Elsevier

Applied Nursing Research

Volume 24, Issue 3, August 2011, Pages 171-178
Applied Nursing Research

Precipitating factors associated with delirium among long-term care residents with dementia

https://doi.org/10.1016/j.apnr.2009.07.001Get rights and content

Abstract

This cross-sectional study (N = 155) investigated precipitating factors associated with delirium among long-term-care residents with dementia and assessed their cumulative effect on the likelihood of having delirium. Use of physical restraints (odds ratio [OR] = 4.64, 95% confidence interval [CI] = 2.61–8.27) was the factor most associated, and the likelihood of being in delirium increased with the number of associated precipitating factors present (OR = 2.53, 95% CI = 1.42–4.49). Given their frailty, only a few precipitating factors need be present to increase the likelihood of these residents being in delirium, hence the need for increased nurse awareness of the risks posed by use of physical restraints with respect to the cognitive function of elderly residents with dementia.

Introduction

Delirium is defined as a mental disorder of acute onset with a fluctuating course, characterized by disturbance in consciousness, attention, orientation, memory, thought, perception, and behavior (Cole, 2004). Its prevalence among older people ranges between 9.6% and 89% (Elie et al., 2000, Fick et al., 2002, Lemiengre et al., 2006). Although it can occur in a wide variety of medical settings, it is particularly common among frail individuals found in long-term-care (LTC) settings with prevalence rates of 57% and 70% (Bradley et al., 2005, Voyer et al., 2009). Delirium is a serious condition because it has been associated with several negative consequences such as cognitive and functional decline as well as greater morbidity and mortality rates (Marcantonio et al., 2003, Rockwood et al., 1999). It is also a great source of distress for family members and an increased burden for nursing staff, and it incurs higher medical costs. Because of these problems, every effort should be made to prevent this syndrome. Identification of risk factors enables nursing staff to quickly identify individuals at risk of developing the condition and to target these residents for preventive interventions.

Section snippets

Review of the literature

During the past decades, efforts have been made to identify risk factors for delirium among older persons. The literature reveals that delirium among elderly individuals is a multifactorial syndrome (Inouye, Studenski, Tinetti, & Kuchel, 2007). Although a single factor, such as an infection, can trigger an episode of delirium, among seniors, several coexisting factors are most often found to be culprits. Supporting this view is the multifactorial model for delirium developed by Inouye and

Study purposes

The purpose of this study was to increase the body of knowledge about precipitating factors of delirium among LTC residents with dementia. The first aim was to identify the precipitating factors associated with delirium, and the second, inspired by the Multifactorial Model for Delirium, was to assess whether the number of precipitating factors present for a particular resident is linked to their likelihood of having delirium.

Study settings and selection of participants

For this cross-sectional study, residents were recruited in three LTC facilities and one LTC unit of a large regional hospital, all located in the Quebec City area, Canada. A convenience sampling procedure was used. All residents 65 years and older with dementia and no history of psychiatric illness (psychotic disorders, bipolar disorders, and major depressive disorders with psychotic features) were eligible for this study.

Following clearances from all appropriate institutional ethics

Results

Of the 293 eligible residents, proxy consent was obtained for 54.6% of them (160 residents). More precisely, 41.6% of proxies did not respond, and 3.8% of them refused to give their consent. Following enrolment, 3 residents died before the evaluation, 1 was transferred and another hospitalized, leaving a total sample of 155 participants.

Of these 155 residents, 109 (70.3%) were ascertained delirious according to the CAM (definite or probable). Baseline characteristics of residents are presented

Discussion

This study was undertaken to identify precipitating factors associated with delirium among LTC residents with dementia and to analyze the effect of the number of precipitating factors present for a given individual on their likelihood of being in delirium. As far as the authors are aware, this study is the first to address these issues among this particular population.

Of all the variables significantly related to delirium in bivariate analyses, only the use of physical restraints was associated

Implications for nursing

Nurses working in LTC setting should be cognizant of the high vulnerability of residents with dementia and their increased risk for being in delirium even in the presence of a small number of precipitating factors. The high prevalence of the use of physical restraints in our population, its strong association with delirium, and the lack of evidence of its effectiveness in reducing falls all underscore the need for limiting the use of physical restraints among this population. Studies that have

Conclusion

Residents with dementia in LTC constitute a frail population. Nurses should be aware that for these individuals, only a few precipitating factors need be present to increase their likelihood of being in delirium. Among the precipitating variables we analyzed, physical restraints appear to play a key role. This result underscores the need to educate nurses about the hazards of using physical restraints and to implement protocols aimed at reducing such practices among this population.

Acknowledgment

Funding for this work was through an Investigator Award to Philippe Voyer from the Quebec Health Research Funds (Fonds de la recherche en santé du Québec) and the Quebec Nursing Research Funds (Fonds de la recherche en sciences infirmières du Québec). Financial support also came from the Saint-Sacrement Hospital Foundation.

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