Jenny Day

Delirium and older people: what are the constraints to best practice in acute care?

An Australian research team conducted a six-month acute care pilot study in a medical ward of a large hospital in New South Wales. Aim.  To explore ways health practitioners might redesign their practice to include prevention, early detection and management of delirium in older people based on the best current practice. Method and design.  Participatory action research (PAR) was selected as the best approach for involving ward staff to make sustainable clinical practice decisions. The PAR group comprised research academics and eight clinicians from the ward. Thirteen PAR sessions were held over 5 months. Clinicians described care of patients with delirium. Stories were analysed to identify constraints to best practice. Following PAR group debate about concerns and issues, there were actions toward improved practice taken by clinicians. Relevance to clinical practice.  The following constraints to best practice were identified: delayed transfer of patients from the Emergency Department; routine ward activities were not conducive to provision of rest and sleep; assisting with the patients orientation was not possible as relatives were not able to accompany and/or stay with the older patient. Underreporting of delirium and attributing confusion to dementia was viewed as an education deficit across disciplines. A wide range of assessment skills was identified as prerequisites for working in this acute care ward, with older people and delirium. Clinicians perceived that management driven by length of a patients stay was incongruent with best practice delirium care which required more time for older patients to recover from delirium. Two significant actions towards practice improvement were undertaken by this PAR group: (i) development of a draft delirium alert prevention protocol and (ii) a separate section of the ward became a dedicated space for the care of patients with delirium. A larger study is being planned across a variety of settings.

Orientation strategies during delirium: are they helpful?

AIM This paper critiques literature that reports older person experiences of orientation strategies in relation to current recommendations for the management of older person delirium and makes recommendations for future research. BACKGROUND Delirium is a common syndrome in hospitalised older people and a difficult syndrome for health care staff to manage. During delirium, older people describe experiencing altered states of reality and use of orientation strategies as part of their care. Orientation, a non-pharmacological approach to the management of delirium, is recommended as a care strategy in evidence-based guidelines and protocols. METHOD Discursive paper. DISCUSSION This paper considers published research into the experiences of hospitalised older people during an episode of delirium and questions the appropriateness of orientation strategies. How care strategies are experienced by older people is emphasised. An approach to care which is a flexible balance of reality orientation and validation therapy, synchronised with the changing reality and reactions of the older person, is identified as a care recommendation from research. CONCLUSION When delirium is experienced during hospitalisation, health care staff have a responsibility to provide care that is person-centred and sensitive to the older persons needs. It has been assumed that no harm comes from the use of orientation approaches, and delirium management guidelines have recommended this approach. However, orientation strategies can lead to mistrust of, and distancing from, health care staff and family, so impeding their relationships with carers. Care practices that consider the older person to be unique and that synchronise with the older persons changing experiences of reality are suggested for further research. RELEVANCE TO CLINICAL PRACTICE Caring for an older person in delirium is challenging for health care staff. Reconsideration of, and research into, care strategies during delirium has the potential to improve the quality of care for hospitalised older people.

Adult family member experiences during an older loved one's delirium: a narrative literature review

AIMS AND OBJECTIVES To provide a narrative literature review about family experiences during older person delirium. BACKGROUND Delirium is a common and serious condition which manifests when older people are unwell. Family members of older people are likely to encounter their loved one and become involved in care during delirium. DESIGN Narrative literature review. METHODS Electronic database and Google Scholar(™) searches were conducted using search terms for delirium, family, experience and older people. RESULTS Though family members are important partners in the care of older people, there has been little exploration of their experiences during delirium. Current literature identifies that family members experience unexpected, rapid and unpredictable changes in their older loved one, absence of the person they know, distress, not knowing about delirium nor how to help, and supportive and unsupportive relationships with health care staff. CONCLUSIONS Health care staff need understanding about what it means for family to have someone close to them have delirium. Without understanding, it is difficult for staff to respond with compassion, provide support and appropriately include family in the older persons care. There is a need to mitigate family distress and provide support, including information which addresses family concerns. RELEVANCE TO CLINICAL PRACTICE The distress family members experience, the impact of losing connection to their loved one, and the difficulty family face in sustaining hope for their loved ones return needs to be recognised and addressed by health care staff, particularly nurses, during the older persons care.

Existential Absence The Lived Experience of Family Members During Their Older Loved One’s Delirium

When older people develop delirium, their demeanor changes; they often behave in ways that are out of character and seem to inhabit another world. Despite this, little is known about the experiences of family members who are with their older loved one at this time. This article reports a phenomenological study that involved in-depth interviews with 14 women whose older loved one had delirium. Analysis and interpretation of the data depict the women’s experiences as “Changing family portraits: Sudden existential absence during delirium,” capturing the way family members lose the taken-for-granted presence of their familiar older loved one and confront a stranger during delirium.

Mum's absence(s): conceptual insights into absence as loss during a loved one's delirium

AIMS AND OBJECTIVES To examine qualitative research findings about family experiences of absence or loss during older person delirium, and provide a critical discussion of the similarities and differences in these experiences with conceptual understandings of absence and loss. BACKGROUND Families who care for older people with chronic illnesses experience many losses. However, the nondeath loss experiences of family during an older loved ones delirium, an acute condition accompanied by marked changes in demeanour, have received little consideration. DESIGN Discursive position paper. METHODS The findings from two qualitative research studies about family experiences during an older loved ones delirium are discussed in relation to the concepts of absence and nondeath loss. RESULTS The uncharacteristic behaviours and cognitive changes that accompany delirium may estrange family who, despite the older persons corporeal presence, sense the profound absence or loss of their loved one. Although the notion of absence, a nondeath loss, is similar to the experiences of family of people with chronic conditions, there are differences that distinguish these encounters. The similarities and differences between absence during delirium and the concepts of psychological absence, nonfinite loss and psychosocial death are discussed. Psychosocial death, reversibility/irreversibility and partial marked change, are suggested as conceptual descriptions for the absence families experience during an older loved ones delirium. CONCLUSIONS The sense of absence or loss that family may experience during their older loved ones delirium needs to be recognised, understood and addressed by healthcare staff. Understanding or appreciating conceptualisations of absence, as a nondeath loss, may enhance understandings of family member needs during delirium and enable better support strategies. RELEVANCE TO CLINICAL PRACTICE Conceptualisations of absence enhance understandings of family distress and needs during their older loved ones delirium. The potential for family members to experience their loved ones absence during delirium, a nondeath loss, needs to be considered by healthcare staff. Family experiences of absence during delirium need to be recognised by healthcare staff, acknowledged as a potential source of distress, and considered when involving family in the older persons care. Nurses are ideally placed to respond compassionately and provide appropriate family member re-assurance, support and information during delirium. Information should include possible impacts on family and coping strategies.

Barriers and facilitators to opportunistic chronic kidney disease screening by general practice nurses

Opportunistic screening in general practice (GP) is a cost‐effective and viable approach to the early identification of chronic kidney disease (CKD). This study sought to identify the barriers and facilitators to CKD screening practices of GP nurses working in a regional area of New South Wales, Australia.

The barriers and facilitators to opportunistic CKD screening by general practice nurses

Opportunistic screening in general practice (GP) is a cost‐effective and viable approach to the early identification of chronic kidney disease (CKD). This study sought to identify the barriers and facilitators to CKD screening practices of GP nurses working in a regional area of New South Wales, Australia.

Experiences of older people following the introduction of consumer-directed care to home care packages: A qualitative descriptive study

To explore the experiences of older people receiving home care package (HCP) support following the introduction of consumer‐directed care (CDC) by the Australian government on 1 July 2015.

Reflexivity and exploring the meaning of delirium through media depictions: Methodological insights from a phenomenological study

In the course of a phenomenological study that explored the experiences of family members during their older loved ones delirium, a range of delirium experiences depicted in artistic, creative, and linguistic media were reviewed. The search for, and compilation of, media sources for reflection during data analysis is described in this paper. In doing so, the researcher reveals how attentiveness and openness to varied depictions of lived experiences, as well as a valuing attitude toward challenging subjective perspectives, can enhance researcher reflexivity and appreciation of interpretive meanings. Turning to media depictions of delirium offered alternative perspectives on the experience. It challenged the researchers assumptions, enhanced phenomenological reflection, promoted critique of evolving interpretations, and suggested meanings that might not have otherwise been realized. The approach used is a potent, although often overlooked, way to differentiate the nature of phenomena shared through lived experience data. Media-based methods and their use in phenomenology continue to be explored. Illustrations of how to integrate media sources, as well as discussion about the benefits and alternatives to more common uses, are needed.