quality meta-analyses and systematic reviews.

The study selection criteria were based on the effects of negative emotions, with a particular focus on the effects of drugs. Only human studies, clinical trials and studies providing relevant information on the treatment of depression were included. The studies were assessed based on the strength of their design, randomized controlled trials (RCTs), randomized controlled trials, and systematic reviews for their robustness. Animal studies were included and reported but were downgraded due to the weakness of their evidence.

This review highlights some findings relevant to the treatment of hyperactive delirium. Clinical trials have not significantly reduced the duration of delirium in different settings (eg, ICU) or critically ill adults. This review emphasizes that antidepressants should be used with caution, at the lowest dose, and for the shortest possible duration. He also noted the importance of choosing antipsychotics with less anticholinergic effects, such as haloperidol, and warned against using these drugs in patients with heart or respiratory problems. Additionally, this review discusses the use of benzodiazepines (BDZ) to treat psychosis, particularly in cases related to alcohol withdrawal, and shows the risks of certain drugs in various cases, including liver and kidney.

This review has several limitations, including its non-literary approach, which may have resulted in biased study selection. Reliance on cross-sectional studies affects final strength. Additionally, the review could not include independent, approved clinical trials examining the effectiveness of new medications such as trazodone in treating hyperactive delirium. Furthermore, although this review provides important information on the toxicity of various drugs, it highlights the need for additional controlled trials (RCTs) to determine the safety and efficacy of these drugs.

These findings are very important for clinical practice, as they contribute to the care of patients with hyperactive delirium. With the potential safety concerns involving severe agitation and the rapid need to intervene, this review provides some recommendations on selecting pharmacological treatments according to patient comorbidities. A tailored approach that considers the patient’s specific clinical profile, such as cardiac, hepatic, or renal dysfunction, is the best recommendation clinicians can follow for medication choice. Such a personalized strategy will minimize adverse side effects such as extrapyramidal symptoms or respiratory depression and optimize treatment outcomes among patients with hyperactive delirium. The review further recommends investigation of other medications like trazodone that might provide an alternative therapy, especially in patients with comorbid cognitive and mood disorders like dementia.

Faeder, M., Hale, E., Hedayati, D., Israel, A., Moschenross, D., Peterson, M., Peterson, R., Piechowicz, M., Punzi, J., & Gopalan, P. (2023). Preventing and treating delirium in clinical settings for older adults.
Therapeutic Advances in Psychopharmacology,
13, 20451253231198462-.
https://doi.org/10.1177/20451253231198462

https://chamberlain.primo.exlibrisgroup.com/discovery/fulldisplay?docid=cdi_doaj_primary_oai_doaj_org_article_3d2ecc7e701345989cff64fe1c0aa728&context=PC&vid=01CUCON_INST:DEFAULT&lang=en&search_scope=MyInst_and_CI&adaptor=Primo%20Central&tab=Everything&query=any,contains,Preventing%20and%20treating%20delirium%20in%20clinical%20settings%20for%20older%20adults&offset=0

This research is a narrative review synthesizing evidence on the prevention and treatment of delirium, mostly about older adults at greater risk. Delirium is a neuropsychological syndrome manifested by acute changes in attention and cognition and clouded consciousness, with raised morbidity: morbidity involving longer hospital stays and long-time cognitive decline, as well as higher mortality. The study examines pharmacological and non-pharmacological interventions for this serious condition. A review of existing studies to present health care practitioners with applicable insights for improved outcomes. This objective is diverging towards the broader objective of bringing about better clinical practice and hence less healthcare burden of delirium on susceptible populations.

This work specifically applies a narrative review methodology and conducts a search through various electronic databases such as PubMed and Google Scholar with search terms “delirium, geriatric, elderly, and encephalopathy.” The idea behind this is to find all available studies regarding delirium prevention and treatment among older adults and to conduct a search related to the articles in English while selecting them thematically rather than exhaustively. The relevance of the abstracts was analyzed prior to analyzing the full articles as a means of deriving essential insights on measures, both pharmacological and non-pharmacological.

These studies are included in the review of human studies published in the English language that present data on the management of delirium in older adults. In this paper, the authors selected studies conducted in various clinical settings, including hospitals, long-term care facilities, and critical care environments. Unlike systematic reviews that adhere to strict predefined criteria for study inclusion, this narrative review allowed a bit more flexibility in the selection of studies for a comprehensive overview. It is, however, stated that studies that did not relate well to older populations or those with weak methodological frameworks were excluded to ensure that the review remained focused and quality-oriented.

The review reported that nonpharmacological interventions like the Hospital Elder Life Program (HELP) or the ABCDEF bundle rank highest among delirium prevention strategies. These programs target several risk factors, such as immobility, dehydration, and sensory distortions, thereby reducing the incidence and severity associated with delirium. Pharmacological interventions often are less conclusive. For example, most frequently prescribed antipsychotics to treat symptoms of agitation are helpful but do not deliver great overall medical benefits while being laden with considerable risks, especially in older individuals. Up-and-coming treatments like melatonin receptor agonists appear to hold promise, but more study is warranted to establish their efficacy and safety.

The study’s underlying limitation is the narrative review design, which by definition does not share the methodological rigor of a systematic review. The selective inclusion of studies means that some potentially important literature may not have been included, introducing possible selection bias. In addition, the review relies on studies with differing designs and populations, which may limit the extent of generalizability. The authors also mention that more rigorous and high-quality randomized clinical trials (RCTs) are required for evidence strengthening, especially regarding pharmacological interventions.

The results of this particular review are really of great importance to clinical practice, especially in managing delirium in older adults. Underdiagnosed and understudied delirium is the norm across healthcare facilities, which largely leads to poor patient outcomes and rising healthcare costs. The paper on nonpharmacological interventions contains viable avenues that can be integrated into routine care to avoid the condition and thus promote patient safety. The information is therefore essential for healthcare providers who want to implement evidence-based interventions for both the acute and the long-term effects of delirium. With early detection and adequate management, the review supports improving the quality of care and reducing the health burden associated with delirium.