Assignment: PICO Analysis of Delirium Example
Assignment: PICO Analysis of Delirium Example
With the increasing prevalence of delirium in the geriatric population, as advanced practitioners we will likely care for elders with this condition, it is important to be able to treat effectively. Delirium is defined as an acute disturbance of consciousness, change in cognition, and a reduced ability to focus, sustain, or shift attention. Delirium has been identified as the most common complication of hospitalization in older patients and can be avoided if recognized early (Inouye, 2015). The purpose of this paper is to formulate a PICO question on delirium, identify resources and key search terms, summarize evidence based research articles and create an evidence table with article summaries on the best screening assessments for this condition for earlier diagnosis and treatment.
PICO Question
In the geriatric population with delirium (P), what are screening tools that could be utilized to diagnose delirium (I) compared to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (C) to effectively treat and manage the population of patients with this disorder (O)?
Search Strategy
Electronic databases used included the MEDLINE with Full Text, Science Citation Index, CINAHL Plus with Full Text, PsycINFO, Science Direct, Journals@OVID, and ScholarWorks were searched for studies that compared delirium bedside screening tools with the DSM-5 defined diagnosis of delirium in hospital inpatients. The following keywords were used to search: delirium, screening tools, confusion, and diagnosis. Articles that met inclusion criteria were articles that were five years old or less and articles that researched delirium assessment screening tools used in the aging or geriatric population. The Boolean search string that was used in this research study was delirium screening tools.
Analysis of Literature
| C Citation | Conceptual Framework/ Theory | Main Finding | Research Method | Strengths of Study | Weakness | Level of Evidence |
|
Hendry, K., Quinn, T. J., Evans, J., Scortichini, V., Miller, H., Burns, J., . . . Stott, D. J. (2016). Evaluation of delirium screening tools in geriatric medical inpatients: a diagnostic test accuracy study. Age and Ageing, (6), 832. Retrieved from
|
Descriptive Theory |
The Abbreviated Mental Test (AMT-4) and the Months of the Year Backwards (MOTYB), were both found to have good sensitivity for underlying delirium. |
Systemic Review of Literature |
This study found that brief cognitive tests, including AMT-4 and MOTYB had good sensitivity for detecting definite delirium, with this sensitivity of these tests being 86%. |
The bCAM had poor sensitivity for definite delirium within the study, even though it is highly specific. |
Level 1 |
|
Han, J. H., Wilson, A., Schnelle, J. F., Dittus, R. S., & Ely, E. W. (n.d.). An evaluation of single question delirium screening tools in the older emergency department patients. American Journal of Emergency Medicine, 36(7), 1249-1252.
|
Observational Study |
Using the combination of both surrogate mental status questions, health care providers should consider using these questions as part of their routine clinical practice to screen for delirium.
|
Prospective Observational Trial |
Have you noticed the patient’s mental status fluctuate throughout the course of the day? Had very good sensitivity |
“Have you had any difficulty thinking clearly? Strongly increased the likelihood of delirium is the patient was unable to answer the question, but had a poor sensitivity. |
Level 5 |
|
Hargrave, A., Bastianens, J., Bougeois, J. A., Neuhaus, J., Josephson, S. A., Chinn, J., . . . Douglas, V. (2017). Validation of a Nurse-Based Delirium Screening Tool for Hospitalized Patients. Psychosomatics, 58(6), 594-603.
|
Predictive Theory |
This study showed the importance of nurses being actively involved in screening geriatric patients for symptoms of delirium, but this study did determine that specialists are needed for hypoactive cases of delirium. |
Randomized Control Trial |
The Nursing Delirium-Screening Scale (Nu=DESC) was helpful in in early recognition of delirium symptoms in order to get the appropriate consultations to see the patient such as a geriatrician or a neurologist. |
The Nursing Delirium-Screening Scale (Nu=DESC) was less sensitive in detecting mixed and especially hypoactive delirium. |
Level 2 |
|
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 hospitalized older people. Age and Ageing, 43(4), 496-502.
|
Prospective Study |
This delirium screening tool is a sensitive and specific tool used for the diagnosis of delirium. It is simple and brief and can easily be integrated into daily clinical practice. |
Cross Sectional Observational Study |
This screening tool gives a clear description of the diagnosis and how it needs to be correctly performed by trained physicians. |
Needs other extensive research in order for this screening tool to be utilized among other healthcare professionals. |
Level 2 |
|
Neufeld, K. J., Leoutsakos, J. S., Sieber, F. E., Joshi, D., Wanamaker, B. L., Rios-Robles, J., & Needham, D. M. (2014). Evaluation of two delirium screening tools for detecting post-operative delirium in the elderly. British Journal of Anaesthesia, 111(4), 612-618.
|
Descriptive Theory |
Both the CAM-ICU and the NuDESC demonstrated high specificity, but inadequate sensitivity for screening purposes. The gold standard for diagnosing delirium is psychiatric evaluation using the DSM criteria. |
Systemic Review of Literature |
Strengths include a rigorous design in which the screening tools and neuropsychiatric examination were administered with each result blinded from the others. |
In this study, the NuDESC was administered by trained research staff rather than the nurse caring for the patient; hence it is unclear if the results would have differed if administered directly by the nurses. |
Level 1 |
Purpose of Study
As advanced practitioners, we will treat many patients with delirium and must be able to diagnose and manage this condition carefully and effectively. Delirium is a common condition, occurring in 25-65% of hospitalized older patients. It is associated with increased mortality, increased length of hospital stay, increased hospital acquired complications, persistent cognitive deficits, and increased rate of discharge to long term care. The DSM criteria for delirium is the gold standard for diagnosis but needs a specialized physician in order to make a diagnosis. Among the many delirium screening tools, the CAM appears to be the best tool to use for bedside nurses (Holroyd-Leduc., et al., 2012). Managing behavioral problems while ensuring both the comfort and safety of the patient can be challenging. Delirium management should involve a multifaceted approach that addresses potential precipitants, manages associated symptoms, and educates patients/family members/caregivers (Resnick, 2016). As an advanced practitioner, by identifying delirium and utilizing interventions as soon as possible we could limit the need for an inpatient stay. While it is important to treat the patient, it is important to stress to family members that delirium is usually not a permanent condition, but improves with time (Resnick, 2016).
Gaps in Existing Literature
Throughout this study, there has been multiple areas without clear guidelines that could provide opportunities for future research. A role for routine delirium screening can be clarified through a well-designed delirium screening trial investigating the benefits of early detection and management of this disorder. Use of pharmacotherapy in delirium patients need to be explored to compare typical antipsychotics, atypical antipsychotics, and a placebo in patients at risk for delirium. Even with such advancement in healthcare, there are many areas of uncertainty such as the benefits and costs of delirium screening, the benefits and harms of single or combined pharmacological drugs for delirium prevention and treatment (Hargrave, et al., 2017). Future research is still warranted to ensure quality care for patients with this condition.
Conclusion
…
Assignment: PICO Analysis of Delirium Example References
Hendry, K., Quinn, T. J., Evans, J., Scortichini, V., Miller, H., Burns, J., . . . Stott, D. J. (2016). Evaluation of delirium screening tools in geriatric medical inpatients: a diagnostic test accuracy study. Age and Ageing, (6), 832. Retrieved from
Holroyd-Leduc, J. & Reddy, M. (Eds). (2012). Evidence-based Geriatric Medicine: A practical clinical guide. Hoboken, NJ: Blackwell Publishing.
Resnick, B. (Ed). (2016). Geriatric nursing review syllabus: A core curriculum in advanced practice geriatric nursing (5th ed.). New York, NY: American Geriatric Society.
The Assignment:
To prepare:
Select one of the following disorders as your topic: dementia, delirium, or depression.
Review the guidelines in the “Literature Review Matrix” document in this week’s Learning Resources.
Think about a research question around your issue as indicated in Part I: PICO Analysis of Research Topic.
Consider the resources you will use, search terms and criteria, and Boolean search strings as indicated in Part II: Search Strategy.
Using the Walden Library and other appropriate databases, locate five articles related to your PICO question. At least one article must be a systematic review. All of the articles should be primary sources.
Reflect on the five articles you selected as indicated in Part III: Analysis of Literature. Consider the conceptual framework/theory, main finding, research method, strengths of study, weaknesses, and level of evidence for each article.
Consider how to use the summaries in Part III to create an evidence table. Use this evidence table to determine appropriate treatment options for patients who present with the disorder you selected as your topic.
To complete:
Formulate a question around the disorder you selected as indicated in Part I: PICO Analysis of Research Topic.
Identify the resources you will use, search terms and criteria, and Boolean search strings as indicated in Part II: Search Strategy.
Summarize the five articles you selected as indicated in Part III: Analysis of Literature. Describe the conceptual framework/theory, main finding, research method, strengths of study, weaknesses, and level of evidence for each article.
Create an evidence table based on the article summaries in Part III. Describe appropriate treatment options for patients based on this evidence table. Assignment: PICO Analysis of Delirium Example