Nursing-led program reduces delirium in elderly patients after acute care

The implementation of a nurse-led training and delirium prevention program led to an annual hybrid conference from September 30th to October 2nd, 2021, according to a quality improvement project by the Gerontological Advanced Practice Nurses Association (GAPNA).

Delirium is common in older adults and occurs in up to 70% of older adults in post-acute care, explained lead author Rebecca Spear, DNP, ARNP, AGNP-C, Nurse Practitioner at Kaiser Permanente, Continuum of Care Skilled Nursing Department, Santa Rosa , California. Risk factors for delirium include age, dementia, history of depression, history of alcohol abuse, physical reluctance, metabolic abnormalities, infections, recent surgery, and medication.

“The consequences of delirium are numerous and can be very significant,” said Dr. Spear. “We often see short- and / or long-term cognitive and functional decline, longer length of stay, increased incidence of 30-day readmissions, hospitalizations, admissions and deaths,” said Dr. Spear.

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Rebecca Speer, DNP, ARNP, AGNP-C

Delirium is preventable, continued Dr. Spear continues, with an estimated 30 to 40% of cases in post-acute care preventable. The goal of their study was to design and implement a delirium prevention protocol in a 116-bed specialist nursing facility in Sonoma County, California. The results are based on chart audits of new admissions supported under Medicare Part A and employee surveys carried out before and after implementation. Patients were excluded if a diagnosis of delirium was made at the time of admission.

The mean patient age was 77 years in the pre-implementation group (n = 25) and 80 years in the post-implementation group (n = 23), approx. 60% of the patients were female and approx. 90% were white. The mean number of drugs at admission was similar in the pre-implementation and post-implementation cohorts. Fracture with or without surgical treatment was the most common reason for inclusion, with other diagnoses such as cardiovascular needs, infections, and strokes, among other disorders.

More than half of patients were prescribed psychotropic drugs, including antidepressants or antipsychotics, at the time of admission (56% pre-implemented and 78% post-implemented). Less than 25% of patients in each group received routine pain medication upon admission (24% and 17%, respectively).

Intervention recognizes patients at risk of delirium

After completing training on delirium risk factors taught by care facility staff, 65% of patients were identified as having an increased risk of delirium using the AWOL risk assessment tool. These patients received an 8-point delirium prevention program that included standing up to eat, maintaining adequate hydration, and tracking urine and bowel movements.

A new onset of delirium was diagnosed in 2 patients in the pre-implementation cohort vs. 0 patients in the post-implementation group during their post-acute care stay. The nursing staff and certified nursing assistants received “excellent” responses to the intervention.

“They found the preventive protocol to be easy to use, and CNAs in particular appreciated the additional education about delirium,” said Dr. Spear. The limitations of the study included the small sample size of the overall charts reviewed and the small sample of respondents.

Dr. Spear believes the protocol can be implemented in other facilities and studied on larger patient samples.

Visit the Clinical Advisor meeting section for full coverage of GAPNA 2021.


Spear R, Martin-Plank L, Kahn-John M, Crist JD. Delirium screening and prevention in older adult post-acute patients. Poster presented at: Gerontological Advanced Practice Nurses Association (GAPNA) Annual Hybrid Conference; September 30, October 2, 2021; San Diego, California: P21.

This article originally appeared on Clinical Advisor

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