Delirium Superimposed on Dementia: Accuracy of Nurse Documentation

Abstract

Delirium is an acute, fluctuating confusional state that results in poor outcomes for older adults. Dementia causes a more convoluted course when coexisting with delirium. This study examined 128 days of documentation to describe what nurses document when caring for patients with dementia who experience delirium. Nurses did not document that they recognized delirium. Common descriptive terms included words and phrases indicating fluctuating mental status, lethargy, confusion, negative behavior, delusions, and restlessness. Delirium is a medical emergency. Nurses are in need of education coupled with clinical and decisional support to facilitate recognition and treatment of underlying causes of delirium in individuals with dementia.

The Language of Delirium: Keywords for Identifying Delirium from Medical Records

“…These trigger words have been used in a previously validated chart-based approach to identifying delirium 7 and were similar to those used in previous studies that extracted key words for confusion from electronic records. 14, 15 Examples of trigger words were: ‘mental status change’, ‘disoriented/re-oriented’, ‘unresponsive’, and ‘agitated’. Table 3 includes a full listing of trigger words.…”

A quality improvement program to increase nurses' detection of delirium on an acute medical unit

“…Unfortunately, nurses typically do not receive formal training in standardized cognitive or delirium assessment. 3,11,14–16 …”

Pay Attention!: The Critical Importance of Assessing Attention in Older Adults with Dementia

“…The mental status examination is a structured evaluation of physical (i.e., appearance, behavior, motor activity), emotional (i.e., attitude, mood/affect, thoughts, perceptions and judgment), and cognitive (i.e., orientation, attention, level of consciousness, speech, memory, abstraction) domains that describe a person’s state of mind (Trzepacz & Baker, 1993). Nurses are familiar with certain aspects of the mental status examination (i.e., orientation, level of consciousness) but pay less attention to other critical components (Steis & Fick, 2012). Attention is one such component.…”

“…Studies have shown that although nurses and physicians prefer and are most comfortable with using orientation as an indicator of change in mental status, in fact, it is one of the least useful indicators (Inouye, Foreman, Mion, Katz, & Cooney, 2001; Steis & Fick, 2012). For this reason and others, nurses must begin to shift their thinking to make assessment of attention a priority over other constructs of mental status.…”

“…Attention affects performance in other cognitive domains, as well as activities of daily living. In their study of hospital nurses’ clinical documentation, Steis and Fick (2012) found that nurses were generally adept at assessing and recognizing problems with memory and orientation but failed to assess and recognize problems with attention. This is a significant finding, given the fundamental importance of attention to overall safety and function in people with AD.…”