EMCR COVID-19 Think Tank: Visitor restrictions’ impact on delirium prevention and management

In April 2020, the Institute for Health Transformation’s EMCR Committee launched its Inaugural Think Tank Competition. Early and Mid-Career researchers were asked to reflect on the implications of the COVID-19 pandemic for their research disciplines. Their pieces are included in this seven-part series of articles.

Written by Dr Emily Tomlinson

Changes to visitor restrictions during COVID-19 and the potential impact on delirium prevention and management

by Dr Emily Tomlinson

Abstract: Visitation restrictions to older people in hospital are essential to reduce the spread of COVID-19. However, visitor restrictions may have unintended consequences for the management of people with delirium. Family members are often essential for managing people with delirium and nurses could consider alternatives such as video calling to connect patients with their family.

With the return to stage 3 COVID restrictions in Melbourne, healthcare organisations restricted access to visitors to vulnerable older people in hospital. The Department of Health and Human Services Victoria states that patients may only have two visits each day for a total of two hours. Restricting visitors is important to reduce the risk of coronavirus spreading to vulnerable older patients. However, limitations on visitors including family members could have potential implications on the prevention and management of patients with delirium.

Delirium is an acute state of confusion that can start suddenly in people who are unwell in hospital. People with delirium cannot think clearly and often become disorientated in an unfamiliar environment. People who have had a delirium often experience worse outcomes than those who do not, including premature death [1]. Delirium also costs the Australian healthcare system billions of dollars each year [2]. Delirium is often preventable with the implementation of appropriate interventions of which family/carer involvement is extremely important [3]. People who experience a delirium while in hospital often need the support of family or close friends to provide reorientation and other care interventions. Research has shown that family involvement can improve outcomes for patients [4, 5]. Restrictions on the ability of family members to visit loved ones during the pandemic could have detrimental implications for increased incidence of delirium and result in worse outcomes for those patients.  

Family and carers can also play a major role in the management of difficult behaviours often associated with delirium. Family members are often called by nurses to help settle their relative who may be highly agitated. If family members are unable to visit, or have length of visits restricted, then there may be increases in highly agitated and aggressive behaviours that need to be managed by nurses. Often these behaviours require face-to-face support by family members. Patients with agitated or aggressive behaviours are often given anti-psychotic medications when nurses are unable to manage the behaviour [6]. However, sedative medications like anti-psychotics can have harmful side effects including incontinence, dizziness, falls, cognitive decline and increased risk of strokes. During these visitor restrictions, in the absence of supportive family members, it is concerning that nurses may need to resort to increased use of anti-psychotics. However, it is unknown the impact visitor restrictions will have on the management of people with delirium in hospital. Access to video calling features on smart devices may need to be considered as interventions for delirium prevention and management during this time. Research is needed to investigate the impact of visitation restriction on the prevention of delirium and if the loss of family presence impacts on management and use of anti-psychotic medications.

References:

  1. Siddiqi N, House AO, Holmes JD. Occurrence and outcome of delirium in medical in-patients: a systematic literature review. Age and Ageing. 2006;35(4):350-64.
  2. Pezzullo L, Streatfeild J, Hickson J, Teodorczuk A, Agar MR, Caplan GA. Economic impact of delirium in Australia: a cost of illness study. BMJ open. 2019;9(9):e027514.
  3. Australian Commission on Safety and Quality in Health Care (ACSQHC). Delirium Clinical Care Standard. Sydney2016.
  4. Inouye S, Bogardus ST, Baker DI, Leo-Summers L, Cooney LM, Jr. Hospital Elder Life Program: a model of care to prevent cognitive and functional decline in older hospitalized patients. Journal of the American Geriatrics Society. 2000;48(12):1697-706.
  5. McKenzie J, Joy A. Family intervention improves outcomes for patients with delirium: Systematic review and meta-analysis. Australas J Ageing. 2020;39(1):21-30.
  6. Cull EJ. Incident delirium in the acute general medical setting. Melbourne Deakin University; 2015.

 

Author profile: Dr Emily Tomlinson is a Lecturer in Nursing in the School of Nursing and Midwifery at Deakin University and an early career researcher in the Institute for Health Transformation. Dr Tomlinson’s research examines the nursing management of patients with delirium during hospitalisation. Her current research is focusing on the use of anti-psychotics to treat symptoms of delirium. Dr Tomlinson is also a committee member for the Australasian Delirium Association.