Journal of Gerontological Nursing

Consequences of Not Recognizing Delirium Superimposed on Dementia in Hospitalized Elderly Individuals

Donna Fick, PhD, RN, CS; Marquis Foreman, PhD, RN, FAAN

Abstract

ABSTRACT

Objective: The purpose of this study was to describe the recognition and management of delirium in hospitalized patients with and without dementia.

Design: A descriptive, exploratory design was used with a convenience sample of 20 hospitalized older patients who were observed indepth using qualitative interviews and observations of 13 family members and 11 staff members.

Setting: This research was conducted on the medical-surgical units of a 550-bed, nonprofit, state-supported teaching hospital in the southeastern United States. The facility provides primary and tertiary care with five intensive care units and eight medical-surgical units.

Participants: This study did not exclude individuals with dementia or pre-existing delirium. Subjects were not excluded on the basis of race or gender. Twenty patients in the sample underwent observation and mental and functional status testing. Thirteen family members and 11 staff members were interviewed and observed.

Measurements: in Phase 1 of the study, patients had daily mental status testing performed by the investigator. In Phase 2, family members and staff members were interviewed about the confusion event. For each patient, demographics and information regarding their health status and current diagnosis and treatment were obtained. The Mini-Mental State Examination (MMSE) and the Confusion Assessment Method were completed on each subject within 36 hours of being admitted to the hospital. The Cornell Depression Scale and Katz Activities of Daily Living scale were completed within 48 hours of admission.

Results: The prevalence of delirium in this study was 60%. The incidence, or new onset of delirium, was 30%. The presence of delirium was associated with new onset incontinence, lower baseline MMSE scores, depression, weight loss, and comorbidity. Of the eight individuals with delirium superimposed on dementia, 63% (n = 5) were re-admitted to the hospital within 30 days, compared to none of the individuals with delirium in the absence of dementia. Delirium superimposed on dementia also was less likely to be recognized by nurses and physicians.

Conclusions: Delirium in individuals with dementia should be assessed and treated routinely because the failure to recognize delirium superimposed on dementia promptly has significant negative personal, social, and financial consequences.

Abstract

ABSTRACT

Objective: The purpose of this study was to describe the recognition and management of delirium in hospitalized patients with and without dementia.

Design: A descriptive, exploratory design was used with a convenience sample of 20 hospitalized older patients who were observed indepth using qualitative interviews and observations of 13 family members and 11 staff members.

Setting: This research was conducted on the medical-surgical units of a 550-bed, nonprofit, state-supported teaching hospital in the southeastern United States. The facility provides primary and tertiary care with five intensive care units and eight medical-surgical units.

Participants: This study did not exclude individuals with dementia or pre-existing delirium. Subjects were not excluded on the basis of race or gender. Twenty patients in the sample underwent observation and mental and functional status testing. Thirteen family members and 11 staff members were interviewed and observed.

Measurements: in Phase 1 of the study, patients had daily mental status testing performed by the investigator. In Phase 2, family members and staff members were interviewed about the confusion event. For each patient, demographics and information regarding their health status and current diagnosis and treatment were obtained. The Mini-Mental State Examination (MMSE) and the Confusion Assessment Method were completed on each subject within 36 hours of being admitted to the hospital. The Cornell Depression Scale and Katz Activities of Daily Living scale were completed within 48 hours of admission.

Results: The prevalence of delirium in this study was 60%. The incidence, or new onset of delirium, was 30%. The presence of delirium was associated with new onset incontinence, lower baseline MMSE scores, depression, weight loss, and comorbidity. Of the eight individuals with delirium superimposed on dementia, 63% (n = 5) were re-admitted to the hospital within 30 days, compared to none of the individuals with delirium in the absence of dementia. Delirium superimposed on dementia also was less likely to be recognized by nurses and physicians.

Conclusions: Delirium in individuals with dementia should be assessed and treated routinely because the failure to recognize delirium superimposed on dementia promptly has significant negative personal, social, and financial consequences.

While much is known about the high incidence of delirium in hospitalized elderly individuals, few studies have investigated recognition and management of elderly individuals with dementia who develop delirium while hospitalized. Yet, the issues involved in the diagnosis and management of delirium superimposed on dementia clearly are more complex and diverse than the diagnosis and management of delirium alone. First, the number of individuals who have dementia in the United States is increasing, and as a result, so is the pool of people at risk for delirium. At least 4% of individuals older than age 65 have a dementing illness, and the cumulative risk of developing dementia by age 80 is approximately 20% (Evans et al., 1989).

Second, in addition to the complex nature of the recognition of delirium superimposed on dementia, delirium in individuals who have dementia is a serious problem. Some authors (lnouye & Charpentier, 1996; Pompei et al., 1994) have found that dementia or even mild cognitive impairment increases the risk for delirium when hospitalized, while Rockwood et al. (1996) reported an increased risk of dementia following an episode of delirium.

Third, delirium is associated with poor outcomes. It is associated with an increased length of hospital stay, increased nursing care, decreased ability to function, delayed rehabilitation, more frequent institutionalization, and higher mortality (Foreman & Grabowski, 1992; lnouye, Rushing, Foreman, Palmer, & Pompei, 1998; O'Keefe & Lavan, 1997; Thomas, Cameron, & Fahs, 1988). Although delirium may be reversible, several studies have shown a poor long-term prognosis or symptoms that persist beyond hospitalization (Francis & Kapoor, 1992; Levkoff, Besdine, & Wetle, 1986;Levkoffetal., 1992).

Fourth, the monetary cost of delirium and dementia is high. According to a 1993 progress report from the National Institute on Aging, Alzheimer's disease costs the United States an estimated $90 billion per year, including medical bills, nursing home costs, home care costs, and lost productivity (National Institute of Healthy 1993, 1994). Delirium has been estimated to cost more than $4 billion annually (lnouye, Schlesinger, & Lydon 1999). In addition, although previous studies have identified dementia as a risk factor for the development of delirium, less is known about the interaction between delirium and dementia, the management and recognition of delirium in individuals with dementia, and the long-term prognosis of individuals with dementia who develop delirium.

The purpose of this study was to explore the recognition and management of delirium by health care professionals and family members in hospitalized elderly individuals who have dementia. This study combined both qualitative and quantitative methods. This article will discuss the results of the observations and mental status testing of hospitalized patients as well as the semistructured interviews with their family members and the staff members who cared for these patients. This study was designed to answer the following questions:

* How do families, nurses, and other health care workers recognize and respond to delirium in elderly individuals?

* What is the experience of elderly individuals who develop delirium while in the hospital?

* What factors (e.g., medical diagnoses, medications, use of physical restraints, environment, interactions with caregivers) are associated with delirium superimposed on dementia?

Answers to these research questions were sought using observations of interactions among elderly patients, their families, and their health care providers; daily mental status testing of the patients; and semistructured interviews with the families and health care providers. Both family members and staff were asked to describe their perceptions of the confusion event. The term dementia is used to refer to an insidious and progressive deterioration of cognitive abilities that interferes with the social or cognitive abilities of the individual. Delirium refers to an abrupt disturbance in consciousness and change in cognition that cannot be better accounted for by a preexisting, established, or evolving dementia, and the disturbance in consciousness and change in cognition tend to fluctuate during the course of the day and night (American Psychiatric Association [APA], 1994).

METHODS

This study was conducted during a period of 12 months and proceeded in three phases. Phase 1 was intensive observation of patients, staff, and family members in a hospital, focusing on general observations of unit activities, interactions with patients, and the daily routine. In Phase 2, efforts focused on observations of patients with delirium, daily mental status testing of enrolled patients, and identification of individuals to interview. Phase 3 consisted of analysis of the data. Informed consent was obtained from all subjects, and the study protocol was reviewed and approved by the participating facility human assurance committee for the protection of human subjects.

Setting

This research was conducted at a 550-bed, nonprofit, state-supported teaching hospital in the southeastern United States. The facility provides primary and tertiary care for indigent people in the region. Approximately 22% of patients have Medicaid insurance at this facility.

Sample

The sampling of both patients and families was a convenience sample. Twenty patients in the sample underwent observation and mental and functional status testing. Thirteen family members and 11 staff members were interviewed and observed. The principal investigator reviewed daily the inpatient census and hospital records of all patients older than age 65. Patients also were observed daily on the selected units for the development of delirium. The nursing staff were asked to page the principal investigator when patients were admitted with confusion or when patients developed confusion. This study did not exclude individuals with dementia or pre-existing delirium. Subjects were not excluded on the basis of race or gender.

Measures

The major outcomes of interest were delirium and dementia status. Cognitive status, defined as memory, speech, thinking, language, orientation, attention, and level of consciousness, was measured using the Mini-Mental State Examination (MMSE) (Folstein, Folstein, & McHugh, 1975). The MMSE commonly is used in geriatric research and clinical practice and is the preferred instrument for use with elderly individuals who have dementia (Folstein et al, 1975). Patients were observed at several times of the day and were screened daily for the presence of delirium. The MMSE is a simplified scored form with 1 1 questions targeting five components of cognitive status, including orientation, registration, short-term recall, attention, and language. Total scores may range from 0 to 30, with scores totaling less than 24 (or less than 21 if less than a ninth-grade education) indicating impairment in cognition.

Delirium was identified using the Confusion Assessment Method (CAM) diagnostic algorithm (Inouye et al., 1990). The CAM is a standardized diagnostic algorithm enabling individuals without formal psychiatric training to quickly and accurately identify delirium. The CAM, based on Diagnostic and Statistical Manual of Mental Disorders (DSM-III R) (APA, 1987) criteria for delirium, was designed to capture information about the cardinal elements of delirium (i.e., acute onset and fluctuating course, altered level of consciousness, disorganized thinking, inattention), based on specific observations relevant to each of these elements. The CAM has been shown to have a sensitivity between 94% and 100%, a specificity between 90% and 95%, and interobserver reliability of k, .81 to 1.0 (APA, 1987, 1994; Inouye et al., 1990; Pompei, Foreman, Cassel, Alessi, & Cox, 1995).

For the Diagnostic and Statistical Manual of Mental Disorders (DSMIV) (APA, 1994) diagnosis of dementia, cognitive deficits must be sufficient to impair social or occupational functioning and must be characterized by gradual onset and patients' continued decline. The Modified Blessed Dementia Scale (Uhlman, Larson, & Buchner, 1987) and the MMSE were used to assess whether patients met the DSM-IV criteria for dementia. The Modified Blessed Dementia Scale was part of the semistructured family interview. In addition, patients must have had a MMSE score less than 24, or less than 21 if the subject had fewer than 9 years of education (lnouye, Viscoli, Horwitz, Hurst, & Tinetti, 1993; Tombaugh & Mclntyre, 1992). The term confusion event was used in this study to define the events surrounding a hospitalized patient's experience with delirium or dementia. The CAM and MMSE were administered to patients daily. Observations, interviews, and chart reviews were used to describe the confusion event.

The other instruments administered on admission included the Cornell Depression Scale, the Katz Index of ADL, and the Charlson Comorbidity Index (Alexopoulus, Abrams, Young, & Shamoian, 1988; Charlson, Pompei, Ales, & MacKenzie, 1987; Katz, Ford, Moskowitz, Jackson & Jaffee, 1963). Evidence of weight loss was obtained from reports of patients or family members and was supported further by observations of patients with delirium superimposed on dementia eating poorly while in the hospital. Table 1 lists the data collection procedures and instruments for each study variable.

Data Analyses

The semistructured interviews and event analysis (i.e., an indepth description and analysis of the acute confusion episode) were focused on describing delirium in the hospitalized elderly individuals and family members' and staff members' experiences with confusion in the elderly individuals and their ability to recognize acute confusion or delirium. Overall distributions were performed on the demographic, medical, psychological, and functional variables. Additionally, distributions of the demographic, medical, psychological, and functional variables were performed by delirium status (i.e., positive or negative) and delirium superimposed on dementia status (i.e., delirium superimposed on dementia, delirium only, dementia only, neither delirium nor dementia). To determine if there were differences in various demographic (i.e., race, gender, insurance status, age, number of years of schooling), medical (i.e., type of anesthesia, incontinence, infection, readmission, use of restraints, weight loss, number of chronic illnesses, length of stay, number of medications), psychological (i.e., dementia, depression), and functional (i.e., discharge to a nursing home, ADL scores, MMSE scores at baseline and discharge, the change between baseline and discharge MMSE scores) variables by delirium status or delirium superimposed on dementia status, Fisher's exact test, a Wilcoxin rank sum test, or a Kruskal-Wallis test was performed where appropriate. There was only one individual with dementia only. This individual was eliminated from any Fisher's exact or Kruskal-Wallis test when examining differences between the delirium superimposed on dementia status variable. All tests were performed at an alpha level of .05.

Table

TABLE 1MEASUREMENT OF STUDY VARIABLES

TABLE 1

MEASUREMENT OF STUDY VARIABLES

RESULTS

Of the 26 patients who met inclusion criteria and were approached for consent, three refused (11.5%), two consented in the preoperative clinic but were not admitted, and one consented then withdrew from the study, leaving a sample of 20 patients. Eleven staff members and 13 family members also were enrolled and interviewed. None of the family members or staff members refused to participate. The mean age of the subjects was 80.6, and the mean education level was 7 years. The majority of patients were Black (65%), were women (75%), lived at home (80%), and were dependent in one or more ADLs (70%). Fortyfive percent of patients were on 10 or more scheduled or as-needed medications while in the hospital, and the mean length of stay at the hospital was 6.5 days. Thirty percent of the patients were insured by Medicaid, and all were covered by Medicare.

Twelve (60%) of the 20 patients screened positive for delirium at some point during their hospitalization. The incidence, or new onset, of delirium as well as the prevalence of delirium on admission was 30%. Forty-five percent (9 of 20) of patients met diagnostic criteria for dementia. Eight of the nine patients with dementia (89%) also were delirious during their hospitalization. The remaining eight patients included one woman with dementia who experienced no change in her cognitive state, and seven patients who did not manifest evidence of either dementia or delirium.

Recognition of Delirium

The first question (i.e., How do families, nurses, and other health care workers recognize and respond to delirium in elderly individuals?) was answered by observations and interviews. Physicians' and nurses* failure to recognize delirium superimposed on dementia was a recurrent theme in both participant observations and interviews of family and staff. Thirteen family members, six nurses, and five physicians were interviewed about the confusion events. Of the family members interviewed, 92% were women, 54% were Black, and 69% were daughters. The interviews lasted from 30 to 90 minutes each.

All family members who were interviewed recognized an abrupt change in mental state of their parent, spouse, or sibling. Sixty-four percent (7 of 11) of family members said the physicians did not talk with them about the abrupt change in mental status occurring in their family members. Eighty-eight percent (7 of 8) of the cases of delirium superimposed on dementia were not recognized by members of the nursing or medical staff, as evidenced by staff interviews and reviews of the medical charts. This persisted despite family members indicating they had observed a significant and abrupt change from the usual mental state or a profound change in level of consciousness during the hospitalization.

Nurses and physicians who were observed and interviewed also lacked knowledge of differentiating delirium from dementia. They expressed lack of knowledge of the problem and were observed not to formally assess mental status. Seventy-five percent of the nurses interviewed stated they did not know the difference between delirium and dementia, although 75% also said they had formal education on the topic or went to a conference about confusion in elderly individuals. When asked whether she knew the difference between delirium and dementia, a nurse responded:

I don't know. I mean to tell you the truth I don't know the exact difference between the two right now, I would have to go back and look that up.

In an interview with a 42-year-old female nurse who cared for one of the study patients with delirium, she discussed her assessment of patients and stated:

I ask them, do you know who you are, and they may or may not answer that appropriately. I try to get them oriented.... I look through the admissions assessment and see if they are giving mostly appropriate answers.

None of the nurses or physicians were observed conducting a formal mental status examination or documented an examination in the charts.

Both nurses and physicians often walked in and out of the rooms in a short period of time. During one observation of a 69-year-old Black man, a group five students and residents were in the room with Mr. H. for less than 60 seconds. They greeted him, and two of the residents pulled up his gown, pressed on his abdomen, and then walked quickly out of the room. Mr. H. said, "Look, they are pulling up my dress without even talking to me. They are doubleteaming me." After they left Mr. H. said, "They come in like this all the time, and this is all the time they spend with me."

Confusion was mentioned in the nursing or medical notes in only a few cases and then only if the patient was interfering with a medical device, such as a brace or an intravenous catheter. A chief resident was observed while she was being consulted to see a patient with delirium. She saw the patient in his room, asked him questions to determine orientation, and listened to his lung sounds. After her assessment, she talked with the investigator about her assessment and stated;

He is fine. He seems perfectly okay to me today. My attending [physician] thinks he is sundowning, but I don't know why we were called. Within 1 hour of the physician assessment, the patient was assessed with the MMSE and scored 18 of 30 points. He was observed to be displaying inattention, disorganized thoughts, poor short-term recall, and disorientation. The consulting physician did not note this. The patient gradually improved over several days and was discharged to a rehabilitation facility with a score of 24 on the MMSE.

Mrs. W. was an 83-year-old Black woman who underwent an elective procedure for total hip replacement. Before surgery she had been living alone in a senior housing complex. Her MMSE score fluctuated by eight points during her hospitalization, and she showed evidence of hallucinations, inattention, and disordered thoughts. She was discharged to a nursing home. During her delirious episodes, the physicians wrote, " confusion unchanged . . .disorientation due to her dementia." The attending physician of Mrs. W. was interviewed during an acute confusion episode. The physician was asked about Mrs. W.'s mental status and replied, "She seemed fine when I met with her. Basically her sister did most of the talking so I did not notice anything." Several of the nurses on that unit were interviewed about the case. As in other cases, the nurses said their assessment focused on appropriateness and did not include the use of a formal assessment tool. A 38-year-old RN who had been on the same unit for 14 years stated:

I go in and just do my routine assessment, I'll just be talking and chit chatting [sic]. If they start to say things inappropriately then I'll start to assess more.... I'll go through the normal: What year is it? Where are you from?

When asked whether she performed a different assessment if she knew someone had Alzheimer's disease, the RN responded, "If they are known to have Alzheimer's then usually I don't even try to ask them questions."

Associated Factors in Delirium

The second and third questions (i.e., What is the experience of elderly individuals who develop delirium while in the hospital? and What factors [e.g., medical diagnoses, medications, use of physical restraints, environment, interactions with caregivers] are associated with delirium superimposed on dementia?) were answered by observations and daily mental status testing.

Table

TABLE 2MEDICAL, FUNCTIONAL, AND PSYCHOLOGICAL VARIABLES BY DELIRIUM STATUS

TABLE 2

MEDICAL, FUNCTIONAL, AND PSYCHOLOGICAL VARIABLES BY DELIRIUM STATUS

The analysis focused on first comparing delirium versus no delirium status and then comparing delirium superimposed on dementia versus delirium alone. Individuals with delirium in this sample, including patients with delirium superimposed on dementia, were found to differ significantly on the variables of interest (i.e., depression, dementia, urinary incontinence, weight loss, comorbidity, use of restraints) from those who did not suffer from delirium (Table 2). The variable age, laboratory values, type of anesthesia, and presence of orienting devices were not statistically significant between the groups of delirious and nondelirious patients.

Forty percent (8 of 20) of the sample had positive depression scores on the Cornell Scale, and 6 of the 12 patients with delirium (50%) were positive for depression per scores on the Cornell Scale. Depression was a predictor variable (p < .05) for the outcome of delirium. Sixty-seven percent (8 of 12) of patients who were delirious at admission or who developed delirium after admission were restrained during their hospitalization. No patients without delirium were restrained.

Urinary Incontinence

Twelve of the patients were observed to be incontinent of urine. Incontinence developed after admission in nine of these patients. Ten were patients with delirium, eight had delirium superimposed on dementia, and two had delirium alone. Several of the incontinent patients were observed during incontinent episodes asking to use the bathroom.

Weight Loss

Eight of the 12 patients with delirium (67%) had a history of weight loss within the past 3 months. There also were several qualitative examples to support this associated variable. The family of Mrs. E. reported she had lost more than 10 pounds in the past 2 to 3 weeks before coming to the hospital. Family members attempted to feed her, but she would fall asleep or shake her head when they brought food to her mouth. Mrs. S. was hospitalized for 8 days then was readmitted and hospitalized 7 more days. She was delirious during both hospitalizations and was observed as either being unable to eat or refusing to eat. Two days after her delirium developed she was observed to be in the room alone. She appeared lethargic, with her eyes closed and her dinner tray in front of her. Food covered her hospital gown and was visible in her mouth. Her daughter was outside the room and she remarked, "She didn't eat breakfast, either; she just holds the food in her mouth." Mrs. S. was observed a few days after her surgery in her room alone, sitting up in a chair with her food tray in front of her. She was moaning, and peas and saliva were falling out of her mouth. The nurse who cared for Mrs. S. stated, "She didn't wake up for me yet, every time I try and feed her she holds food in her mouth." She was weighed in the nursing home the week she fell and broke her hip and then 10 days after her return from the hospital. She lost 17 pounds during a 4-week period.

Table

TABLE 3MEDICAL, FUNCTIONAL, AND PSYCHOLOGICAL PREDICTOR VARIABLES BY DEMENTIA STATUS

TABLE 3

MEDICAL, FUNCTIONAL, AND PSYCHOLOGICAL PREDICTOR VARIABLES BY DEMENTIA STATUS

Another patient with delirium superimposed on dementia who experienced weight loss was an 84year-old woman whose daughter reported the patient had not been eating or drinking for 2 to 3 days prior to being hospitalized. The patient's serum albumin on admission was 2.0 mg/dL. During her hospitalization, Mrs. J. was observed on five different occasions falling asleep in front of her tray and leaving her meal untouched.

Delirium Superimposed on Dementia

In comparing patients with delirium superimposed on dementia with patients suffering from delirium alone, patients with delirium superimposed on dementia were older (mean age of 86 versus 77) and less educated (7 years of schooling versus 10 years). Patients with delirium superimposed on dementia had a mean comorbidity index of 2.8, versus 3.3 for patients without dementia who developed delirium. However, these differences were not statistically significant at ? < .05.

These patients did differ significantly on incontinence, MMSE scores, re-admission to the hospital in less than 30 days, and restraint use during their hospitalization. Patients with delirium superimposed on dementia were more likely to have new onset incontinence, to have lower MMSE scores at admission and discharge, to be restrained, and to be re-admitted to the hospital in less than 30 days (Table 3).

Subjects with delirium superimposed on dementia had shorter length of stay (a mean of 7 days versus 10 days) and lower MMSE scores when discharged (10 versus 27). Additionally, 63% (5 of 8) of patients with delirium superimposed on dementia were re-admitted to the hospital during the study, while no patients with delirium alone were readmitted.

Re-admission

During the course of this study, five of the eight patients with delirium superimposed on dementia were re-admitted to the hospital within 30 days. No patients with delirium in the absence of dementia were readmitted. One 83-year-old woman, Mrs. G, was discharged from the hospital while still meeting all four criteria for delirium per the CAM diagnostic algorithm (Inouye et. al., 1990). She was re-admitted to the hospital 3 days later with an elevated blood urea nitrogen/creatinine and white blood cell count, and admitting medical diagnoses of urinary tract mfection, dehydration, and a change in mental status. During this admission, she had a fluctuating mental status, with a MMSE score of 6 on admission and a score of 3 the following day. Her second hospitalization lasted 7 days. A member of the nursing home staff was interviewed later about this patient, and the nurse stated she had identified the change in mental status when the patient returned to the nursing home from the hospital. She then telephoned the primary care physician, and the order was received to readmit the patient to the hospital. Two months later the patient was interviewed in the nursing home by the principal investigator. Her mental status score had improved markedly, and her MMSE score had increased from 0 on her first discharge to 11. She was conversant, followed directions, and participated in activities at the nursing home.

Despite evidence of her inattention, hypoalertness, lethargy, and hallucinations, Mrs. J. was discharged from the hospital to her home because these characteristics were considered by the hospital staff to be a "normal" part of her dementia. She was re-admitted to the hospital 7 days later with dehydration, hypothermia, and phenytoin (Dilantin) toxicity. The length of stay for her first hospitalization was 4 days, while her second admission was for 7 days.

Mr. M. was a man with dementia and a hip fracture who developed delirium during his hospitalization. His mental status change was labeled alcoholic dementia despite his daughter's verbalizations that this was a change for him. His delirium was not recognized or treated by the health care professionals. He was discharged from the hospital to a rehabilitation facility after 6 days and was re-admitted less than 30 days later with a wound infection. He was restrained during both hospitalizations. He developed Stage III pressure ulcers on his heels and remained dependent for ambulation. These three cases exemplify the consequences of not recognizing delirium superimposed on dementia.

Change In Mental Status

Patients with delirium superimposed on dementia showed the greatest variability in MMSE scores from enrollment to discharge. Seventy-five percent of these subjects' scores declined during the course of their hospitalization (Table 3). The range of decline was 2 to 9 points. Three of the individuals with delirium alone had improved MMSE scores, and one had no change in score from admission to discharge. Six of the individuals with delirium superimposed on dementia had a decline in their MMSE scores irom admission to discharge for a net change of -24 on their Time 1 to Time 2 MMSE scores.

DISCUSSION

These findings have important implications for clinical practice and provide direction for further research. Perhaps the most important results of this study are the findings that individuals with delirium superimposed on dementia were not recognized as delirious, were discharged from the hospital when they were not fully recovered from the delirium, and were more hkely to be re-admitted to the hospital in less than 30 days, compared to individuals with neither dementia nor delirium and individuals with delirium alone. In addition, 63% of patients with delirium superimposed on dementia were restrained during their hospitalizations. These findings have implications for the quality of life of their families and the economic viability of health care providers.

Acute changes in the mental state of patients with dementia must be recognized as important phenomena. Delirium superimposed on dementia is more important than understood previously and less likely to be recognized and treated by practitioners. The condition usually is not recognized or is recognized late in the syndrome. Delirium superimposed on dementia should not be regarded as unimportant, be labeled as sundowning syndrome, or be considered an exacerbation of dementia that will resolve when the patient returns home. Education regarding this condition must be provided to students and practitioners, and communication between families and health care professionals must improve. Families often have important information to communicate, but clinicians must be willing to listen. The lack of recognition of delirium by health care providers is not a new finding. In a study by lnouye et al. (1993), 65% of physicians and 43% of nurses failed to recognize delirium in hospitalized elderly patients. This study extends that work by highlighting reasons why delirium is recognized less frequently in individuals with dementia.

Several investigators also have shown that delirium contributes independently to decreased outcomes of hospitalization, such as functional decline and death (lnouye et al., 1998; Lipowski, 1990; Pompei et al., 1994). In this study, individuals with delirium superimposed on dementia had the poorest outcomes regarding re-admission, weight loss, death, decreased functioning, and mental state. Rockwood et al. (1996) reported an increased risk of dementia following an episode of delirium. These findings suggest practitioners need to not only recognize acute mental status changes in individuals with dementia but also seek an acute, reversible reason for the change. This is a shift from traditional thinking that individuals with dementia are experiencing sundowning in the evening or natural exacerbation of their behavior. Delirium must be recognized and treated because the failure to recognize delirium superimposed on dementia promptly has significant negative personal, social, and financial consequences.

Why did members of the nursing and medical staff fail to recognize delirium in individuals with dementia? This question can be answered only in part by this descriptive data. Nurses' and physicians' observations regarding mental status and self-reports of mental state documented in subjects' hospital records indicate minimal assessments and superficial evaluations at best, focusing on orientation and appropriateness of verbal responses and behaviors. Generally, mental state was not assessed. This was compounded further by the disregard by staff of families' comments regarding patients' mental states and by poor communication among health care providers regarding patients' mental states.

As evidenced in interviews and observations of patients and staff members, nurses and physicians spent Utile time with each individual patient - time that is necessary to assess mental status. In addition, staff either may label any confusion as normal for patients with dementia or simply may fail to assess mental state in patients for whom they are caring. In this study, any deviation in mental state from normal, new or not, was attributed to dementia or aging. Staff failed to attend to patients' behaviors and abilities and did not recognize or acknowledge new decrements in patients' ability to think. Recognizing delirium in individuals with dementia requires a change in both attitude and knowledge of the individuals' baseline mental and physical functioning.

The findings of this study extend those of others who have studied the recognition of delirium in elderly individuals (Inouye, 1993; Lipowski, 1990). A case study in critical care using chart audits, observations, and interviews of nurses found two main problems in underrecognition of delirium in critical care: nurses' lack of knowledge about ways to detect delirium and ineffective communication among staff in reporting symptoms of onset (Eden & Foreman, 1996). Inouye (1993) and Foreman (1989) found orientation to be one of the least sensitive features for assessment of delirium. In a study of 432 medical-surgical patients, confusion was mentioned most often in the medical record by nurses but was not identified as an acute change with a reversible cause (Inouye, 1993). Lack of recognition of delirium also may be increased because patients with delirium superimposed on dementia exhibited the quiet or hypoactive form of delirium more often than other patients with delirium. If delirious patients do not act out, nurses and physicians may not see exacerbation as a problem and, as a result, fail to recognize delirium (Lipowski, 1990). The fact that nurses and physicians indicated they lacked basic knowledge of how to assess mental status, especially in patients with dementia, further compounded the problem of recognition of delirium. As described in the interviews with staff members, nurses and physicians lacked basic training and education in the area of mental status. Other current nursing research focuses on the physical factors that may lead to delirium in individuals with dementia such as poor hydration, infections, and medication use, as well as environmentally based interventions for caregivers that may help prevent delirium superimposed on dementia (CuIp et al., 1997; Gerdner, Hall, & Buckwalter, 1996).

Finally, it is important to acknowledge certain limitations of this study. This study combined qualitative and quantitative methods. Therefore, the convenience sample and small sample size limited the results. The principal investigator performed both the interviews and the validation of delirium status. The data were collected in a large, state-supported teaching hospital in the southeastern United States. This setting may or may not be representative of other cities and geographical areas.

IMPLICATIONS FOR PRACTICE

This study has several implications for nursing practice:

* Assessment of mental status in individuals with and without dementia.

* The importance of early recognition and prevention of delirium.

* Treatment strategies for delirium.

* Post-hospital follow up of patients with delirium.

This study suggests recognition of delirium in individuals who have dementia is vitally important and assessment of mental state should be considered a priority in the care of these patients.

A careful assessment of mental state, manipulation of the environment, and treatment of any suspected physiological causes for the delirium must occur simultaneously and immediately on hospitalization. Nurses and physicians in this study assessed mental state in a subjective manner, or not at all, and only documented the confusion if the patients displayed obvious signs such as interference with medical devices. Nurses are in a position to coordinate this multidisciplinary approach. Nurses and physicians must recognize that delirium is both prevalent in and costly to patients who have dementia and their families. Management of the environment may involve normalizing the environment to the structure and routine the elderly individuals are most familiar with, discontinuing use of invasive medical devices as soon as possible, and having a familiar individual sit with the elderly individuals.

Discharging patients with delirium to their homes also will affect nursing care of patients in that setting. Patients may be discharged home so the length of stay is shorter, but if they are re-admitted it is an additional burden to the patients and families, and ultimately, it increases health care costs. With the current health care changes and shift to managed care, shortened lengths of stay will continue to be seen. As a result, an increasing number of patients may be discharged with unrecognized delirium superimposed on dementia. Nurses also will have a greater need for interventions for handling delirium in the community as care is shifted to families and community providers. Post-hospital follow up of individuals who have delirium is necessary to define the long-term effects and the recovery process for delirium.

Although the media and health sciences curricula are giving increased attention to aging changes and diseases of older adults, this awareness does not seem to be reflected in the care of individuals with cognitive impairment in this study population. Mental status often is overlooked as a vital area of assessment, and confusion continues to be labeled as normal for older hospitalized individuals. Early recognition could improve outcomes for individuals who have delirium. Geriatric interdisciplinary education should teach a standardized mental status assessment for all hospitalized elderly individuals. Finally, delirium superimposed on dementia needs to be investigated in greater depth, both in hospitals and communities.

REFERENCES

  • Alexopoulus, G.S., Abrams, R.C., Young, R.C., & Shamoian, CA. (1988). Cornell scale for depression in dementia. Biological Psychiatry, 23, 271-284.
  • American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd. ed.). Washington, DC: Author.
  • American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
  • Charlson, ?.?., Pompei, P., Ales, KX. & MacKenzie, R. (1987). A new method of classifying prognostic co-morbidity in longitudinal studies: Development and validation. Journal of Chronic Diseases, 40, 373-383.
  • CuIp, K., Tripp-Reimer, T, Wadle, K., Wakefield, B., Akins, J., Mobily, P., & Kundradt, M. (1997). Screening for acute confusion in elderly long-term care residents. Journal of Neuroscience Nursing, 29, 86-88, 95-100.
  • Eden, B.M., & Foreman, M.D. (1996). Problems associated with under recognition of delirium in critical care: A case study. Heart & Lung, 25, 388-400.
  • Evans, D.A., Funkenstein, H.H., Albert, M.S., Scherr, P.A., Cook, N.R., Chown, M.J., Herbert, L.E., Hennekens, C.H., & Taylor, J.O. (1989). Prevalence of Alzheimer's disease in a community population of older persons. Higher than previously reported. Journal of the American Medical Association, 262, 2551-2556.
  • Folstein, M.F., Folstein, S.E., & McHugh, P.R. (1975). Mini-mental state: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189-198.
  • Foreman, M.D. (1989). Confusion in the hospitalized elderly: Incidence, onset, and associated factors. Research in Nursing and Health, 12, 21-29.
  • Foreman, M.D., & Grabowski, R. (1992). Diagnostic dilemma: Cognitive impairment in the elderly. Journal of Gerontological Nursing, 18(9), 5-12.
  • Francis, J., & Kapoor, WN. (1992). Prognosis after hospital discharge of older medical patients with delirium. Journal of the American Geriatria Society, 40, 601-606.
  • Gerdner, L.A., Hall, G.R., & Buckwalter, K.C. (1996). Caregiver training for people with Alzheimer's based on a stress threshold model. Image: The Journal of Nursing Scholarship, 28, 241-246.
  • Inouye, S. K. (1993). Delirium in hospitalized elderly patients: Recognition, evaluation, and management. Connecticut Medicine, 57, 309-315.
  • Inouye, S. K. & Charpentier, RA. (1996). Precipitating factors for delirium in hospitalized elderly persons: Predictive model and interrelationship with baseline vulnerability. Journal of the American Medical Association, 275, 852-858.
  • Inouye, S.K., Rushing, J.T., Foreman, M.D., Palmer, R.M., & Pompei, P. (1998). Does delirium contribute to poor hospital outcomes: A three site epidemiologic study. Journal of General Internal Medicine, 13, 234-242.
  • Inouye, S.K., Schlesinger, M.J., & Lydon, TJ. (1999). Delirium: A symptom of how hospital care is failing older persons and a window to improve quality of hospital care. The American Journal of Mediane, 106, 565-573.
  • Inouye, S.K., VanDyck, C.H., Alessi, CA., Balkin, S., Siegal, A.P., & Horwitz, R.I. (1990). Clarifying confusion: The confusion assessment method a new method for detection of delirium. Annals of Internal Mediane, 113, 941-948.
  • Inouye, S.K., Viscoli, CM., Horwitz, R.I. Hurst, L.D., & Tinetti, M.E. (1993). A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics. Annals of Internal Medicine, 119, 474-481.
  • Katz, S., Ford, A.B., Moskowitz, R.W., Jackson, B. A., & Jaffee, M. W. (1963). Studies of illness in the aged. The Index of ADL: A standardized measure of biological and psychosocial function. Journal of the American Medical Association, 185, 94.
  • Levkoff, S.E., Besdine, R., St Wetle, T. (1986). Acute confusional states (delirium) in the hospitalized elderly. Annual Review of Gerontology and Geriatrics, 6, 1-26.
  • Levkoff, S.E., Evans, D.A., Liptzin, B., Cleary, P., Lipsitz, L., Wetle, T., Reilly, C, Pilgrim, D., Schor, J., & Rowe, J. (1992). Delirium: The occurrence and persistence of symptoms among elderly hospitalized patients. Archives in Internal Mediane, 152, 334-340.
  • Lipowski, ZJ. (1990). Delirium: Acute confusional states. New York: Oxford University Press.
  • National Institute on Aging, National Institutes of Health. (1993). Progress report on Alzheimer's disease 1993 (NIH Publication No. 93-3409). Washington, DC: Author.
  • National Institute on Aging, National Institutes of Health. (1994). Progress repon on Alzheimer's disease 1994 (NIH Publication No. 94-3885). Washington, DC: Author.
  • O'Keefe, S., & Lavan, J. (1997). The prognostic significance of delirium in older hospital patients. Journal of the American Geriatrics Society, 45, 174-178.
  • Pompei, P., Foreman, M. Cassel, CK., Alessi, C, & Cox, D. (1995). Detecting delirium among hospitalized older patients. Archives of Internal Medicine, 155, 301307.
  • Pompei, P., Foreman, M., Rudberg, M.A., Inouye, S., Braund, V., & Cassel, CK. (1994). Delirium in hospitalized older persons: Outcomes and predictors. Journal of the American Geriatrics Society, 42, 809815.
  • Rockwood, K., Cosway, S., Stadnyk, K., Carver, D., Jarrett, J., Fisk, J., & Stolee, P. (1996). The long term risk of dementia following delirium. The Gerontologist, J6(I,October).
  • Thomas, R.I., Cameron, DJ-, & Fahs, M.C (1988). A prospective study of delirium and prolonged hospital stay. Archives of General Psychiatry, 45, 937-940.
  • Tombaugh, T.N., & Mclntyre, NJ. (1992). The mini-mental state examination: A comprehensive review. Journal of American Geriatrics Society, 40, 922-935.
  • Uhlman, R.F., Larson, E.B., Buchner, D.M. (1987). Correlates of Mini-Mental Stote and modified dementia rating to measures of transitional health status in dementia. Journal of Gerontological Nursing, 42, 33-36.

TABLE 1

MEASUREMENT OF STUDY VARIABLES

TABLE 2

MEDICAL, FUNCTIONAL, AND PSYCHOLOGICAL VARIABLES BY DELIRIUM STATUS

TABLE 3

MEDICAL, FUNCTIONAL, AND PSYCHOLOGICAL PREDICTOR VARIABLES BY DEMENTIA STATUS

10.3928/0098-9134-20000101-09

Sign up to receive

Journal E-contents