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Using Standardized Case Vignettes to Evaluate Nursing Home Staff Recognition of Delirium and Delirium Superimposed on Dementia
Affiliations:
School of Nursing, Pennsylvania State University, University Park, PA
Acknowledgments:
This study is based on data from the 5-year, ongoing RESERVE For DSD randomized clinical trial. The trial is funded by the National Institute of Nursing Research (NINR). Ann M. Kolanowski, PhD, RN, FGSA, FAAN, and Donna Fick, PhD, GCNS-BC, FGSA, FAAN, acknowledge partial support from an NINR grant (5 R01 NR012242 02). Nikki L. Hill is a National Hartford Center of Gerontological Nursing Excellence Claire M. Fagin Fellow and acknowledges support from that award program.
The aim of RESERVE For DSD is to test the efficacy of cognitive stimulation for resolving delirium in persons with dementia who are admitted to skilled nursing facilities subsequent to hospitalization. The institutional review board of The Pennsylvania State University has approved the parent study, and the protocol has been published in Trials (2011;12:119). The contents of the paper are solely the responsibility of the authors and do not necessarily represent the official views of the NINR or the National Institutes of Health.
Abstract: The purpose of this study is to describe nursing home staff knowledge regarding delirium detection and the most common causes of delirium. Specific aims that guided this study include identifying the rate of nurse recognition of delirium and delirium superimposed on dementia (DSD), including different motoric subtypes of delirium, using standardized case vignettes, and exploring what nursing home staff describe as the potential causes of delirium. The study showed overall poor recognition of delirium and DSD, which did not improve over time. Interventions have the potential to increase the early detection of delirium and DSD by the staff and warrant development.
Key words: Dementia, delirium, delirium superimposed on dementia, recognition education, nursing home staff, delirium causes.
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Educating staff about delirium in the long-term care (LTC) setting has been called the “Trojan horse” solution for improving the quality of delirium care in nursing homes1; however, only a few studies have addressed delirium in LTC.1-3 Despite the high incidence of delirium in older adults and the substantial mortality rate and adverse outcomes associated with the condition, it remains unrecognized by nurses and physicians in more than 50% of cases.4,5
In addition, there is a paucity of data on staff recognition and knowledge of delirium in LTC residents with dementia, a condition referred to as delirium superimposed on dementia (DSD).1,6 This condition occurs when a person with preexisting dementia develops delirium, and reports indicate that it occurs in more than half of older adults with dementia and is associated with adverse outcomes, such as a decline in physical function, an increased rate of cognitive deterioration, and death.7,8 Until recently, most research has focused on delirium as a single clinical entity in the acute care or home care setting, and little attention was given to DSD recognition and optimal management across different care settings.
Delirium comprises three motoric subtypes: hypoactive, hyperactive, and mixed.9 Patients with hypoactive delirium, also called quiet delirium, may present with signs and symptoms that are similar to those observed with depression (eg, lethargy, reduced awareness of surroundings, decreased speed and amount of speech, listlessness, reduced alertness, withdrawal); patients with the hyperactive subtype of delirium typically appear agitated, which may manifest as increased motor activity, loss of control of motor activity, restlessness, and an increased propensity to wander; and patients with the mixed subtype present with signs and symptoms of both hypoactive and hyperactive delirium.9-11 Patients with dementia may present with any of these variants of delirium. When LTC residents with dementia experience an acute cognitive change, it may be missed completely by staff, misattributed to their dementia or normal aging, or labeled as “sundowning” (ie, behavioral problems and confusion that occur in the evening and are common in persons with dementia); in addition, both the presence of dementia and the hypoactive subtype of delirium have been found in previous studies to contribute to delirium being underrecognized.4,9
The ability of nurses to detect delirium has been studied mainly by examining chart documentation or comparing nurse ratings with those of researchers in prospective studies.3,5,12 Voyer and colleagues3 have shown that DSD is common in nursing home residents, with more than half of residents with dementia developing delirium at some point, yet in their observational study involving seven LTC facilities, nurses recognized only 51% of the 43 cases identified as DSD by trained research assistants. In addition, the overall detection of delirium symptoms by the nurses ranged from 25% to 66.7%, with delirium more likely to remain undetected when residents manifested fewer depressive symptoms.3 In another study by Voyer and colleagues,12 nursing documentation was reviewed for detection of nine delirium symptoms, which revealed similar findings, with the proportion of delirium symptoms documented correctly in the nursing notes ranging from 1.9% to 53.5%. Inattention was the least documented delirium symptom (1.9%). There was also a trend toward a lower proportion of documented symptoms when there were higher resident-to-nurse ratios, but this finding did not reach statistical significance. Based on the findings, the authors concluded that efforts should be made to provide better training to nurses and to make nursing documentation more efficient.12 In a Finnish study evaluating recognition of delirium by nurses in an acute care geriatric ward, similar results were found.5 Although delirium was diagnosed in 77 patients by researchers, the condition was only recorded in 31 medical records (40.3%) by the nurses. Confusion was the most widely recorded symptom, noted in 64 cases (83.1%).5
Although delirium has been and continues to be overlooked across care settings, nurses in the LTC setting remain in a better position to detect and manage delirium than nurses in the acute care setting. This is because LTC nurses are familiar with the individuals residing in their facilities and are more likely than acute care staff to know their residents’ baseline mental status, enabling them to more readily recognize many of the key features of delirium, such as acute onset and altered level of consciousness. Therefore, training these staff members to recognize delirium is essential; however, few measures exist to assess delirium knowledge among nursing home staff, which is essential to help identify the knowledge gaps among these healthcare providers and develop more effective strategies for improving recognition of this problem.
In the acute care setting and the home setting, case vignettes have been used to assess the knowledge and detection of delirium.13,14 This method has the benefit of being able to focus on real case scenarios while emphasizing specific points of interest, and it has been used in studies of delirium, end-of-life care, and surrogate decision-making.13,15-17 As a result, we opted to use this strategy to gauge knowledge among nursing home staff regarding detection of delirium. All of the nursing homes included in our study are taking part in the randomized controlled trial RESERVE For DSD,18 an ongoing trial (expected completion in June 2015) that is testing the efficacy of cognitive stimulation via recreational activities for resolving DSD. In contrast to the goal of RESERVE For DSD, the specific goals that guided our study included: (1) identifying the rate of nurse recognition of delirium and DSD, including different subtypes (hyperactive and hypoactive) of delirium using standardized case vignettes; and (2) exploring what causes the nursing home staff ascribed to the delirium outlined in the vignettes. This article summarizes the findings of our study and their implications.
Methods
Participants were nursing staff, including registered nurses (RNs), licensed practical nurses (LPNs), and nursing assistants (NAs) or certified nursing assistants (CNAs), across seven sites in central and northeastern Pennsylvania that participated in RESERVE For DSD. These study sites varied in staff size, ranging from 90 to 270 nursing staff members. Three of the sites were located in larger, urban areas and the other four were in smaller, more rural settings.
Nursing staff were asked to complete five standardized case vignettes at baseline, 6 months, and 12 months. We had them complete these vignettes at three different time points because we wanted to capture any changes in their overall level of delirium knowledge. The same five vignettes were used at each time period, with each vignette representing a different condition (eg, dementia or hyperactive delirium), and respondents were provided with a list of potential diagnoses from which to choose.
These vignettes were previously developed as a way to assess healthcare provider knowledge about the motoric subtypes of delirium in the hospital setting, and they were evaluated by a panel of healthcare providers with geriatric and psychiatric expertise.13 The panel independently rated the diagnosis and delirium subtype (where appropriate) for each vignette; their overall agreement on the cases was 84% and their agreement on the identification of the delirium motoric subtypes was 100%.13 This level of agreement gave us confidence that the cases accurately depicted the conditions for which we were testing knowledge; thus, we opted to use these vignettes rather than creating new ones.
The five vignettes we used focused on the staff’s ability to identify dementia, hypoactive delirium, hyperactive delirium, hyperactive DSD, and hypoactive DSD. Using vignettes to assess knowledge provided us with two key advantages: (1) a standardized format for assessing staff knowledge; and (2) the ability to gather qualitative data from the staff regarding what they saw as potential causes of and management strategies for delirium. The text below provides an example of a case vignette used in our study. All vignettes can be accessed free of charge online from The Portal of Online Geriatric Education.
Case Vignette of Hyperactive DSD
Diane is an 83-year-old woman who has been in the hospital for 1 day. According to her family, Diane has had increasing memory problems over the past year and has had problems getting lost while driving to a local restaurant, where she has been many times. She also has had increasing difficulty finding the correct name for things and has experienced increased difficulties in completing activities of daily living. In the morning, you enter her room to check her vital signs, and suddenly she is even more confused. She tells you to stay away and tries to punch you. She accuses you of trying to kill her and steal her belongings. This is not her usual behavior at home. She is disoriented to time and place, and does not recognize you as her nurse. You leave the room, and you hear her talking to herself and moving items around in the room. You return to check on her and find that she has pulled out her IV and is trying to get out of bed.
Results
Overall, 552 staff members (20.3%) across the sites completed the vignettes over the three time points (baseline, 6 months, and 12 months). At baseline, 60% of the responding nursing home staff correctly identified the dementia vignette, but had greater difficulty correctly identifying DSD and the hypoactive forms of delirium and DSD. Only 18% correctly identified the hypoactive form of DSD; 34% correctly identified the hypoactive form of delirium; and 37% correctly identified the hyperactive form of DSD. Staff knowledge of delirium did not improve over the 12-month period, as there were no statistically significant differences in the correct and incorrect responses across time periods for the five different case scenarios presented.
Despite their difficulty identifying delirium, in many cases, the staff noted patients’ acute mental change and identified possible underlying and reversible reasons for the symptoms presented in the vignettes. The top reasons given for the symptoms included multiple causes, infection/urinary tract infection, medications, environmental changes, dementia/Alzheimer’s disease, aging/normal
aging process, depression, and increased confusion due to hospitalization and new surroundings. When asked what caused the delirium, staff members were able to identify important common and reversible reasons for delirium, including medications, urinary tract infection, increased confusion due to hospitalization and new surroundings, and depression. By far, infection was the most frequently identified cause of the delirium; it was mentioned as a cause 52 times by respondents who responded to the open-ended question about causes. The staff also indicated that delirium could be a multicausal problem, and there were instances when the staff thought that the patient’s acute mental change was due to normal aging, using phrases such as “getting older,” “losing memory and sight,” “system declining,” and “normal aging.”
Limitations and Strengths
Our study was limited by being a convenience sample, by not identifying the position (RN, LPN, NA/CNA) of the staff who completed the vignettes, and by a low overall response rate (20.3%). Despite these limitations, this study has several strengths, including a large sample size and the use of previously validated case vignette measures for delirium recognition. Even though we were not able to identify the staff position in this study, since LTC direct-care staff are primarily NAs and CNAs, and delirium is common in LTC, it is crucial for all staff members to be able to recognize delirium as an acute and reversible event.
Discussion
Staff recognition of delirium was poor in this study, and this lack of recognition persisted over the 12-month study period, especially for the recognition of the hypoactive subtype of delirium and for DSD. Attention to delirium recognition and strategies to reduce delirium in LTC is critical. Many individuals admitted from the hospital to an LTC facility for rehabilitation may be readmitted to the hospital in fewer than 30 days due to delirium and “post-hospital syndrome,” which has been recently identified as a costly risk during the critical 30-day period after hospitalization.19
To our knowledge, our study is one of the few that uses standardized case vignettes to assess the ability of nursing staff to recognize delirium. The Table compares our results with those of two other studies13,14 that used case vignettes to assess staff knowledge regarding delirium, but these studies took place in acute care and home care settings. As the Table shows, the rates of recognition in the LTC setting are worse than the rates of recognition in both the acute care and home care setting. This is likely due to the much greater number of NAs and CNAs providing direct care in LTC settings compared with the acute care setting, where professional staff (RNs, LPNs) tend to provide most of the care. However, both acute care and LTC nursing staff did poorly recognizing hypoactive DSD. This is likely because individuals who present with the hypoactive form of delirium or DSD garner less attention from nursing and LTC staff because they are not disruptive. LTC staff may also assume that the symptoms these individuals display are a normal part of the aging process or a result of dementia, rather than being a symptom of delirium. The need to educate direct-care staff on delirium recognition in LTC settings is critical because residents are at high risk for developing this complication while institutionalized.
On a more promising note, the LTC staff did almost as well with recognizing dementia as home care nurses, with a mean of 60% of staff recognizing the dementia case correctly.14 The reason more staff recognized dementia than delirium may be due to dementia being a higher priority area in LTC education; delirium has not received the same attention despite the frequency and seriousness of the problem.20 Although recent changes to the Minimum Data Set 3.0 includes the Confusion Assessment Method for the assessment of delirium, much variation exists in terms of who should perform this assessment in the LTC setting.21
The staff in our study also recognized several common causes of delirium and in some cases noted that it may be a multicausal problem. Since staff often indicated possible underlying and reversible causes for the delirium, this finding may reflect that the staff members need help understanding how to screen for delirium and be empowered to “name” it as delirium.6 Knowing how to effectively communicate with healthcare providers and work collaboratively to identify and treat these issues is critical for improving the quality of patient care.22
The results of our study highlight several areas in which interventions could be targeted, including the recognition of hypoactive delirium and the understanding that delirium often occurs on top of an existing dementia. Educational interventions in LTC are challenged by high turnover, a shortage of nursing leadership, and the lack of a systematic process for integration of innovation into facility systems. Barriers and incentives to delirium assessment and management must also be better understood and addressed to make an impact on delirium care.23
Conclusion
Delirium is deadly, costly, preventable, and occurs across all settings of care. Despite the high incidence of delirium in the elderly—particularly in those with dementia—and the substantial mortality rate associated with the condition, it is poorly recognized in LTC. Prompt detection of delirium could enable staff to treat the person with delirium in his or her own setting, thereby avoiding costly hospitalizations and further decline. Our study clearly shows that we need to do a better job of working with and educating nursing staff at all levels about delirium detection. Interventions to increase the early detection of delirium by nursing home staff have the potential to decrease the severity and duration of delirium, prevent unnecessary suffering, reduce costs from treating the complications of delirium, and prevent unnecessary readmissions or transfers to the hospital. Future studies should focus on developing effective training tools to enhance delirium and DSD detection by LTC and other nursing staff.
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Disclosures: The authors report no relevant financial relationships.
Address correspondence to: Donna Fick, PhD, Distinguished Professor School of Nursing Pennsylvania State University, Suite 127, Health and Human Development East, University Park, PA 16802; dmf21@psu.edu
