Delirium, a transient and etiologically non-specific, organic mental syndrome of acute onset poses a common and serious health problem in elderly patients with hip fracture. It occurs in 9% to 61.3% of this patient population (Andersson, Gustafson, & Hallberg, 2001; Berggren et al., 1987; Brännström, Gustafson, Norberg, & Winblad, 1989; Brauer, Morrison, Silberzweig, & Siu, 2000; Duppils, & Wikblad, 2000; Gustafson et al., 1988; Gustafson et ah, 1991; Williams, Campbell, Raynor, Mlynarczyk, & Ward, 1985), depending on the measurement methods and criteria used to detect delirium. Delirium has significant negative postoperative consequences.
Delirium independently contributes to protracted functional decline (Brännström et al., 1989; Brännström, Gustafson, Norberg, & Winblad, 1991; Milisen, Abraham, & Broos, 1998), higher rates of postoperative complications (e.g., incontinence, pressure ulcers), and longer lengths of hospital stay (Berggren et al., 1987; Gustafson et al, 1988) as compared to non-delirious elderly hip fracture patients. Moreover, delirium is associated with higher mortality (Inouye, Rusing, Foreman, Palmer, & Pompei, 1998; Tess, 1991).
DEMOGRAPHIC VARIABLES AND CO-MORBIDITY: COMPARISON BETWEEN DELIRIOUS AND NON-DELIRIOUS PATIENTS
Although much clinical literature (e.g., medical, nursing, allied health) during the past 15 years has addressed the importance of early identification of delirium in this patient population, research into this issue is scant and dated. Delirium remains frequently under-diagnosed by nurses and physicians in 32% to 72% of the cases (Francis, Strong, Martin, & Kapoor, 1988; Palmateer & McCartney, 1985). In addition, transient changes in cognition frequently are misattributed to dementia, depression (Fick & Foreman, 2000; Pompei, Foreman, Cassel, Alessi, & Cox, 1995), or senescence (i.e., part of the normal aging process) (Lipowski, 1983). Furthermore, nurses inaccurately and incompletely evaluate the changes in a patient's cognitive functioning (Morency, 1990; Souder & O'Suilivan, 2000), and too often use the terms "confused" and "acute confusion" inappropriately (Morency, 1990). Yet, failure to diagnose delirium limits attempts at primary and secondary prevention, thus contributing to the risk of the aforementioned poor prognosis and outcomes associated with delirium.
The purpose of this study was to determine the accuracy of diagnosis and documentation of delirium in nursing and medical records of elderly patients with hip fracture.
A convenience sample was used in which consecutive admissions of patients to two traumatological units of the University Hospitals Leuven (Belgium) from September 1996 until March 1997 were included. The rights and dignity of all participants involved in this research were safeguarded according to national standards. Patients were included if they were older than 65 years, were admitted from the emergency department with a traumatic fracture of the proximal femur (intra- and extra-capsular), and were to be hospitalized within 24 hours after surgery to one of the traumatological wards.
All patients, or the closest relative for patients with significant cognitive impairment, gave their oral consent for participation. Exclusion criteria were multiple trauma, concussion, pathological fractures, surgery occurring later than 72 hours after admission, aphasia, blindness, deafness, and fewer than 9 years of formal education (the latter because of validity concerns of the Mini-Mental State Examination) (Tombaugh & Mclntyre, 1992).
A total of 55 patients with hip fracture were enrolled in the study. The mean age of the sample was 78.4 years (SD = 8.4, range = 65 to 95 years). Women constituted 80% of the sample (n = 44); 16 (29%) participants had neuropsychiatrie co-morbidity (i.e., concurrent diagnoses of dementia, depression, Parkinson's disease).
Diagnosis of Delirium
Delirium was assessed by trained raters using the Confusion Assessment Method (CAM) (Inouye et al., 1990) on days 1, 3, 5, 8, and 12 postoperatively. The CAM consists of nine criteria developed from the Diagnostic and Statistical Manual^ third edition (DSM-III-R) criteria for delirium (American Psychiatric Association, 1987) to efficiently and effectively detect delirium. The CAM algorithm contains four core criteria for delirium:
* Acute onset and fluctuation.
* Disorganized thinking.
* Altered level of consciousness.
The first two, and at least one of the other two criteria must be fulfilled to classify a patient as delirious. The diagnostic value of the CAM is excellent when using a standardized diagnosis by a psychiatrist as the "gold standard." More specifically, the CAM has a 94% to 100% sensitivity, 90% to 95% specificity, 91% to 94% positive predictive value, and 90% to 100% negative predictive value (Inouye et al., 1990). Interobserver reliability (Kappa) ranged between 0.81 to 1. Convergent validity with other similar tests includes the Mini-Mental State Examination (k = 0.64) (Folstein, Folstein, & McHugh, 1975), the Visual Analog Scale (or Confusion (k = 0.82) (Foreman, 1989), Digit Span test (k = 0.66) (Cummings, 1985; Strub & Black, 1977), and a memory recall test (k = 0.59) (Scherr et al., 1988).
Figure 1 : Proportion of delirium postoperatively for all time points of measurement.
Medical and nursing records were reviewed retrospectively on a patient's discharge from the hospital for documentation about the diagnosis of delirium, or reference to this clinical problem using one or more of the myriad synonyms (e.g., acute confusional state, confusion, acute brain syndrome, acute brain failure, exogenous psychoses, toxic-metabolic encephalopathy, pseudosenility), or by a description of the patient's behavior via clinical indicators or symptoms of delirium. Because patients were assessed by members of the research team on days 1, 3, 5, 8, and 12 postoperatively, only the documentation for these days were reviewed. Clinicians were blinded to the purpose of the study.
For each patient, the CAM results obtained by the research team were compared to the documentation notes made by nurses and physicians for the respective data collection points. Clinical and demographic data were recorded from patient files.
Incidence and Course of Delirium
The uicidence of delirium in this sample was 20% (n = 1 1 ), and was calculated on the basis of a patient being delirious according to the CAM diagnostic algorithm on at least one of the time points of measurements. As depicted in Figure 1, the incidence of delirium on postoperative days 1, 3, 5, 8, and 12, was 14.5% (n = 8 of 55), 9.1% (n = 5 of 55), 10.9% (n = 6 of 55), 7.7% (n = 4 of 52), and 5.6% (n = 2 of 36) respectively.
Differences Between Groups
Patients with delirium were older (p = .011) and had more neuropsychiatrie co-morbidity (p < .001) compared to non-delirious participants (see Table 1). No differences were found between the two groups with respect to gender and type of fracture.
Medical Record Documentation
The physicians' documentation in the medical records of these participants was devoid of any mention of delirium. No formal diagnoses of delirium were made, nor were any of the common synonyms of delirium (e.g., confusion) found in the physicians' documentation. Moreover, none of the clinical indicators of delirium were used as a means for describing the behavior of these patients.
Figure 2: Documentation of delirium by nurses.
Nursing Record Documentation
In contrast to the physicians' documentation, nurses' clinical notes included information about the cognitive status of patients. However, nurses tended to use synonyms for delirium in their documentation (e.g., confused, acutely confused). The term delirium was not found in any of the nurses* clinical notes. Despite a higher rate of documentation, delirium was drastically underreported in the nursing documentation as compared to the research team's patient assessments (Figure 2). False-negative documentation (i.e., no documentation of delirium or synonyms when the patient was delirious) ranged from a high of 87.5% on the first postoperative day, to a low of 50% on the 12th postoperative day. False-positive documentation (documentation of delirium or synonyms when the patient was not delirious) was lower, with rates varying between a high of 8.5% on the first postoperative day and a low of 4% on the third postoperative day.
An overview of nurses' documentation of symptoms or clinical indicators of delirium is shown in Table 2. Delirium was referred to in 96 separate instances using 22 different symptoms. The majority of these descriptions are of three well-known subtypes of delirium, indicative of the level of psychomotor activity and alertness of the patient (O'Keeffe & Ni Chonchubhair, 1994; Rummans, Evans, Krahn, & Fleming, 1995; Trzepacz, 1994).
The first category refers to symptoms of the aggressive, hyperactive form of delirium. The number of symptoms documented in this category was the highest, compared to the other categories. The second category refers to the passive, sleepy, hypoactive form of delirium. These symptoms were mentioned less frequently. The third subtype of delirium is a mixed form in which the patient fluctuates between behavior of the two previously mentioned subtypes. Surprisingly, nurses also documented some characteristics of the patients' cognitive well-functioning (e.g., able to communicate, alert, lucid, conscious, oriented).
The incidence for delirium in this study was 20%. This is lower than that reported in the aforementioned studies for similar patient populations. As noted previously, the incidence of delirium in this patient population generally ranges from 9% to 61.3% (Andersson et al., 2001; Berggren et al., 1987; Brännström et al., 1989; Brauer et al., 2000; Duppils & Wikblad, 2000; Gustafson et al., 1988; Gustafson et al, 1991; Williams et al., 1985). The lower rate of incidence in this study could be a result of differences in methods for assessment and divergent clinical criteria used for detecting delirium between all aforementioned studies and the current study. However, the criteria used in the current study (i.e., the CAM-algorithm [Inouye et al., 1990]) appears to be more sensitive and specific for delirium than other cognitive screening instruments or criteria (Pompei et al., 1995), and currently is the most commonly used clinical diagnostic measure for delirium.
In examining the course of delirium (Figure 1), it is evident the first 5 postoperative days are a critical period for decline in cognitive functioning. This finding is congruent with Milisen, Abraham, et al. (1998), suggesting prompt intervention is the most effective approach for reducing or preventing the risk of delirium.
A few methodological caveats must be raised. First, patient records were not evaluated every day postoperatively. Therefore, these data represent only a selection of what was effectively recorded by nurses and medical doctors. Yet, these data provide an indication of nurses' and physicians' approaches in the mental evaluation of elderly patients with hip fracture.
A second methodological issue is that records (nursing and medical) were screened for mental status documentation for the morning, evening, and night shifts, thus allowing for a greater opportunity to find documentation of delirium. However, the time period for screening encompasses more time than that of the research team's evaluation (i.e., the gold standard), which was limited to the 15 to 20 minutes time range needed for interview. Yet, for CAM scores "acute onset and fluctuating course," the primary nurse was asked for additional observation beyond the time frame needed to administer the CAM. Based on these observations, nursing and medical documentation must be viewed cautiously.
No documentation by physicians was found concerning the patients' mental functioning in these records. Although surgeons visit patients on a daily basis, their interactions are probably too short for a thorough assessment of patients' cognitive status. Nevertheless, the results indicate physicians should pay more attention to the patients' mental functioning. However, nurses have the most frequent ongoing contact with the patient, and are in a good position for screening patients' mental evolution and observing their behavior (Foreman, 1986).
Although nurses' clinical notes contained information about patients' cognitive status, the documentation of patients' mental status was seldom accurate in these records. Records were semantically inappropriate^ - patients often were described as "confused" or "acutely confused.*' The term delirium was never used. Nurses may "know" what confusion means, yet when asked to describe or define confusion, the responses indicate there is no universal conceptualization, and understanding of confusion is unclear.
FREQUENCY OF DOCUMENTATION IN THE NURSING RECORDS ABOUT 22 SYMPTOMS AND CLINICAL INDICATORS OF DELIRIUM
Confusion is used both as a descriptive term or symptom (e.g., dementia is characterized by severe confusion), or as a diagnosis (e.g., the patient is confused). These findings are similar to those reported by Simpson (1984) who surveyed 274 nurses and physicians about the characteristics of a confusional state. Great variability in symptoms and signs was indicated by these participants, ranging from disorientation, inability to concentrate, short-term memory loss, and cognitive decline to anxiety, restlessness, or psychotic symptoms (Simpson, 1984).
These findings indicate a semantic misunderstanding and lack of clarity concerning the definition of confusion. For many "confusion" implies an irreversible, untreatable condition (Martin, 1987; O'Keeffe & Ni Chonchubhair, 1994), and, therefore, use of this term should be avoided. It is recommended the term delirium be used to describe the occurrence of acute confusion (Milisen, Haekens, De Geest, Abraham, & Godderis, 1997).
Nurses' clinical notes also contained a high rate of false-negative misclassification. This under-detection of delirium could be explained by that fact that 72.2% of all patients with delirium in this study had a preexisting neuropsychiatrie disturbance. It is difficult to diagnose a delirium superimposed on a neuropsychiatrie disturbance such as dementia or depression (Fick & Foreman, 2000; Inouye, 1994).
Another reason for the underdetection could be that the hypoactive form of delirium, which is common in elderly patients (Farrell & Ganzini, 1995; Inouye, 1993; O'Keeffe & Ni Chonchubhair, 1994; Rummans et al., 1995), is more difficult to detect and more frequently overlooked because these patients are considered cooperative. Symptoms of the hyperactive form of delirium are more frequently documented in contrast to symptoms of the hypoactive form, probably because the former are more disruptive and interfere with the provision of nursing care (Wolanin & Phillips, 1981).
More important, altered attention, which is one of the core symptoms of delirium, was not documented at all. Although not the most obvious feature of delirium, disordered attention is the most frequent and consistent abnormality found in patients with delirium (O'Keeffe & Ni Chonchubhair, 1994; Rummans et al., 1995), and is essential for the diagnosis of delirium (American Psychiatric Association, 1994; Inouye et al., 1990).
Additionally, features of delirium, such as onset and course of the syndrome, were never documented, yet provide critical information with respect to the differential diagnosis of delirium. Some (Jacobson, 1997; Milisen, Foreman, Godderis, Abraham, & Broos, 1998) contend this information may be even more important in making the diagnosis than knowing which specific symptoms vary in intensity and fluctuate diurnally.
Descriptions of delirium were scant in the records of nurses and physicians who under-diagnosed delirium in this patient population. Even when symptoms in the nursing records were reported, documentation was fragmentary and inconsistent. Poor assessment and documentation is a threat to patient welfare because a correct diagnosis and early recognition of delirium might enhance the management of this syndrome, and, therefore, patient outcomes.
Use of standardized assessment instruments for the routine, systematic, and comprehensive assessment of changes in overall cognitive functioning (e.g., Mini-Mental State Examination) or detecting delirium (e.g., CAM, NEECHAM Confusion Scale [Neelon, Champagne, Carlson, & Funk, 1996]) could guide the prompt and accurate diagnosis of delirium.
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DEMOGRAPHIC VARIABLES AND CO-MORBIDITY: COMPARISON BETWEEN DELIRIOUS AND NON-DELIRIOUS PATIENTS
FREQUENCY OF DOCUMENTATION IN THE NURSING RECORDS ABOUT 22 SYMPTOMS AND CLINICAL INDICATORS OF DELIRIUM