Causes and Risk Factors for Delirium
Develop a new policy or update an existing policy, from your workplace or the public domain, which impacts on the potential for older people to engage actively and meaningfully in their community.
The current assignment focuses upon the aspect of delirium within the elderly. Delirium refers to a disturbed state of mind and is characterised by restlessness, illusions, incoherence in speech, fever and other disorders. Delirium is often the result of fatigue or an ecstatic mind. It could be stimulated by physical or mental trauma. Additionally, the condition often requires frequent hospitalisations. The rate is immensely high where at least 10% of Australians aged over 70 had experienced emergency admissions for delirium care (health.gov.au 2018). The state of delirium affects consciousness, attention as well as memory within the patients. The older patients admitted with delirium in hospitals have low recovery rate and are at increased risk of mortality (Maldonado, 2013). In 2006, the first set of national clinical practice guidelines for management of delirium on older people was developed.
The study here focuses upon currently developed policies and guidelines for the management of delirium in older people. Some of the government based policies have been revised further in order to provide a patient centred care. The evaluation of the policies also highlights the various loopholes, which makes the appropriate implementation and optimization of the policies impossible.
The state of delirium is defined as a state of mental agitation and restlessness which is characterised by a number of physical and mental anomalies. Some of the factors responsible for causes delirium in a patient are- severe illness, infection, medication and use or withdrawal of alcohol. The delirium is often characterised my improper sodium-potassium balance in the blood. This could be often attributed to physical stress or anxiety within the patient. As mentioned by Pendlebury et al. (2016), acute anxiety or trauma causes vasoconstriction of the blood vessels limiting sufficient supply of blood glucose level to the brain causing a situation of delirium. In older people multiple causes can co-exist such as age-induced cognitive impairment. Additionally, dependence on medications such as tranquilizers can also affect the normal thinking patterns of the brain. There are 14.1% chances of delirium within the old age population suffering from dementia, as the memory as well as normal cognition capacities of the patients are affected suffering from dementia (Tropea et al. 2008).
A number of diagnostic tools could be used for the management of delirium. Some of these are confusion assessment method (CAM) and
Delirium Rating Scale (DRS). The CAM-ICU method has been validated for use in intensive care unit. The delirium risk levels could be determined based upon the vulnerability of the patient and the precipitating factors. It could be further represented graphically on a scale of low to high. When the precipitating factors are less and the patient is less vulnerable the risk of contracting delirium is the least. When the patient is highly vulnerable and the precipitating factors are lesser in number, the patient is at moderate risk of developing delirium or vice-versa. The patient who is highly vulnerable and exposed to more numbers of precipitating factors lies in the high-risk zone (health.gov.au 2018). Some of the precipitating factors for dementia are as follows- history of cerebrovascular stroke, past history of hypertension which high blood cholesterol. Some of these can block the adequate flow off glucose to the brain resulting in state of delirium.
Diagnostic Tools for Delirium
The policy has been developed by the Australian Government department of health and ageing. It mainly focuses upon the delirium care pathways, which takes into consideration the risk factors and the alternative strategies. The policy suggested by the government in this regard provides a detailed process for the assessment of delirium. It begins with identification of the patient suffering from delirium. This should be followed by performing baseline cognitive assessments. The changes in the cognition and thinking patterns of the patient should be identified. Based upon the results obtained the patient could be put under gradual assessment test.
The policy guidelines, the detailed steps for the identification of the causes of delirium. Some of the steps have been entailed below as – obtaining the history of the patient regarding any recent changes in medication, dehydration, falls, infection, balder and bowel function, past medical history, social history, alcohol history, dietary and fluid intake. The information may be drafted from the general practitioners, carers and family members of the patient (Vos et al. 2017). In order to ascertain the state of delirium within the patient some of the vital signs should be checked such as temperature, pulse, blood pressure, respiratory rates etc. Apart from mental state examination the skin surfaces of the patient could be tested for the presence of dehydration (Oh et al. 2017). Additionally, urine retention, faecal impaction are physical stressors which could enhance the state of the delirium in the patient. Some of the tests could be conducted such as CT scan in order to confirm the presence of lesions due to falls earlier as well as to rule out the presence of any internal damage. The policy also places sufficient amount of importance on the management of delirium through involvement of the family members of the patient. As suggested by Inouye (2018), provision of proper diet along with rest and sleep can also help in relieving the pertinence of delirium within the patient.
The article places sufficient importance upon the prevention strategies, which could be further divided into clinical strategies for delirium care and environmental policies. The environmental strategies may include controlling the exposure to light of the patient. as mentioned by Timmons et al. (2017), adequate exposure to light during the day within minimal exposure at night could restore the sleep patterns within an aged patient suffering from delirium and associated restlessness. The focus should be upon reducing the distraction levels of the patient. As suggested by Mumford et al. (2018), involvement of the family members of the patient can make the process of support care more acceptable and friendly to the patient. As mentioned by Brown et al. (2017), the old age patient suffering from mental delirium often become violent and aggressive towards the support carers. The involvement of the family members can make them more comfortable around the support carers. The diet and drinking pattern in the patient could be effectively managed for prevention of constipation. Additionally, the patient should be checked for an intake of psychoactive drugs as they have been seen to induce fatigue or slow down the thought process of the patient.
Policies and Guidelines for Delirium Management
The policy places sufficient importance upon management of delirium within the older people. The delirium within the people could be accessed using some the standard protocols and techniques such as Pool’s algorithm. The pool’s algorithm utilises sequential steps to access the condition of delirium within the patient. The results obtained could be used to initiate supportive communication and care techniques. The policy focuses upon the long-term management of delirium within people with the use of support and counselling services. This also places sufficient importance upon the inclusion of the family members of the patient. As suggested by Lamond et al. (2018), the inclusion of family members helps in promoting the policy of informed decision making. It focuses upon pharmacological as well as non-pharmacological management of delirium. The pharmacological methods help in treatment of some of the medical causes in the patient such as – constipation, urinary retention and hypoxia etc. In case the health situation of the patient eases, non-pharmacological treatment could be initiated and the symptoms for recovery within the patient closely monitored (Sampson et al. 2017). In case the symptoms worsen in the patient antipsychotic medication should be followed up along with non-pharmacological strategies. Some of the psychotic drugs, which could be suggested to the patient are- Haloperidol and olanzapine etc. The haloperidol could be prescribed at a dosage of .25 grams to the patient (Mercadante et al. 2017). This is further followed by monitoring of symptoms within the patient which further dictates the future course of action. In case the patient depicts improvement in health symptoms the patient is provided with non-pharmacological care strategies along with monitoring the improvement status within the patient. On the other hand, if the patient does not depict sufficient improvement in overall health the pharmacological interventions are continued for the patient.
The revised policy focuses upon holistic care for the monitoring and management of the patient condition. As mentioned by Reynish et al. (2017), the holistic care places more importance upon implementation of an effective diet along with closely monitoring the sleep patterns in the patient. The non-pharmacological method reduces the dependency of the patient upon medications and restores capacity for more self-autonomy within the patient. As suggested by Agar et al. (2017), the good food and sleep can help in reducing the psychical ailments within the patient, which increases the chance of recovery of the patient. Additionally, it reduces the duration of hospital stay of the patient which helps in reducing the overall healthcare costs.
Prevention Strategies for Delirium
On the other hand, inclusion of the family members of the patient helps in promoting the policies of informed decision making. The policy also separately highlights the role of the support carers as well as the family members of the patient in improving the condition of the patient.
The scope of the policy could further expanded in order to meet the requirements of the patient or to provide the patient with improved quality care. As mentioned by Bond and Goudie (2015), sufficient importance should be given upon staff education which helps in improving the quality of care. Some of the hospitals miss delirium management as part of the basic curricula. As mentioned by Flikweert et al. (2014), education and re-enforcement of effective delirium management guidelines can help in improving the quality of care. As mentioned by Sattin et al. (2017), there is lack of context-specific intervention strategies and most of the intervention strategies applied within Australian healthcare are generalised in structure or form. As mentioned by Bond and Goudie (2015), lack of cost-effective data makes implementation of evidence-based health policies difficult.
The policy could be evaluated based upon a number of evidence-based methods and practices. The policy has focussed upon some of the evidence-based practices such as Pool’s algorithm for the treatment and management of the patient condition suffering from delirium. It provides a structured method where responses collected at each and every step serves as the evidence based upon which future course of actions are decided (Lin et al. 2015). Additionally, the policy places sufficient importance upon the use of evidence-based diagnostic tools such CAM assessment methods for analysing the mental state of the patient (Shields et al. 2017).
The treatment and cure for delirium has been further divided into pharmacological and non-pharmacological component. It takes into consideration both the holistic and non-pharmacological methods and the pharmacological methods. The scores from the assessment test such as CAM are further used to design an effective care plan for the patient. It is based upon the assessment scores that the future mode of action is decided. However, there are limitations as the policy lacks specific care structure and follows a generalised care module. As argued by Page and Ely (2015), there may be underlying causes for the development of mental delirium within people. Most of the times, they could be associated with progressive Alzheimer’s or lesions caused due to cerebrovascular attack.
Pharmacological and Non-Pharmacological Management of Delirium
A number of recommendations could be suggested over here in order to provide the patient with optimum support. Some of these are implementation of person-centred approach and policy of informed decision making. For example, the patients suffering from mental delirium often depict violent or aggressive behaviour. In this case , the involvement of the family members are important as having a trustworthy person around can make the patient cooperate with the support carers effectively. Additionally, taking into consideration the wishes of the patient helps in the promotion of sufficient autonomy in the patients. The involvement of the family members can also help in promoting the policy of informed decision making, as sometimes the patient themselves lack the capability of making effective decisions (Zaal et al. 2015).
Additionally, the government based policies reviewed over here fails to take into consideration the specialised care needs of the patient. Hence, patient-specific care and support policies need to be designed. Additionally, sufficient amount of staff training needs to be implemented who could help in generating sufficient awareness regarding delirium care and treatment within the elderly. Thus, implementing need-based training can also help in improving the skills sets of the hospitals staffs.
Conclusion
The current study focuses upon the development of effective policies for aged care. In the current study treatment and management of delirium for aged care has been taken into consideration. The assignment focuses upon various government based policies for the treatment of delirium, which are based upon standard guidelines of care. The study here takes into consideration a number of policy and frameworks for analysis of the patient situation. The evidence-based methods employed over here take into consideration various pharmacological and non-pharmacological methods for the provision of an effective and balanced care to the patients. Though, the policy can restore overall health in the people there are number of loopholes such as the lack of specialised care approaches. This is because the underlying cause of delirium may vary from person to person. Therefore, much emphasis needs to be provided upon diagnosis techniques and procedure. The presence of sufficient skills within the healthcare staff also serves as an additional support. The policy also places sufficient importance upon the inclusion of the patient and their respective families in designing of the care and treatment plan. This is because involvement of the family members can make the environment more supportive for the patient. Additionally, placing importance upon the holistic care and support structures can reduce the dependency on pharmacology and hospitals. In this respect, the focus should be upon the improving the diet of the patient to improve the progression of conditions such as constipation within the patient and urine incontinence within the patient which further makes the situation of delirium worse.
Role of Family Members and Support Carers
References
Agar, M.R., Lawlor, P.G., Quinn, S., Draper, B., Caplan, G.A., Rowett, D., Sanderson, C., Hardy, J., Le, B., Eckermann, S. and McCaffrey, N., 2017. Efficacy of oral risperidone, haloperidol, or placebo for symptoms of delirium among patients in palliative care: a randomized clinical trial. JAMA internal medicine, 177(1), pp.34-42.
Bond, P. and Goudie, K., 2015. Identifying and managing patients with delirium in acute care settings. Nursing Older People (2014+), 27(9), p.28.
Brown, E.G., Josephson, S.A., Anderson, N., Reid, M., Lee, M. and Douglas, V.C., 2017. Predicting inpatient delirium: The AWOL delirium risk-stratification score in clinical practice. Geriatric Nursing, 38(6), pp.567-572.
Flikweert, E.R., Izaks, G.J., Knobben, B.A., Stevens, M. and Wendt, K., 2014. The development of a comprehensive multidisciplinary care pathway for patients with a hip fracture: design and results of a clinical trial. BMC musculoskeletal disorders, 15(1), p.188.
Gosselt, A.N., Slooter, A.J., Boere, P.R. and Zaal, I.J., 2015. Risk factors for delirium after on-pump cardiac surgery: a systematic review. Critical Care, 19(1), p.346.
health.gov.au 2018, health.gov.au , available at: https://www.health.gov.au/internet/main/publishing.nsf/Content/FA0452A24AED6A91CA257BF0001C976C/$File/D0537(1009)%20Delirium_combined%20SCREEN [Accessed on 17 May 2018]
Inouye, S.K., 2018. Delirium—A Framework to Improve Acute Care for Older Persons. Journal of the American Geriatrics Society, 66(3), pp.446-451.
Lamond, E., Murray, S. and Gibson, C.E., 2018. Delirium screening in intensive care: A life-saving opportunity. Intensive and Critical Care Nursing, 44, pp.105-109.
Lin, W.L., Chen, Y.F. and Wang, J., 2015. Factors associated with the development of delirium in elderly patients in intensive care units. Journal of Nursing Research, 23(4), pp.322-329.
Maldonado, J.R., 2013. Neuropathogenesis of delirium: review of current etiologic theories and common pathways. The American Journal of Geriatric Psychiatry, 21(12), pp.1190-1222.
Mercadante, S., Adile, C., Ferrera, P., Cortegiani, A. and Casuccio, A., 2017. Delirium assessed by Memorial Delirium Assessment Scale in advanced cancer patients admitted to an acute palliative/supportive care unit. Current medical research and opinion, 33(7), pp.1303-1308.
Mumford, V., Kulh, M.A., Hughes, C., Braithwaite, J. and Westbrook, J., 2018. Controlled pre-post, mixed-methods study to determine the effectiveness of a national delirium clinical care standard to improve the diagnosis and care of patients with delirium in Australian hospitals: a protocol. BMJ open, 8(1), p.e019423.
Oh, E.S., Fong, T.G., Hshieh, T.T. and Inouye, S.K., 2017. Delirium in Older Persons: Advances in Diagnosis and Treatment. Jama, 318(12), pp.1161-1174.
Page, V.J. and Ely, E.W., 2015. Delirium in critical care. Cambridge University Press.
Pendlebury, S.T., Lovett, N.G., Smith, S.C., Wharton, R. and Rothwell, P.M., 2016. Delirium risk stratification in consecutive unselected admissions to acute medicine: validation of a susceptibility score based on factors identified externally in pooled data for use at entry to the acute care pathway. Age and ageing, 46(2), pp.226-231.
Reynish, E.L., Hapca, S.M., De Souza, N., Cvoro, V., Donnan, P.T. and Guthrie, B., 2017. Epidemiology and outcomes of people with dementia, delirium, and unspecified cognitive impairment in the general hospital: prospective cohort study of 10,014 admissions. BMC medicine, 15(1), p.140.
Sampson, E.L., Vickerstaff, V., Lietz, S. and Orrell, M., 2017. Improving the care of people with dementia in general hospitals: evaluation of a whole-system train-the-trainer model. International psychogeriatrics, 29(4), pp.605-614.
Sattin, D., Morganti, L., De Torres, L., Dolce, G., Arcuri, F., Estraneo, A., Cardinale, V., Piperno, R., Zavatta, E., Formisano, R. and D’Ippolito, M., 2017. Care pathways models and clinical outcomes in Disorders of consciousness. Brain and behavior, 7(8).
Shields, L., Henderson, V. and Caslake, R., 2017. Comprehensive Geriatric Assessment for Prevention of Delirium After Hip Fracture: A Systematic Review of Randomized Controlled Trials. Journal of the American Geriatrics Society, 65(7), pp.1559-1565.
Sullivan, D.O., Mannix, M. and Timmons, S., 2017. Integrated Care Pathways and Care Bundles for Dementia in Acute Care: Concept Versus Evidence. American Journal of Alzheimer’s Disease & Other Dementias®, 32(4), pp.189-193.
Timmons, S., Mannix, M., McKiernan, M., Connolly, M., Foley, M., Cahill, S. and Chorcorain, A., 2017. A novel integrated care pathway for people with dementia presenting to acute hospitals. International Journal of Integrated Care, 17(5).
Tropea, J., Slee, J.A., Brand, C.A., Gray, L. and Snell, T., 2008. Clinical practice guidelines for the management of delirium in older people in Australia. Australasian journal on ageing, 27(3), pp.150-156.
Vos, A., Cramm, J.M., Wijngaarden, J.D., Bakker, T.J., Mackenbach, J.P. and Nieboer, A.P., 2017. Understanding implementation of comprehensive geriatric care programs: a multiple perspective approach is preferred. The International journal of health planning and management, 32(4), pp.608-636.
Zaal, I.J., Devlin, J.W., Peelen, L.M. and Slooter, A.J., 2015. A systematic review of risk factors for delirium in the ICU. Critical care medicine, 43(1), pp.40-47
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