Memory Diaries After Delirium A simple, multidisciplinary tool can help rehab patients regain cognitive function after experiencing delirium in the hospital. On the Pulse
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On the Pulse  |   July 01, 2018
Memory Diaries After Delirium
Author Notes
  • Kristen Martin, MA, CF-SLP, is an acute care clinical fellow at Johns Hopkins Hospital in Baltimore. She received her master’s degree from the University of North Carolina at Greensboro in 2017, and has a special interest in translational research and adult medical speech-language pathology. kmarti86@jhmi.edu
    Kristen Martin, MA, CF-SLP, is an acute care clinical fellow at Johns Hopkins Hospital in Baltimore. She received her master’s degree from the University of North Carolina at Greensboro in 2017, and has a special interest in translational research and adult medical speech-language pathology. kmarti86@jhmi.edu×
Article Information
Healthcare Settings / Attention, Memory & Executive Functions / On the Pulse
On the Pulse   |   July 01, 2018
Memory Diaries After Delirium
The ASHA Leader, July 2018, Vol. 23, 36-38. doi:10.1044/leader.OTP.23072018.36
The ASHA Leader, July 2018, Vol. 23, 36-38. doi:10.1044/leader.OTP.23072018.36
Critical illness, interrupted sleep, low activity, mechanical ventilation, medication and sedation, infection—is it any wonder that many patients in the intensive care unit experience delirium?
And effects of delirium may not resolve by hospital discharge. Patients may have severe cognitive impairments—they may actively hallucinate, recall periods of not being themselves, or be confused—after they experience significant delirium during their hospitalizations.
Given these patients’ cognitive difficulties, how can rehab providers expect them to remember and comply with therapy strategies, keep track of their medical information, and focus on recovery?
In a three-month inpatient rehabilitation rotation during my clinical fellowship in acute care, I first witnessed the severity of cognitive deficits in patients whose delirium had resolved. During this rotation, I analyzed the current evidence for delirium, effective treatment approaches, and my unit’s needs, and then developed a multidisciplinary method of using external memory aids to help these patients.
Delirium data
Delirium is a sudden and severe change in brain function that can cause confusion, disorientation, inattention, impaired memory and fluctuating mental status. An estimated 20 to 40 percent of critically ill patients experience delirium, a figure that reaches 60 to 80 percent in patients who have had surgery or mechanical ventilation. Other risk factors include sedation, sleep deprivation, low activity, sepsis, age and pre-existing cognitive impairments (see sources).
To prevent delirium, hospital staff are encouraged to keep lights on and window shades up to maintain a regular night-day/sleep-wake cycle, reduce sedation, encourage mobility, avoid over- and under-stimulation, and have patients wear their hearing aids and glasses.
Another strategy for patients with delirium is the use of intensive care unit (ICU) diaries. These diaries—essentially logs in which staff (physicians, nurses, therapists and others) and the patient’s loved ones record daily events in the patient’s life—emerged in Europe in the 1970s and 1980s. The goal of this multidisciplinary approach is to help fill in patients’ memory gaps by providing an account of factual events.
The diaries are patient-centered, and the writers use personal language rather than complex medical jargon and abbreviations. They often are easy to use and low-tech, such as a spiral-bound notebook or a binder.
Several studies (see sources) have shown these diaries help patients recall and form memories during their ICU stay, set realistic recovery goals, and track their progress. The diaries may also be associated with a reduction in associated post-traumatic stress disorder or post-intensive care syndrome (for an explanation, see this video).

These dairies help patients recall and form memories during their ICU stay, set realistic recovery goals, and track their progress.

Rehab diaries
Would a similar diary help the cognitive function of patients in inpatient acute rehab? To find out, I developed a project that incorporated diaries into the rehab unit where I worked. If I wanted to see consistent diary use, I knew I needed to start with support and training (see sources).
And I needed buy-in to make a program of rehab diaries functional and effective. In a simple needs assessment with staff, I determined potential facilitators of, barriers to and knowledge of memory diaries.
The nurses, physical therapists (PTs), occupational therapists (OTs) and SLPs estimated that 41 to 50 percent of their patients had memory deficits, but they knew of only 11 to 20 percent using memory aids. They identified the effects of memory deficits on patients’ treatment: decreased new learning, impaired carryover of education/safety precautions, decreased safety awareness and need for repetition. They also identified two main barriers: inconsistent use among the medical and therapy team members, and patients forgetting they had a memory aid to use.
From this assessment, I knew I needed to have a program that improved team communication and was easy to use. I developed a plan, presented it at 10-minute in-services with the nursing staff, charge nurses, PTs, OTs and rehabilitation techs, and adjusted the plan based on feedback:
  • The SLPs and OTs agreed to identify memory impairments, administer memory diaries and provide skilled training in using memory aids.

  • To improve multidisciplinary communication, the clinician initiating the memory diary would indicate its use in four ways: on the “treatment team sticky note” on our electronic medical record, in our unit communication book, as a team goal established during our weekly rounds, and via a sign on the patient’s door.

  • The level of assistance is specific to the patient, but the general goal was to have three entries a day in the memory diary to aid in recall of therapy sessions and medical plan.

  • The meta-cognitive awareness training (self-monitoring internal thoughts and performance) that I facilitated would be carried over to the other disciplines (see example at right).

An estimated 20 to 40 percent of critically ill patients experience delirium, a figure that reaches 60 to 80 percent in patients who have had surgery or mechanical ventilation.

Diaries in action
Over the next month, I provided memory diaries to patients who had acute memory deficits. One liver-transplant patient had a post-operative course complicated by altered mental status, including visual hallucinations. He had no acute neurological findings and his cognitive-linguistic assessment indicated moderate-severe attention and short-term memory deficits, mild executive functioning deficits, tangential and unorganized thought organization and verbal expression, and slow processing.
When we discussed his cognitive deficits and treatment approaches, he was initially hesitant to use a memory diary, but was willing to try it. On day two of using it, he independently kept track of key locations during an off-unit executive functioning and visuospatial task.
During his 10-day stay, he exceeded his goal number of diary entries, kept track of functional medical information and evaluated his performance in other therapy sessions. By his final day, he demonstrated improved self-awareness of his performance and was better able to identify when he needed assistance with tasks.
As with most quality-improvement initiatives, there was a lot of initial excitement and positive feedback. I immediately saw an increase in the number of diary entries (written by staff members and patients) and consistency of patients bringing their diaries to therapy sessions. However, the consistency of the program diminished when I completed my rotation on the acute inpatient rehabilitation unit, likely because there was no champion to keep it going.
The unit is still using memory diaries, but only informally and somewhat sporadically. For projects to continue to be successful, I believe it is essential to have a team approach with continued support and guidance from a champion.
Meta-Cognitive Awareness Training

Patients with cognitive impairments can lack insight into their deficits. To improve awareness and use of compensatory strategies, the SLP can help a patient self-monitor thoughts and performance and respond appropriately. This training can carry over into therapy in other disciplines. Here’s an example:

  • Patient’s task: Walk 100 yards with rolling walker.

  • Prediction: Before beginning the task, the patient predicted they can walk 100 yards if they used the rolling walker to improve balance and took a one-minute rest break to improve endurance.

  • Estimating performance: Following the task, patient estimated they walked 120 yards with a two-minute rest break.

  • Internal distractions/inhibitors: During the task, the patient reported fatigue.

  • External distractions/inhibitors: None—task was completed in a quiet room.

  • Compensatory strategies: The patient requested a rest break when feeling tired.

  • Insight: Following the task, the patient reported improved distance when taking rest breaks to help with endurance.

  • Actual performance: Therapist told the patient that they walked 140 yards with a one-minute rest break.

  • Result: The patient developed improved awareness of performance and tracks progress.

Sources
Cicerone, K. D., Langenbahn, D. M., Braden, C., Malec, J. F., Kalmar, K., Fraas, M., … Ashman, T . (2011). Evidence-based cognitive rehabilitation: Updated review of the literature from 2003 through 2008. YAPMR Archives of Physical Medicine and Rehabilitation, 92(4), 519–530. [Article] [PubMed]
Cicerone, K. D., Langenbahn, D. M., Braden, C., Malec, J. F., Kalmar, K., Fraas, M., … Ashman, T . (2011). Evidence-based cognitive rehabilitation: Updated review of the literature from 2003 through 2008. YAPMR Archives of Physical Medicine and Rehabilitation, 92(4), 519–530. [Article] [PubMed]×
Ewens, B. A., Hendricks, J. M., & Sundin, D. (2015). The use, prevalence and potential benefits of a diary as a therapeutic intervention/tool to aid recovery following critical illness in intensive care: A literature review. Journal of Clinical Nursing, 24(9–10), 1406. [Article] [PubMed]
Ewens, B. A., Hendricks, J. M., & Sundin, D. (2015). The use, prevalence and potential benefits of a diary as a therapeutic intervention/tool to aid recovery following critical illness in intensive care: A literature review. Journal of Clinical Nursing, 24(9–10), 1406. [Article] [PubMed]×
Girard, T. D., Jackson, J. C., Pandharipande, P. P., Pun, B. T., Thompson, J. L., Shintani, A. K., … Ely, E. W. (2010). Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Critical Care Medicine, 38(7), 1513–1520. [Article] [PubMed]
Girard, T. D., Jackson, J. C., Pandharipande, P. P., Pun, B. T., Thompson, J. L., Shintani, A. K., … Ely, E. W. (2010). Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Critical Care Medicine, 38(7), 1513–1520. [Article] [PubMed]×
Pandharipande, P. P., Ely, E. W., Arora, R. C., Balas, M. C., Boustani, M. A., La, C. G. H., … Smith, H. A. B. (2017). The intensive care delirium research agenda: A multinational, interprofessional perspective. Intensive Care Medicine, 43(9), 1329–1339. [Article] [PubMed]
Pandharipande, P. P., Ely, E. W., Arora, R. C., Balas, M. C., Boustani, M. A., La, C. G. H., … Smith, H. A. B. (2017). The intensive care delirium research agenda: A multinational, interprofessional perspective. Intensive Care Medicine, 43(9), 1329–1339. [Article] [PubMed]×
Shum, D., Fleming, J., Gill, H., Gullo, M. J., & Strong, J . (2011). A randomized controlled trial of prospective memory rehabilitation in adults with traumatic brain injury. Journal of Rehabilitation Medicine, 43(3), 216–223. [Article] [PubMed]
Shum, D., Fleming, J., Gill, H., Gullo, M. J., & Strong, J . (2011). A randomized controlled trial of prospective memory rehabilitation in adults with traumatic brain injury. Journal of Rehabilitation Medicine, 43(3), 216–223. [Article] [PubMed]×
Teece, A., & Baker, J. (2017). Thematic analysis: How do patient diaries affect survivors’ psychological recovery? Intensive and Critical Care Nursing Intensive and Critical Care Nursing, 41, 50–56. [Article] [PubMed]
Teece, A., & Baker, J. (2017). Thematic analysis: How do patient diaries affect survivors’ psychological recovery? Intensive and Critical Care Nursing Intensive and Critical Care Nursing, 41, 50–56. [Article] [PubMed]×
Ullman, A. J., Aitken, L. M., Rattray, J., Kenardy, J., Le Brocque, R., MacGillivray, S., & Hull, A. M. (2015). Intensive care diaries to promote recovery for patients and families after critical illness: A cochrane systematic review. International Journal of Nursing Studies, 52(7), 1243. [Article] [PubMed]
Ullman, A. J., Aitken, L. M., Rattray, J., Kenardy, J., Le Brocque, R., MacGillivray, S., & Hull, A. M. (2015). Intensive care diaries to promote recovery for patients and families after critical illness: A cochrane systematic review. International Journal of Nursing Studies, 52(7), 1243. [Article] [PubMed]×
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July 2018
Volume 23, Issue 7