Delirium superimposed on dementia is pervasive and associated with restraint use among older adults residing in long-term care
- Correspondence to Donna Marie Fick
School of Nursing, The Pennsylvania State University, 201 HHDE, University Park, PA 16802, USA;
Implications for practice and research
■ Delirium is common in long-term care and was associated with physical restraint use in this study, which may worsen mental status and increase falls.
■ Nurses should carefully consider the trigger for behaviours that lead to the use of restraints (untreated delirium, pain or misinterpretation of stimuli) and attempt to manage these behaviours without chemical or physical restraints.
■ More research is needed to better measure environmental factors associated with delirium superimposed on dementia (DSD).
Delirium occurs frequently in older adults and leads to poor outcomes including increased death, higher costs and increased nursing care.1 2 Delirium is reversible, preventable and treatable when recognised early. Risk factors identified previously for delirium in acute care include sensory impairment, infection, having three or more medications administered, increasing age and dehydration.2
Nurses frequently fail to recognise delirium, especially in persons with dementia (PWD) and may not intervene appropriately when an older adult has a change in mental status. In order to prevent delirium, it is crucial to be able to quickly detect delirium and to identify those at risk. In this study, Voyer et al investigated precipitating factors for delirium in long-term care.
The authors used a cross-sectional design and convenience sample of residents from three long-term care settings in Canada who were 65 years of age and older with dementia and no other major psychiatric disorders. The head nurse was asked to identify patients with dementia for the study based on a chart diagnosis of dementia. A nurse measured delirium using the Confusion Assessment Method (CAM) over a 7 h period during the day. A second research nurse blinded to delirium status collected data on risk factors.
The investigators found that of the 155 residents, 109 (70%) had delirium according to the CAM. In the bivariate analysis use of physical restraints, level of sensory stimulation, and adequacy of physical environment were all associated with delirium. In the multivariate analyses, only the use of physical restraints remained significant (OR=4.64, 95% CI 2.61 to 8.27) for delirium.
The current study adds important evidence to previous studies that have found restraint use associated with the risk of delirium. Restraint use was high (51%) in this study, despite regulatory efforts in many countries to decrease the use of restraints. Delirium symptoms may have led nurse to use restraints. Nurses need to regularly assess for delirium and be aware of alternatives to the use of chemical and physical restraints. It is important to note the finding that sensory stimulation and environment appeared to have some protective effect. In a study by Kolanowski et al, nurses working in long-term care indicated they did not have enough time or staff to use non-drug strategies instead of restraints in PWD.3 4 A recent 2011 study by Monette et al4 found that antipsychotic use for disruptive behaviours was associated with room characteristics such as a clock and calendar. The authors correctly point out that the measurement of environment in the context of delirium has been difficult.
However, this study did have some important limitations such as the cross-sectional design, convenience sampling and the definition of dementia and delirium. The use of a unit nurse to identify patients with dementia for the study initially may have led to study bias. Incident delirium measurement was not used in this study. Probable delirium was included, which may have made the rate of delirium appear higher since acuteness of the change is often difficult to ascertain in PWD. Strengths of the study include the blinding of the data collectors and the rating of the CAM based on a 7 h observation period.
In summary this study is one of only a few examining DSD in this setting, and advances our understanding of the prevalence and risk factors for delirium in long-term care. The rate of delirium in this setting was alarmingly high. Nurses should avoid using restraints, consider delirium as a serious and preventable cause of worsening mental status, and institute measures to prevent delirium in PWD. The use of more sensitive measures for environmental and orienting factors associated with delirium may yield different results in the future. Future research should consider a longitudinal design and sampling to better define risk factors for this population while considering additional factors that may be unique to DSD.