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Gaps in patient care practices to prevent hospital-acquired delirium

Thomas Marrie, MD
Dean in the Faculty of Medicine and Dentistry at the University of Alberta

Darryl Rolfson, MD and William Coke, MD
Dr Rolfson is an Associate Professor in the Division of Geriatric Medicine and Dr Coke is an Associate Professor and Divisional Director in the Division of General Internal Medicine, both in the Department of Medicine at the University of Alberta

Richard Camicioli, MD MSc and D’Arcy Duggan, MD
Dr Camicioli is an Associate Professor in the Division of Neurology and Dr Duggan is an Associate Professor in the Division of General Internal Medicine, both in the Department of Medicine at the University of Alberta

Bonnie Launhardt, RN MN
Nurse practitioner at Grey Nuns Hospital in Edmonton

Bruce Fisher, MD
Associate Professor in the Division of General Internal Medicine in the Department of Medicine at the University of Alberta

Debbie Gordon, RN MBA
Vice President and Chief Operating Officer at the University of Alberta Hospital and Stollery Children’s Hospital in Edmonton

Marilou Hervas-Malo, MSc
Biostatistician at the EPICORE Centre in Edmonton

Bernice Magee, MN
Clinical Nurse Specialist at the University of Alberta Hospital

Cheryl Wiens, PharmD
Associate Professor in the Faculty of Pharmacy and Pharmaceutical Sciences at the University of Alberta

Correspondence: Dr K. Alagiakrishnan, Glenrose Rehabilitation Hospital, Room 1259, 10230-111 Ave, Edmonton, AB T5G 0B7; telephone 780 735-8800; fax 780 735-8846; e-mailkalagiak{at}cha.ab.ca

OBJECTIVE To evaluate the current patient care practices that address the predisposing and precipitating factors contributing to the prevention of hospital-acquired delirium in the elderly.

DESIGN Prospective cohort (observational) study.

PARTICIPANTS Patients 65 years of age and older who were admitted to medical teaching units at the University of Alberta Hospital in Edmonton over a period of 7 months and who were at risk of delirium.

SETTING Medical teaching units at the University of Alberta.

MAIN OUTCOME MEASURES Demographic data and information on predisposing factors for hospital-acquired delirium were obtained for all patients. Documented clinical practices that likely prevent common precipitants of delirium were also recorded.

RESULTS Of the 132 patients enrolled, 20 (15.2%) developed hospital-acquired delirium. At the time of admission several predisposing factors were not documented (eg, possible cognitive impairment 16 [12%], visual impairment 52 [39.4%], and functional status of activities of daily living 99 [75.0%]). Recorded precipitating factors included catheter use, screening for dehydration, and medications. Catheters were used in 35 (26.5%) patients, and fluid intake-and-output charting assessed dehydration in 57 (43.2%) patients. At the time of admission there was no documentation of hearing status in 69 (52.3%) patients and aspiration risk in 104 (78.8%) patients. After admission, reorientation measures were documented in only 16 (12.1%) patients. Although all patients had brief mental status evaluations performed once daily, this was not noted to occur twice daily (which would provide important information about fluctuation of mental status) and there was no formal attention span testing. In this study, hospital-acquired delirium was also associated with increased mortality (P < .004), increased length of stay (P < .007), and increased institutionalization (P < .027).

CONCLUSION Gaps were noted in patient care practices that might contribute to hospital-acquired delirium and also in measures to identify the development of delirium at an earlier stage. Effort should be made to educate health professionals to identify the predisposing and precipitating factors, and to screen for delirium. This might improve the prevention of delirium.