Delirium, an acute disorder fluctuating in nature that can affect attention, memory, and perception, is common in older adults admitted to the hospital, particularly those with dementia (Young & Inouye, 2007). In 2015, there were 10.7 million adults age ≥60 years in Thailand; by 2050, this number is expected to increase to 23.1 million people (Knodel et al., 2015). The number of adults age ≥65 will be approximately 60 million by 2030 in the United States (Administration on Aging, 2017) and 20 million by 2030 in the United Kingdom (UK Office for National Statistics, 2015). In 2017, there were >15.3 million people in the United Kingdom age ≥60 (UK Office for National Statistics, 2017).
Accompanying this population surge will be an increase in the prevalence of hospitalized patients with delirium. Delirium occurs in up to 50% of older adults admitted to the hospital, yet remains unrecognized in 32% to 66% of individuals, possibly due to delirium having similar symptoms to dementia and uncertainty around the person's baseline cognition (Australian Institute of Health and Welfare, 2013; Cole et al., 2009; Flaherty, 2011). Delirium is associated with longer hospital stays, increased morbidity and mortality, increased nursing time per patient, and increased health care costs (Young & Inouye, 2007). One study estimated that health care costs attributable to delirium in the United States were between $38 billion and $152 billion, rivaling the costs of falls and diabetes mellitus (Leslie et al., 2008).
In the United Kingdom (National Institute for Health and Care Excellence, 2019) and Australia (Australian Commission on Safety and Quality in Health Care, 2016; Traynor et al., 2016), delirium care pathways were developed to assist in the coordination of care and to improve how older adults are managed during a delirium episode to enhance care and minimize adverse outcomes. Much research has been conducted in this area and many tools exist to provide practitioners with guidance on how to more effectively prevent, recognize, and manage a patient experiencing delirium. However, effective detection, management, and prevention remain difficult. Thailand does not have practice guidelines specific to their population or medical systems for delirium identification and management. For this reason, Thai professionals have limited resources to guide them in understanding the detection, management, and prevention of delirium among Thai older adults.
Several tools exist to detect delirium. The most widely used instrument is the Confusion Assessment Method (CAM) (Inouye et al., 1990), which is available in a range of languages, including Portuguese (Fabbri et al., 2001), Spanish (González et al., 2004), German (Hestermann et al., 2009), and Thai (CAM-T) (Wongpakaran et al., 2011). There is also the CAM specific for use in intensive care units (CAM-ICU) (Ely, Inouye, et al., 2001; Ely, Margolin, et al., 2001), which has also been translated into Thai (Pipanmekaporn et al., 2014). However, specific training is required to ensure optimum application of this tool. The 4AT had a sensitivity of 89.7% and specificity of 84.1% when delirium is superimposed on dementia and does not require specific training for effective use (Bellelli et al., 2014). Early detection and targeted management have obvious advantages, such as reducing hospital stays and decreasing mortality (Chong et al., 2014; Lundström et al., 2005; Mudge et al., 2013). Thus, it is imperative to understand how to identify and manage delirium to reduce its significant morbidity and mortality, especially in older adults. There is extensive research on managing delirium; however, few studies on delirium assessment and management have been conducted in Thailand. The purpose of the current article is to review the prevalence of delirium among older adults and the role of nurses and physicians in detecting, managing, and/or preventing delirium in Thailand hospital settings.
Two independent reviewers conducted a literature search of CINAHL, Medline, and Google Scholar. Search terms were delirium AND older people AND hospital AND Thailand between 2011 and 2019 with full text available and not limited to English language. Snowballing was also adopted, where references from retrieved studies were searched for relevance. Studies were screened using the following inclusion criteria: the exploration of the prevalence, assessment, and treatment of delirium among people age ≥55 in Thailand in nursing and medical practice. The search strategy is shown in Figure 1 (National Health and Medical Research Council [NHMRC], 2000). Study quality was assessed using the NHMRC (2013) Principles of Peer Review. Two reviewers independently extracted data and assessed the quality from the included studies using the standardized NHMRC levels of evidence and grades for rating evidence tool (Australian Government NHMRC, 2009). Most studies (n = 9) were of NHMRC Level of Evidence IV (NHMRC, 2000), which indicates study results obtained from case series, either posttest or pretest/posttest. These results have a high risk of bias and recommendations must be applied with caution.
Flow diagram of study article selection.
Note. SLR = systematic literature review.
Thirteen studies between 2011 and 2019, all published in English, met inclusion criteria (Table 1). No articles published in Thai were found. Snowballing led to retrieval of four relevant studies focused on delirium published by The Medical Association of Thailand in English. All studies were undertaken in a hospital setting in Thailand, two in the emergency department (ED), seven in the general ward, and four in the ICU.
An integrative overview was undertaken, which enabled diverse primary research methods to become a greater part of evidence-based practice initiatives (Whittemore & Knafl, 2005). The current integrative review of the literature was conducted according to the following strategies: problem identification, literature search, data evaluation, data analysis, and presentation. The review process involved documenting commonalities found in the articles and categorizing them to capture recurring themes. Three themes were identified to explain the understanding of delirium in Thailand: Epidemiology, Detection, and Role of Nurses and Physicians.
Incidence of Delirium in Thailand
Nine studies reported the incidence of delirium in Thailand. One large study recruiting participants from nine university-based surgical ICUs (SICU) found the incidence of delirium to be only 3.6% (162/4,450, 95% confidence interval [CI] [3.09, 4.19]). The incidence of delirium was higher in patients with >48-hour admissions than those with <48-hour admissions (8.3% [141/1,685, 95% CI (7.04, 9.68)] vs. 0.7% [21/2,967, 95% CI (0.41, 1.01)], respectively) (Pipanmekaporn et al., 2015). Patients with delirium were markedly older than patients without delirium, with 90% of those with delirium age >60 years (Chanidnuan et al., 2019). Three studies reported the same data-set of adults age ≥70 years and showed the prevalence of delirium to be 40.4% and the incidence to be 8.4%. The total occurrence rate of delirium was remarkably high (48.9%), with the delirium rate increasing with age (p = 0.003) (Praditsuwan et al., 2012; Praditsuwan et al., 2013; Srinonprasert et al., 2011). Another study focused on delirium in Thai older adults admitted to the ED, with 12% of its 232-patient cohort identified as experiencing delirium, of which 16 (59%) were not recognized by the ED physician (Sri-on et al., 2016).
Risk Factors for Delirium
The independent risk factors for delirium were identified by three studies (Chanidnuan et al., 2019; Muangpaisan et al., 2015; Pipanmekaporn et al., 2015). The proportions of patients with chronic disease, such as hypertension, diabetes mellitus, previous stroke, and dementia, were significantly larger among patients with delirium than those without delirium (Chanidnuan et al., 2019). Moreover, one study found that 45% of older adults developed delirium after receiving hip replacement surgery (Muangpaisan et al., 2015). Other factors, such as emergency surgery, mechanical ventilator use, and exposure to sedative medications, have been identified as risk factors for delirium (Pipanmekaporn et al., 2015). These factors have been shown to be precipitating or predisposing factors of delirium.
Consequences of Delirium
Older adults have a greater propensity for delirium in hospital settings. Older adults with delirium had longer hospital stays and higher mortality rates. One study found the average length of hospital stay of patients with delirium was 22.3 days compared to 5.4 days for those without delirium (Limpawattana et al., 2012). A similar study indicated older adults with delirium had increased length of stay compared to those without delirium (10 and 8 days, respectively) (Praditsuwan et al., 2013). In the ED, older adults with delirium were associated with a higher mortality rate than those without delirium (15% vs. 2%, p = 0.004) (Sri-on et al., 2016). In another study, the mortality rate for older adults with delirium was 6.1 per 100,000 individuals (Limpawattana et al., 2012). Significantly higher in-hospital and 3-month mortality rates were also seen in general medical wards (Praditsuwan et al., 2013). Similar results were found in a recent study conducted in the SICU, which showed the hospital mortality rate was significantly greater among individuals experiencing delirium than those without delirium (25% vs. 6%, p < 0.01) with longer hospital lengths of stay (Chanidnuan et al., 2019; Pipanmekaporn et al., 2015). The cost of care for older adults with delirium was 3.4 times more than the cost of care for older adults without delirium (18,230.80 Baht to 53,174 Baht [$552.95 to $1,612.79 U.S. dollars) (Limpawattana et al., 2012).
Detection of Delirium in Thailand
Five studies evaluated detection of delirium in Thailand. The CAM-T was validated in one study in general wards and proven to have a sensitivity of 91.9% and specificity of 100% (Wongpakaran et al., 2011). The CAM-T was easy to use and quick; however, it requires training for use. Another study developed a Thai version of the 4AT and found a sensitivity of 83.3% and specificity of 86.3% and declared it a valid delirium screening tool for hospitalized older adults that requires no training for use (Kuladee & Prachason, 2016). This study investigated Thai nurses' use of the tool, providing evidence for the effective use of delirium screening by nurses (Kuladee & Prachason, 2016). This study found the 4AT to be easy to use, practical, and accurate but requires further validation in greater numbers of Thai older adults.
Underrecognition of delirium is common, as seen in studies conducted in EDs and ICUs. In the ED study of 232 patients, 27 patients with delirium and an additional 16 were not recognized as having delirium by a physician (Sri-on et al., 2016). In the ICU study, delirium occurred and was detected by researchers in 44 (44.4%) of 99 patients. Of these 44 patients, nurses only detected delirium in 31 (70.5%), underrecognizing approximately one third of cases (Limpawattana et al., 2016; Panitchote et al., 2015). Similarly, in a survey of 228 ED physicians in Thailand, 76% reported that delirium was underdiagnosed in the ED (Sri-On et al., 2014). The same study also found that only 24% of patients were routinely screened for delirium in the ED, with 16% reporting that they used a specific tool: general clinical assessment (74%), Mini-Mental State Examination (13%), CAM-ICU (5%), and Delirium Rating Scale (4%) (Praditsuwan et al., 2013).
Role of Physicians and Nurses in Delirium Screening
A total of four studies explored the role of nurses and physicians in detecting (n = 4) and treating (n = 1) delirium. When ED physicians were surveyed, only 24% routinely screened older adults for delirium, with no significant difference between their level or years of experience in emergency medicine and the routine use of screening. The main reasons for not completing delirium screening in the ED were: it was secondary to the presenting complaint (29%), lack of time (25%), low prevalence (14%), it was not an emergency condition (12%), and no tools or guidelines (11%) (Sri-On et al., 2014), as well as lack of knowledge and training (Davis & MacLullich, 2009).
The study that found ED physicians did not adequately screen for delirium did not mention the potential role for nurses to perform delirium screening in the ED (Pipanmekaporn et al., 2014). The study highlighted that during emergency situations screening was less likely to be conducted by physicians, suggesting a geriatric specialist could perform delirium screening. Two studies considered the role of nurses in detecting or treating delirium in Thailand. One validation study for the 4AT included nurses and found they could quickly and accurately assess for delirium (Kuladee & Prachason, 2016). Another study by Panitchote et al. (2015) found that nurses could not identify delirium in 29.6% of patients using the CAM-ICU compared with researchers. These findings indicate that screening of delirium is not a routine task for physicians or other health care professionals.
The current integrative review explored the prevalence, assessment, and management of delirium among older adults in Thailand. A total of 13 studies were included. Only two studies were found validating tools for use in detecting delirium in Thailand, the 4AT-T (Kuladee & Prachason, 2016) and CAM-T (Wongpakaran et al., 2011). Although both tools had strong correlations in detecting delirium among Thai older adults, larger population studies are needed to ascertain the reliability of the tools. Choice of the appropriate tool depends on several factors, including the number of features, the time required to administer, the level of knowledge assumed, and the training required. In the clinical setting, patient characteristics and health history must also be considered. Thus, further research focusing on the health care environment and professionals involved in delirium assessment in Thailand is necessary.
The overall incidence of delirium in Thailand hospital settings varied between 3.6% and 24.4% in the reviewed studies. After exploration of patient characteristics, it was found that the SICU had the highest incidence of delirium. This finding was related to a significantly higher percentage of postoperative patients, mechanical ventilation use, and sedative medication use compared to general medical wards, which had the lowest incidence of delirium. Identification of high-risk patients and early detection could reduce the incidence and severity of delirium in hospital settings.
The role of physicians and nurses in delirium screening has not been explored fully. Although physicians are responsible for detecting delirium, it remained underrecognized in the included studies. There are multiple explanations for why delirium was underrecognized, including poor knowledge of its diagnosis, treatment, and reporting, as well as the need for better training. The current review identified a gap in the understanding of nurses' role in detecting delirium. Nurses are the largest group of health care professionals and have the potential to identify subtle changes in mental status of patients in their care. This ability to identify delirium is particularly important during high emergency situations in which physicians are unable to prioritize delirium screening over other duties and is evidenced by the high rates of under-diagnosis by physicians (Sri-On et al., 2016; Sri-On et al., 2014). However, only two studies focused on nursing professionals and delirium detection and management (Kuladee & Prachason, 2016; Panitchote et al., 2015); no studies focused on delirium detection training programs. Hence, additional studies on enhancing delirium training to increase early detection, management, competence, and confidence in using delirium screening tools is required, particularly for nurses who play a key role in delirium care. Nurses should be aware of how to detect, prevent, and treat risk factors that cause delirium.
Many countries, including Australia and the United Kingdom, have developed their own population-specific pathways and practice guidelines for preventing, detecting, and managing delirium (Australian Commission on Safety and Quality in Health Care, 2016; National Institute for Health and Care Excellence, 2019; Traynor et al., 2016). Despite having these guidelines, effective identification and management remains difficult. Thailand does not have practice guidelines specific to patients and medical systems in terms of delirium identification and management. Thai professionals have limited resources to assist them in understanding and managing delirium. This finding is in line with previous studies in other countries where delirium is common among older adults but poorly detected and managed. Nurses should learn how to detect, prevent, and manage risk factors that cause delirium. Training programs need to focus on delirium care knowledge and detection of delirium using the CAM-T, CAM-ICU (Thai), or the 4AT.
The current review found only 13 studies regarding delirium in older adults in Thailand and most (n = 7) were of level IV evidence, highlighting the lack of understanding of delirium in older adults in general and emergency wards in Thailand.
Underrecognition of delirium in older adults is a common occurrence, yet there is limited research exploring delirium among older adults in Thailand. The 4AT-T was found to be a reliable and valid delirium screening instrument for hospitalized older adults with acute medical illnesses. The tool appears practical even in high-workload settings without a need for specific training. Further validation studies in patients with other specific clinical conditions and validation in greater numbers of Thai older adults are needed. The implementation and development of routine screening, prevention programs, and improved management of delirium in older adults is recommended. Future studies on delirium in Thailand also need to explore how nurses can more effectively detect and treat delirium among older adults during a hospital admission.
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Summary of Literature Review Findings
|Studya||Participants||Study Design||NHMRC Level of Evidenceb||Main Findings|
|Praditsuwan et al. (2012)||225 patients age 70 years admitted to general hospital wards||Prospective observational
Patients were assessed within 24 hours of admission using DSM-IV criteria by geriatricians. Patients also underwent assessment using the Thai MMSE. Patients followed until development of delirium or discharge.||IV||Prevalence = delirium on admission, incidence = delirium developed during hospital stay. Prevalence = 40.4%, incidence = 8.4%. Delirium was significantly associated with increased age (>80 years) (p = 0.003), illness severity (p < 0.001), and ADL dependence (p < 0.001). Incidence was high, but comparable with other studies. Delirium assessment requires attention from physicians, nurses, and administration staff.|
|Praditsuwan et al. (2013)||225 patients age >70 years admitted to general hospital wards||Prospective cross-sectional
Delirium diagnosed by geriatricians using DSM-IV criteria. Patients followed until development of delirium or discharge.||IV||48.9% of patients had delirium, of which 40.4% developed delirium during admission. Delirium was significantly associated with being severely ill, female, having dementia (p < 0.001), and impaired ADLs. Delirium increased LOS significantly (10 vs. 8 days) (p = 0.001). Delirium increased in-hospital (p < 0.001) and 3-month mortality (p < 0.001) rates.|
|Sri-on et al. (2016)||232 patients age 65 years who presented to the ED of an urban hospital||Prospective cross-sectional
CAM-ICU was used by research assistants.||IV||12% of patients had delirium on presentation to the ED of which 59% were not recognized by the ED physician. 41% of patients with unidentified delirium were discharged home. Dementia, auditory impairment, and metabolic derangement were associated with delirium in the ED. Delirium was associated with a higher 30-day mortality rate (15% vs. 2%) (p = 0.004).|
|Wongpakaran et al. (2011)||66 hospitalized Thai older adults||Case-control
CAM-T was developed and used by three trained geriatricians and compared to results by psychiatrists using DSM-IV TR criteria.||III-2||CAM-T demonstrated a sensitivity of 91.9% and specificity of 100%. Average time spent completing the assessment was significantly less than the time spent completing DSM-IV TR. CAM-T was easy to use and quick; however, training is required. A full cognitive assessment should be completed to rule out false negatives in patients with dementia.|
|Kuladee & Prachason (2016)||97 patients aged ≥60 years admitted to general wards||Case-control
The English 4AT was translated into Thai (4AT-T). Psychiatrists assessed patients 24 hours after admission using the DSM-IV-TR and the 6-item Thai Delirium Rating Scale. The 4AT-T was then administered by nurses.||III-2||4AT-T had a sensitivity of 83.3% and specificity of 86.3%. 4AT-T falsely detected 10 patients without delirium and missed 4 patients with delirium. Nurse feedback: simple and easy to understand, completed within 5 minutes, could be included in routine workload easily, and not burdensome. Di culty identified: some patients gave year of birth in Chinese zodiac signs. 4AT-T is reliable, valid, and practical. Further validation is needed.|
|Sri-on et al. (2014)||Thai ED physicians||Descriptive cross-sectional survey
ED physicians completed online surveys between July and September 2013||IV||50% (n = 228) of physicians responded >40% of ED patients were age ≥65; 85% of physicians recognized delirium as a problem needing intervention; 76% reported that delirium was underdiagnosed in the ED; 24% routinely screened for delirium in the ED, 16% reporting they used a specific screening tool. 42% regularly treat delirium with long-acting benzodiazepines and 29% reported using haloperidol. 40% reported overdosing was the most common complication of treatment. 55% routinely screened older adult patients. Screening was not affected by level/experience of the physician. Tools used: general clinical assessment (74%), MMSE (13%), CAM-ICU (5%), Delirium Rating Scale (4%). Reasons for not screening: delirium as secondary importance, small prevalence, no tool/guideline, lack of time, not an emergent condition.|
|Muangpaisan et al. (2015)||80 patients age ≥60 (18 men, 62 women) admitted to a hospital for fall from standing height over a period of 1.5 years||Observational
Patients were assessed within 24 hours of admission and followed until discharge. Assessment methods were not disclosed.||IV||Mean age = 79.4 years. 92.5% underwent surgery. Most common in-hospital complication was delirium (45%). Limitations: short-term follow-up and small sample size.|
|Limpawattana et al. (2012)||Patients admitted to hospital nationwide||Observational
Information was collected from hospital admissions and insurance claims||IV||Delirium occurred in 11,410 of all admissions, contributing to 155.4 per 100,000 older adults. Top three causes of delirium were: (1) respiratory disease, (2) UTI, and (3) circulatory diseases. Mortality rate of older adults with delirium was 6.1 per 100,000. LOS for older adults with delirium was 22.3 days, without delirium was 5.4 days. Cost to care for older adult patients with delirium was 53,174 Baht, without delirium 18,230.8 Baht. Delirium risk increases with increased age, rising significantly in patients ages 61 to 70. Male sex was significantly associated with delirium. Highlighted importance of nurses in recognizing delirium, although training is required. No sample size or gender information provided. Limitations in data gathering/diagnosis.|
|Srinonprasert et al. (2011)||225 hospitalized patients age ≥70 years||Prospective observational
Delirium diagnosed by geriatricians using DSM-IV criteria. Patients followed until delirium developed or discharge.||IV||Mean age was 78 years. 50% had four comorbidities, 42% had dementia, and ∼30% had severe illness on admission. 110 (48.9%) patients developed delirium during admission, of which 91 (40.4%) had delirium on admission. Pre-existing dementia, severe illness, infection, and azotemia were significantly (p < 0.05) associated with development of delirium.|
|Limpawattana et al. (2016)||99 older adults admitted to the ICU of a tertiary care hospital||Prospective observational
Delirium was rated by trained clinical researchers using the CAM-ICU within 48 hours of admission to the ICU (included demographic information).||IV||Delirium occurred in 44 (44.4%) of 99 patients with an incidence of 22.2% (22/99). Prevalence of delirium in patients on mechanical ventilation was 62.5% (30/48). The majority of patients developed delirium within 5 days of ICU admission.|
|Panitchote et al. (2015)||99 older adults admitted to the ICU of a tertiary care hospital||Prospective observational
Delirium was rated by trained clinical researchers using the CAM-ICU within 48 hours of admission to the ICU (included demographic information).||IV||Delirium occurred in 44 (44.4%) of 99 patients. Nurses could not identify delirium in 29.6% of patients compared with researchers. Independent factors associated with under-recognition by nurses were identified—heart failure (adj. OR = 77.8; 95% CI [2.5, 2,543], p = 0.01) and pre-existing delirium taking benzodiazepines (adjusted OR = 22.6; 95% CI [1.8, 85], p = 0.01).|
|Chanidnuan et al. (2019)||250 adults who underwent surgery within the preceding 1 week and had been admitted to a SICU for a period that was expected to be longer than 24 hours||Prospective, observational, cohort
CAM-ICU score was used to determine the occurrence of delirium||III-2||Of 250 patients enrolled, delirium was found in 61 (24.4%). Hospital mortality rate was significantly greater among patients with delirium compared to those without delirium (25% vs. 6%, p < 0.01). Factors that remained independently associated with delirium were age and dementia (as defined by an average score of the modified IQ CODE ≥3.42).|
|Pipanmekaporn et al. (2015)||4,450 patients of nine university-based SICU admitted between April 2011 and October 2012||Multicenter, prospective cohort
Delirium was diagnosed using the Intensive Care Delirium Screening Checklist (ICDSC)||III-2||Overall incidence of delirium was 3.6% (162/4,450, 95% CI [3.09, 4.19]) whereas the incidences of delirium for patients being admitted 48 hours and >48 hours were 0.7% (21/2,967, 95% CI [0.41, 1.01]) and 8.3% (141/1,685, 95% CI [7.04, 9.68]), respectively. Patients with delirium had significantly longer duration of ICU stay (mean = 8 days [range = 5 to 19 days]) vs 2 days [range = 1 to 4 days], p < 0.001) and higher ICU mortality rate (23.5% vs 8.1%, p < 0.001).|