Tela 2 Analysis of a Health Team’s Records and Nurses’ Perceptions Concerning Signs and Symptoms of Delirium

Endereço para correspondência: Abel Avelino de Paiva e Silva Escola Superior de Enfermagem do Porto Rua Dr. António Bernardino de Almeida, s/n 4200-072 Porto, Portugal E-mail:abel@esenf.pt Rosa Carla Gomes da Silva2 Abel Avelino de Paiva e Silva3 Paulo Alexandre Oliveira Marques4 Análise dos registros produzidos pela equipe de saúde e da percepção dos enfermeiros sobre os sinais e sintomas de delirium1


Introduction
Acute Confusion (AC) is frequently described as Acute Confusional State (ACS) or delirium (1)(2)(3) .However, some caveats are found in the literature.AC/ACS are labels frequently used and people tend to identify this clinical condition through the responses given to these episodes.The concept of delirium most strictly defined is based on the Diagnostic and Statistical Manual of Mental Disorders presented by the Psychiatric Association (APA) (3) .
The APA characterizes delirium as reduced consciousness manifested by cognitive, orientation, memory, attention, thinking or behavior disorders, also involving errors in sensorial perception (4) .This syndrome is more frequently found among elderly hospitalized individuals (1)(2)(3)(4)(5) than among individuals in other age groups (6) , and holds a high clinical interest because it is related to less favorable health results, increased cases of dementia, morbidity, mortality, time Silva RCG, Paiva e Silva AA, Marques PAO.
of hospitalization and the costs associated with it (1)(2)(3)(4)(5) .It has a multifactorial cause and is usually associated with predisposing factors (visual impairment, severe disease) and precipitant ones (immobility, poor nutrition) (1,3,5) .Despite its importance, the evidence shows it remains under-diagnosed in about 25% to 75% of the cases, reaching 100% in its hypoactive subtype (5) , which is more difficult to recognize (7)(8) .The fluctuating nature of its manifestations coupled with health professionals' lack of knowledge concerning this syndrome's characteristics, the low use of evaluation instruments to monitor it (5,(9)(10)(11) -such as the NeeCham Confusion Scale (11) -and lack of recording the phenomenon on the part of the health team, are other reasons leading to its under-diagnosis.
Because nurses are constantly in contact with patients, they are in a better position to detect subtle changes early and diagnose the problem.If this condition remains under-diagnosed it is not treated (2)(3)7,9) and can result in innumerous personal, social and economic (8) consequences. Therfore, investigating this issue is considered a priority.

Method
This is a non-experimental, exploratory and correlational descriptive study with a quantitative approach, a method that allows an objective description of historical facts.It was conducted at the hospital of the University of Coimbra, which is composed of various buildings with diverse medical specialties and cares for a large number of patients.The exclusion criteria were: being hospitalized for less than 24 hours; being younger than 17 years old; having concurrent psychiatric diagnosis or aphasia.A non-probabilistic convenience sample was used and the Portuguese version of the NeeCham Confusion Scale (11) validated for the Portuguese culture was applied; this is a good instrument to evaluate the studied phenomenon (3) .
The services available for data collection were the following units: medicine, cardiology, surgery, endocrinology, gastroenterology, hematology, neurology, orthopedics, pneumology, intensive therapy, infectology and urology.Cross-sectional data collection was carried out over two months and a sample of 111 patients was obtained.The selected patients were those who obtained scores below 25 on the NeeCham Confusion Scale.
A documentary analysis was performed in the clinical processes of the 111 patients (medical and nursing records) and the nurses responsible for caring for these patients were interviewed immediately after the NeeCham Confusion Scale was applied.The following question guided the interview: how do you evaluate your patient's mental condition?Answers provided the nurses' perceptions concerning the phenomenon.The documentary analysis aimed to quantify the level of under-diagnosis of the phenomenon given the presence of diagnosis, signs and symptoms.The interview aimed to unveil the nurses' perceptions concerning the presence of AC/delirium at that point in time.A total of 111 interviews were conducted, one per patient, while some nurses had more than one patient in this condition.
The analysis of collected data, clinical records and interviews was based on the technique of content analysis (12) .For that, an analysis model was initially conceived.It was composed of categories and dimensions listed in the literature as indicators of AC/delirium based on the International Classification for Nursing Practice ® version 1.0 (13) .The method used to organize the corpus of analysis within the established categories was guided by the semantic value.The semantic value was the base unit from which information was categorized; each unit was recorded in each dimension only once (12) .
Hence, it was a categorical, frequency and quantitative analysis.Data were analyzed by the Statistical Package for the Social Sciences -version 14.0.Descriptive and inferential statistics were used in order to provide richer information.
The study was approved by the Research Ethics Committee after it was submitted to and authorized by the directors and managers of the nursing units (Doc.no.111).Because the confused patients were considered vulnerable individuals, their legal/family representatives were asked to sign free and informed consent forms.
The nurses also signed free and informed consent forms in order to participate in the study.

General Data
The obtained results indicate that the 111 patients (with AC/delirium) were between 23 and 96 years of age, with an average age of 75.6 years.About half (56.8%) were between 65 and 84 years old, and 52.3% were men.Patients were hospitalized for an average of 12.2 days.According to the NeeCham Confusion Scale (this scale also reveals the condition's level of severity), 59.5% presented the highest level of severity -moderate to severe confusion.The remaining 40.5% displayed mild or early development of confusion.The individuals were distributed in the different units.A total of 69.3% belonged to three types of units: medicine (39.6%); neurology (19.8%) and orthopedics (9.9%).In terms of medical diagnosis, the largest groups were the circulatory system (26.1%),followed by the respiratory tract (22.5%), and neoplasms 10.8%.

Documentation of the phenomenon
The diagnosis of AC/delirium was identified in 4.5% (n=5) of the 111 patients in the sample.
However, the clinical records allowed the identification of various indicators of AC/delirium, which were called documentation of the phenomenon.
The documentation of the phenomenon, the result of analyzing the hospital records of patients with AC/ delirium, fit in the categories: psychological process, behavior, body process, neurological status, ability and other dimensions associated with the phenomenon.Based on this conception, the phenomenon was documented in 86.5% of the cases, hence, under-diagnosis of the documentation of the phenomenon was identified in 13.5% of the cases.
A total of 504 descriptors were identified and these can be related to AC/delirium, especially in the nurses' records.The most frequent are the 31.9% that refer to neurological status, the 21.7% that refer to body process, the 18.2% that refer to psychological process; the 17.5% that refer to behavior, and the 10.7% that refer to alterations at other levels as presented in Table 1.
According to the adopted classification, confusion is a type of cognition, which in turn is a psychological process at a higher and abstract level (13) .

Documentation of nursing interventions
The

Perceptions of nurses
The interviews with nurses showed that 30.6% of them did not identify AC/delirium.A total of 131 associated concepts were identified among the nurses who identified the phenomenon.These concepts gave origin to the same categories used in the documentation of the phenomenon, only with different frequencies.A total of 36.6% of the concepts referred to the category neurological status, 32.8% to the psychological process and 15.4% to body process, and 9.2% and 6.1% to behavior and ability, respectively.The dimension that obtained the highest number of answers was orientation (29.0%), followed by confusion with 24.4%.
The perception of nurses was significantly related to the degree of severity of AC/delirium (t=5.397 and p <0.001) and also with the degree of documentation of the phenomenon (χ 2 =7.041 and p=0.008), noting that the more severe patients were more easily identified and also that 92.2% of the patients with documentation of the phenomenon were identified by the nurses as having AC/delirium.

Discussion
Most of the documentation related to patients with AC/delirium emerges from the documentation performed by nurses, which is consistent with the literature.Given the most intense contact of nurses with patients, nurses are able to more rapidly identify changes in patients' mental conditions (1,3,14) .However, establishing the diagnosis is difficult (5,(8)(9) and may be related to the syndrome's characteristics (fluctuation of symptoms and the hypoactive subtype), infrequent use of reliable evaluation instruments, and factors inherent to the nurses themselves (9)(10)(11) .As the data show, the characteristics of patients with AC/delirium (age and gender) and the particularities of the hospitalization (service and time of hospitalization) can also influence the recognition of the phenomenon and the conception of nursing care.
The study confirmed that a large portion of patients with AC/delirium are elderly, which is in agreement with the literature (1)(2)(3)(4)(5)(9)(10)(11)15) . This age roup tends to have a set of conditions that favors the development of this syndrome due to these individuals' vulnerability and also due to their more active use of health services (16) .They have also lived more years with more weaknesses.At the same time, more than two thirds of these patients were concentrated in three types of service -medical, orthopedics and neurological -that are already known to be related to a set of prevalent pathologies (such as the diseases in the circulatory system and respiratory tract) and the characteristics inherent to this age group (2,17) .AC/delirium is primarily identified through clinical indicators of exacerbation of motor behavior such as the exteriorization of medical devices, attempt to get out of the bed, which often results in falls and has been confirmed by evidence (18) .It is known that many elderly patients have the hypoactive subtype that is more difficult to detect, unlike patients who have more expressive signs and symptoms;

Documentation of the phenomenon
the hyperactive subtype is more easily detected.This study's concept of severity is in agreement with data from the literature and seems to be strongly related to the hyperactive subtype (7)(8) .Hence, the conclusion is that under-diagnosis of AC/delirium is mainly present is cases of lethargy, sleepiness, or apathy.
The existence of documentation but with absence of perception of the phenomenon was identified, which may indicate a lack of understanding on the part of nurses concerning the specificities of this syndrome.
Attention deficit is one of the most common changes distinguishing AC/delirium (10,19) and a reduced number of cases was identified in this study.Additionally, indicators of rapid onset and fluctuation of symptoms were never recorded in the analyzed documentation.The literature also indicates that nurses have deficient knowledge related to geriatrics (20)(21) and AC/delirium (10)(11) , which might explain the lack of records of this phenomenon's characteristics.
The documentation of nursing interventions is related to the documentation of the phenomenon and to the patients' gender.The first aspect seems logical.
There is a higher probability of a patient to undergo nursing interventions once the problem is identified.
However, the gender aspect is more of a problem since  (22) .Nursing practices should go beyond the simple management of signs and symptoms (23) , as in the case of physical restraint.Hence, this study's findings require professionals to reflect on why interventions considered important in the literature, such as reality orientation (5,(9)(10) , are not documented and the following Rev. Latino-Am.Enfermagem 2011 Jan-Feb;19(1):81-9.
Perhaps, the professionals working in these units are less attentive to the phenomenon given its lower incidence in these units.
Age is an important factor in the under-diagnosis issue because the older the individual the lower is underdiagnosis of AC/delirium, a factor already described in another study (24) .Although age is associated with AC/delirium, any inpatient is susceptible to this syndrome (1,6,15) .
Even though an absolute rate of 8.1% of AC/delirium under-diagnosis was identified, it is a less expressive rate compared with data from other studies (7,14,16) .When problem in diagnosing AC/delirium (5,14,16) .

Conclusion
This study made clear that the patients' mental condition is not properly evaluated.The use of evaluation However, these limitations do not belittle the importance of its findings.When a professional writes the expression vacant stare, s/he may not associate it with AC/delirium but s/he has evidently identified the change in state.
Relaxing the criteria would certainly increase absolute under-diagnosis, which does not diminish the quality of the findings.
This study's general objective was to identify the level of under-diagnosis of AC/delirium in a central university hospital in Portugal.Its specific objectives were: to identify the level of severity of AC/delirium; analyze the proportion of indicators (signs and symptoms) of AC/delirium in the records kept by physicians and nurses at the clinical level through the descriptions that indicate the phenomenon or related interventions; and analyze the nurses' level of perception concerning the phenomenon of AC/delirium.This study also explored the relationship between the characteristics of patients and of hospitalization with the documentation of the phenomenon, documentation of nursing interventions, nurses' perceptions and underdiagnosis of AC/delirium, aiming to find the causes, besides those already known, that might explain its under-diagnosis.
was identified in about 86% of the clinical records and is related to hospitalization service and time, severity of AC/ delirium and documentation of nursing interventions.The professionals of services that have a frequency of patients with AC/delirium above the average are more familiar with the phenomenon and are able to observe it better.Longer hospitalizations advance identification of the phenomenon.When professionals spend more time with patients they improve their knowledge of them and become more able to detect changes in their mental condition, increasing opportunities to document it.
male patients are more susceptible to the development of this phenomenon and this fact may be related to potential beliefs and stereotypes.It is important to keep in mind that a significant number of interventions are related to behavior control measures, which may indicate more hyperactivity manifestations on the part of male patients and explain the restraint measures.The truth is that these interventions per se represent a risk factor for AC/delirium and indicate the poor quality of care delivery question is posed: is it possible that interventions are planned but not recorded, or that they are undervalued or unknown?The fact that about one third of the patients with documentation of phenomenon did not have any documentation of nursing interventions is of concern.The hospitalization service was an element that influenced the documentation of the phenomenon and documentation of interventions.The urology, hematology and surgery services displayed significantly higher rates of under-diagnosis in documentation than other units.
one broadens the concepts and includes indicators of altered mental condition, under-diagnosis substantially decreases.On the other hand, when only the concepts AC and/or delirium are considered at the level of clinical process, only 4.5% of the cases were diagnosed, which reveals under-diagnosis rates that are truly of concern.Additionally, if only the concept delirium was taken into account, which was observed only once in the medical records, the under-diagnosis rate would be virtually 100%.Therefore, the fact that this investigation enabled the identification of concepts or indicators indicating the phenomenon does not mean the professionals confirmed the diagnosis.Hence, under-recognition is the main instruments such as the NeeCham Confusion Scale is an important strategy because it makes more objective a phenomenon of great subjectivity.The under-diagnosis of AC/delirium is a fact and regardless of the reasons involved in its genesis, it is important to know and overcome them.This study allowed the identification of some of them, which is innovating and relevant for contributing to the knowledge in this subject.It additionally exposes the context of a large European hospital in relation to the under-recognition and underdiagnosis of AC/delirium, a very significant problem for the safety of patients and quality of care delivery.Most of the documented nursing interventions refer to Physical Restraint, which is not in agreement with advanced nursing practices, though it is not clear whether other measures were implemented but not documented.Professionals' experience should be complemented with the use of better evidence available in the literature in order to provide improved care to the population.This study opens up the possibility of implementing training measures concerning AC/delirium and also measures to systematically evaluate the phenomenon and nursing interventions since such measures can lead to positive results.This study's limitations especially refer to the affected individuals because the study includes a broad set of concepts related to the phenomenon, a reduced contextualization of the study field and of the clinical experience of the involved nurses with AC/delirium.

Table 2 -
Descriptors of nursing interventionsTable 3 shows that among patients without documentation of the phenomenon, only one had documentation of interventions.
since patients with documentation of interventions display, on average, more severe AC/delirium.A significant relationship was found with documentation of interventions in relation to gender and hospitalization service (χ 2 =6.355 and p=0.012; χ 2 =23.205 and p=0.010).In the cases without documentation of The results also permitted verifying that the documentation of the phenomenon is significantly related to the documentation of interventions (χ 2 =20.053 and p≤0.001), since most of the patients with documentation www.eerp.usp.br/rlaeRev. Latino-Am.Enfermagem 2011 Jan-Feb;19(1):81-9. of the phenomenon also have documentation of nursing interventions.

Table 3 -
Relationship between documentation of the phenomenon and documentation of nursing interventions Extent of under-diagnosis of confusion in documentation According to the data, 12.6% of patients did not present any documentation of the phenomenon or documentation of interventions; hence this is the value of under-diagnosis in the documentation.The relationships between documentation of the phenomenon and documentation of interventions presented in Table4are evidence of the importance of identifying the phenomenon.

Table 4 -
Relations between documentation of the phenomenon and documentation of interventions p=0.040).The urology service was the service that presented the highest level of under-diagnosis: 57.1% of its patients did not present documentation of the phenomenon or documentation of interventions.The

Table 5 -
Relationship between total under-diagnosis and under-diagnosis in the documentation