factors influencing management of cognitive impairment amon g older...

노인간호학회지 제15권 제3호, 2013년 12월J Korean Gerontol Nurs Vol. 15 No. 3, 205-217, December 2013 ISSN 1229-5299

Factors Influencing Management of Cognitive Impairment among

Older Adults in Acute Care Settings: A Review of the Literature

Kang, Yun Young

School of Nursing, Cheju Halla University, Jeju, Korea

Purpose: This study was done to better understand factors affecting care management of older adults with cogni-tive impairments (CI) in acute care settings and to provide a discussion of the literature focusing on educational issues for nurses caring for older adults with CI in acute care settings. Methods: Analysis was done of 26 articles related to management of acute or chronic confusion in older adults in acute care settings, which were published between 2000 and 2012. Results: The theoretical literature outlines nurse-related and organizational-related fac-tors that influence management of dementia or delirium in older adults in acute care settings. These themes offer grounding for further research and the development of education that address the needs of older adults with CI undergoing management for co-morbidity in acute care settings. Conclusion: In the current studies, the emphasis was on the need for education, which has the potential to lead to a significantly positive improvement in RNs’ knowl-edge and attitudes, and the appropriate management and empowerment of family members to participate through the early detection of dementia or delirium in hospitalized older adults with CI. Consequently, facilitating care im-provement for older adults with CI, particularly those with dementia, needs to be given attention in Korean acute care settings.

Key Words: Dementia, Delirium, Management, Hospital, Aged

Corresponding author: Kang, Yun YoungSchool of Nursing, Cheju Halla University, 38 Halla Daehakro, Jeju 690-708, Korea.Tel: +82-10-2797-1295, Fax: +82-64-741-7639, E-mail: [email protected]

투고일: 2013년 3월 12일 / 수정일: 2013년 8월 7일 / 게재확정일: 2013년 10월 14일

INTRODUCTION

The growth in the older population, coupled with a

longer life expectancy, is likely to result in an increase

in the incidence of chronic illness, use of hospital serv-

ices and length of hospital stays (Phelan, Borson, Gro-

thaus, Balch, & Larson, 2012). A period of hospitaliza-

tion can have an adverse effect on the health of frail old-

er adults and in particular people with dementia (Phelan

et al., 2012). People with dementia have the highest risk

for developing delirium; the prevalence of delirium in

hospitalized older adults with dementia is found to range

from 59% to 89% (Margiotta, Bianchetti, Ranieri, & Tra-

bucchi, 2006).

There were 495,000 Koreans (8.9% of the population

aged over 65 years) with a diagnosis of dementia in

2011, with an increase of 3.4% in one year (n=469,000

or 5.5%)(Ministry of Health and Welfare, 2011). Currently,

in Korea, approximately one in ten older adults aged

over 65 years is diagnosed with dementia. The propor-

tion of Korean people with dementia is projected to

reach 9.7%(n=750,000) by 2020 as the growth of the

older population continues (Ministry of Health and Wel-

fare, 2011). Despite increasing needs for long-term care

(LTC), the capacity of informal caregiving has been

shrinking due to a decrease in the rate of co-residence

of older parents and adult children alongside the in-

crease in women's employment (Jeong et al., 2005). Al-

though the number of formal LTC facilities and services

has increased following the initiation of the Long-term

Care Insurance Program in July 2008, formal LTC facili-

ties and services to replace or supplement informal care-

giving are in severe shortage. Also, the use of institu-

tionalized care services is often interpreted as children

relinquishing filial duty and older adults being aban-

doned by their adult children (Park, Butcher, & Mass,

ⓒ 2013 Korean Gerontological Nursing Society http://www.gnursing.or.kr

206 Journal of Korean Gerontological Nursing

Kang, Yun Young

Table 1. Search Strategy and Outcome

Source Limits Search termsTotal amount of

inclusions

Four major databases Cumulative Index of Nursing and Allied Health Literature (CINAHL), Proquest, PsychLit and Medline 2002~2012

Quantitative and qualitative studies

Acute care setting, older adults with dementia, management, nurses

Acute care setting, older adults with chronic confusion, management, nurses

Acute are setting, older adults with delirium, management, nurses

Acute are setting, older adults with acute confusion, management, nurses

101

13

55

32

2004). Therefore, many older adults with unmet needs

for LTC services are hospitalized, even though many of

them do not require medical care (so-called social hos-

pitalization) in Korea (Kim & Choi, 2008). This may re-

sult in an increase in the number of older Korean peo-

ple with dementia or without a diagnosis of dementia

being placed in acute care settings, because Korean so-

ciety perceives institutionalized care services negati-

vely and believe that acute care hospitals provide better

medical services (Lee & Moon, 2010). Acute care nurses

are expected to provide optimum care for these patients

with the best possible outcomes, despite the lack of

suitable ward environments, appropriate staffing or ed-

ucational preparation (Moyle, Borbasi, Wallis, Oloren-

shaw, & Gracia, 2011). However, nurses’ management

of older adults with cognitive impairment (CI) is of great

concern as their task-oriented care in a fast-paced acute

care environment may negatively impact the complexi-

ties of these patients (Moyle et al., 2011). Consequently,

facilitating care improvement for older adults with CI,

particularly those with dementia, needs to be given at-

tention in Korean acute care settings.

This literature review was done to further understand-

ing of factors affecting care management of CI in acute

care settings and to provide a discussion of the literature

focusing on educational issues for nurses caring for old-

er adults with CI in acute care settings.

METHODS

Research literature published in English or Korean is

presented in this paper. Papers included in this review

were chosen according to the following criteria:

1. Inclusion CriteriaMain focus on nurses' management of acute or chro-

nic confusion in older adults (65 years and older) in

acute care settings.

Published in a paper-reviewed journal between 2002

and 2012.

Restricted only to quantitative and qualitative studies.

2. Exclusion Criteria

Main focus was not on an acute care setting.

Published in a non-peer reviewed journal.

3. Search Strategy

Four major databases, the Cumulative Index of Nursing

and Allied Health Literature (CINAHL), Proquest, PsychLit

and Medline were searched, using combinations of

search terms including acute care setting-older adults

with dementia-management-nurses, acute care setting-

older adults with chronic confusion-management-nurses,

acute care setting-older adults with delirium-manage-

ment-nurses, and acute care setting-older adults with

acute confusion-management-nurses. Additional reports

were identified from the reference lists of retrieved pa-

pers. From a summary of the literature and field experi-

ence, a researcher distilled the following definition: acute

care setting is an in-patient adult health medical-surgical

care unit, intensive care unit, or emergency department

in a health care facility (excluding paediatrics, mother/

baby, and psychiatric units). For the relevant literature

search, it was decided to limit the review to acute care

settings that met the criteria in this definition. Table 1

gives an overview of the initial batch of articles (n= 201)

resulting from a search for which there was only a limi-

tation on publication date (2002~2012) and on type of

publication (quantitative study, qualitative study). After

selecting articles based on title and abstract and after re-

moving doubles a total of 44 articles (37 quantitative stu-

dies, 7 qualitative studies) from databases were retained.

A manual search through references and journals yield-

ed 10 more studies, of which only 4 were different. Of

Vol. 15 No. 3, 2013 207

Factors Influencing Management of Cognitive Impairment among Older Adults in Acute Care Settings: A Review of the Literature

the 48 articles retained for the literature review, 26 were

eligible for inclusion. The following discussion of the

findings commences with an identification of the com-

mon themes of factors influencing care management of

CI in older adults in acute care settings followed closely

by a critique of the educational interventions of man-

agement of CI in older adults in an acute care setting.

RESULTS

Common themes gleaned from the literature on fac-

tors affecting the management of CI in older adults as a

result of dementia or delirium in the acute care setting

provides some consensus on patient care. They are div-

ided into two factors; nurse-related and organization-

related. Nurse-related factors include a lack of know-

ledge; personal and professional characteristics; philo-

sophy of care for older adults with CI; and inadequate

assessment and documentation issues. Organizational-

related factors are; acute care culture; priority of safety;

and lack of educational efforts. Such themes offer

grounding for further research and the development of

education that would addresses the needs of older peo-

ple with CI undergoing management for co-morbidity

in acute care settings (Table 2).

1. Nurse-related Factors

1) Nurses’ Knowledge

Nurses’ knowledge about older adults with CI has a

significant influence on nursing practice for the man-

agement of CI in acute care settings (Hamdan-Mansour,

Farhan, Othman, & Yacoub, 2010). Korean nurses’ know-

ledge of delirium, especially its manifestations, were

lower (Choi et al., 2011; Lee et al., 2007). It could be as-

sumed that Korean nurses attribute the cognitive and

behavioral changes of delirium to part of the normal ag-

ing process, and they are not able to differentiate delir-

ium from dementia, because Korean society's expect-

ation is that older adults may become forgetful and

confused. It is likely that delirium is under- or misdiag-

nosed as dementia in Korea, thus preventing acute care

nurses from appropriately managing care to prevent

poor outcomes associated with CI in older adults. A re-

cent study measured registered nurses' (RNs') knowl-

edge on delirium superimposed on dementia (DSD),

using standardized case vignettes and the Mary Starke

Harper Aging Knowledge Exam (MSHAKE) in an Ame-

rican acute care setting (Fick, Kolanowski, & Waller,

2007). It was found that RNs had a high level of general

geropsychiatric nursing knowledge as measured by the

MSHAKE, yet had difficulty recognizing DSD compared

to dementia alone or delirium alone (Fick et al., 2007).

This knowledge level can result in an increase in psy-

chotropic medication use among older adults with DSD

(Fick et al., 2007), which can worsen the condition or

further delay recognition of the problem (Voyer, Ri-

chard, Doucet, & Carmichael, 2009). This indicates that

there is an association between RNs' geropsychiatric

knowledge level and quality of care management. Con-

sequently, an educational intervention developed with

the aim to increase knowledge and then awareness of

delirium in older adults with dementia is an important

consideration to improve recognition and management

of this problem (Fick et al., 2007).

A lack of knowledge contributes to low self-confi-

dence in the ability to manage delirium following as-

sessment (Flagg, Cox, McDowell, Mwose, & Buelow,

2010). Some studies explored the association between

acute care nurses’ knowledge level and self-confidence

in caring for patients with delirium in Korea and the

USA (Choi et al., 2011; Flagg et al., 2010; Yang, 2010).

These studies showed that acute care nurses with defi-

cient knowledge tended to have low confidence in ap-

propriately identifying and managing patients with de-

lirium (Choi et al., 2011; Flagg et al., 2010; Yang, 2010).

In addition to nurses’ knowledge of delirium, one study

found that there were significant differences in self-con-

fidence levels, depending on length of work experience,

status of experience of caring for patients with delirium,

and sufficient number of opportunities for delirium ed-

ucation (Yang, 2010). In this study, acute care nurses

who have worked for more than 5 years, have experi-

enced caring for patients with delirium, or have received

sufficient delirium education were most likely to have

confidence in managing delirium following assessment

(Yang, 2010). This result might be related to nurses’

perception of the importance of delirium in acute care

settings (Flagg et al., 2010). Acute care nurses are not

likely to identify delirium as a common problem and

thus compromise the quality of care provided to pati-

ents at risk for delirium (Flagg et al., 2010). These find-

ings emphasize the need of educational programs to im-

prove nurses’ knowledge.

A study in Japan (Akechi et al., 2010) investigated the

preliminary usefulness of a novel delirium training pro-

gram to improve nurses' self-confidence in caring for

patients with delirium on inpatient wards in a university-

affiliated hospital. This program showed positive results

in improving nurses' self-confidence in caring for pa-


Kang, Yun Young

Table 2. Studies on Factors Affecting the Management of CI among Older Adults in Acute Care Settings

Items Factors Findings Studies

Nurse-related Nurses' knowledge

RNs' lower knowledge level of delirium manifestations attributedthe cognitive and behavioral changes of delirium to part of the normal aging process, and they are not able to differentiate delirium from dementia.

Choi et al., 2011; Lee et al., 2007

RNs' knowledge of DSD measured by standardized care vignettes found that they had difficulty recognizing DSD compared to dementia alone and delirium alone. This knowledge level results in an increase in psychotropic medication use among older adults with DSD.

Fick et al., 2007 Hamdan-Mansour et al., 2010

Nurses' lack ofknowledge tended to result in low confidence in appropriately identifying and managing patients with delirium. They are not likely to identify delirium as a common problem and thus compromise the quality of care provided to patients at risk for delirium.

Choi et al., 2011; Flagg et al., 2010;

Yang, 2010

Nurses' personal and professional characteristics

RNs who had a master's degree, had received gerontological education or had perceived the necessity of in-service education for older adults' care, had a higher knowledge level of delirium than those who did not have this education.

Lee et al., 2007

Regardless of educational level, years of experience, or shift worked, orthopedic RNs had difficulty with knowledge related to the recognition of delirium, risk factors, and medications that can contribute to delirium.

Meako et al., 2011

Higher levels of knowledge as a result of education equal more positive attitudes and greater tolerance

Kata et al., 2009; Nilsson et al., 2012

Nurses' negative attitudes attributed delirium to the individual client's personality and not to a physiologic, pathological condition that presents as a disturbance to cognition.

Dahlke & Phinney, 2008; McDonnell & Timmins, 2012

A lack of knowledge and skill led nurses to feel powerless, frustrated and a failure when faced with challenging behaviors thus they increased use of medication and physical restraint to mediate these behaviors

Moyle et al., 2011;Voyer et al., 2009

Nurses' philosophy of care in older adults with CI

Nurses using the healthful perspective were more likely to differentiate between acute and chronic confusion in hospitalized older adults, whereas nurses using the decline perspective were least likely to detect acute confusion.

McCarthy, 2003

Cognitive decline was accepted as normal and contributed to delay or neglect in the assessment of delirium, which results in low rates of recognition of delirium, although delirium is a medical emergency.

Yevchak et al., 2012

Nurses' inadequate assessment and documentation

Nurses superficially assessed their patients' cognition, using subtle questioning and observed behavioral cues, or they only focused on a few questions about orientation due to a lack of knowledge and awareness of cognitive assessment tools.

Choi et al., 2011; Dahlke & Phinney, 2008;

Lee et al., 2007; Yang, 2010;


Nurses depended on reports by family caregivers, the primary carers for hospitalized older adults, who had been asked to watch for symptoms of cognitive decline. Therefore, confused behavior may be overlooked, because family caregivers are not skilled at detecting delirium.

Choi et al., 2011; Lee et al., 2007;

Yang, 2010

With an inaccurate documentation of patients' cognitive status, delirium features weremisinterpreted as dementia or other similar cognitive impairments, adding to the difficulty differentiating delirium from dementia.

Fick et al., 2007; Steis & Fick, 2012

Vol. 15 No. 3, 2013 209


Table 2. Studies on Factors Affecting the Management of CI among Older Adults in Acute Care Settings (Continued)

Items Factors Findings Studies

Organizational-related

Acute care culture Acute care culture focuses on technological and task-driven care, and thus older adults with dementia are devalued and a holistic approach to care is limited, because of the inconveniences that these patients cause to nurses' routines.

Moyle et al, 2011

Priority of safety For both staff safety and patient security, nurses suggested that chemical or physical restraints were needed to control challenging behaviors in persons with CI, despite the fact that these restraints are risk factors for developing delirium.

Dahlke & Phinney, 2008; Moyle et al., 2011; Park et al., 2006;


Lack of educational efforts

Due to a lack of educational efforts regarding the assessment and management of CI, nurses have not integrated them into their everyday nursing care. As a result, nurses tend to focus more on the patients' physical signs and symptoms rather than their cognitive status.

Moyle et al., 2011; Yang, 2010;


tients with delirium (Akechi et al., 2010). Clinical guide-

lines for nurses should also incorporate a formal educa-

tional program on their use to provide high-quality care

to hospitalized older patients with CI and to improve

acute care nurses' self-confidence (Akechi et al., 2010;

Meako, Thompson, & Cochrane, 2011).

2) Nurses’ Personal and Professional Characteristics

Nurses' personal and professional characteristics seem

to have an influence on the quality of care management

and in particular their knowledge about older adults

with CI (Nilsson, Lindkvist, Rasmussen, & Edvardsson,

2012). Depending on nurses' educational level, attend-

ance at gerontological education course, and percep-

tion of the necessity of in-service education related to

older adults' care, there are differences in the level of

their knowledge of delirium (Lee et al., 2007). In this

study, RNs who had a master's degree, had received

gerontological education or had perceived the necessity

of in-service education for older adults' care had a high-

er level of knowledge of delirium than those who did

not these characteristics (Lee et al., 2007). Meanwhile,

regardless of educational level, years of experience, or

shift worked, orthopedic RNs had difficulty with knowl-

edge related to recognition of delirium, risk factors, and

medications that can contribute to delirium (Meako et

al., 2011).

Nurses’ negative attitudes towards older adults with

CI as well as their lower knowledge level can be an ob-

stacle to the provision of quality care (Dahlke & Phin-

ney, 2008; Kada, Nygaard, Mukesh, & Geitung, 2009;

Nilsson et al., 2012). Previous studies found that nurses

who had negative attitudes were most likely to have

lower levels of education (Kada et al., 2009; Nilsson et

al., 2012). In other words, a higher level of knowledge

as a result of education equals a positive attitude and

greater tolerance (Kada et al., 2009; Nilsson et al., 2012).

Nurses’ negative attitudes attribute delirium to the indi-

vidual client's personality and not to a physiologic, pa-

thological condition that is presented as a disturbance

to cognition (Dahlke & Phinney, 2008). Consequently,

hospitalized older adults with CI are viewed as a bur-

den, because disruptive behaviors are strong predictors

of nurses’ distress that can potentially impact negatively

on patients’ care (Dahlke & Phinney, 2008; McDonnell

& Timmins, 2012). Nurses also experience feelings of

discomfort and incomprehension when dealing with

patients suffering from delirium (Dahlke & Phinney,

2008). Akechi et al., (2010) identified an association be-

tween level of knowledge and skill in relation to cogni-

tion disorders and nurses’ perception of the disorders.

A lack of knowledge and skill led nurses to feel power-

less, frustrated and a failure when faced with challeng-

ing behaviors, so they increased the use of medication

and physical restraint to mediate these behaviors (Voyer

et al., 2009). Consequently, hospitalized older adults

with CI may receive an inferior quality of care in com-

parison to patients without CI, as they are often cared

for by nurses with minimal knowledge or training in this

field (Moyle et al., 2011).

In summary, nurses need more formal education and

training to acquire appropriate knowledge, which can

improve nurses’ self-confidence in assessing and man-

aging the CI of hospitalized older adults as well as pro-

mote positive attitudes (Akechi et al., 2010; McDonnell

& Timmins, 2012; Nilsson et al., 2012). This improved

care practice should result in positive outcomes for

these patients.


Kang, Yun Young

3) Nurses’ Philosophy of Care in Older Adults with CI

Nurses’ philosophy of care is frequently based on in-

dividual beliefs rather than on evidence for the delivery

of care (McCarthy, 2003). McCarthy (2003) revealed that

recognition of acute confusion was influenced by the

philosophical orientation of the nurse towards health in

aging. Three distinct perspectives were identified; (1)

decline perspective (regards health in aging as decre-

mental), (2) vulnerable perspective (regards health in

aging as either positive or negative), and (3) healthful

perspective (regards ‘good health’ in aging as normal).

Nurses using the healthful perspective were more likely

to differentiate between acute and chronic confusion in

hospitalized older adults, whereas nurses using the de-

cline perspective were least likely to detect acute con-

fusion (McCarthy, 2003). In addition, the fact that cogni-

tive decline is accepted as normal contributes to delay

or neglect in the assessment of delirium, which can re-

sult in low rates of recognition of delirium, although de-

lirium is a medical emergency (Yevchak et al., 2012). In

older adults with dementia, changes in cognition and

behavior are seldom perceived as important and thus

are more often managed with chemical or physical re-

straints, as a result of being viewed as negative and un-

acceptable (Yevchak et al., 2012). Consequently, em-

phasis should be given to nurses’ views and knowledge

with regard to health in older adults.

4) Nurses’ Inadequate Assessment and Documentation

A lack of knowledge about delirium and its detection

following assessment affects decisions regarding strat-

egies to care for and manage older people in acute care

settings (Yevchak et al., 2012). In fact, nurses are well-

placed to systematically screen for and recognize de-

mentia or delirium in hospitalized older adults because

of their significant presence at the bedside (Fick et al.,

2007). However, the difficulty nurses have in recogniz-

ing delirium (Fick et al., 2007; Yevchak et al., 2012), de-

mentia (Moyle et al., 2011) and DSD (Fick et al., 2007;

Steis & Fick, 2012) has been substantiated.

Acute care nurses superficially assess their patients’

cognition, using subtle questioning and observed be-

havioral cues (Choi et al., 2011; Dahlke & Phinney, 2008;

Lee et al., 2007; Yang, 2010) or they only focus on a few

questions about orientation such as ‘Where are you?’ or

‘Who is your doctor?’ due to a lack of knowledge or

awareness of cognitive assessment tools in the acute

care environment (Yevchak et al., 2012). Also, nurses in

Korea are dependent on reports by family caregivers as

the primary caregivers for hospitalized older adults,

who have been asked to observe the symptoms of cog-

nitive decline (Choi et al., 2011; Lee et al., 2007; Yang,

2010). As a result, confused behavior may be over-

looked, because family caregivers are not skilled at de-

tecting delirium (Yang, 2010). There is a possibility that

hospitalized older adults are managed by nurses' sub-

jective assessment, rather than objective assessment in-

struments.

Currently, nurses are using the term confusion to de-

scribe their patients’ mental status and this is ineffective

in providing quality care management of a patient's

cognitive functioning as it is not a clear term because of

the many different definitions used among health care

professionals (Steis & Fick, 2012). Using this term may

demonstrate that instead of terms prompted by assess-

ment tools such as the Confusion Assessment Method

(CAM) for mental status, nurses limit their assessment to

orientation only and therefore fail to recognize the be-

havioral aspects of delirium in their patients (Steis &

Fick, 2012).

With an inaccurate documentation of patients’ cogni-

tive status, delirium features may be misinterpreted as

dementia or other similar cognitive impairments, add-

ing to the difficulty of discerning delirium from demen-

tia (Fick et al., 2007; Steis & Fick, 2012). Steis and Fick

(2012) reported that American nurses did not recognize

delirium as evidenced by the absence of nurses' nota-

tions of the terms delirium or acute confusion. Also,

nurses documented confused more often in the DSD

group than in the no delirium (ND) group, but there

was no indication that the nurses’ use of the term con-

fusion communicated that the patient was experiencing

delirium (Steis & Fick, 2012). Consequently, it is not

clear whether the term confusion as used by nurses in-

dicates confusion with dementia or delirium as this term

is not consistently defined. As a result, inappropriate

management of delirium or dementia following under-

detection or misdetection leads to an increase in nurs-

ing workload as well as adverse outcomes for older

adults (Pretto et al., 2009).

Therefore, educational efforts are needed to improve

nurses’ ability to detect delirium early as well as to im-

prove their management skills in the busy acute care

environment (Steis & Fick, 2012). Nurses who are caring

for older adults are unsure of how to assess CI, not be-

ing able to differentiate between dementia and delirium

as a result of lack of knowledge and awareness of cog-

nitive assessment tools (Moyle et al., 2011; Yevchak et

al., 2012). Also, they incorrectly assume that a standard

neurological examination is sufficient to identify signs

Vol. 15 No. 3, 2013 211


of delirium (Flagg et al., 2010). Nurses need to begin to

use the term delirium as a well-defined and objective la-

bel consistently, in line with their assessment results

rather than the term confusion, which causes misunder-

standings in the process of observation and diagnosis

(Steis & Fick, 2012).

2. Organizational Characteristics of Acute Care

1) Acute Care Culture

In an acute care culture that focuses on technological

and task-driven care, older adults with dementia are de-

valued and a holistic approach to care is limited, be-

cause of the inconveniences that they cause to nurses’

routines (Moyle et al., 2011). As a result, patients with

disruptive behaviors are managed with physical or che-

mical restraints rather than compassionate care to meet

complex care needs (Moyle et al., 2011). Hospitalized

older adults with CI are frequently inadequately as-

sessed and managed based on a medical model of care

delivery that focuses attention solely on the patients'

acute condition (Moyle et al., 2011).

This kind of care also frequently fails to incorporate

the family into the care of hospitalized older adults with

CI (Moyle et al., 2011). Family members as primary

caregivers may be able to recognize a change in pati-

ents’ mental status, even though nurses may have iden-

tified the problem incorrectly (Fick et al., 2007). Acute

care nurses with a better understanding of CI have the

self-confidence to accurately explain delirium presen-

tation and management to patients’ families. This then

empowers family members to participate in patient care

in an effort to reduce the complications associated with

the development of delirium and avoid family suffering

(Flagg et al., 2010).

2) Priority of Safety

Safety is the number one priority identified by nurses

when caring for both chronically or acutely confused

patients. Moyle et al., (2011) reported that Australian

acute care nurses focused on minimizing injury or harm

to a patient, other patients and staff as a consequence of

a lack of understanding about the difference between

dementia and delirium. Despite the importance of per-

son-centered care for people with CI, this care appear-

ed to be overlooked, with resources being allocated

based on the level of risk rather than the level of need

(Moyle et al., 2011).

As a best care practice, person-centered care for older

adults with CI is encouraged to respect the person's past

and focus on ability, rather than disability (Moyle et al.,

2011). However, studies have shown that nurses moved

confused patients' beds close to the nursing station or

into the hallways, or placed patients in geriatric chairs

during the day or at night to restrain movement with lit-

tle perception of the importance of cognitive assess-

ment (Dahlke & Phinney, 2008; Yevchak et al., 2012).

Assessment and care management in such situations

seemed to be task-orientated, rather than about meeting

the psychosocial needs of the confused person (Moyle

et al., 2011). This task-orientated care is commonly used

to prevent falls and to watch over the confused patient

to reduce risks to patient's safety (Dahlke & Phinney,

2008; Yevchak et al., 2012).

For both staff safety and patient security, nurses sug-

gest that chemical or physical restraints are needed to

control challenging behaviors in persons with CI, de-

spite the fact that these restraints are risk factors for de-

veloping delirium (Dahlke & Phinney, 2008; Moyle et

al., 2011; Yevchak et al., 2012). Often older patients

with dementia may be prescribed antipsychotic medi-

cation without recognition or management of the un-

derlying cause of the behavior (Voyer et al., 2009).

Delirium is a cause of disruptive behaviors in many in-

stances (Fick et al., 2007), and inappropriate use of

these medications in hospitalized older adults with de-

mentia may worsen the condition, or further delay rec-

ognition of the problem and thus increase the risk of

death for these patients with dementia (Fick et al., 2007;

Voyer et al., 2009). Safety and the quality of nursing

care provided to hospitalized older adults with demen-

tia at risk for delirium is compromised, and as a result

their lives might be at risk.

As the first line of care management, acute care nurses

need to recognize delirium and use non-pharmacologi-

cal interventions (Fick et al., 2007). However, currently

nurses’ practice is often based on nurses’ experiential

knowledge and trial and error, rather than evidence for

the management of delirium (Yevchak et al., 2012). In

Korea, most acute care nurses are likely to be interested

in the treatment of delirium, despite the importance of

its prevention (Park, Kim, Song, & Kang, 2006). The val-

ue or consequences of currently used non-medication

strategies to manage delirium should be replaced by

evidence-based training and knowledge with practical

guidelines to implement non-pharmacological strategies

(Yevchak et al., 2012).

3) Lack of Educational Efforts

Due to a lack of educational efforts regarding the as-


Kang, Yun Young

sessment and management of CI, nurses have not in-

tegrated these into their everyday nursing care (Moyle

et al., 2011; Yang, 2010; Yevchak et al., 2012). In acute

care settings, cognitive assessment is not routinely con-

sidered as an important component of standardized nurs-

ing care (Moyle et al., 2011; Yang, 2010; Yevchak et al.,

2012). As a result, nurses tend to focus more on the pa-

tients' physical signs and symptoms rather than their

cognitive status. A study in Jordan confirmed an associ-

ation between knowledge and nursing practice and

found that ICU RNs with more knowledge about delir-

ium were more likely to have a higher level of effective

nursing practice regarding its management (Hamdan-

Mansour et al., 2010).

In Korean acute care settings, there has been little at-

tention given to education or training about the man-

agement of CI. Yang (2010) reported that 24.3 % of

Korean acute care nurses had not received any training

or education on delirium, and 74.9% of those who had

received education on delirium had only a basic under-

standing of the subject. As a result, acute care nurses ex-

perience an elevated level of stress and strain when

managing these patients due to the challenge of im-

plementing highly skilled assessment and care planning

(McDonnell & Timmins, 2012; Yevchak et al., 2012).

This deficit also results in disruptive behaviors because

hospitalized older adults with delirium or dementia do

not have their physical and mental health needs met

(Moyle et al., 2011).

In order to change practices with regard to the ap-

propriate management of dementia or delirium follow-

ing cognitive assessment, the use of cognitive assess-

ment instruments at the bedside should be incorpo-

rated into nursing education to promote more consis-

tent assessment and higher levels of recognition of de-

lirium or dementia (Steis & Fick, 2012). In the end, pro-

viding education to acute care nurses may help to pro-

vide a solution to these problems and can potentially

lead to improved health outcomes and considerable

cost savings.

3. Educational Interventions for Nurses

Studies were reviewed to evaluate the effectiveness

of approaches to education for delirium or dementia

(Akechi et al., 2010; Fick et al., 2011; Lundström et al.,

2005; Lundström et al., 2007; Meako et al., 2011; Naugh-

ton et al., 2005; Pretto et al., 2009; Robinson, Rich, Weit-

zel, Vollmer, & Eden, 2008; Tabet et al., 2005; Voellin-

ger et al., 2011). In these studies, assessment measures

are divided into two measures: nurses’ outcome meas-

ures and patient clinical outcome measures, in order to

assess the effectiveness of the educational intervention.

Despite a number of methodological limitations, it is

reported in some studies that nurses knowledge regard-

ing delirium or dementia improved significantly after

the educational intervention (Meako et al., 2011; Vo-

ellinger et al., 2011) and their performance improved,

showing an increase in nursing assessments for delirium

(Lundström et al., 2007) and the initiation of targeted

management of hospitalized older adults with cognitive

decline (Lundström et al., 2007). With a better under-

standing of assessment and management, delirium was

consequently detected and managed more quickly,

which led to less care needed, especially at night (Pretto

et al., 2009). Meako et al., (2011) investigated the effec-

tiveness of an educational intervention based on evi-

dence to improve orthopedic nurses’ knowledge of

delirium. An educational intervention, given as an

in-service and lecture format with Power Point slides,

was developed on the basis of nationally recommended

guidelines from the American Association of Colleges of

Nursing and the John A. Hartford Foundation Institute

for Geriatric Nursing's Geriatric Nursing Education Con-

sortium in the USA. The presentation contains content

that helps to distinguish between delirium and demen-

tia, recognize risk factors including medications con-

tributing to delirium, and to formulate a management

plan for delirium. Regardless of educational level or

years of experience, a baseline knowledge assessment

confirmed nurses' lack of understanding of delirium.

This baseline knowledge improved significantly follow-

ing the one-hour educational intervention.

In other studies, results also showed positive patient

health care outcomes such as a reduced incidence of

delirium post-intervention (Naughton et al., 2005; Robin-

son et al., 2008; Tabet et al., 2005), fewer complications

during hospitalization and shorter length of stay (Lund-

ström et al., 2007, 2005; Naughton et al., 2005), espe-

cially in people with dementia (Lundström et al., 2007).

However, for the prevention and management of delir-

ium, dementia or DSD, all educational intervention pro-

grams claimed moderate successes (Akechi et al., 2010;

Fick et al., 2011; Lundström et al., 2005, 2007; Meako et

al., 2011; Naughton et al., 2005; Pretto et al., 2009;

Robinson et al., 2008; Tabet et al., 2005; Voellinger et al.,

2011). Table 3 displays studies evaluating the impact of

an educational intervention to improve delirium know-

ledge for acute care.

Vol. 15 No. 3, 2013 213


Tabl

e 3.

Stu

dies

Eva

luat

ing

the

Impa

ct o

f Edu

catio

nal I

nter

vent

ions

for A

cute

Car

e

Ref

eren

ceEduca

tional

met

hod

Study

des

ign

Par

tici

pan

tsO

utc

om

e m

easu

res

Lim

itat

ions

Akec

hi

et a

l.

(201

0)

Del

iriu

m T

rain

ing

Pro

gram

: R

Ns

sele

cted

fro

m e

ach w

ard, w

ho

bec

om

e th

e del

iriu

m-lin

k n

urs

es,

rece

ived

a 4

-hour

work

shop incl

udin

g

lect

ure

s, d

iscu

ssio

n a

nd tra

inin

g in

the

use

of

the

Nee

lon C

ham

pai

gne

Confu

sion A

sses

smen

t Sc

ale

(NEEC

HA

M)

and then

pas

sed o

n thei

r sp

ecia

l tr

ainin

g to

the

oth

er n

urs

es in

th

eir

war

ds

thro

ugh

sm

all gr

oup

dis

cuss

ions

and c

ase

pre

senta

tions

Bef

ore

/after

in

terv

ention

390

RN

s in

inpat

ient

war

ds

of

gener

al

hosp

ital

s

Res

earc

her

-dev

eloped

mea

sure

(15

-ite

m

self-c

onfiden

ce m

easu

re):

sig

nific

ant

impro

vem

ent in

RN

's s

elf-

confiden

ce

rega

rdin

g as

sess

men

t an

d c

are

for

pat

ient w

ith d

elir

ium

in inte

rven

tion

gr

oup

No a

sses

smen

t of

RN

s' a

ctual

per

form

ance

or

pat

ients

' outc

om

es

Not a

random

ized

contr

olle

d tri

alN

o s

ignific

ant ef

fect

on e

arly

det

ection

The

exis

tence

of

bac

kgr

ound

diffe

rence

s due

to a

big

gap

of

test

-com

ple

tion b

etw

een c

ontr

ol gr

oup

(2

6%)

and inte

rven

tion g

roup (

88%

)

Inst

rum

ent's

val

idity

and r

elia

bili

ty n

ot

confirm

ed

Mea

ko

et a

l.

(201

1)

1-hour

in-s

ervi

ce e

duca

tion o

n d

elir

ium

in

lec

ture

form

at b

ased

on

reco

mm

ended

guid

elin

es

Bef

ore

/after

in

terv

ention

23 o

rthoped

ic R

Ns

in o

ne

singl

e ge

ner

al h

osp

ital

Res

earc

her

-dev

eloped

mea

sure

(10

m

ultip

le-c

hoic

e ques

tions)

: si

gnific

ant

impro

vem

ent in

RN

's k

now

ledge

aft

er

the

educa

tion p

rogr

am

Smal

l sa

mp

le s

ize

Educa

tional

inte

rven

tion n

ot va

lidat

edRN

's k

now

ledge

exa

min

ed im

med

iate

ly

afte

r th

e ed

uca

tional

inte

rven

tion

For

the

inst

rum

ent, c

onte

nt va

lidity

by

nurs

e ex

per

ts a

nd then

pilo

t te

stin

g

conduct

ed b

ut its

relia

bili

ty n

ot

confirm

ed

Voel

linge

r et

al.

(201

1)

1-hour

trai

nin

g se

ssio

ns

in s

mal

l gr

oups,

fo

cusi

ng

on p

reve

ntion a

nd s

cree

nin

g

and u

se o

f cl

inic

al p

ract

ice

guid

elin

es

Bef

ore

/after

in

terv

ention

62 R

Ns

and 2

3 as

sist

ant nurs

es in

neu

rolo

gy &

neu

rosu

rger

y w

ards

Res

earc

her

-dev

eloped

mea

sure

(1

3-ques

tion m

ultip

le c

hoic

e ques

tionnai

re):

sig

nific

ant

impro

vem

ent in

RN

's k

now

ledge

thre

e m

onth

s af

ter

the

educa

tion inte

rven

tion

Low

rat

e of p

artici

pat

ion thre

e m

onth

s af

ter

inte

rven

tion

Inst

rum

ent's

val

idity

and r

elia

bili

ty n

ot

confirm

ed

Fick

et

al.

(201

1)

DSD

educa

tional

module

s fo

cusi

ng

on

cl

inic

al a

sses

smen

t of

del

iriu

m u

sing

the

CA

M, an

d o

n m

anag

emen

t of D

SD,

and u

se o

f cl

inic

al p

roto

cols

in

el

ectr

onic

med

ical

rec

ord

s (E

MR)

in

60-m

inute

ses

sions

Pro

spec

tive

co

hort

pilo

t st

udy

All

unit-b

ased

RN

s an

d lic

ense

d

pra

ctic

al n

urs

es

(LPN

s)

Nurs

e ad

her

ence

to E

MR

docu

men

tation: 10

0% o

n the

del

iriu

m

asse

ssm

ent dec

isio

n s

upp

ort

scr

eens

and 7

5% o

n the

man

agem

ent sc

reen

s

No r

andom

ized

contr

ol g

roup

C

linic

al p

roto

col in

EM

R n

ot te

sted

Lundst

röm

et a

l.

(200

7)

A m

ulti-fa

ctori

al inte

rven

tion p

rogr

am:

a 4-

day

cours

e co

veri

ng

rehab

ilita

tion,

team

work

, in

div

idual

car

e pla

nnin

g,

del

iriu

m a

nd a

ssoci

ated

com

plic

atio

ns,

an

d u

se o

f pro

toco

ls f

or

pai

n

man

agem

ent an

d r

isk fac

tors

for

post

oper

ativ

e co

mplic

atio

ns

and

del

iriu

m

Ran

dom

ized

in

terv

ention

Staf

f w

ork

ing

in a

ge

riat

ric

unit

spec

ializ

ing

in

ort

hoge

riat

rics

Lengt

h o

f st

ay: sh

ort

er (

5 vs

.10

day

s) in

in

terv

ention g

roup

Com

plic

atio

ns:

few

er in inte

rven

tion

group

Lengt

h o

f st

ay: sh

ort

er in inte

rven

tion

group

The

num

ber

of day

s of p

ost

-oper

ativ

e del

iriu

m: le

ss p

ost

op

erat

ive

day

s (3

.2

vs. 12

.8)

with d

elir

ium

in p

eop

le w

ith

dem

entia

in in

terv

ention g

roup

Char

t re

view

use

d to d

iagn

ose

del

iriu

m.

Ass

esso

rs n

ot blin

ded

to the

war

d o

f th

e p

atie

nt

Tw

o g

roups

uneq

ual

at bas

elin

e fo

r w

ard typ

e (s

urg

ical

vs.

ger

iatr

ic tra

ined

st

aff)


Kang, Yun Young

Tabl

e 3.

Stu

dies

Eva

luat

ing

the

Impa

ct o

f Edu

catio

nal I

nter

vent

ions

for A

cute

Car

e (C

ontin

ued)

Ref

eren

ceEduca

tional

met

hod

Study

des

ign

Par

tici

pan

tsO

utc

om

e m

easu

res

Lim

itat

ions

Lundst

röm

et a

l.

(200

5)

A m

ulti-fa

ctori

al inte

rven

tion p

rogr

am:

educa

tion focu

sing

on the

asse

ssm

ent,

pre

vention, an

d tre

atm

ent of del

iriu

m,

and o

n c

areg

iver

-pat

ient in

tera

ctio

n,

month

ly g

uid

ance

fo

r nurs

ing

staf

f,

and r

eorg

aniz

atio

n fro

m a

ta

sk-a

lloca

tion c

are

syst

em to a

pat

ient-

allo

cation s

yste

m w

ith

in

div

idual

ized

car

e

Pro

spec

tive

ca

se-c

ontr

ol

study

RN

s an

d d

oct

ors

(D

rs)

on a

med

ical

w

ard

Dura

tion o

f del

iriu

m: lo

wer

rat

es a

t day

se

ven in inte

rven

tion w

ard

Lengt

h o

f st

ay: sh

ort

er in inte

rven

tion

war

d

Mort

ality

duri

ng

hosp

ital

izat

ion: lo

wer

in

inte

rven

tion w

ard

Pat

ients

not ra

ndom

ly a

lloca

ted to

in

terv

ention o

r co

ntr

ol w

ard

Pre

sence

of

del

iriu

m n

ot as

sess

ed d

aily

Nau

ghto

n

et a

l.

(200

5)

A m

ulti-fa

ctori

al inte

rven

tion p

rogr

am:

dev

elop

men

t of

guid

elin

es a

nd

pro

toco

ls for

the

asse

ssm

ent an

d

med

icat

ion m

anag

emen

t of p

atie

nts

w

ith d

elir

ium

, beh

avio

ral dis

turb

ance

an

d c

ogn

itiv

e im

pai

rmen

t

Bef

ore

/after

in

terv

ention

RN

s an

d D

rsin

an

emer

gency

dep

artm

ent (E

D)

and a

n a

cute

ge

riat

ric

unit

(AG

U)

Pre

vale

nce

of del

iriu

m: si

gnific

antly

reduce

d a

t 4

(22.

7%)

and 9

month

s (1

9.1%

) co

mpar

ed w

ith b

asel

ine

(40.

95)

Lengt

h o

f st

ay: sh

ort

er for

del

irio

us

pat

ients

in A

GU

com

par

ed w

ith

bas

elin

e pre

-AG

U p

atie

nts

(11

.5 v

s. 8

.2

day

s)

Less

contr

ol of co

nfo

undin

g fa

ctors

with

pre

/post

-tes

t des

ign

Leve

l of ex

per

ience

with g

eria

tric

pat

ients

in s

taff

on A

GU

lik

ely

to h

ave

bee

n c

onsi

der

ably

gre

ater

than

non-A

GU

war

ds,

incr

easi

ng

the

diffe

rence

bet

wee

n g

roups

Pre

tto

et a

l.

(200

9)

An inte

rdis

ciplin

ary

nurs

e-le

d d

elir

ium

pre

vention a

nd m

anag

emen

t pro

gram

(D

PM

P):

educa

tion focu

sing

on

pre

vention, ea

rly

reco

gnitio

n, an

d

trea

tmen

t of del

iriu

m

Bef

ore

/after

in

terv

ention

pilo

t st

udy

All

nurs

ing

and

surg

ical

sta

ff o

n a

tr

aum

a w

ard

(i

nte

rven

tion)

or

on the

oth

er

surg

ery

war

ds

Nurs

ing

work

load

: re

duct

ion b

y 22

% a

t nig

ht on the

trau

ma

war

d c

om

par

ed

with o

ther

surg

ical

war

ds

afte

r th

e in

terv

ention

Del

iriu

m c

ases

det

ecte

d s

ubje

ctiv

ely

usi

ng

a non-v

alid

ated

scr

eenin

g to

ol

Fact

ors

confo

undin

g w

ork

load

on

diffe

rent w

ards

not co

ntr

olle

d f

or

smal

l sa

mp

le s

ize

with p

ow

er les

s th

an 0

.8

Robin

son

et a

l.

(200

8)

Four

hal

f-day

cla

sses

on d

elir

ium

, dem

entia,

sen

sory

loss

es a

nd m

obili

ty

for

nurs

ing

assi

stan

ts, si

mila

r ed

uca

tion

to p

rofe

ssio

nal

nurs

es in s

taff

mee

tings

an

d u

se o

f a

del

iriu

m p

reve

ntion

pro

toco

l

Bef

ore

/after

in

terv

ention

RN

s &

nurs

ing

assi

stan

ts o

n a

re

nal

unit

Inci

den

ce o

f del

iriu

m: le

ss a

fter

the

inte

rven

tion (

37.5

vs.

13.

8%)

Del

iriu

m d

etec

ted v

ia o

nly

ret

rosp

ective

ch

art re

view

A v

alid

ated

tool to

dia

gnose

del

iriu

m

not use

d

No a

sses

smen

t of

the

pro

toco

l ad

her

ence

Tab

et e

t al

.

(200

5)

A 1

-hour

did

actic

pre

senta

tion, sm

all

group d

iscu

ssio

n, w

ritten

man

agem

ent

guid

elin

es a

nd f

ollo

w-u

p s

essi

ons

Pro

spec

tive

ca

se-c

ontr

ol

study

Nurs

es a

nd d

oct

ors

w

ork

ing

on a

n

acute

med

ical

w

ard

Poin

t pre

vale

nce

of del

iriu

m: le

ss o

n

inte

rven

tion w

ard (

9.8

vs. 19

.5%

)

Clin

ical

sta

ff in the

inte

rven

tion w

ard

more

lik

ely

to c

orr

ectly

iden

tify

del

iriu

m

Ass

esso

rs n

ot blin

d to the

pat

ient's

war

d

stat

us

Pre

vale

nt ca

ses

of del

iriu

m m

aybe

mis

sed w

ith a

one-

off

ass

essm

ent

mad

e by

revi

ewin

g file

s on a

dm

issi

on

Vol. 15 No. 3, 2013 215


DISCUSSION

In the literature, there are nurse-related and organiza-

tional-related factors affecting the management of CI in

hospitalized older adults. The acute care settings consti-

tute a different care environment, culturally focusing on

technological and task-driven care, and the priority of

safety and lack of educational efforts regarding the as-

sessment and management of CI (Moyle et al., 2011;

Yang, 2010; Yevchak et al., 2012). In the busy acute care

environment, educational efforts are needed to acquire

appropriate knowledge, which can improve nurses'

ability to assess and manage the CI of older adults as

well as promote positive attitudes (Akechi et al., 2010;

McDonnell & Timmins, 2012; Nilsson et al., 2012). This

improved care practice may result in positive outcomes

for these patients. However, little attention has been

paid to enhance acute care nurses' management toward

CI in older adults, although the number of older adults

with dementia admitted to acute care settings has rapid-

ly increased in Korea. Based on an incorrect assumption

that a standard neurological examination is sufficient to

identify delirium, nurses are more likely to focus on ob-

vious medical diagnoses (Flagg et al., 2010). They may

overlook cognitive and behavioral changes in older pa-

tients, which lead to inappropriate management of CI in

acute care settings. The reason may be the result of a

lack of knowledge and awareness of cognitive assess-

ment tools, or not being able to differentiate between

dementia and delirium (Moyle et al., 2011; Yevchak et

al., 2012). Also, the development of a nursing education

program to improve care management for people with

CI is arguably not seen to be a priority in an acute care

setting. In Korea, the majority of acute care settings have

no standardized care protocols to manage dementia or

delirium following cognitive assessment. Although Ko-

rean acute care nurses address the educational needs of

these patients, formal education or training rarely in-

cludes the assessment and management of CI (Park et

al., 2006). Family members as the primary caregivers are

at the bedside 24 hours a day for hospitalized older

adults and they are usually asked to watch for symp-

toms of cognitive decline. However, confused behavior

could be overlooked by professional nurses as they are

bound by Korean social expectations of filial piety, and

the family caregivers are not skilled at detecting delir-

ium (Yang, 2010). It is assumed that family members as

the primary caregivers are not able to manage dementia

or delirium without receiving appropriate education.

Consequently, delirium is often missed in hospita-

lized older adults, and this condition may be mislabeled

as dementia, acute care nurses not being able to distin-

guish dementia from delirium (Fick et al., 2007). As evi-

denced by the absence of nurses’ use of the terms delir-

ium or acute confusion in documentation (Steis & Fick,

2012), nurses' low rates of identifying delirium has been

linked to multiple factors. Identified nurse-related fac-

tors include a lack of knowledge about delirium, or de-

mentia and its detection (Fick et al., 2007). A lack of

awareness among nurses of the clinical importance of

delirium was also found to be linked to undetected de-

lirium (Yevchak et al., 2012). The result can be in an in-

crease in psychotropic medication use among hospi-

talized older adults with delirium, in particular those

with DSD (Fick et al., 2007), which can worsen the con-

dition or further delay recognition of the problem

(Voyer et al., 2009). This factor indicates that there is an

association between nurses' knowledge level and the

quality of care management of CI.

Acute care nurses might lack formal and evidence-

based training, which results in a lower knowledge lev-

el and negative attitudes toward older adults with CI, al-

though they might encounter patients with delirium

who are being managed without clinical care protocols

for CI (Choi et al., 2011; Kada et al., 2009; Lee et al.,

2007; Nilsson et al., 2012). This is especially the case in

Korea where acute care nurses do not have the appro-

priate nursing education in relation to the management

of delirium in hospitalized older adults (Choi et al., 2011;

Lee et al., 2007). Acute care nurses have the potential to

improve patients’ outcomes through the early detection

of dementia or delirium in their patients. In order to im-

prove knowledge and attitudes towards older adults

with or without dementia who have delirium, an educa-

tional intervention needs to be developed to prompt

nurses' recognition and management of these problems

(Fick et al., 2007). With a better understanding of CI,

acute care nurses can empower family members to un-

derstand the symptoms and management of delirium

and therefore enable a reduction in the complications

associated with the development of delirium as well as

additional cost and suffering for patients and family care-

givers (Flagg et al., 2010).

CONCLUSION

This review identifies the potential for nurses’ knowl-

edge deficit of CI as well as how negative attitudes influ-

ence the quality of care management in acute care set-

tings. It also emphasizes the need for education, which


Kang, Yun Young

has the potential to lead to a significantly positive im-

provement in nurses’ knowledge and attitudes and the

appropriate management and empowerment of family

members to participate through the early detection of de-

mentia or delirium in hospitalized older adults with CI.

As a result, it can potentially maximize patients' pos-

itive health outcomes, minimize health care costs, and

decrease the emotional distress of family caregivers.

Studies have shown that nurses’ level of knowledge and

attitudes towards older adults with CI are critical factors

contributing to the quality of care in their patients. Within

the literature, despite some consensus on the manage-

ment of older adults with CI in an acute care setting

(Moyle et al., 2008), knowledge and skills as well as atti-

tudes towards the care of older adults with CI have been

emphasized less, resulting in acute care nurses in Korea,

failing to appreciate the challenges associated with car-

ing for older adults with CI (Choi et al., 2011; Lee et al.,

2007; Yang, 2010). Clinically, differentiation between

dementia and delirium is important as delirium points to

a serious illness and may indicate that the older adult's

life is at risk. Also, dementia is a high risk factor for old-

er adults to develop delirium and causes a more con-

voluted course when coexisting with delirium (Fick et

al., 2007). Consequently, facilitating care improvement

for older adults with CI, particularly those with dementia,

needs to be given attention in Korean acute care

settings.

However, given the relative paucity of studies that test

and report on educational interventions for best man-

agement of older adults with CI, and the dominance of

small scale studies, this review of the literature demon-

strates the need for further research that aims to identify

and evaluate such an educational intervention validation

of CI management. Also, the researcher argues that the

review demonstrates the need for intervention studies

that move beyond the descriptive to an evidence base

for CI management in older adults in acute care settings.

Further research should incorporate the current mana-

gement of older adults with CI into intervention studies

that document the type of intervention used, in suffi-

cient detail to be useful in implementation.

REFERENCES

Akechi, T., Ishiguro, C., Okuyama, T., Endo, C., Sagawa, R., U-

chida, M., et al. (2010). Delirium training program for nurses.

Psychosomatics, 51(2), 106-111.

Choi, E. J., Lee, H., Kim, I. A., Lim, Y., Lee, M. S., & Kim, M. J.

(2011). Delirium assessment ability of clinical nurses. Jour-

nal of Korean Gerontological Nursing, 13(2), 233-241.

Dahlke, S., & Phinney, A. (2008). Caring for hospitalized older

adults at risk for delirium: The silent, unspoken piece of

nursing practice. Journal of Gerontological Nursing, 34(6),

41-47.

Fick, D., Kolanowski, A., & Waller, J. (2007). High prevalence of

central nervous system medications in community-dwelling

older adults with dementia over a three-year period. Aging

& Mental Health, 11(5), 588-595.

Fick, D. M., Steis, M. R., Mion, L. C., & Walls, J. L. (2011). Com-

puterized decision support for delirium superimposed on

dementia in older adults. Journal of Gerontological Nurs-

ing, 37(4), 39-47.

Flagg, B., Cox, L., McDowell, S., Mwose, J. M., & Buelow, J. M.

(2010). Nursing identification of delirium. Clinical Nurse

Specialist CNS, 24(5), 260-266.

Hamdan-Mansour, A. M., Farhan, N. A., Othman, E. H., & Ya-

coub, M. I. (2010). Knowledge and nursing practice of criti-

cal care nurses caring for patients with delirium in intensive

care units in Jordan. Journal of Continuing Education in

Nursing, 41(12), 571-576.

Jeong, K. H., Oh, Y. H., Seok, J. E., Oh, S. R., Kim, C. W., Lee, Y.

K., et al. (2005). National needs assessment of the elderly in

2004. Seoul, Korea: Korean Institute for Health and Social

Affairs.

Kada, S., Nygaard, H. A., Mukesh, B. N., & Geitung, J. T. (2009).

Staff attitudes towards institutionalised dementia residents.

Journal of Clinical Nursing, 18(16), 2383-2392.

Kim, H., & Choi, W. (2008). Willingness to use formal long-term

care services by Korean elders and their primary caregivers.

Journal of Aging & Social Policy, 20(4), 474-492.

Lee, Y. S., & Moon, S. K. (2010). A study on the affecting factors

to utilization of long term care hospitals according to the

elderly long term care insurance system in Korea. Korea

Society of Hospital Administration Journal, 15(21), 49-69.

Lee, Y. W., Kim, C. G., Kong, E. S., Kim, K, B., Kim, N. C., Kim,

H. K., et al. (2007). A study of nurses’ knowledge level and

assessment experience of delirium. Korean Journal of Adult

Nursing, 19(1), 35-44.

Lundström, M., Olofsson, B., Stenvall, M., Karlsson, S., Nyberg,

L., Englund, U., et al. (2007). Postoperative delirium in old

patients with femoral neck fracture: A randomized inter-

vention study. Aging Clinical and Experimental Research,

19(3), 178-186.

Lundström, M., Edlund, A., Karlsson, S., Brännström, B., Bucht,

G., & Gustafson, Y. (2005). A multifactorial intervention

program reduces the duration of delirium, length of hos-

pitalization, and mortality in delirious patients. Journal of

the American Geriatrics Society, 53(4), 622-628.

Margiotta, A., Bianchetti, A., Ranieri, P., & Trabucchi, M. (2006).

Vol. 15 No. 3, 2013 217


Clinical characteristics and risk factors of delirium in de-

mented and not demented elderly medical inpatients. The

Journal of Nutrition, Health & Aging, 10, 535-539.

McCarthy, M. (2003). Situated clinical reasoning: Distinguishing

acute confusion from dementia in hospitalized older adults.

Research in Nursing & Health, 26(2), 90-101.

McDonnell, S., & Timmins, F. (2012). A quantitative exploration

of the subjective burden experienced by nurses when caring

for patients with delirium. Journal of Clinical Nursing, 21

(17-18), 2488-2498.

Meako, M. E., Thompson, H. J., & Cochrane, B. B. (2011). Ortho-

paedic nurses' knowledge of delirium in older hospitalized

patients. Orthopaedic Nursing/National Association of Or-

thopaedic Nurses, 30(4), 241-248.

Ministry of Health and Welfare. (2011). Retrieved May 15, 2012

from the World Wide Web: http://junggu.seouldementia.

or.kr/morgue/news.asp?pagename=view&num=20342

&page=8&search=

Moyle, W., Borbasi, S., Wallis, M., Olorenshaw, R., & Gracia, N.

(2011). Acute care management of older people with de-

mentia: A qualitative perspective. Journal of Clinical Nurs-

ing, 20(3-4), 420-428.

Naughton, B. J., Saltzman, S., Ramadan, F., Chadha, N., Priore,

R., & Mylotte, J. M. (2005). A multifactorial intervention to

reduce prevalence of delirium and shorten hospital length

of stay. Journal of the American Geriatrics Society, 53(1),

18-23.

Nilsson, A., Lindkvist, M., Rasmussen, B. H., & Edvardsson, D.

(2012). Staff attitudes towards older patients with cognitive

impairment: Need for improvements in acute care. Journal

of Nursing Management, 20(5), 640-647.

Park, M., Butcher, H. K., & Mass, M. L. (2004). A thematic analy-

sis of Korean family caregivers’ experiences in making the

decision to place a family member with dementia in a long-

term care facility. Research in Nursing & Health, 27, 345-

356.

Park, Y. S., Kim, K., Song, K., & Kang, J. (2006). A preliminary

survey of nurses’ understanding of delirium and their need

for delirium education. Journal of Korean Academy of Nurs-

ing, 36(7), 1183-1192.

Phelan, E. A., Borson, S., Grothaus, L., Balch, S., & Larson, E. B.

(2012). Association of incident dementia with hospitaliza-

tions. The Journal of the American Medical Association,

307(2), 165.

Pretto, M., Spirig, R., Milisen, K., DeGeest, S., Regazzoni, P., &

Hasemann, W. (2009). Effects of an interdisciplinary nurse-

led delirium prevention and management program (DPMP)

on nursing workload: A pilot study. International Journal

of Nursing Studies, 46(6), 804-812.

Robinson, S., Rich, C., Weitzel, T., Vollmer, C., & Eden, B. (2008).

Delirium prevention for cognitive, sensory, and mobility

impairments. Research and Theory for Nursing Practice, 22

(2), 103.

Steis, M. R., & Fick, D. M. (2012). Delirium superimposed on

dementia: Accuracy of nurse documentation. Journal of

Gerontological Nursing, 38(1), 32-42.

Tabet, N., Hudson, S., Sweeney, V., Sauer, J., Bryant, C., Mac-

donald, A., et al. (2005). An educational intervention can

prevent delirium on acute medical wards. Age and Ageing,

34(2), 152-156.

Voellinger, R., Stiefel, F., Michaud, L., Michel, P., Dorogi, Y.,

Burnand, B., et al. (2011). Implementation of guidelines on

delirium in a general hospital. Schweizer Archiv fur Neu-

rologie und Psychiatrie, 162(1), 31-34.

Voyer, P., Richard, S., Doucet, L., & Carmichael, P. (2009). De-

tecting delirium and subsyndromal delirium using different

diagnostic criteria among demented long-term care resi-

dents. Journal of the American Medical Directors Associ-

ation, 10(3), 181-188.

Yang, Y. H. (2010). Comprehension and knowledge about deli-

rium in nurses working at long-term care hospitals or gene-

ral hospital. Journal of Korean Academic Society Nursing

Education, 16(2), 312-320.

Yevchak, A., Steis, M., Diehl, T., Hill, N., Kolanowski, A., & Fick,

D. (2012). Managing delirium in the acute care setting: A

pilot focus group study. International Journal of Older Peo-

ple Nursing, 7(2), 152-162.

factors influencing management of cognitive impairment amon g older...

Documents