Review ArticleThe delirium experience: A review
Introduction
Delirium is a common neuropsychiatric illness characterized by disturbances of consciousness, attention, cognition, and perception that develop over a short period of time and tend to fluctuate during the course of the day [1]. While the adverse medical complications and consequences of delirium has been well studied, the same is not true of the psychological morbidity associated with the condition.
Many reviews of delirium suggest that delirium is an unpleasant condition for patients [1], [2]. There are several reasons why this might be so. Perceptual disturbances and delusions are important symptoms of delirium. Behavioral problems and agitation during delirium suggest patient distress. Emotional disturbance is also commonly reported and is an essential feature in the International Statistical Classification of Diseases, 10th Revision criteria for delirium [3]. The opinions of expert clinicians have differed regarding the extent to which people with delirium might recall their experiences [4], [5]. However, people who have recovered from the condition have written of the unpleasantness of their experience [6], [7], and psychological sequelae and even posttraumatic stress disorder (PTSD) have been reported [6], [8], [9]. A better understanding of what it means to a patient to be delirious has the potential to improve recognition, management, and treatment of delirium.
The impact of delirium may extend beyond the patient. Nurses are the staff in most frequent and intimate contact with patients, and it is generally acknowledged that caring for delirious patients may be difficult, stressful, and at times, dangerous [10]. It is also accepted that delirium adds to the upset for families of having a loved one suffering from the underlying illness. While nurses and, often, families may have an important role in caring for and comforting delirious patients, it is also important that their own needs and stresses are recognized and minimized.
These are important issues. However, it was our view that there was a paucity of systematic empirical research to illuminate our understanding of the experience of delirium from the perspective of patients, families, and nurses. In this review, we examine and synthesize the relevant literature. Finally, suggestions for further work that might advance our understanding of these issues are outlined.
Section snippets
Methods
A systematic literature search using the terms delirium in combination with each of mental recall, posttraumatic stress disorders, nurse-patient relations, attitude of health personnel and professional–family relations was carried out using the National Library of Medicine PubMed and CINAHL databases on papers published in English between 1980 [when Diagnostic and Statistical Manual of Mental Disorder, Third Edition (DSM-III) criteria for delirium were introduced] and April 2008. Reference
Emotional feelings
The dominant emotions in many studies were fear, anxiety, and of feeling threatened during the episode of delirium [11], [12], [13], [14], [15], [16], and these feelings may be directly related to patients' aggressive behavior [16]. Feelings of hopelesness, loneliness, and depression are also common [16], [17]. For some patients, a disinterested perplexity, in which they observe events as through a mist, may be the most common mood experienced [11]. Less commonly, patients report enjoying their
Impact of delirium on families and staff
Breitbart et al. [26] reported that 76% of spouses/caregivers and 73% of nurses reported severe distress related to delirium. Mean distress levels were significantly higher for spouses/caregivers than for nurses caring for the patients and even for the patients themselves. Hyperactive delirium and poor functional status were major predictors of family distress, while severe delirium and perceptual disturbances were the strongest predictors of nursing distress.
Qualitative studies of professional
Recommendations for further research
The qualitative literature provides many insights into how distressing and disturbing delirium is for many patients. One obvious question for the future is how this information can be used to improve patient care and to minimize the distress for patients. Different authors have reached conflicting conclusions. Schofield [16] argued that reality orientation is likely to be effective, but Fagerberg and Jonhagen [13] noted that this can exacerbate patients' feelings of hopelessness and isolation.
Acknowledgments
We are grateful to Professor Ingegerd Fagerberg, Karolinska Institutet, Stockholm, Sweden for providing a pre-publication copy of Ref. [17].
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