PICO Analysis of Delirium Sample Essay
With the aging of our population, cognitive aging has emerged as a leading public health concern. In a 2014 AARP survey, 93% of respondents identified maintaining brain health as a top priority (Inouye, 2015). Yet a substantial void exists in the fundamental understanding of the cognitive aging process and its distinction from cognitive impairments such as delirium and dementia-related conditions. Nearly one third of the older population in the United States is hospitalized each year in relation to acute illness or surgery, and delirium is the most common complication of hospitalization in older persons, and it occurs in an estimated 2.6 million of older adults each year. Delirium has been identified as a leading contributor to short and long term cognitive decline after hospitalization, and at least 40% of these cases are preventable when identified. PICO Analysis of Delirium Sample Essay. The purpose of this analysis is to ascertain a PICO question related to delirium, identify resources used to find supportive literature, review the supportive information, and create an evidence-based table summarizing the data to determine the best delirium screening options.
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PICO Question
In older adult patients with delirium (P), what are the best delirium screening tools (I) compared to the Diagnostic and Statistical Manual or International Classification of Diseases used in defining the diagnosis of delirium (C) to improve early detection and management in older adult patients with delirium (O)?
Search Strategy
To find research to support the chosen PICO question, electronic databases such as CINAHL, Google Scholar, PubMed, PsychInfo, and Medline were used. The Hartford Institute for Geriatric Nursing, the American Geriatrics Society as well as the book Evidence-Based Geriatric Medicine were also used as resources. PICO Analysis of Delirium Sample Essay. The following keywords and phrases were used to search: delirium screening tools, aging, older adults, geriatric, and primary care setting. Articles that were older than five years old as well as secondary sources were excluded. Articles that applied to the geriatric population, and analyzed the various delirium screening tools and met the criteria were included. The following Boolean search strings were used: delirium screening tools systematic review, and delirium and aging.
Analysis of Literature
Evidence Table
| Citation | Conceptual Framework | Finding | Research Method | Implications of Literature Review | Level of Evidence |
| O’Sullivan, D., O’Regan, N. A., & Timmons, S. (2016). Validity and Reliability of the 6-Item Cognitive Impairment Test for Screening Cognitive Impairment: A Review. Dementia and Geriatric Cognitive Disorders, 42(1-2), 42-49. doi:10.1159/000448241. PICO Analysis of Delirium Sample Essay.
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Descriptive Theory | The Six-Item Cognitive Impairment Test (6-CIT) has been suggested as a useful dementia screening instrument in primary care. The studies on the 6-CIT in primary care present conflicting results and all 3 have significant variations in their selection of cases/reference standards used. | Systematic Review of Literature | Although researchers have investigated its accuracy in diagnosing cognitive impairment in primary and secondary care settings, its validity in primary care use has been questioned and there are limited validation studies on its use in secondary care. In addition, the cut-offs used in 2 of the studies favored specificity over sensitivity, which is not desirable for a screening test. The authors recommend that larger studies, which test the psychometric properties of the 6-CIT in primary and acute care settings, are conducted to establish recommendations for routine screening use. | Level I |
| De, J. & Wand, A. (2015). Delirium Screening: A Systematic Review of Delirium Screening Tools in Hospitalized Patients, The Gerontologist, 55(6), 1079–1099. Retrieved from https://doi.org/10.1093/geront/gnv100. PICO Analysis of Delirium Sample Essay | Descriptive Theory | Thirty-one studies describing 21 delirium screening tools were included in the systematic review. Most studies were conducted across a broad range of inpatient settings internationally in elderly inpatients, including patients with dementia but most excluded nonnative language speakers. | Systematic Review of Literature | The Confusion Assessment Method was the most widely used instrument to identify delirium, however, specific training is required to ensure optimum performance. The Delirium Rating Scale and its revised version performed best in the psychogeriatric population but requires an operator with psychiatric training. The Nurses’ Delirium Screening Checklist appears best suited to the surgical and recovery room setting. The Single Question in Delirium shows promise in oncology patients. The Memorial Delirium Assessment Scale, while demonstrating good measures of validity in the surgical and palliative care setting, may be better used a measure of delirium severity. The 4As Test performed well when delirium was superimposed on dementia, but it requires further study. | Level I
PICO Analysis of Delirium Sample Essay |
| Iatraki, E. et al. (2017). Cognitive screening tools for primary care settings: examining the ‘Test Your Memory’ and ‘General Practitioner assessment of Cognition’ tools in a rural aging population in Greece. European Journal of General Practice, 23(1), 171-178. Retrieved from http://dx.doi.org/10.1080/13814788.2017.1324845 | Predictive Theory | The ‘Test Your Memory’ (TYM) and ‘General Practitioner assessment of Cognition’ (GPCog) instruments appear to be suitable for routine use in the primary care setting as tools for cognitive impairment risk detection in elderly rural populations.
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Randomized Control Trials (RCT)
PICO Analysis of Delirium Sample Essay |
The clinical validity of TYM/GPCog was assessed through comparison with a screening test that was used to establish risk for cognitive impairment instead of clinical diagnosis of dementia. Although, MMSE is widely used and considered by many as the gold-standard instrument for dementia screening, it has far from perfect sensitivity or specificity. The limited gender and education-level susceptibility of GPCog render it preferable over TYM for routine use in primary care settings in accordance with a growing number of studies in other cultures. | Level II |
| Bellelli, G., Morandi, A., Davis, D. H. J., Mazzola, P., Turco, R., Gentile, S., … MacLullich, A. M. J. (2014). Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age and Ageing, 43(4), 496–502. http://doi.org/10.1093/ageing/afu021. PICO Analysis of Delirium Sample Essay | Prospective Study | The 4AT screening tool is a sensitive and specific method of screening for delirium in older people. Its brevity and simplicity support its use in routine clinical practice. | Cross-Sectional Observation Study | A strength of this study is the provision of a clear description of exactly how the delirium diagnosis was obtained, detailing the procedure which informed scoring by DSM-IV-TR criteria. Some limitations of this study must be acknowledged. The 4AT assessments were performed by experienced physicians, though no specific training in the 4AT was given. Further research is needed to assess the ease of use of 4AT among other professional groups of varying levels of seniority. The clinical outcomes in relation to ‘possible delirium’ as assessed by the 4AT was not studied.
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Level II. PICO Analysis of Delirium Sample Essay |
| Fick, D. & Mion, L. (2013). Assessing and Managing Delirium in Older Adults with Dementia. Retrieved from https://consultgeri.org/try-this/dementia/issue-d8.pdf
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Geriatric Models of Care | The Hartford Institute states that the best tools for delirium screening in the older adult population are the Confusion Assessment Method (CAM) algorithm, which relies on the presence of acute onset of symptoms and a fluctuating course, inattention, and either disorganized thinking or an altered level of consciousness; and the Delirium Superimposed on Dementia Algorithm (DSDA) is recommended for delirium for people with a pre-existing dementia (Fick and Mion, 2013). | Evidence-Based Practice Guidelines (systematic reviews, RCTs, Cohorts)
PICO Analysis of Delirium Sample Essay |
While the CAM is a useful tool, the Delirium Superimposed on Dementia Algorithm recognizes that the patient’s baseline mental status is a critical parameter for assessing and treating delirium. The algorithm presents practical ways for bedside nurses to assess delirium and CAM features such as poor attention and fluctuation. The algorithm can be used with patients with dementia who present to the hospital without previous medical evaluation, and/or family members who cannot describe the patient’s mental status pre-hospitalization, who are at increased risk for undetected delirium. The algorithm helps address ageism, a significant barrier to detecting the presence of delirium, wherein clinicians attribute further cognitive loss or lethargy in a person with dementia as an inevitable fact of life for older adults. | Level I |
Purpose of Research Paper
Delirium is a common, often underdiagnosed, geriatric syndrome characterized by an acute change in attention and consciousness. The elderly population, especially those who are age 70 and older are particularly vulnerable to delirium than those younger due to changes in brain function, multiple general medical problems, polypharmacy, reduced hepatic metabolism of medications, multisensory declines, and brain disorders such as dementia. Polypharmacy is very common in the elderly, and the possibility of drug-drug interactions must be considered as a cause of agitation. PICO Analysis of Delirium Sample Essay. According to Rosen et al (2015), Delirium is frequently seen in older patients in the emergency department (ED), is under-recognized, and has potentially serious consequences. About 7–17% of older adults who present to the ED suffer from delirium (Rosen, 2015). Delirium is a medical emergency with significant associated morbidity and mortality requiring rapid diagnosis and management. Delirium has been identified as a leading contributor to short and long term cognitive decline after hospitalization, and at least 40% of these cases are preventable. As a neuropsychiatric disorder with an underlying organic cause, delirium is known to occur as both an acute and subacute condition that carries significant morbidity and mortality. Combined with its association with dementia and aging, this makes delirium an important topic for primary care providers to become more familiar with as they are tasked with caring for an aging population (Setters and Solberg, 2017).
Gaps in Existing Literature
Presently, there are very few RCTs and studies assessing the effectiveness of delirium screening tools in older adults with delirium in primary care settings. Most of the research focused mostly in acute care/hospital settings. A role for routine delirium screening can be clarified through a well-designed delirium screening trial investigating the benefits of delirium screening, coupled with a multicomponent intervention versus usual care. PICO Analysis of Delirium Sample Essay. It could be challenging to measure emotions and cognitive improvement in a consistent manner across patients. Studies are needed to rigorously evaluate the benefits and potential harms of screening in relation to multiple outcomes such as medical intervention requirements, preventive strategies, delirium reversibility, care needs and economic burden.
Conclusion
Despite the limitations on the available research, most data show that the Confusion Assessment Method is widely used, and can used in any clinical setting. And for the patients with underlying dementia conditions, then, the Delirium Superimposed on Dementia Algorithm is recommended per evidence-based practice guidelines. Poor attention is a key marker in delirium and delirium superimposed on dementia patients. In addition, evaluations of the elderly should include a comprehensive review of all drugs being taken, including those that are prescribed, and those taken OTC and herbals. Delirium is often multifactorial and requires an immediate medical attention. Health practitioners should make it a habit to evaluate elderly patients for signs of delirium in every clinical setting especially in primary care settings as it often overlooked. PICO Analysis of Delirium Sample Essay.
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Bellelli, G., Morandi, A., Davis, D. H. J., Mazzola, P., Turco, R., Gentile, S., … MacLullich, A. M. J. (2014). Validation of the 4AT, a
new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age and Ageing, 43(4), 496–502. http://doi.org/10.1093/ageing/afu021
De, J. & Wand, A. (2015). Delirium Screening: A Systematic Review of Delirium Screening Tools in Hospitalized Patients, The
Gerontologist, 55(6), 1079–1099. Retrieved from https://doi.org/10.1093/geront/gnv100
Fick, D. & Mion, L. (2013). Assessing and Managing Delirium in Older Adults with Dementia. PICO Analysis of Delirium Sample Essay. Retrieved from https://consultgeri.org/try-this/dementia/issue-d8.pdf
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Iatraki, E. et al. (2017). Cognitive screening tools for primary care settings: examining the ‘Test Your Memory’ and ‘General
Practitioner assessment of Cognition’ tools in a rural aging population in Greece. European Journal of General Practice, 23(1), 171-178. Retrieved from http://dx.doi.org/10.1080/13814788.2017.1324845. PICO Analysis of Delirium Sample Essay.
Inouye, S. K. (2015). Enhancing cognitive aging: clinical highlights of a report from the Institute of Medicine. Annals Of Internal
Medicine, 163(4), 307-310. doi:10.7326/M15-1228
National Institute on Aging (2013). The Dementias: Hope through Research. Retrieved from https://www.nia.nih.gov/alzheimers/publication/dementias/treatment
O’Sullivan, D., O’Regan, N. A., & Timmons, S. (2016). Validity and Reliability of the 6-Item Cognitive Impairment Test for Screening
Cognitive Impairment: A Review. Dementia and Geriatric Cognitive Disorders, 42(1-2), 42-49. doi:10.1159/000448241
Rosen, T., Connors, S., Clark, S., Halpern, A., Stern, M. E., DeWald, J., & Flomenbaum, N. PICO Analysis of Delirium Sample Essay. (2015). Assessment and Management of Delirium in Older Adults in the Emergency Department: Literature Review to Inform Development of a Novel Clinical Protocol. Advanced Emergency Nursing Journal, 37(3), 183–E3. http://doi.org/10.1097/TME.0000000000000066
Setters, B., & Solberg, L. M. (2017). Delirium. Primary Care, 44(3), 541-559. doi:10.1016/j.pop.2017.04.010. PICO Analysis of Delirium Sample Essay.