Sherry Robinson, PhD, CNS, BC. Catherine Rich, MSN, MBA, RNBC Tina Weitzel, RN-BC, MA Charlene Vollmer, BSN-BC Brenda Eden, MS, APRN, BC

Transcription

1 Research and Theory for Nursing Practice: An International Journal, Vol. 22, No. 2, 2008 Delirium Prevention for Cognitive, Sensory, and Mobility Impairments Sherry Robinson, PhD, CNS, BC Southern Illinois University, Springfield, Illinois Catherine Rich, MSN, MBA, RNBC Tina Weitzel, RN-BC, MA Charlene Vollmer, BSN-BC Brenda Eden, MS, APRN, BC Memorial Medical Center, Springfield, Illinois The purpose of this study was to determine the effectiveness of a protocol designed to prevent delirium in hospitalized elders with the risk factors of dementia and/or vision, hearing, and/or mobility impairments. A group of 80 patients with risk factors hospitalized before the protocol was implemented was matched with a group of 80 patients admitted after the implementation of the protocol. Records of patients in both groups were reviewed to identify patients with delirium. A significant reduction in delirium, from 37.5% to 13.8%, occurred in the elders receiving the protocol. Keywords: delirium; prevention; hospital; older adults Delirium represents a frequent complication for hospitalized elders and is associated with longer hospital stays, increased functional decline, longterm care placement, and increased risk of death (Agostini, Baker, Inouye, & Borgus, 2001). To deal most effectively with delirium, nursing care should emphasize prevention. Many researchers have identified risk factors for delirium and have made recommendations for prevention. Few studies have examined the effectiveness of the prevention strategies recommended by these risk factor studies. The present study examines the effectiveness of a delirium prevention protocol targeting the risk factors of dementia, vision loss, hearing loss, and mobility impairment. PREVENTION OF DELIRIUM Experts in delirium have stressed that prevention is the best approach to deal with it. Once delirium develops, treatment is difficult. Delirium may persist for many 2008 Springer Publishing Company 103 DOI: /

2 104 Robinson et al. weeks, even months (Agostini et al., 2001). The first step in prevention is to identify patients who are at risk for developing delirium. Multiple studies have identified a broad range of risk factors for the development of delirium in hospitalized elders. In a meta-analysis of 24 studies published between 1966 and 1995, the most common risk factors for delirium were found to be dementia, severe illness, alcohol abuse, depression, diminished activities of daily living (ADLs), male gender, abnormal sodium levels, hearing impairment, and visual impairment (Weber, Coverdale, & Kunik, 2004). Other researchers have identified additional risk and precipitating factors including advanced age, sleep deprivation, elevated BUN/creatinine ratio, low albumin level, bone metastasis, heart failure, inadequate pain management, physical restraints, benzodiazepines, low cardiac output, and admission from another facility (Elie, Cole, Primeau, & Bellavance, 1998; Flaherty & Morley, 2004; Inouye, 1998; Inouye, Viscoli, Horwitz, Hurst, & Tinetti, 1993; Milisen, Steeman, & Foreman, 2004; Wakefield, 2002). Basic interventions targeting risk factors should be successful in preventing many cases of delirium. Suggestions include the following: hydration man agement, pain management, elimination of unnecessary medications, cognitive stimulation, use of sensory protocols, early mobilization, continuity of care, cues for orientation such as clocks and calendars, prevention of sensory overload and deprivation, family support, and clear communication (Fick, Agostini, & Inouye, 2002; Fick, Kolanowski, Waller, & Inouye, 2005; Hall & Buckwalter, 1987; Milisen et al., 2004). A few intervention studies have been reported. Inoyue, Bogardus, Baker, Leo- Summers, and Cooney (2000) developed the Hospital Elder Life Program (HELP), which successfully reduced delirium. The program targeted the risk factors of cog nitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration. Delirium developed in 9.9% of the intervention group compared with 15% of the usual-care group. Intervention protocols were implemented by specially trained hospital volunteers called elder life specialists. A geriatric clinical nurse specialist and a geriatrician provided assessments and consultation. The components included (a) a daily visitor program providing cognitive orientation, communication, and social support; (b) a therapeutic activities program for cognitive stimulation and socialization; (c) early mobilization to promote daily exercise and walking; (d) a nonpharmacological sleep protocol to promote relaxation and sufficient sleep; (e) a hearing and vision protocol with adaptive equipment; and (f ) oral fluid volume repletion and feeding assistance (Inouye, 2000; Inouye et al., 1999, 2000). As a component of the study, the level of adherence to delirium protocols was measured. In the sample, patients in the highest adherence group had a delirium rate of only 2.9%, compared with 38.1% in the lowest adherence group (Inouye, Bogardus, Williams, Leo-Summers, & Agostini, 2003). The effectiveness of any prevention program is critically dependent on the level of adherence to interventions. The more interventions received, the better the response. No significant effects on outcomes were detected 6 months following discharge (Bogardus et al., 2003). Two intervention studies targeted delirium in hip fracture patients. Marcantonio, Flacker, Wright, and Resnick (2001) incorporated a preoperative geriatrics consulta-

3 Delirium Prevention 105 tion followed by daily geriatric visits. The specialized care included oxygen delivery, fluid and electrolyte balance, treatment of severe pain, elimination of unnecessary medication, regulation of bowel and bladder function, nutrition, early mobility, and appropriate environmental stimuli. Delirium occurred in 32% of the patients in the intervention group compared with 50% in the control group. Milisen and colleagues (2001) studied a nurse-led interdisciplinary program for the prevention of delirium in hip fracture patients. The intervention included the education of nursing staff on the detection of delirium, systematic cognitive screening, the use of scheduled pain medications, and the provision of consultative services by delirium resource nurses. Delirium occurred in 23.3% of the control group compared with 20.0% in the intervention group. Although only a small reduction in delirium was detected, delirium episodes were of shorter duration ( p =.03) and were less severe ( p =.0049) in the intervention group. A study of 240 patients on a renal unit at our hospital identified risk factors for delirium similar to those found in previous studies. Age, dementia, vision impairment, hearing impairment, and mobility impairment correlated significantly with the development of delirium (Vollmer, Rich, & Robinson, 2005). To address the problem of delirium, our original intent was to adopt the HELP program. As we were without the resources of a geriatrician and a full-time gerontological clinical nurse specialist, we incorporated those interventions recommended by researchers into a protocol that could be implemented by the nursing assistants. PURPOSE The purpose of this study was to determine if a delirium prevention protocol targeting the risk factors of dementia, hearing impairment, vision impairment, and limited mobility could prevent delirium in older adults hospitalized on a renal unit. CONCEPTUAL MODEL Two conceptual models guided the development of the interventions for the protocol. Dementia was a major risk factor for delirium. Approximately 45% of patients with dementia will develop delirium with hospitalization (Fick et al., 2002, 2005). The progressively lowered stress threshold model (Hall & Buckwalter, 1987) guided the protocol for those with dementia. In this model, persons with dementia react to the stress that is created by the environment. The stress threshold can easily be reached in the hospital, compounding the dementia with delirium. Hall and Buckwalter emphasized structuring the environment to create as little stress as possible. They recommended promoting continuity and keeping activities as familiar as possible. The protocol encouraged staff to contact caregivers and determine the usual ways to perform ADLs, the patient s food likes and dislikes, and sleep habits. The protocol also encouraged nursing staff to reduce stress by using a gentle tone and by ensuring that patients are comfortable, warm, and pain-free.

4 106 Robinson et al. Vision losses, hearing losses, and mobility limitations restrict an individual s ability to perceive, interpret, and explore the new environment of the hospital. Both sensory deprivation and sensory overload can result in sensory distortion expressed as delirium. The model of sensoristrain developed by Black, McKenna, and Deeny (1997) guided the development of interventions for vision, hearing, and mobility impairment. In this model, mental status is maintained through sensoristasis, where the correct amount of sensory input and relevancy of the input is maintained. If the person cannot receive correct messages because of diminished senses, cannot interpret the sensory input, or cannot explore the environment because of decreased mobility, sensoristrain occurs. Subsequently, this sensoristrain is expressed as delirium. The protocol utilized interventions that adapted the environment for vision and sensory losses. To improve mobility and exploration of the environment, the protocol included increasing ambulation and assisting patients to chairs for meals. METHODS DESIGN The study was a preintervention and postintervention study. Data were collected using retrospective record review. The study was granted exemption by the Institutional Review Board of the local university and was approved by the research committee of the participating midwestern hospital. SAMPLE The preintervention group consisted of a convenience sample of 80 patients over the age of 65 with any combination of the risk factors of dementia, vision impairment, hearing impairment, and mobility impairment who were admitted prior to the implementation of the delirium prevention protocol. This group was matched with a postintervention group of 80 patients with the same risk factors who were admitted to the unit after the implementation of the protocol. In addition to risk factors, the two groups were matched on age (within 5 years) and gender. The patients were all admitted to a 36-bed renal unit in a 562-bed hospital over a period of a year. OPERATIONAL DEFINITIONS AND MEASURES Delirium was defined according to Inouye and colleagues (2005) chart-based method for the identification of delirium with the presence of any of the following in the nurse s or physician s notes indicating delirium: acute confusion, mental status change, inattention, disorientation, hallucinations, agitation, inappropriate behavior, combativeness, or decreased responsiveness. Dementia was defined by the presence of a diagnosis of dementia on the admission records. The definitions of vision, hearing, and mobility were adapted so that a nurse admitting a patient could recognize potential problems within the course of the usual admission process. Vision impairment was defined as the inability to read

5 Delirium Prevention 107 the words Medical Center on the nursing staff member s badge at 14 inches (indicating less than 70/20 vision). Less than 70/20 vision was recommended in the HELP program (Inouye et al., 2000). Hearing impairment was defined as present if the admitting nurse raised his or her voice or repeated items often during the assessment. Mobility impairment was defined as the inability to walk to the bathroom without the help of a nurse. Patients were not impaired if they could get out of bed on their own and could walk even with the use of walkers or canes. DATA COLLECTION Data collected from the records included age, gender, risk factors for delirium (dementia, vision loss, hearing loss, mobility impairment), development of delirium, and hospital day of onset of delirium. Records were reviewed for documentation of any of the descriptors from the chart-based method of identification of delirium. Instrument: Chart-Based Method for the Identification of Delirium. This instrument identifies any of the following terms in the nurse s or physician s notes indicating delirium: acute confusion, mental status change, inattention, disorientation, hallucinations, agitation, inappropriate behavior, combativeness, or decreased responsiveness. Inouye and colleagues (2005) compared the chart-based method to direct cognitive assessment using the confusion assessment method (CAM) (Inouye et al., 1990). The sensitivity of the chart-based method was 74% and the specificity was 83% when compared with direct cognitive assessment using the CAM. The researchers concluded that the chart-based method was suitable for evaluating broad-based clinical programs but not for diagnostic purposes in individual patient care (Inouye et al., 2005). INTERVENTION Nursing assistants provide much of the direct patient care on the renal unit and were considered crucial in delivering the interventions. It was imperative for them to understand the critical nature of delirium as well as the interventions that they would help implement. The nursing assistants attended four half-day classes on delirium, dementia, sensory losses, and mobility. They explored the hypoactive as well as the hyperactive forms of delirium and the characteristics of delirium: acute onset, fluctuating course, inattention, and either disorganized thinking or altered level of consciousness. Nursing assistants participated in a sensory loss simulation and then learned interventions to enhance the senses. Physical and occupational therapy representatives provided a session on the promotion of mobility and functional status (Weitzel & Robinson, 2004). Similar education was provided to the professional nursing staff of the renal unit during staff meetings. On admission, patients over 65 were assessed for risk factors by the registered nurse admitting the patient. If the patient had any of the risk factors, appropriate interventions were necessary to avoid delirium. The delirium protocol used interventions from the HELP program and strategies suggested by Foreman, Mion, Trygstad, and Fletcher (2003). The interventions from the delirium protocol were implemented by the nursing assistants (see Table 1). A locked cart containing all

6 108 Robinson et al. TABLE 1. Delirium Prevention Measures by Risk Factor Dementia Call caregiver and obtain information on ADLs, food likes, sleep habits Use a gentle tone of voice Make pain medication scheduled rather than as needed Tell patient each thing you are going to do as simply as possible Keep patient warm No TV; use music instead Vision Impairment Be sure glasses are on when awake Magnifier at bedside Red tape on call bell, water pitcher, TV control, telephone, etc. TV screen enlarger Dry erase board with caregiver names Large-print menu Large-print books and magazines Sign on door, kardex, & chart Hearing Impairment Be sure hearing aids are in place and working (while awake) Use Pocket Talker (hearing amplifier) Face patient, do not shout Turn down background noise Sign on door, kardex, & chart Mobility Impairment Ambulate twice a day (be sure patient has floor-gripping slippers) Use walk board Up in chair for meals Ambulate to toilet (be sure path to bathroom is clear) the equipment and a large supply of the items listed in the protocol was easily accessible on the unit. The cost of the equipment, supplies, and locked cart was approximately $800. Daily, the clinical nurse III or the nurse manager made rounds to ensure the protocol was implemented. If the interventions were not in place, they were then implemented. DATA ANALYSIS Subjects were matched on age (within 5 years), gender, presence of dementia, vision impairment, hearing impairment, and mobility impairment. To be certain that groups were matched, the criterion of age was subjected to univariate analysis of variance. A chi-square test (Fisher s Exact Test) was used to determine the proper matching of the criteria of presence of dementia, vision loss, hearing loss, and mobility loss. The dependent variable of development of delirium was compared in the two groups by using Fisher s Exact Test. The various combinations of risk factors were not analyzed individually because the numbers within each category were too small.

7 Delirium Prevention 109 RESULTS SAMPLE CHARACTERISTICS Analysis indicated that the two groups were matched on all criteria. There were no significant differences in age for the two groups. The mean age of Group 1 was years and for Group 2 was years ( p =.779). Both groups were composed of 37 men (46%) and 43 women (54%). There were no significant differences in the groups on the presence of dementia ( p = 1.00), vision loss ( p = 1.00), hearing loss ( p = 1.00), and mobility loss ( p = 1.00). In each group, 39 of the subjects had one risk factor; 28 had two risk factors, 11 had three risk factors, and 2 had four risk factor, in various combinations. In each group, 12 (15%) suffered from dementia, 34 (42.5%) were vision impaired, 29 (36.3%) were hearing impaired, and 58 (72.5%) were mobility impaired. PREINTERVENTION AND POSTINTERVENTION COMPARISONS In the preintervention group of patients with risk factors for delirium, a total of 30 (37.5%) patients demonstrated symptoms of delirium. In the postintervention group of 80 at-risk patients, 11 (13.8%) patients demonstrated symptoms of delirium. The percentage of patients who developed delirium declined from 37.5% to 13.8% with the use of the protocol; the occurrence of delirium was significantly lower ( p <.001). Of the 30 cases of delirium in Group 1, a total of 28 (93%) patients were exhibiting symptoms by hospital day 2. Similarly, of the 11 cases of delirium in group 2, a total of 9 (82%) had developed delirium by day 2. The various combinations of risk factors were not analyzed separately, due to the large number of combinations with few subjects in each. In examining the 12 subjects with dementia with various other risk factors, six of them in the preintervention group developed delirium while only one person with dementia in the postintervention group developed delirium. DISCUSSION In the United States, approximately 2.3 million hospitalized elders experience delirium annually, with over $4 billion in Medicare costs. The cost of one case of delirium has been estimated conservatively at $6,341 (Agostini et al, 2001). Complications from delirium result in higher mortality rates, longer hospitalization, and a decrease in functional ability posthospitalization (Elie et al., 1998). The findings of this study indicate that simple interventions targeting dementia, vision loss, hearing loss, and mobility limitations can prevent delirium in some patients when these risk factors are identified and targeted by nurses. The findings are comparable to those of previous researchers who found that simple interventions could prevent delirium (Inouye et al., 1999, 2000). The vision protocol, which included eight interventions, was particularly useful for this renal unit. A large number of patients with renal impairment have the

8 110 Robinson et al. comorbidity of diabetes with associated retinopathy. In this study, 34 (42.5%) of the patients in each group were identified as having visual impairment. Providing aids for visual perception can improve orientation to the environment and ability to perform ADLs. Marking a pitcher with red tape enables a patient to gain easier access to fluids and can help with hydration. The hearing protocol helped to facilitate the communication necessary to keep patients oriented and to ensure that communication was received as intended. The portable amplifying device was seen as a positive resource for nursing staff for improving information exchange. This amplifying device was available in the room to facilitate communication with physicians and other health care workers. The mobility protocol resembles normal nursing interventions for impaired mobility in any patient. By designating expectations for ambulation on the walk board, staff and patients anticipated and followed through with timely interventions. Most experts in delirium list dementia as the major risk factor. Although the sample of persons with dementia was not large enough to analyze individually, those with dementia who developed delirium after the implementation protocol were fewer in number. Managing the patient s dementia according to the protocol ensured that a patient s planned care was based on the usual home regimen, to decrease the amount of stress in change of environment. Scheduled pain medications rather than as needed pain medications are recommended for elders with dementia due to their inability to ask for pain medication. Practice guidelines also recommend scheduled medications for those with renal insufficiency (Launay-Vacher, Karie, Fau, Izzedine, & Deray, 2005). Additional interventions in the protocol helped to ensure a quiet, peaceful environment, to reduce the stress of hospitalization. Eleven of the 80 participants in the postintervention group became delirious, despite implementation of the protocol. Nursing staff continued to use the protocol for these patients to minimize the effects of the delirium. Many of these patients suffered from renal failure. Fluid and electrolyte disturbances were common and may have contributed to the delirium. LIMITATIONS A limitation of the study was in its design. Detection of delirium through retrospective record review was dependent upon thorough documentation of mental status. Nurses do document mental status during every shift under the category of cognitive status on the patient summary. To improve the documentation, education was provided to staff prior to beginning the study, in order to encourage fuller description of mental status changes. The educational programs may have influenced the recognition of delirium as well as the documentation in the latter stages of the study, particularly for the hypoactive state. Thus, while there is the possibility that some patients were misclassified in both the preintervention and the postintervention groups, improved detection of delirium was likely greater for the postintervention group, resulting in underestimation of the effects of the intervention. Without the use of a validated instrument such as the CAM and other cognitive tests such as the Mini Mental State Exam, the identification of all cases of delirium is uncertain (Inouye, Foreman, Mion, Katz, & Cooney, 2001).

9 Delirium Prevention 111 Another weakness of the study is that patients were not formally assessed for vision, hearing, and mobility using validated, reliable instruments. The protocol attempted to simplify identification of these risk factors for the busy staff nurse. In hindsight, it can be seen that background noise might have caused the nurse to repeat. Additionally, some older adults may not reveal a hearing loss in interviews that include many yes and no questions. Use of the whisper test, where the clinician stands behind the patient and determines the correct response in terms of 6 whispered numbers or letters, might have been a quick and more reliable method of detecting hearing loss (Keller, Morton, Thomas, & Potter, 1999). Because of the multiple combinations of the four risk factors for delirium (dementia, vision impairment, hearing impairment, and impaired mobility), the relationship of the prevention protocol to each individual risk factor could not be examined. A larger sample would have allowed an examination of the relationship of each component of the protocol to the targeted risk factor. Further, the strength or dose of the intervention varied across participants because elements of the protocol were individualized based upon each patient s specific risk factors. During their rounds to ensure the implementation of the protocol, the nurses did not record the number of times that the intervention protocol had not been implemented on admission. The nurses have estimated that in about one-third of the patients, the protocol was not implemented until the nurse made rounds. Thus, some of the at-risk patients were without the protocol for at least a day, a critical time for the development of delirium. The study would have been strengthened if this data had been available. The association of the implementation of the protocol either on admission or on the day after could have been examined in relation to the development of delirium. Additionally, data on the duration of delirium and the presence of delirium on discharge might have provided information on the impact of the protocol on the duration of delirium. CONCLUSION Although the protocol prevented some cases of delirium, nursing protocols will not prevent delirium in all elderly patients. The etiology of delirium is often multifactorial. Causes such as medications, hypoxia, infection, pain, malnutrition, low cardiac output, or any disturbance that leads to metabolic toxicity can cause delirium and will need medical intervention. Nurses who work on specialized units can be alert for additional precipitating factors often seen in patients with specific diagnoses. For example, a nurse on an orthopedic unit may be alert to the risk factors of urinary catheters and inappropriate pain management for those with hip fracture (Williams, Campbell, Raynor, Mlynarczyk, & Ward, 1985). Environmental factors, such as those addressed in this study, can exacerbate the problem without a dedicated effort to minimize them. The HELP program, which has been replicated and disseminated throughout the United States, is the most comprehensive program for delirium prevention. Our findings should encourage smaller hospitals that do not have the resources required for the HELP program to adopt the components that it is feasible to implement in

10 112 Robinson et al. their organizations. This simple protocol for the prevention of delirium requires only nursing interventions. It does not require physician orders, can be applied to the general hospitalized population, and can be implemented by support staff. REFERENCES Agostini, J. V., Baker, D. I., Inouye, S. K., & Bogardus, S. T. (2001, July). Prevention of delirium in older hospitalized patients. In Making health care safer (chapter 28). AHRQ Publication No. 01-E058. Retrieved November 17, 2005, from chap28.htm Black, P., McKenna, H., & Deeny, P. (1997). A concept analysis of the sensoristrain experienced by intensive care patients. Intensive Critical Care Nursing, 13 (4), Bogardus, S.T., Jr., Desai, M. M., Williams, C. S., Leo-Summers, L., Acampora, D., & Inouye, S. K. (2003). The effects of a targeted multicomponent delirium intervention on postdischarge outcomes for hospitalized older adults. American Journal of Medicine, 114, Elie, M., Cole, M. G., Primeau, F. J., & Bellavance, F. (1998). Delirium risk factors in elderly hospitalized patients. Journal of General Internal Medicine, 13, Fick, D. M., Agostini, J. V., & Inouye, S. K. (2002). Delirium superimposed on dementia: A systematic review. Journal of the American Geriatrics Society, 50, Fick, D. M., Kolanowski, A. M., Waller, J. L., & Inouye, S. K. (2005). Delirium superimposed on dementia in a community-dwelling managed care population: A 3-year retrospective study of occurrence, costs, and utilization. The Journals of Gerontolog y Series A: Biological Sciences and Medical Sciences, 60, Flaherty, J. H., & Morley, J. E. (2004). Delirium: A call to improve current standards of care. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 59, M341 M343. Foreman, M. D., Mion, L. C., Trygstad, L. J., & Fletcher, K. (2003). Delirium: Strategies for assessing and treating. In M. Mezey, T. Fulmer, I. Abraaham, & D. Zwicker (Eds.). Geriatric nursing protocols for best practice (2nd ed., pp ). New York: Springer. Hall, G. R., & Buckwalter, K. C. (1987). Progressively lowered stress threshold. A conceptual model for care of adults with Alzh eimer s disease. Archives of Psychiatric Nursing, 6, Inouye, S. K. (1998). Delirium in hospitalized older patients: Recognition and risk factors. Journal of Geriatric Psychiatry and Neurolog y, 11, Inouye, S. K. (2000). Prevention of delirium in hospitalized older patients: Risk factors and targeted intervention strategies. Annals of Medicine, 32 (4), Inouye, S. K., Bogardus, S. T., Jr., Baker, D. I., Leo-Summers, L., & Cooney, L. M., Jr. (2000). The Hospital Elder Life Program: A model of care to prevent cognitive and functional decline in older hospitalized patients. Journal of the American Geriatrics Society, 48, Inouye, S. K., Bogardus, S. T., Jr., Charpentier, P. A., Leo-Summers, L., Acampora D., & Holford, T. R. (1999). A multicomponent intervention to prevent delirium in hospitalized older patients. New England Journal of Medicine, 340, Inouye, S. K., Bogardus, S. T., Jr., Williams, C. S., Leo-Summers, L., & Agostini, J. V. (2003). The role of adherence on the effectiveness of nonpharmacologic interventions. Archives of Internal Medicine, 163 (8), Inouye, S. K., Foreman, M. D., Mion, L. C., Katz, K. H., & Cooney, L. M. (2001). Nurses recognition of delirium and its symptoms. Archives of Internal Medicine, 161 (20), Inouye, S. K., Leo-Summers, L., Zhang, Y., Bogardus, S. T., Leslie, D. L., & Agostini, J. V. (2005). A chart-based method for identification of delirium: Validation compared with interviewer ratings using the confusion assessment method. Journal of the American Geriatrics Society, 53,

11 Delirium Prevention 113 Inouye, S. K., van Dyck, C. H., Alessi, C. A., Balkin, S., Siegal, A. P., & Horwitz, R. I. (1990). Clarifying confusion: The confusion assessment method. Annals of Internal Medicine, 113, Inouye, S. K., Viscoli, C. M., Horwitz, R. I., Hurst, L. D., & Tinetti, M. E. (1993). A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics. Annals of Internal Medicine, 119, Keller, B. K., Morton, J. L., Thomas, V. S., & Potter, J. F. (1999). The effect of visual and hearing impairments on functional status. Journal of the American Geriatrics Society, 47 (11), Launay-Vacher, V., Karie, S., Fau, J., Izzedine, H., & Deray, G. (2005). Treatment of pain in patients with renal insufficiency: The World Health Organization three-step ladder adapted. Journal of Pain, 6 (3), Marcantonio, E. R., Flacker, J. M., Wright, R. J., & Resnick N. M. (2001). Reducing delirium after hip fracture: A randomized trial. Journal of the American Geriatrics Society, 49, Milisen, K., Foreman, M. D., Abraham, I. L., De Geest, S., Godderis, J., & Vandermeulen, E. (2001). A nurse-led interdisciplinary intervention program for delirium in elderly hipfracture patients. Journal of the American Geriatrics Society, 49, Milisen, K., Steeman, E., & Foreman, M. D. (2004). Early detection and prevention of delirium in older patients with cancer. European Journal of Cancer Care, 13, Vollmer, C., Rich, C., & Robinson, S. (2005). Acute confusion risk assessment on a renal unit. Unpublished manuscript. Wakefield, B. J. (2002). Risk for acute confusion on hospital admission. Clinical Nursing Research, 11 (2), Weber, J. B., Coverdale, J. H., & Kunik, M. E. (2004). Delirium: Current trends in prevention and treatment. Internal Medicine Journal, 34 (3), Weitzel, T., & Robinson, S. B. (2004). A model of nurse assistant care to promote functional status in hospitalized elders. Journal for Nurses in Staff Development, 20 (4), Williams, M. A., Campbell, E. B., Raynor, W. J., Mlynarczyk, S. M., & Ward, S. E. (1985). Reducing acute confusional states in elderly patients with hip fractures. Research in Nursing and Health, 8, Acknowledgments. The authors wish to thank the NICHE group (Nurses Improving Care to Health Systems Elderly) for their assistance in data collection, the nursing assistants, nursing technicians, and nurses of the staff of the urology/nephrology unit for their diligent implementation of the delirium prevention protocol, and Dr. Larry Hughes, statistician, for assistance with the analysis of the data. Correspondence regarding this article should be directed to Sherry Robinson, PhD, CNS, BC, Southern Illinois University School of Medicine, Department of Internal Medicine, P.O. Box 19636, Springfield, IL srobinson3@siumed.edu

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