Delirium among Home-Dwelling Elderly after a Recent Hospitalization: An Urgent Need for Effective Nursing Interventions.

Introduction

Due to the pressure applied on the health care system, the majority of hospitalized elderly people are quickly discharged home and the care needed is provided by home care services [1]. An acute confusional state (delirium), which is linked to high percentages of morbidity and mortality, is likely to develop amongst this fragile population [2]. This syndrome, at the crossroads of numerous pathologies, is almost exclusively studied in the hospital environment, which is extremely conducive to the triggering of a delirium episode [3]. The prevalence of delirium among hospitalized elderly people can be as high as 60%. Also, in approximately half of the elderly patients leaving hospital, an episode of delirium (often rather silent) is not detected. By giving careful consideration to the high prevalence of post-hospitalization confusion, the non-detection and the undertreatment of silent delirium episodes, the negative impact of delirium on the elderly person, his/her loved ones as well as on the home care nurses is expected to be reduced [3].

For the elderly person, the consequences of delirium are numerous. At the biological level, delirium increases the risk of early death. After an episode, the elderly individual often has to accept help with activities of daily living due to the physical and cognitive decline, but sometimes with great difficulty. This decline entails, in the longer term, a risk of institutionalization within the year following the delirium episode [4]. Other discomforts and health problems such as falls, dehydration and malnutrition are also associated with an episode of delirium [5]. Delirium is often related to increased fragility, even in healthy elderly people. For those who are already vulnerable or fragile, delirium may be the trigger for a significant physiological decline causing a decrease in quality of life – sometimes up to the point of having to leave one's home [6]. From a psychological point of view, acute delirium is a traumatic experience from which the elderly keeps fragmented and agonizing memories. The affected person feels as if he or she is ‘out of his or her mind’ and lives with the anxiety of experiencing psychosis again and behaving inappropriately towards his or her family and the nurses [7]. Temporary or definitive loss of autonomy frequently causes psychological distress and a decrease in self-esteem with the risk of developing other comorbidities such as depression, overmedication or alcohol abuse [7]. The consequences of delirium not only affect the elderly but also his or her family and the home care nurses. For loved ones, the elderly's functional impairment is demanding and requires an almost continuous presence, allowing only few moments of respite [8]. Delirium that is associated with a progressive functional decline due to dementia often leads relatives, who can no longer assume responsibility for safe care, to resort to early placement in a nursing home. This decision can bring on a sense of failure and induce a depressive state as well as physical and emotional exhaustion [8]. Following the early death of an elderly after delirium, the often shocked family members are likely to experience a difficult if not pathological period of grief [9].

Nurses may experience the repercussions in their work and their person [10]. Patients afflicted by delirium require more support in their daily living activities, repeated, precise and generalized explanations as well as increased monitoring, which substantially increases the workload. Accompanying the confused person and his or her loved ones creates an impression of ‘intensive care’ for the nurses and sometimes a feeling of threat for their physical and psychological safety, which affects their confidence [11]. Delirium may create conflicts among professionals, but also between professionals and the relatives of confused patients. Nurses report difficulties in managing the unexpected, the increased complexity and the additional burden of care and mistrust towards the unpredictable behavior and reactions of the affected person [12].

In any care environment, nurses should play a predominant role in delirium detection and supervision by ensuring monitoring of manifestations such as agitation, hydration, urinary and fecal elimination, insomnia, disorientation and immobility, as well as the biological parameters associated with underlying pathologies [3]. The goal is to prevent the occurrence of delirium by including specific detection interventions for any elderly person cared for by a home care service [13]. These multifaceted interventions must include a quick and systematic evaluation of risk factors and close monitoring of early warning signs of delirium. It is important to consider both non-modifiable factors (or hardly modifiable factors), which promote the development of delirium (old age, cognitive impairment, chronic diseases), and modifiable factors such as infections or poly-medications [14]. In order to fulfill this role, nurses must know the clinical and early prodromal signs. However, studies in the hospital environment show that they do not recognize the signs of delirium and, consequently, the non-recognition of delirium causes major problems pertaining to care quality, workload and the development of intervention and prevention strategies [1, 2, 3].

Strategies for the prevention or early detection of delirium at home are currently unavailable. The evidence accumulated in hospitals [15] and the findings from few clinical intervention studies on the prevention of physical decline in elderly persons at home [13] could serve as foundations for the development of targeted nursing interventions. These interventions should include an educational component supported by an advanced practice paradigm so that nurses quickly detect deterioration signs in the elderly as well as contribute to the development, application and evaluation of standardized tools for risk factor assessment. There is an urgent need to better understand delirium, to develop new home care approaches and to rigorously evaluate their efficiency in terms of the well-being of the elderly as well as of their effectiveness for the health care system itself.

Disclosure Statement

No conflict of interest has been declared by the authors.