The effect of delirium education on use of target PRN medications in older orthopaedic patients.

SIR—Medications, including anticholinergics [1, 2], neuroleptics and narcotics [3], are recognised as contributing factors to delirium. Often, these medications are prescribed on a PRN (as needed) basis for management of post-operative nausea, delirium and pain. Additionally, antipsychotics and benzodiazepines are the prescribed PRN for delirium symptoms. Delirium complicates the assessment of pain because of the overlapping symptoms and impaired communication, thus resulting in inadequate treatment of pain in delirious older patients [4]. Poor pain control may contribute to worsening cognition and a cycle of ineffective management. The desire to improve delirium management resulted in a geriatric service nurse practitioner and pharmacist from a large Canadian hospital being invited to participate in a one-day session on education for orthopaedic nurses. The purpose of this study is to evaluate one of the outcomes of the educational intervention program: use of PRN medications following repair of hip fracture or elective hip arthroplasty. Little is known regarding the process of clinical decisionmaking among nurses with regard to administering PRN medications, although physicians and nurses may have different approaches. In a psychiatric setting, nurses and physicians had disparate views on the use of PRN medications, including the use of antipsychotics and benzodiazepines [5]. Using simulations of analgesics needed in post-operative cancer patients, Di Giulio and Crow reported a non-statistically significant difference in the amount of patient information collected by the two disciplines during assessment [6]. Differences between the medication prescriber (physician) and administrator (nurse) have the potential to adversely affect patient care. There is an absence of evidence that can be used to base the clinical use of PRN psychotropic medication in mental health settings [7], and we suggest that this situation exists with regard to delirious older adults as well. Nurses are called upon to manage complex and overlapping symptoms, pain and delirium, often with little guidance for practice.