Summary and conclusion

Several issues have been highlighted by the literature reviewed in this chapter. The phenomenon of delirium was outlined, with a clear distinction between the different

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subtypes of the condition. The predisposing and precipitating factors were also described as well as the various diagnostic criteria for delirium. Several standardised delirium bedside tools were discussed, alongside their psychometric properties in the acute hospital setting. It was suggested in earlier publications that some of the tools are not entirely suitable for use in a busy ward environment, and some are particularly unsuitable for use with a cohort of stroke patients (McManus et al. 2007, Nys et al. 2005). The question regarding the suitability of bedside tools for use in a stroke cohort is addressed in four studies which explored the psychometric properties of these tools in detecting delirium in acute stroke (Lees et al. 2013, Mitasova et al. 2012, Kutlubaev et al. 2016, Infante et al. 2017). Whilst each of these studies was medium in scale (see section 2.5.6) and clearly more work is required in this area, this is a promising advance in improving the detection monitoring of delirium after stroke (Mitasova et al. 2012).

It is clear from the literature that the determination of incident delirium in older patients in the acute medical setting is affected by the wide variety of means of identifying delirium and that these incidence rates are regarded as an under-estimate (Inouye et al. 2014).

A gap in the literature around the incidence rates of delirium in acute stroke clearly existed at the start of this programme of research: single studies published prior to the commencement of this programme presented a range of incidence of between 10% (Dahl et al. 2010) to 48% (Gustafson et al. 1991). This gap could be filled with a synthesis of the data available from single studies, as presented in chapter IV of this thesis.

Routine monitoring of delirium is important in a variety of settings, as recognition of delirium is key both in the ability to pinpoint incidence rates and in the improvement of day to day care in clinical practice (Hall et al. 2012). Practice guidelines for delirium recommend routine screening in older adults, however the difficulties associated with recognising a delirium in a stroke cohort are not mentioned in either delirium or stroke

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practice guidelines (Scottish Intercollegiate Guidelines Network 2010, National Institute for Health and Care Excellence 2010). It is unclear how often and by whom delirium is identified in routine clinical practice within the acute stroke care setting. Chapter V of this thesis aims to address this question, as well as exploring clinicians’ views on the suitability of generic bedside tools when used with stroke patients.

The literature review synthesised material from the general medical and geriatric settings to illustrate the serious consequences associated with developing delirium:

increased mortality and morbidity, increased length of hospital stay and an increased risk of developing dementia in the long term (Witlox et al. 2010). Single studies suggested that these consequences are similar in stroke patients (McManus et al. 2009a, van Rijsbergen et al. 2011). Furthermore, delirium is associated with significant economic costs (Leslie and Inouye 2011, O'Mahony et al. 2011) as well as having an emotional impact on the individual, their significant-others and the professionals caring for them in hospital (Belanger and Ducharme 2011, Partridge et al. 2013). A recognition of these important consequences of delirium have led to a call upon clinicians and healthcare managers to work to prevent delirium in at-risk populations and improve the management of this condition (Young and Inouye 2007, Young et al. 2010, Teodorczuk et al. 2012, Inouye et al. 2014).

Early recognition of delirium is a key step in effective management (Holly et al. 2013), yet several barriers to early, accurate identification of delirium are identified in the literature. These range from lack of knowledge and understanding of the condition (Morandi et al. 2013) to lack of clarity around the use of language to describe a delirium (Yevchak et al. 2012) in addition to some evidence of negative attitudes towards people experiencing delirium (Neville 2008, Dahlke and Phinney 2008, Kjorven et al. 2011).

These barriers further compound an already established difficulty in identifying the

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condition and the distinction between the subtypes of delirium (Siddiqi et al. 2006, Young 2010, Inouye et al. 2014). The symptoms of stroke often heighten the challenge of delirium identification: patients are often seriously ill and have communication difficulties as well as cognitive impairment resultant from the stroke itself (Lees et al. 2013, Mitasova et al. 2012). This leaves a problem unique to a stroke patient population, yet at present, the specific challenges to delirium identification as experienced by stroke care teams are not reported in the literature. A further gap in the literature relates to the involvement of AHPs in the recognition of delirium: It is recognised that multidisciplinary team work is crucial in the identification and management of delirium (Yevchak et al. 2012, Schwartz et al. 2016) yet most of the literature describes the barriers experienced by doctors and nurses alone (Flagg et al. 2010, Davis and MacLullich 2009, Baker et al. 2015).

Therefore, the aims of this doctoral programme, as outlined in section 1.6 are designed to address these identified gaps: chapter IV details the work undertaken in the systematic review which scoped the field of delirium in acute stroke, pinpointing the incidence rates by means of a meta-analysis and shedding light on the means by which delirium is identified in stroke research, as well as the risk factors and outcomes associated with the condition. Chapter V details the Scotland-wide survey of doctors and nurses in an attempt to reveal their screening and diagnostic practices within an acute stroke population. Chapter VI details the qualitative work undertaken to explore how multidisciplinary staff within the acute stroke unit reportedly respond to a suspected delirium (Figure 2 on p.80 captures the three strands of the programme). This research highlights an important area, previously unexplored in the literature, the response of occupational therapists to a patient with delirium in their care.

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Chapter III

Methodology

3.1 Introduction

This chapter outlines the overarching methodology of the thesis, provides justification for the choice of mixed methods research and identifies the guiding philosophical standpoint as pragmatism. This chapter summarises the design considerations and demonstrates how each strand of the programme of research is linked in a sequential manner to gain a broad understanding of delirium in acute stroke. This chapter does not outline the details of each methodology employed in the separate strands, these particulars are presented within the chapters corresponding to each strand (Figure 1). A uniting element of the separate studies within this programme of research is the utilisation of online methods as a means of collecting data: from using powerful online search engines and databases to utilising an online survey tool and finally, an online platform upon which focus groups were hosted. This is discussed within this chapter, alongside a mention of some of the overarching ethical considerations that are relevant to this unique research environment.

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