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Preventing Delirium in the Hospital: Simple Solutions Can Work Best


Colleen Regan (c) with student geriatric associates Rachel Kanter and Ian Jeong, who helped bring Marjorie back to the person she once was.

Older adults are at extremely high risk of experiencing delirium and functional decline (an inability or difficulty in performing daily living activities) when hospitalized. Indeed, these conditions can affect more than 50 percent of this population. And it’s easy to see why: Patients are often confined to a bed with a catheter or IV, are sleep deprived, and suffer emotional distress. While both delirium and functional decline can lead to longer hospital stays and other negative outcomes, preventing them from occurring can be as simple as walking with these patients, helping them with their daily hygiene and engaging them in social activities.

Now, a partnership between nurses at the Hospital of the University of Pennsylvania and students at Penn’s School of Nursing (SON) is helping these patients get the attention and support they need, through the Student Geriatric Associates (SGA) Program. SGAs are part of a nurse-driven, geriatric nurse consultation program at HUP that addresses issues that are likely to impact older adults when hospitalized. Specially trained geriatric nurse consultants (GNCs) assess patients – usually those 70 years or older – on their physical, mental and cognitive abilities, and then create a daily customized plan to help prevent or remediate delirium or other issues. “The GNCs not only assess for delirium but also the risk for it. That way, it’s always on our radar,” said Rebecca Trotta, PhD, RN, director of Nursing Research and Science. “Our goal is to see all newly admitted older adult patients on the medical services. They have the highest potential to responding well to interventions.”

The challenge, though, is incorporating these interventions in an already busy and highly complex environment. “Bedside nurses want to provide all these things for their patients… they deserve them,” said geriatric nurse consultant Colleen Regan, BSN, RN-BC, “but they don’t always have the time.”

Enter the student geriatric associates. They put the customized plans into action.

Rachel Kanter, who graduated from the SON in December, has been an SGA since the initiative started last summer. She often helps patients with daily living activities, like eating and using a bed pan, but many patients just want to talk and engage socially. “They like to reminisce, talk about their families…. and give me marriage advice!” she said laughing. “But you can tell when you’re making a difference. There is immediate gratification. I love having the time to just sit and be with these patients.”

“It’s surprising what re-orients a patient,” said geriatric nurse consultant Anne Shoemaker, MSN, RN. “Patients may be agitated because they have a need that’s not being met but they can’t verbally express it, for example, they’re hungry or want to make a phone call. The students are specially trained to anticipate these needs and help patients satisfy them.”

Of course, some patients are not as welcoming as others. “You feel frustrated because someone needs help and you just don’t know how to reach them,” Regan said. Marjorie was one such patient. When she was transferred to HUP this past December, she refused to talk or get out of bed and didn’t seem to trust anyone. “She didn’t leave her bed because she had poor eye sight and was afraid of falling, and she was fearful of strangers because of a facial abnormality. She didn’t want people to see her initially,” Kanter said.

The turnaround started with a book. Regan had recommended reading to Marjorie as part of her care plan but at first she wasn’t interested. Then, SGA Renee Harris, also a recent SON graduate, looked up books on the bestseller list on her phone and read each of the plots lines out loud to Marjorie. She chose The Nightingale by Kristin Hannah. As the days passed, Marjorie not only listened as the students read but also started looking forward to their visits. Even after the students finished reading the book, she remained engaged. “She would ask how a test went that I had told her about,” Kanter said. “Or she’d ask me about my week.”

Marjorie also conquered her fear of falling, getting out into the unit hallway with her walker accompanied by an SGA or other staff member.

In fact, Marjorie was so delighted with the SGA program that she wanted to make sure others knew the benefits. So, as Marjorie dictated, Kanter keyed in her thoughts: Having the book read to her was “a God-send during the holidays. I don’t have anyone to visit me, so the visits from the geriatric team cheered me enormously. They became my family, my children…. They took the time and care to listen to what an older person has to say or is trying to say.”

Marjorie’s condition created a speech difficulty but “the students listened so acutely , they were able to interpret what I was saying to the RN team.” She also spoke about the students providing “calming” hand massages, brushing her hair and “helping me maintain my personal hygiene when I was unable to do it myself…. Anything that can relieve the frustrations of everyday life makes a significant difference.”

Although the geriatric team is still reviewing data from the initial pilot on three of HUP’s medical units, Trotta believes the initiative is making a positive difference. Because this program is evidence-based, “it is highly likely to drive positive outcomes. Patient case reviews have demonstrated prevention of delirium, maintenance of functional ability, and more judicious use of medication to control symptoms,” Trotta said. She is hoping to expand this program to cardiac units at HUP as well as the ED, where there are high numbers of older adults in need of this supportive care. 

Another benefit of the program is exposing student nurses to caring for older patients. “Student nurses don’t typically think about a career in geriatric nursing, but by participating in this program, they can see how rewarding it can be and the difference they can make,” Trotta said. “Just having this knowledge is important for a nurse’s future career because nurses undoubtedly interface with many older adults, no matter where they end up working.”

“I keep thinking about how Marjorie was that first day and tell her ‘I don’t recognize you. You look amazing,’” Regan said. “The students brought her back to the person she once was.”

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