Discuss About The Diagnosis Prevention Management Of Delirium?
Delirium is a common yet often under-diagnosed or mismanaged disorder. As a result of the aging population, the disorder is becoming more prevalent (Martins & Fernandes, 2012).Delirium is characterized by an inability to focus, change in cognition, reduced awareness clarity, and distractibility(Martins & Fernandes, 2012).Delirium, which affects up to 50% of elderly patients, can be clinically categorized as either hyperactive or hypoactive delirium. This healthcare improvement plan will concentrate on hypoactive delirium.
Under hypoactive delirium, patients are usually withdrawn and quiet (Schuurmans, Duursma& Shortridge, Baggett, 2001). Although there existstrategies to detect and diagnose delirium, the disorder is oftenmisdiagnosed as dementia or not detected at all (Cole, 2005). Studies by Fick, Agostini & Inouye (2002) emphasize the importance of recognizing and consequently preventing delirium. Better knowledge and understanding of delirium among professionals in the healthcare sector can lead to early detection,reduction of risk factors, and better management in the acute phase (Saxena & Lowley, 2009). It is important to give attention to the identification of delirium because more than half of the cases are potentially reversible.
Immediately delirium is detected, prompt management and intervention arecritical. Early patient mobilization, removal of precipitating factors and environmental changes are all warranted as soon a delirium is recognized. Once detected, delirium should be treated as an emergency. It’s important to note that delirium causes a lot of distress to the patient, his or her family, the healthcare staff and even the medical institution.The families delirium patients describe the behavior and emotional manifestations as disturbing(Mailhot et al., 2014). Proper care is necessary especially for patients with hypoactive dementia. The hospital and staff should care for these patients so as to prevent the patient’s prolonged stay or more adverse effects.
Research and treatment gaps exist in the early detection and management of hypoactive delirium. Hypoactive delirium is characterized by a quiet and withdrawn behavior, and although its presentation is more common than hyperactive delirium, the disorder is usually overlooked(Hosker & Ward, 2017). Most of the patients with delirium are therefore often undertreated or underdiagnosed. It is assumed that delirium is not a problem on its own but merely a clinical symptom of other pathologies. Furthermore, although there is growing research on hypoactive delirium, there is no conclusive evidence regarding symptom association and presentation (Peritogiannis, Bolosi, Lixouriotis & Rizos, 2015 ). A lot of research focusing on the primary care setting is needed. It is important to regularly assess all patients diagnosed with delirium for signs of hypoactive delirium. Diagnosing delirium earlyon is necessary so as to enable the patient and supporters to understand and accept the changes soas to plan for the future.
Providing an enriching environment to patients with hypoactive delirium is important.Delirium is usually treated through combining the treatment of presumed underlying cause and by optimizing the patient’s conditions. This treatment of deliriumshould, however,be supplemented by initiating therapy and person-centered care(Hosker & Ward, 2017).To facilitate their recovery, the patients need support from both their families and healthcareprofessionals. Due to the symptoms of their disorder, patients with delirium are often stigmatized.
Another critical gap in relation to hypoactive delirium manifests in the educating the medical staff. Professionals and care staff who deal with delirium related cases quite oftenmisdiagnose delirium patients. Measures must be taken to sensitize the staff on ways to detect the onset of delirium at the early stages. Patients with hypoactive delirium due to their characteristic withdrawal are easily ignored. Without proper care mechanisms, these patients may end up staying in hospital longer or even agitating their symptoms.
In relation to delirium patients, person-centered care is an approach by a medical institution that treats the staff, patients and their family as partners in developing and administering care to meet their needs. It involves considering what the people desire and want. Person-centered care is a term associated with high-quality care (Brooker, 2003). By utilizing a person-centered approach, operations can provide flexible, responsive and accessible services that meet the preferences and needs of the community. With the demographic shift in Australia and New Zealand whereby the number of old population is rapidly increasing, a person-centered approach is important to provide support in managing delirium(Australian hospital statistics 2008-09, 2010).
A person-centered care approach enables patients and staff to make their own decisions and control the services their lifestyle ( Richard, Coulter & Wicks, 2015). The medical care staff will have a sense of responsibility for the people they take care. The organization will also be well placed to provide responses that are culturally appropriate especially to patients with delirium. A person-centered approach in treating patients with delirium will consequently help in alleviating issues related to the identification and diagnosis of patients with delirium. The personalized care with also contribute to reducing adverse effects of delirium that often result in a prolonged stay in hospitals ( Brooker & Latham, 2015). This approach will especially be significant to patients with hypoactive delirium. Such patients are often ignored because of their ‘undemanding’ nature. Since the approach is community-based involving friends and family, it enables a wholesome health care system. Therefore, person-centered care can have significant effects on the well-being of dementia patients by helping in the prevention of delirium, its early detection, response, and management. (Dewing, 2009)
Delirium is an overlooked yet pressing concern in our health care system. It is necessary to identify the existing gaps relating to the detection, management and care services provided to the patients. Gaps in the early detection and management of delirium, environmental factors relating to delirium and the level of awareness and education exhibited by the health care practitioners need to be addressedso as to improve delirium care. This healthcare improvement plan utilizes a Plan-Do-Study-Act (PDSA) cycle conducted by a focus group to analyze and provide possible courses of action to address issues the gaps identified.
Focus groups are commonly used to discuss a specified topic in a short period.A focus group allows a range of opinion to be discussed in a short period and provides a chance to mingle with others, the group’s composition may inhibit some member (Whittaker, 2012). A PDSA cycle is often used to turn an idea into action and in turn connect the action to a learning experience (Langley et al., p. 97).In relation to delirium, the health care improvement plan will provide a plan to improve the healthcare practices and culture, implement the plans, determine their effectiveness in solving the issue and finally refine the procedure based on the findings. By utilizing the PDSA cycle, the first step in the action plan will be to define and design the intervention into the gaps in delirium health care. After planning how to mitigate the gaps, the actual changes will be implemented and documented. The documented information on the intervention process will then be analyzedafterwhich the finding will be used to identify additional gaps or improve on the existing delirium healthcare improvement plan.
Hypoactive delirium, whichis characterized by a quiet and withdrawn behavior is usually overlooked (Hosker & Ward, 2017). To further complicate its early detection and subsequent management, studies into hypoactive delirium have provided inconclusive evidence regarding symptom association and presentation. These characteristics have resulted in people, and healthcare practitioners having an assumption that delirium is not a problem on its own but merely a clinical symptom of other pathologies. With the number of people with delirium expected to increase as a result of an aging population, it is prudent to improve on the detection and management of hypoactive delirium(Hosker & Ward, 2017).
Interventions to increase early detection and management of hypoactive delirium include reducing the time between the onset of delirium symptoms and communication of diagnosis, improving on research related to identification and management and, improving the approach of health care practitioners’ to treating delirium.These interventions will be implemented by improving the quality of healthcare services offered in theinstitution. This will be achieved by improving the processes involved in assessing a potential case of delirium and admitting the diagnosed patient for care(Spiller & Keen, 2006). An efficient system will facilitate the quick and accurate communication of diagnosis making the management of delirium easier. The support staff should also be educated on the appropriate methods of taking care of patients. To properly manage delirium, all parties involved should have all the relevant information on how to identify symptoms of hypoactive delirium and how to handle affected patients.The success of the intervention will be assessed based on the number of newly detected cases together with the amount of time spent in the institutions. The core limitation to this intervention is the lack of conclusive evidence on symptom association and presentation (Spiller & Keen, 2006).
Most patients portraying symptoms of hypoactive delirium are often misunderstood and even discriminated. An enriching environment comprises of relevant, psychological, physical, and sensory support (Bridges, Flatley & Meyer, 2010). Since patients with delirium need a supportive environment of family, friends, and carers, it is necessary to design a plan that facilitates this kind of enriching environment. An enriching environment should also be safe, comfortable, and sensitive to the needs of the diagnosed patient. After discussions in the focus group, a possible strategy to mitigate risks associated with the environmental conditions surrounding delirium patients is to incorporate a comprehensive person-centered care system into the health institutions and community. The relevant institutions should provide a personalized care system that incorporates the patients, their family, and the community. The key objective in delirium management is maintaining the patient’s and carer’s quality of life(Young, Murthy, Westby, Akunne & O’Mahony, 2010). This can be done by sensitizing the community and carers on the importance of knowing the characteristics of a patient with possible hypoactive delirium and why/how to respond to diagnosed patients. This strategy is expected to create awareness and bring the whole community together to tackle the delirium issue.To improve community care especially in care homes, it is important to reduce the inappropriate use of antipsychotic drugs. With a successful campaign, family, friends, and carers will have the necessary knowledge and understanding of how to take care of patients. The strategy may, however, be limited by the complex nature of hypoactive delirium in that it is characteristically hard to detect and manage.
The support staff of patients with hypoactive delirium have oftenbeen accused of ignoring the patients due to the reasoning that the patients are ‘un-demanding.’ It is therefore important to educate the staff on ways of managing and taking care of patients diagnosed with delirium.To improve the patient and staff’s quality of life, an intervention to educate the healthcare staff is necessary. There exists a service delivery gap between the actual services offered by staff and what is appropriate.Patients are often misdiagnosed due to lack of crucial information. Educating the staff will help in early detection of delirium and its management. The healthcare improvement action plan will employ a comprehensive educational package that delivers information on delirium, preventive measures, treatment, and management.This will be done using small group presentations, formal presentations, and guidelines on how to detect, prevent and manage hypoactive delirium coupled with follow-up lessons (Law, Connelly, Prentice, & Rooke, 2009)
PARIHS is a conceptual framework that postulates the important elements influencing the successful application of evidence-based practices (Helfrich et al., 2010). To evaluate the clinical practice context’s readiness for the suggested changes, the healthcare improvement plan used the PARIHS framework. The framework explains interactions between the context of a study, the evidence available, and facilitation of the change (Kitson et al., 2008). This tool was embedded in the evaluation because it provided a relevant guide to help in the development of the healthcare improvement plan and evaluation of the implementation process. The PARIHS tool was used to guide decisions on the design of the intervention, collection of data and the analysis of the processes while focusing on early detection and management of hypoactive delirium, providing the enriching environment and educating employees. So as to fully understand the process of implementation and the impacts to the management of delirium, a process evaluation embedded with PARIHS was designed.
Strategies for the implementation of the three evidence-based recommendations were designed. The guidelines include that institutions should adopt a person-centered care approach, the health care staff should be educated and trained on effective ways of caring for delirium patients, and effective ways of detecting and managing delirium.The core purpose of the evaluation is to determine how the interventions will be received in a delirium healthcare setting, impacts observed, and how the changes played out.
In relation to the evaluation framework, the hypoactive delirium interventions can function at multiple levels within healthcare organization’s context based on an assessment of the readiness using PDSAcycle.Data will be collected pre-intervention and post-intervention from healthcare institutions managing patients with hypoactive delirium.This will be obtained from pre-existing case studies, focus groups and interviews conducted afterward. Interview topics for both staff and patient interviews will be developed based on the framework and hence will include questions on early detection and management of delirium, staff education and provision of an enriching environment. The inductive and deductive analysis will be used based on Ritchie and Spencer’s (2002) approach to analysis. The influence that contextual factors such the individual patient (micro), the care staff (meso) and healthcare institutions(macro) will have on the implementation of the changes mustbe considered(Rycroft-Malone et al., 2013). These themes usually interact with each other in a practical setting.Finally, facilitation is necessary to make implementation easier
To enhance the chances for successful implementation of the initiatives, the suggested changes may be aligned with existing initiatives related to improving the health care of patients with hypoactive delirium. For the successful implementation of this healthcare practice improvement plan, the recommendations highlighted will need to be used in practice and impacton the management of delirium and related issues(Rycroft-Malone et al., 2013).Findings will be presented based on the main criteria of the PARIHS framework: context, evidence, and facilitation. In a practical clinical setting, it is expected that there will be dynamism and complexity underlying the findings.
According to Donabedian (2005), the quality of health care should be measured by taking the processes, structure, and outcomes into account. Under process, we measure thedelivery of services by providers. Structure is concerned with the availability, accessibility, and quality of resources. The outcome indicates the resulting effect of the healthcare process and includes factors such as patient satisfaction, mortality, or improved health status. The healthcare improvement plan will adopt a collaborative approach to come up with a change framework to support improvements.
Confusion Assessment Method (CAM) is a harmonized evidence-based method, which gives health practitioners not trained in the psychiatry field the ability to detect and correctly diagnose delirium at an early stage in research and clinical settings (Waszynski, 2004). The method utilizes four steps that collectively provide delirium healthcare practitioners the best ability to differentiate delirium from other types of disorders. The main advantages of the CAM method are that the hospital staff can adopt it in their normal day-to-day evaluation of patients. The method can also be translated into different languages so that as many patients as possible can be treated correctly regardless of the language they understand. Due to its short administering period, this delirium diagnosis and assessment tool can help in the early detection and management of hypoactive delirium. Implementing CAM, therefore, results in an improvement of delirium health care but only if the staffs are properly trained (Ely et al., 2001).
Nurses from other wards can be trained on how to identify and care for deliriumpatients so that incase they encounter one as they are treating patients, they know how to handle the situation effectively.This will help solve the healthcare gap relating to staff education. Training the nurses the fellow nurses on skills that will help in the early detection and management of hypoactive delirium will contribute to the overall mitigation of delirium in the hospital and community.This will contribute towards bringing about change in the diagnosis and treatment of hypoactive delirium in the long run.
An online training course for staff on identifying and managing delirium can be done regularly so that the healthcare practitioners are upto date with the effective ways of preventing, identifying, and managinghypoactive delirium. An online training program is an appropriate tool,especially where the medical staff are on busy schedules or need reference material as and when they suspect manifestations of hypoactive delirium symptoms. This activity will facilitate change in the healthcare system by educating employees on how to detect the onset of delirium and manage diagnosed patients.
Although most health carepractitionersare trained on identification and management of delirium, new studies are being conducted to improve our understanding and response to this clinical diagnosis (O’hanlon et al., 2013). Therefore, to facilitate the implementation and success of the suggested interventions into delirium health care, the staff need to be re-trained. While staff members are re-trained on delirium care practices, the training sessions should be well documented so that future groups can reference and learn from them.This will ease the process of conducting similar re-training activities. It is, however, important to note that training activities are costly and time-consuming. Re-training session should, therefore,be conducted on a need basis. This activity will facilitate the reinforcement of existing knowledge while updating the medical staff on recent developments or approaches to hypoactive delirium.
To help enforce the changes suggested, being part of the delirium representatives in the ward will provide a field experience on the conditions present in a real-world setting. The best way to ensure that the suggested changes are implemented is by personally facilitating their implementation. By being part of the delirium representatives in the ward, it will be easier to monitor, evaluate and enforce necessary adjustments aimed at implementing changes in the hypoactive delirium health care system in the particular health facility. It will make it possible to contribute towards providing an enriching environment, educate fellow staff members on important issues related to delirium, and improve the detection and management of hypoactive delirium in a clinical setup.
According to Rudolf et al., (2011) delirium does not have a single causal pathway.A basicdeliriummanagementpathwaystarts from determining the risk factors for delirium based on a patient’s history, a clinical assessment to diagnose delirium symptoms, measures to manage the underlying causes, admission, and supervision if it’s determined to be an emergency, reduction of delirium, and finally managing the diagnosed patient.
A person-centered collaborative care system that incorporates the patients, their family, and the community, with help in the management of delirium patients. According to Young, Murthy, Westby, Akunne & O’Mahony (2010), the key objective in deliriummanagement is maintaining the patient’s and carer’s quality of life. This can be donethrough the collaboration of the patients, their family, hospital staff and thegeneral community on the importance of knowing the characteristics of a patient with possible hypoactive delirium and why/how to respond to diagnosed patients. This care system is expected to create awareness and bring the whole community together to tackle the delirium issue.A successful care plan with becharacterized by a situation where the family, friends, and carers will have the necessary knowledge and understanding of how to take care of patients
The effectiveness of this health care improvement plan with be evaluated using a survey on the healthcare facility staff. The survey with collect and evaluate information so as to determine whether there was a significant improvement in early detection of hypoactive delirium and the management of diagnosed cases. This information will be collected from statistics relating to the number of new delirium patients admitted, the gap between the onset of symptoms and diagnosis and the length of stay by hospitalized delirium patients. Information related to the intervention on staff education will be collected by randomly surveying the retaining delirium knowledge.
Conclusion
In conclusion, hypoactive delirium remains a clinical diagnosis that needs to be critically evaluated and managed. Its presence should be approached as a medical emergency. The overall approach when dealing with delirium should start with assessment using appropriate tools or methods. Once hypoactive delirium is detected, the next step is to identify and remove the underlying cause.The only strategy that conclusively improves outcomes is the early mobilization of delirium patients. It is also important to note that patients without delirium posses the risk of developing delirium in the course of their hospitalization. The examination of delirium provides a chance for us to improve health care service towards the elderly(Inouye, Schlesinger, & Lydon, 1999).
Fueled by an aging demographic structure, there has been an increased need to focus on effective methods of detecting delirium early so as to better manage the disorder. The healthcare staff overseeing patients with delirium have often misdiagnosed, mistreated or ignored patients with hypoactive delirium. Therefore, it is necessary to formulate and implement changes that will assist in the early detection and management of hypoactive delirium, provide an enriching environmentconducive for delirium patients, and to educate the healthcare staff on matters pertaining to hypoactive delirium. Evaluation of the interventions aimed to ensure the changes had a positive impact and that they helped mitigate the existing service delivery gaps in hypoactive delirium healthcare. This healthcare improvement plan emphasized on the importance of a person-centered care approach.
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