CRITICAL CARE CONNECTION
Preventing Delirium in Postoperative Patients Mary Beth Flynn Makic, PhD, RN, CNS, CCNS, FAAN DELIRIUM IS AN ACUTE confusion disorder characterized by altered mental status, inattention, disorganized thinking, and altered level of consciousness, and it is potentially preventable.1,2 This acute confusional state was described by Hippocrates more than 2,500 years ago and remains an important clinical problem today.3 Significant strides have been made in identifying and treating the condition; however, the science to guide practice remains young.3 What is known about delirium is that it affects 12,500,000 patients and has significant adverse outcomes for these patients; specifically, longer mechanical ventilation and length of hospitalization, functional decline, and higher risk of morbidity and mortality after hospitalization.1-5 Additionally, it is estimated that delirium occurs in 14% to 56% of the postoperative, hospitalized elderly persons, making it one of the most common postoperative complications for the older patient.6,7 Perianesthesia nurses are in an ideal position to identify patients at risk of developing delirium postoperatively and to implement strategies to mitigate the severity of the acute confusional state.
Delirium The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, defines delirium as an acute and fluctuating brain organ dysfunction presenting with a disturbance of consciousness with
Mary Beth Flynn Makic, PhD, RN, CNS, CCNS, FAAN, is a Research Nurse Scientist, Critical Care, University of Colorado Hospital, and an Associate Professor, University of Colorado College of Nursing, Aurora, CO. Conflict of interest: None to report. Address correspondence to Mary Beth Flynn Makic, University of Colorado Hospital, 12401 E 17th Avenue, Campus Box 901, Leprino Building, Aurora, CO 80045; e-mail address: [email protected]. Ó 2013 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2013.09.002
404
reduced ability to focus, sustain, or shift attention.8 Delirium is a change in cognition that is not accounted for by a previously diagnosed condition such as dementia. This change in cognition or perceptual disturbance develops over a short period of time (hours to days) and may fluctuate over the course of a day. Delirium can be classified into three subtypes, namely hyperactive, hypoactive, or mixed.3,8,9 Hyperactive delirium is the most frequently recognized form as it is characterized by agitation, acute disorientation, restlessness, and emotional liability. Hypoactive delirium occurs more commonly, but is often unrecognized as the patient usually presents with a flat affect and is withdrawn, lethargic, quiet, but disoriented and confused. Mixed delirium is a combination of hyperactive and hypoactive types in which the patient’s behaviors swing from agitated to calm moods commonly associated with daytime sedation and nighttime agitation.10 The pathophysiologic process of delirium is not completely understood; however, there are several theories that attempt to explain postoperative delirium. The medication theory focuses on the drugs delivered and associated neurotoxicity.3,11 The surgical theory identifies inflammation from both anesthetics and surgical interventions as the etiology of neuronal changes.11 Stress responses, release of inflammatory cytokines, increased circulation of cortisol, and sleep deprivation are believed to cause changes in neuronal pathways triggering delirium.9,11 The patient theory examines factors such as the frailty and cognitive deficits of the patient before the surgical event. The environmental theory credits disorientation and unfamiliar surroundings as the contributory factor in postoperative delirium.3 Current research continues to examine the role of several neurotransmitters believed to play a role in acute delirium. These neurotransmitters are acetylcholine, dopamine, serotonin, and gamma-aminobutyric acid. Fluctuating levels of these neurotransmitters
Journal of PeriAnesthesia Nursing, Vol 28, No 6 (December), 2013: pp 404-408
405
CRITICAL CARE CONNECTION
and interactions with medications, specifically benzodiazepine agents, are an area of active research in the efforts to more clearly understand what triggers postoperative delirium.
Which Patients Are at Risk for Postoperative Delirium? Although any patient is at risk of developing postoperative delirium, certain factors place the patient at increased risk. These risk factors include: advanced age (risk increases with age), alcohol use, smoking history, chronic disease states, underlying cognitive disorder (eg, dementia), pulmonary disease, history of depression, polypharmacy, medications (anticholinergics, benzodiazepines, and central nervous system depressant agents), electrolyte imbalances, hyper/hypoglycemia, acidbase imbalances, infection, blood loss, dehydration, hypoxia, end-organ failure, hyper/hypothermia, hypoalbuminemia, sleep deprivation, and unrelieved pain. Some risk factors are specific to certain surgeries, such as cardiac and orthopaedic surgeries.3 Although the list of possible triggers is extensive, the perianesthesia nurses’ awareness of the multiple risk elements coupled with assessment of subtle changes in the patient’s cognition is essential to early recognition and treatment of the syndrome.
Assessing Postoperative Delirium Diagnosis of delirium in the critically ill postoperative patient can be challenging because of the subtle and fluctuating nature of the cognitive dysfunction. Current practice standards endorse the use of valid and reliable tools developed to more objectively identify patients with delirium. Delirium assessment tools should be used frequently and consistently to allow for early identification of the syndrome and appropriate treatment interventions. The two most widely used and adopted delirium assessment tools are the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and Intensive Care Delirium Screening Checklist (ICDSC).10 Both tools have recently been recommended by the Society of Critical Care Medicine as the most valid and reliable tools for use in the routine monitoring of ICU patients for the presence of delirium.12 The tools are also appropriate for use in the perioperative practice setting.3
The CAM-ICU was developed specifically for the ICU patient population to include mechanically ventilated individuals.13 This tool has the assessor determine if the patient exhibits acute and fluctuating changes in cognition; it then measures the individual’s level of inattention, overall cognitive function, and disorganized thinking (Figure 1).13 Resources for how to use the CAM-ICU are available at http://www.mc.vanderbilt.edu/icude lirium/assessment.html. The ICDSC uses a checklist format and scoring system to assess the presence of delirium. The scoring system assigns a ‘‘1’’ to the presence of altered level of consciousness, inattention, disorientation, hallucinations, inappropriate speech or mood, psychomotor changes, sleep-wake cycle disturbances, and symptom fluctuation.14 If a score greater than or equal to four is assessed, the provider performs a clinical assessment to confirm the diagnosis of delirium.14 Given the high prevalence of delirium in postoperative patients, especially elderly patients, assessment of patients for acute cognitive dysfunction postoperatively using a valid and reliable delirium assessment tool should be a critical element of ongoing surveillance. Several interventions have been found to be beneficial in the prevention and treatment of patients with delirium. However, effectiveness of interventions continues to be an area of active research.3,12
Pain Management Managing pain is a priority for perianesthesia nurses. Ensuring effective pain management, especially in the first 48 hours postoperatively, has been found to significantly reduce the incidence of postoperative delirium.6 Current guidelines advocate for treatment of pain to include preemptive analgesia before procedures and/or interventions expected to cause discomfort.12 Although opiate agents increase the risk of postoperative delirium, untreated pain is also a known risk factor for cognitive dysfunction.1-7,12,15 Perianesthesia nurses should collaborate with the prescribing provider and pharmacist to develop a patient-specific pain relief regimen that augments opioid agents with nonopioid agents and nonpharmacologic interventions (ie, relaxation and music therapy) and limit administration of sedating agents.
406
MARY BETH FLYNN MAKIC
Figure 1. Vanderbilt. ICU Delirium Group.CAM-ICU pocket card. Available at: http://www.mc.vanderbilt.edu/ icudelirium/docs/PocketCards.pdf. ICU, intensity care unit; CAM-ICU, Confusion Assessment Method for the Intensive Care Unit. Copyright Ó 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved.
Orientation Providing ongoing reorientation to the patient at risk of postoperative delirium is an important and
easy step for the nurse to implement. Ongoing orientation encompasses maximizing social interaction and family visitation for the patient as soon as possible after the procedure.2,3 Other strategies
407
CRITICAL CARE CONNECTION
include the presence of calendars, clocks, newspapers, and other time-oriented references. During daytime hours, have the lights on and dim or turn off lights during evening/night hours to replicate a normal day-night schedule for the patient. Ensure that any sensory-assistive devices are in use by the patient as soon as possible to help prevent sensory deprivation and disorientation (ie, hearing and visual aids). Lastly, remove all unnecessary invasive devices and lines (ie, excessive intravenous tubing or indwelling urinary catheters). Invasive devices increase an older patient’s risk of delirium; thus, efforts should be made to remove unnecessary devices as soon as clinically feasible.1,2,9 For mechanically ventilated patients, daily evaluation of the patient’s readiness to wean or extubate (spontaneous breathing trials) coupled with spontaneous awakening trials (cessation of sedation agents) have been found to enhance the patient’s orientation and reduce acute delirium.12
Sleep Hygiene Promoting sleep and re-establishing normal sleep patterns for the patient while hospitalized is an important intervention in both the prevention and treatment of delirium.9,12 Sleep also restores the body’s immune protection, improves metabolism, and reduces pain.16 Sleep hygiene protocols strive to restore the patient’s normal sleep cycle by encouraging daytime and nighttime routines within the care structure and functions of a busy nursing unit. Normal sleep cycles are typically 90 minutes; thus, efforts to provide uninterrupted sleep postoperatively is important in the treatment and prevention of postoperative delirium. Benzodiazapine agents should be avoided when possible as these agents alter the sleep architecture decreasing effectiveness of the restorative stages of deep sleep.15,16 Current evidence has found that continuous sedative infusions for sleep
promotion does not enhance restorative sleep and actually results in higher delirium rates and greater risk of mortality in ICU patients.16 Strategies found to be effective in promoting sleep include reducing ambient lights and noise, clustering nighttime care to minimize interruptions, rethinking the practice environment, and routine tasks to prevent awaking the patient (eg, timing labs and bathing during awake hours rather than middle of the night).
Early Mobility Several studies have found that promotion of patient mobility is an effective intervention in reducing and treating delirium.12,17 Mobility reestablishes both a physical and cognitive function for the patient. Early mobility protocols for critically ill patients encourage gradual and progressive mobility that begins with passive range of motion from moving to sitting at the edge of the bed to full mobilization. For the perianesthesia practice environment, encouraging patient mobility as much as possible and as soon as possible, to include mobilizing the mechanically ventilated patients, is an important intervention addressing postoperative delirium. Nurses often lead the efforts changing the culture of ‘‘immobility’’ to one that embraces and encourages early and progressive patient mobility.
Summary Perianesthesia nurses are vital in the effort to recognize risk factors that may increase a patient’s risk of developing postoperative delirium. Early recognition of patients who have acute cognitive dysfunction and implementation of strategies to prevent or minimize this complication are needed to reduce the adverse outcomes associated with postoperative delirium.
References 1. Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340:669-676. 2. Schreier AM. Nursing care, delirium, and pain management for the hospitalized older adult. Pain Manag Nurs. 2010;11:177-185. 3. Field RR, Wall MH. Delirium: Past, present, and future. Semin Cardiothorac Vasc Anesth. 2013;17:170-179.
4. Dasgupta M, Dumbrell AC. Preoperative risk assessment for delirium after noncardiac surgery: A systematic review. J Am Geriatr Soc. 2006;54:1578-1589. 5. Witlox J, Eurelings LSM, deJonghe JFM, et al. Delirium in elderly patients and the risk of post-discharge mortality, institutionalization and dementia. JAMA. 2010;204: 443-451.
408
MARY BETH FLYNN MAKIC
6. DeCrane SK, Sands L, Ashland M, et al. Factors associated with recovery from early postoperative delirium. J Perianesth Nurs. 2011;26:213-241. 7. Rudolph JL, Marcantonio ER. Postoperative delirium: Acute change with long-term implications. Anesth Analg. 2011;112:1202-1211. 8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association; 2000. 9. Pun BT, Ely EW. The importance of diagnosing and managing ICU delirium. Chest. 2007;132:624-636. 10. Wong CL, Holroyd-Leduc J, Simel DL, et al. Does this patient have delirium? Value of bedside instruments. JAMA. 2010; 304:779-786. 11. Crosby G, Culley DJ. Surgery and anesthesia: Healing the body but harming the brain? Anesth Analg. 2011;112: 999-1001. 12. Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in
adult patients in the intensive care unit. Crit Care Med. 2013; 41:263-306. 13. ICU Delirium and Cognitive Impairment Study Group. Vanderbilt University Medical Center and United States Department of Veterans Affairs. Available at: http://www.mc.vanderbilt. edu/icudelirium/assessment.html. Accessed August 23, 2013. 14. Bergeron N, Dubois MJ, Dumont M, et al. Intensive care delirium screening checklist: Evaluation of a new screening tool. Intensive Care Med. 2001;27:859-864. 15. Peitz GJ, Balas MC, Olsen KM, et al. Top 10 myths regarding sedation and delirium in the ICU. Crit Care Med. 2013;41: S46-S56. 16. Matthews EE. Sleep disturbances and fatigue in critically ill patients. AACN Adv Crit Care. 2011;22:204-224. 17. Davidson JE, Harvey MA, Bemis-Dougherty A, et al. Implementation of the pain agitation and delirium clinical practice guidelines and promoting patient mobility to prevent post intensive care syndrome. Crit Care Med. 2013;41: S136-S145.
Erratum In the original article, ‘‘The Medicine of Music: A Systematic Approach for Adoption Into Perianesthesia Practice’’ by Amanda M. Beccaloni (26;5:323-330), there was an unintentional reference omission in the abstract. This mistake resulted in the failure to cite and properly attribute a direct quote from the original article by Dileo C, Bradt J, Murphy K, ‘‘Music for preoperative anxiety,’’ Cochrane Database of Systematic Reviews 2008, Issue 1. Art. The corrections mentioned in this erratum have already been made to the article online.
Preventing Delirium in Postoperative Patients Mary Beth Flynn Makic, PhD, RN, CNS, CCNS, FAAN DELIRIUM IS AN ACUTE confusion disorder characterized by altered mental status, inattention, disorganized thinking, and altered level of consciousness, and it is potentially preventable.1,2 This acute confusional state was described by Hippocrates more than 2,500 years ago and remains an important clinical problem today.3 Significant strides have been made in identifying and treating the condition; however, the science to guide practice remains young.3 What is known about delirium is that it affects 12,500,000 patients and has significant adverse outcomes for these patients; specifically, longer mechanical ventilation and length of hospitalization, functional decline, and higher risk of morbidity and mortality after hospitalization.1-5 Additionally, it is estimated that delirium occurs in 14% to 56% of the postoperative, hospitalized elderly persons, making it one of the most common postoperative complications for the older patient.6,7 Perianesthesia nurses are in an ideal position to identify patients at risk of developing delirium postoperatively and to implement strategies to mitigate the severity of the acute confusional state.
Delirium The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, defines delirium as an acute and fluctuating brain organ dysfunction presenting with a disturbance of consciousness with
Mary Beth Flynn Makic, PhD, RN, CNS, CCNS, FAAN, is a Research Nurse Scientist, Critical Care, University of Colorado Hospital, and an Associate Professor, University of Colorado College of Nursing, Aurora, CO. Conflict of interest: None to report. Address correspondence to Mary Beth Flynn Makic, University of Colorado Hospital, 12401 E 17th Avenue, Campus Box 901, Leprino Building, Aurora, CO 80045; e-mail address: [email protected]. Ó 2013 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2013.09.002
404
reduced ability to focus, sustain, or shift attention.8 Delirium is a change in cognition that is not accounted for by a previously diagnosed condition such as dementia. This change in cognition or perceptual disturbance develops over a short period of time (hours to days) and may fluctuate over the course of a day. Delirium can be classified into three subtypes, namely hyperactive, hypoactive, or mixed.3,8,9 Hyperactive delirium is the most frequently recognized form as it is characterized by agitation, acute disorientation, restlessness, and emotional liability. Hypoactive delirium occurs more commonly, but is often unrecognized as the patient usually presents with a flat affect and is withdrawn, lethargic, quiet, but disoriented and confused. Mixed delirium is a combination of hyperactive and hypoactive types in which the patient’s behaviors swing from agitated to calm moods commonly associated with daytime sedation and nighttime agitation.10 The pathophysiologic process of delirium is not completely understood; however, there are several theories that attempt to explain postoperative delirium. The medication theory focuses on the drugs delivered and associated neurotoxicity.3,11 The surgical theory identifies inflammation from both anesthetics and surgical interventions as the etiology of neuronal changes.11 Stress responses, release of inflammatory cytokines, increased circulation of cortisol, and sleep deprivation are believed to cause changes in neuronal pathways triggering delirium.9,11 The patient theory examines factors such as the frailty and cognitive deficits of the patient before the surgical event. The environmental theory credits disorientation and unfamiliar surroundings as the contributory factor in postoperative delirium.3 Current research continues to examine the role of several neurotransmitters believed to play a role in acute delirium. These neurotransmitters are acetylcholine, dopamine, serotonin, and gamma-aminobutyric acid. Fluctuating levels of these neurotransmitters
Journal of PeriAnesthesia Nursing, Vol 28, No 6 (December), 2013: pp 404-408
405
CRITICAL CARE CONNECTION
and interactions with medications, specifically benzodiazepine agents, are an area of active research in the efforts to more clearly understand what triggers postoperative delirium.
Which Patients Are at Risk for Postoperative Delirium? Although any patient is at risk of developing postoperative delirium, certain factors place the patient at increased risk. These risk factors include: advanced age (risk increases with age), alcohol use, smoking history, chronic disease states, underlying cognitive disorder (eg, dementia), pulmonary disease, history of depression, polypharmacy, medications (anticholinergics, benzodiazepines, and central nervous system depressant agents), electrolyte imbalances, hyper/hypoglycemia, acidbase imbalances, infection, blood loss, dehydration, hypoxia, end-organ failure, hyper/hypothermia, hypoalbuminemia, sleep deprivation, and unrelieved pain. Some risk factors are specific to certain surgeries, such as cardiac and orthopaedic surgeries.3 Although the list of possible triggers is extensive, the perianesthesia nurses’ awareness of the multiple risk elements coupled with assessment of subtle changes in the patient’s cognition is essential to early recognition and treatment of the syndrome.
Assessing Postoperative Delirium Diagnosis of delirium in the critically ill postoperative patient can be challenging because of the subtle and fluctuating nature of the cognitive dysfunction. Current practice standards endorse the use of valid and reliable tools developed to more objectively identify patients with delirium. Delirium assessment tools should be used frequently and consistently to allow for early identification of the syndrome and appropriate treatment interventions. The two most widely used and adopted delirium assessment tools are the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and Intensive Care Delirium Screening Checklist (ICDSC).10 Both tools have recently been recommended by the Society of Critical Care Medicine as the most valid and reliable tools for use in the routine monitoring of ICU patients for the presence of delirium.12 The tools are also appropriate for use in the perioperative practice setting.3
The CAM-ICU was developed specifically for the ICU patient population to include mechanically ventilated individuals.13 This tool has the assessor determine if the patient exhibits acute and fluctuating changes in cognition; it then measures the individual’s level of inattention, overall cognitive function, and disorganized thinking (Figure 1).13 Resources for how to use the CAM-ICU are available at http://www.mc.vanderbilt.edu/icude lirium/assessment.html. The ICDSC uses a checklist format and scoring system to assess the presence of delirium. The scoring system assigns a ‘‘1’’ to the presence of altered level of consciousness, inattention, disorientation, hallucinations, inappropriate speech or mood, psychomotor changes, sleep-wake cycle disturbances, and symptom fluctuation.14 If a score greater than or equal to four is assessed, the provider performs a clinical assessment to confirm the diagnosis of delirium.14 Given the high prevalence of delirium in postoperative patients, especially elderly patients, assessment of patients for acute cognitive dysfunction postoperatively using a valid and reliable delirium assessment tool should be a critical element of ongoing surveillance. Several interventions have been found to be beneficial in the prevention and treatment of patients with delirium. However, effectiveness of interventions continues to be an area of active research.3,12
Pain Management Managing pain is a priority for perianesthesia nurses. Ensuring effective pain management, especially in the first 48 hours postoperatively, has been found to significantly reduce the incidence of postoperative delirium.6 Current guidelines advocate for treatment of pain to include preemptive analgesia before procedures and/or interventions expected to cause discomfort.12 Although opiate agents increase the risk of postoperative delirium, untreated pain is also a known risk factor for cognitive dysfunction.1-7,12,15 Perianesthesia nurses should collaborate with the prescribing provider and pharmacist to develop a patient-specific pain relief regimen that augments opioid agents with nonopioid agents and nonpharmacologic interventions (ie, relaxation and music therapy) and limit administration of sedating agents.
406
MARY BETH FLYNN MAKIC
Figure 1. Vanderbilt. ICU Delirium Group.CAM-ICU pocket card. Available at: http://www.mc.vanderbilt.edu/ icudelirium/docs/PocketCards.pdf. ICU, intensity care unit; CAM-ICU, Confusion Assessment Method for the Intensive Care Unit. Copyright Ó 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved.
Orientation Providing ongoing reorientation to the patient at risk of postoperative delirium is an important and
easy step for the nurse to implement. Ongoing orientation encompasses maximizing social interaction and family visitation for the patient as soon as possible after the procedure.2,3 Other strategies
407
CRITICAL CARE CONNECTION
include the presence of calendars, clocks, newspapers, and other time-oriented references. During daytime hours, have the lights on and dim or turn off lights during evening/night hours to replicate a normal day-night schedule for the patient. Ensure that any sensory-assistive devices are in use by the patient as soon as possible to help prevent sensory deprivation and disorientation (ie, hearing and visual aids). Lastly, remove all unnecessary invasive devices and lines (ie, excessive intravenous tubing or indwelling urinary catheters). Invasive devices increase an older patient’s risk of delirium; thus, efforts should be made to remove unnecessary devices as soon as clinically feasible.1,2,9 For mechanically ventilated patients, daily evaluation of the patient’s readiness to wean or extubate (spontaneous breathing trials) coupled with spontaneous awakening trials (cessation of sedation agents) have been found to enhance the patient’s orientation and reduce acute delirium.12
Sleep Hygiene Promoting sleep and re-establishing normal sleep patterns for the patient while hospitalized is an important intervention in both the prevention and treatment of delirium.9,12 Sleep also restores the body’s immune protection, improves metabolism, and reduces pain.16 Sleep hygiene protocols strive to restore the patient’s normal sleep cycle by encouraging daytime and nighttime routines within the care structure and functions of a busy nursing unit. Normal sleep cycles are typically 90 minutes; thus, efforts to provide uninterrupted sleep postoperatively is important in the treatment and prevention of postoperative delirium. Benzodiazapine agents should be avoided when possible as these agents alter the sleep architecture decreasing effectiveness of the restorative stages of deep sleep.15,16 Current evidence has found that continuous sedative infusions for sleep
promotion does not enhance restorative sleep and actually results in higher delirium rates and greater risk of mortality in ICU patients.16 Strategies found to be effective in promoting sleep include reducing ambient lights and noise, clustering nighttime care to minimize interruptions, rethinking the practice environment, and routine tasks to prevent awaking the patient (eg, timing labs and bathing during awake hours rather than middle of the night).
Early Mobility Several studies have found that promotion of patient mobility is an effective intervention in reducing and treating delirium.12,17 Mobility reestablishes both a physical and cognitive function for the patient. Early mobility protocols for critically ill patients encourage gradual and progressive mobility that begins with passive range of motion from moving to sitting at the edge of the bed to full mobilization. For the perianesthesia practice environment, encouraging patient mobility as much as possible and as soon as possible, to include mobilizing the mechanically ventilated patients, is an important intervention addressing postoperative delirium. Nurses often lead the efforts changing the culture of ‘‘immobility’’ to one that embraces and encourages early and progressive patient mobility.
Summary Perianesthesia nurses are vital in the effort to recognize risk factors that may increase a patient’s risk of developing postoperative delirium. Early recognition of patients who have acute cognitive dysfunction and implementation of strategies to prevent or minimize this complication are needed to reduce the adverse outcomes associated with postoperative delirium.
References 1. Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340:669-676. 2. Schreier AM. Nursing care, delirium, and pain management for the hospitalized older adult. Pain Manag Nurs. 2010;11:177-185. 3. Field RR, Wall MH. Delirium: Past, present, and future. Semin Cardiothorac Vasc Anesth. 2013;17:170-179.
4. Dasgupta M, Dumbrell AC. Preoperative risk assessment for delirium after noncardiac surgery: A systematic review. J Am Geriatr Soc. 2006;54:1578-1589. 5. Witlox J, Eurelings LSM, deJonghe JFM, et al. Delirium in elderly patients and the risk of post-discharge mortality, institutionalization and dementia. JAMA. 2010;204: 443-451.
408
MARY BETH FLYNN MAKIC
6. DeCrane SK, Sands L, Ashland M, et al. Factors associated with recovery from early postoperative delirium. J Perianesth Nurs. 2011;26:213-241. 7. Rudolph JL, Marcantonio ER. Postoperative delirium: Acute change with long-term implications. Anesth Analg. 2011;112:1202-1211. 8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association; 2000. 9. Pun BT, Ely EW. The importance of diagnosing and managing ICU delirium. Chest. 2007;132:624-636. 10. Wong CL, Holroyd-Leduc J, Simel DL, et al. Does this patient have delirium? Value of bedside instruments. JAMA. 2010; 304:779-786. 11. Crosby G, Culley DJ. Surgery and anesthesia: Healing the body but harming the brain? Anesth Analg. 2011;112: 999-1001. 12. Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in
adult patients in the intensive care unit. Crit Care Med. 2013; 41:263-306. 13. ICU Delirium and Cognitive Impairment Study Group. Vanderbilt University Medical Center and United States Department of Veterans Affairs. Available at: http://www.mc.vanderbilt. edu/icudelirium/assessment.html. Accessed August 23, 2013. 14. Bergeron N, Dubois MJ, Dumont M, et al. Intensive care delirium screening checklist: Evaluation of a new screening tool. Intensive Care Med. 2001;27:859-864. 15. Peitz GJ, Balas MC, Olsen KM, et al. Top 10 myths regarding sedation and delirium in the ICU. Crit Care Med. 2013;41: S46-S56. 16. Matthews EE. Sleep disturbances and fatigue in critically ill patients. AACN Adv Crit Care. 2011;22:204-224. 17. Davidson JE, Harvey MA, Bemis-Dougherty A, et al. Implementation of the pain agitation and delirium clinical practice guidelines and promoting patient mobility to prevent post intensive care syndrome. Crit Care Med. 2013;41: S136-S145.
Erratum In the original article, ‘‘The Medicine of Music: A Systematic Approach for Adoption Into Perianesthesia Practice’’ by Amanda M. Beccaloni (26;5:323-330), there was an unintentional reference omission in the abstract. This mistake resulted in the failure to cite and properly attribute a direct quote from the original article by Dileo C, Bradt J, Murphy K, ‘‘Music for preoperative anxiety,’’ Cochrane Database of Systematic Reviews 2008, Issue 1. Art. The corrections mentioned in this erratum have already been made to the article online.
