Nurses positioned to lead prevention of hospital-acquired delirium in older adults
Dr Laurie Grealish PhD FACN and Dr Jo-Anne Todd
The Australian population is ageing, with 21% projected to be over the age of 65 years by 2061 (ABS, 2013) and in 2014, 41% of hospital separations were aged 65 years and older (AIHW, 2014). Older adults have a higher risk of developing delirium whilst in hospital. The incidence of cognitive impairment, for example Dementia and delirium in hospitalised older adults, in Australia, is estimated at approximately 20.7% and 8.7% respectively (Travers et al., 2013).
Delirium is an acute decline in cognitive function, characterised by fluctuations in attention, awareness and cognition. There are numerous adverse outcomes for older people with delirium including, cognitive and functional decline, increased risk of falls, and increased length of stay (Travers et al., 2013). The risk of hospital-acquired delirium increases five to six times for people with Dementia (Inouye, Westendorp & Saczynski, 2014). Delirium is a serious medical condition, often fatal, but frequently not recognised and misunderstood in acute hospital settings (Inouye et al., 2014). Moreover, Inouye and colleagues (2014) suggest that 30-40% of cases of delirium in people over 65 years can be prevented.
Nurses are well positioned to lead the prevention of delirium in older adult patients. Prevention of hospital-acquired delirium requires a review of medication, monitoring hydration, nutrition and constipation, mobilising, pain assessment and management, oxygen therapy, reorientation and reassurance, cognitive stimulation, non-drug measures to promote sleep, and ensuring visual and hearing aids are correctly fitted (Delirium Clinical Standard, 2016). These can be considered as fundamental nursing care. However, Australian nurses are spending less than half of their time on direct patient care activities, such as assessment, family and patient interactions, nutrition and mobility (Chaboyer, et al., 2008). Not only can delirium be prevented through fundamental nursing care, an association between fundamental nursing care and prevention of other common complications, such as urinary tract infection, pressure areas and pneumonia, in older adult patients has been postulated (Bail & Grealish, 2016).
Possible causes for reduced completion of fundamental care activities for older adult patients have not been established. Nurses have been found to prioritise care activities, which they consider medically important and are likely to have immediate negative consequences for patients’ physical health, such as administering medications on time, providing medically directed treatments, and undertaking procedures (Ausserhofer et al., 2014). Care activities often required by older adult patients to prevent complications, such as assistance with elimination, eating and drinking, and psycho-social engagement, may not be the priority in a fast paced acute care setting. While many nurses recognise that care for older people is not ideal, this is attributed to the older person being in the “wrong place” and that there should be a better place for “them”, indicating that there is a built-in discrimination against the delivery of high quality care for older people (Moyle et al., 2010).
A recent article by Baumbusch et al. (2015) explored the factors associated with nurses’ readiness to provide care for older hospitalised people. The primary theme identified was one of a “poor fit” between the needs of older patients and the hospital environment. Three key factors were highlighted; a lack of skills and knowledge to provide appropriate care for older people; incongruence between the organisational context and the needs of older people; and societal ageism, which shapes both personal and organisational beliefs about older people.
Nurses are well positioned to lead improvements in the care of older adult patients. Funded research into the causes of missed fundamental care generally, and for older adult patients specifically, is urgently required. Policy, education and practice development related to gerontological nursing could align with that used in palliative care; gerontological specialists work closely with the patients who have the most complex needs and all nurses understand the general principles of care for older adults. Older adult patients can be found across most areas of contemporary hospital and health services, and nurses can lead a renewed focus on fundamental care activities that can reduce hospital-acquired delirium and other complications in older people.
Ausserhofer, D., Zander, B., Busse, R., Schubert, M., De Geest, S., Rafferty, A. M., Ball, J., Scott, A., Kinnunen, J., Heinen, M., Strømseng Sjetne, I., Moreno-Casbas, T., Kózka, M., Lindqvist, R., Diomidous, M., Bruyneel, L., Sermeus, W., Aiken, L. H., & Schwendimann, R. 2013, ‘Prevalence, patterns and predictors of nursing care left undone in European hospitals: results from the multicountry cross-sectional RN4CAST study’, BMJ Quality and Safety, vol. 23, no. 2, 126-135
Australian Bureau of Statistics (ABS) 2013, Population Projections, Australia, 2012 (base) to 2101, accessed 12 May 2017, < http://www.abs.gov.au/>
Australian Commission on Safety and Quality in Health Care 2016, Delirium Clinical Care Standards, Sydney; ACSQHC
Australian Institute of Health and Welfare (AIHW) 2014, Admitted patient care, accessed 12 May 2017, <http://www.aihw.gov.au/haag13-14/admitted-patient-care/>
Bail, K., & Grealish, L. 2016, ‘Failure to maintain: A theoretical proposition for a new quality indicator of nursing care rationing for complex older people in hospital’, International Journal of Nursing Studies, vol. 63, 146-161
Baumbusch, J., LeBlanc, M-E., Shaw, M., & Kjorven, M. 2015, ‘Factors influencing nurses’ readiness to care for hospitalised older people’, International Journal of Older People Nursing, vol. 11, no. 2, 149-159
Chaboyer, W., Wallis, M., Duffield, C., Courtney, M., Seaton, P., Holhauser, K., Schluter, J., & Bost, N. 2008, ‘A comparison of activities undertaken by enrolled and registered nurses on medical wards in Australia: An observational study’, International Journal of Nursing Studies, vol. 45, no. 9, 1274-1284
Inouye, S.K., Westendorp, R.G.J., Saczynski, J.S., 2014, ‘Delirium in elderly people’, The Lancet, vol. 383, no. 9920, 911-922
Moyle, W., Borbasi, S., Wallis, M., Olerenshaw, R., Gracia, N., 2010, ‘Acute care management of older people with dementia: a qualitative perspective’, Journal of Clinical Nursing, vol. 20, no. 3-4, 420-428
Travers, C., Byrne, G. J., Pachana, N. A., Klein, K., Gray, L., 2013, ‘Delirium in Australian hospitals: a prospective study’, Current Gerontology and Geriatric Research, vol 2013, Article ID 284780