A Family-Focused Delirium Educational Initiative With Practice and Research Implications

Delirium is burdensome and psychologically distressing for formal and informal caregivers, yet family caregivers often have very little understanding or knowledge about delirium. As part of a large multisite intervention study, the Early Nurse Detection of Delirium Superimposed on Dementia (END-DSD), the authors identified a need for family educational materials. This educational initiative's purpose was to develop a delirium admission brochure for family members to aid in the prevention and earlier identification of delirium during hospitalization. A brochure was developed using an iterative approach with an expert panel. Following three iterations, a final brochure was approved. The authors found that an iterative expert consensus approach can be used to develop a brochure for families. Major content areas were helping families understand the difference between delirium and dementia, signs and symptoms of delirium, causes of delirium, and strategies family members can use to prevent delirium. A caregiver-focused educational brochure is one intervention to use in targeting older adults hospitalized with delirium.

Prevalence of potentially inappropriate medication use in older adults using the 2012 Beers criteria

OBJECTIVES

To use the most recently available population-based data to estimate potentially inappropriate medication (PIM) prevalence under the 2012 update of the Beers list of PIMs and to provide a benchmark from which to measure future changes.

DESIGN

Retrospective cohort study using nationally representative data.

SETTING

2006-2010 Medical Expenditure Panel Survey (MEPS).

PARTICIPANTS

Community-dwelling sample of U.S. older adults (N=18,475).

MEASUREMENTS

The updated Beers criteria were operationalized, generating a "broad" PIM definition that incorporated form, route, or dose restrictions where clearly specified and a "qualified" definition that applied specific exceptions where mentioned in the rationale associated with each drug category. Bivariate analyses described PIM prevalence, comparing the two operational definitions, and examined time trends.

RESULTS

Of older adults with prescription medications, 42.6% had at least one medication fill that met the broad definition, with nonsteroidal anti-inflammatory drugs (NSAIDs) having the highest prevalence (10.9%). The rate declined from 45.5% in 2006-2007 to 40.8% in 2009-2010. The categories with the largest absolute decline were NSAIDs, selected sulfonylureas, and estrogens. PIM prevalence was 30.9% using the qualified definition.

CONCLUSION

Despite the overall high use of PIMs, there has been a decline observed in recent years. Future studies should test the effect of educational and clinical interventions on changes in PIM use and outcomes. The current study results can aid in targeting these interventions.

Cognitive and Physical Demands of Activities of Daily Living in Older Adults: Validation of Expert Panel Ratings

Background

Difficulties with performance of functional activities may result from cognitive and/or physical impairments. To date, there has not been a clear delineation of the physical and cognitive demands of activities of daily living.

Objectives

To quantify the relative physical and cognitive demands required to complete typical functional activities in older adults.

Design

Expert panel survey.

Setting

Web-based platform.

Participants

Eleven experts from eight academic medical centers and 300 community dwelling elderly adults age 70 and older scheduled for elective non-cardiac surgery from two academic medical centers.

Methods

Sum scores of expert ratings were calculated and then validated against objective data collected from a prospective longitudinal study.

Main Outcome Measurements

Correlation between expert ratings and objective neuropsychological tests (memory, language, complex attention) and physical measures (gait speed and grip strength) for performance-based tasks.

Results

Managing money, self-administering medications, using the telephone, and preparing meals were rated as requiring significantly more cognitive demand, while walking and transferring, moderately strenuous activities, and climbing stairs were assessed as more physically demanding. Largely cognitive activities correlated with objective neuropsychological performance (r=0.13–0.23, p<.05) and largely physical activities correlated with physical performance (r=0.15–0.46, p<.05).

Conclusions

Quantifying the degree of cognitive and/or physical demand for completing a specific task adds an additional dimension to standard measures of functional assessment. This additional information may significantly influence decisions about rehabilitation, post-acute care needs, treatment plans, and caregiver education.

Pain, delirium, and physical function in skilled nursing home patients with dementia

OBJECTIVE

Skilled nursing facilities (SNFs) are major sites of postacute care for patients with dementia. A recent Office of the Inspector General report indicated that outcomes in SNFs are suboptimal because of poor-quality treatment, including the failure to provide needed care. Pain is frequently unrecognized and untreated in patients with dementia. The aim of this exploratory study was to examine the effect daily pain has on delirium and physical function in patients with dementia in SNFs. The association of daily pain with discharge disposition was also examined.

DESIGN

Secondary analysis of data from an on-going randomized clinical trial.

SETTING

Eight SNFs located in central and northeast Pennsylvania.

PARTICIPANTS

A total of 103 SNF patients with adjudicated dementia and delirium diagnoses and a mean age of 86 (±6.8) years; most were women (66%) and white (98%).

MEASUREMENTS

Measures of pain (Pain Assessment in Advanced Dementia), delirium (Confusion Assessment Method), and physical function (Barthel Index) were taken daily for 30 days or until discharge.

RESULTS

On days when participants experienced greater than their average level of pain, they also experienced more delirium symptoms (P < .001) and lower physical function (P < .001). Participants with higher levels of average daily pain were more likely to die (odds ratio [OR] 6.306, 95% confidence interval [CI] 1.914-20.771, P = .003) or be placed in a nursing home (OR 4.77, 95% CI 1.7-13.2, P = .003) compared with returning to the community at 3-month follow-up.

CONCLUSION

Greater attention to pain in patients with dementia may be a potential solution to some of the quality problems and high costs of care in SNFs.

Gender differences in factors associated with delirium severity in older adults with dementia

The purpose of this descriptive correlational study was to explore potential gender differences in the relationship of dementia severity, age, APOE status, cognitive reserve and co-morbidity (two potentially modifiable factors), to delirium severity in older adults. Baseline data from an ongoing clinical trial and a Poisson regression procedure were used in the analyses. Participants were 148 elderly individuals with dementia and delirium admitted to post-acute care. In women, delirium severity was related to dementia severity (p=0.002) and co-morbidity moderated that effect (p=0.03). In men, education was marginally associated with delirium severity (p=0.06). Implications for research are discussed.

Delirium superimposed on dementia strongly predicts worse outcomes in older rehabilitation inpatients

Objective

Delirium superimposed on dementia (DSD) is common in many settings. Nonetheless, little is known about the association between DSD and clinical outcomes. The study aim was to evaluate the association between DSD and related adverse outcomes at discharge from rehabilitation and at 1-year follow-up in older inpatients undergoing rehabilitation.

Design

Prospective cohort study.

Setting

Hospital rehabilitation unit.

Participants

A total of 2642 patients aged 65 years or older admitted between January 2002 and December 2006.

Measurements

Dementia predating rehabilitation admission was detected by DSM-III-R criteria. Delirium was diagnosed with the DSM-IV-TR. The primary outcome was that of walking dependence (Barthel Index mobility subitem score of <15) captured as a trajectory from discharge to 1-year follow-up. A mixed-effects multivariate logistic regression model was used to analyze the association between DSD and outcome, after adjusting for relevant covariates. Secondary outcomes were institutionalization and mortality at 1-year follow-up, and logistic regression models were used to analyze these associations.

Results

The median age was 77 years (interquartile range: 71–83). The prevalence of DSD was 8%, and the prevalence of delirium and dementia alone were 4% and 22%, respectively. DSD at admission was found to be significantly associated with almost a 15-fold increase in the odds of walking dependence (odds ratio [OR] 15.5; 95% Confidence Interval [CI] 5.6–42.7; P < .01). DSD was also significantly associated with a fivefold increase in the risk of institutionalization (OR 5.0; 95% CI 2.8–8.9; P < .01) and an almost twofold increase in the risk of mortality (OR 1.8; 95% CI 1.1–2.8; P = .01).

Conclusions

DSD is a strong predictor of functional dependence, institutionalization, and mortality in older patients admitted to a rehabilitation setting, suggesting that strategies to detect DSD routinely in practice should be developed and DSD should be included in prognostic models of health care.

Nurse/family caregiver intervention for delirium increases delirium knowledge and improves attitudes toward partnership

Delirium is highly prevalent, especially in hospitalized older adults and is a costly, significant predictor of poor outcomes, including mortality and institutionalization. Partnership between family caregivers and staff nurses could be a cost-neutral preventive strategy. The Nurse/Family Caregiver Partnership for Delirium Prevention (NFCPM) is an innovative educational program that concurrently teaches family caregivers and nurses about delirium and partnering in prevention. The purpose of this feasibility study was to examine the effect of the NFCPM on knowledge of delirium, attitudes toward partnership, and satisfaction with the NFCPM. A quasi-experimental pretest-posttest design was used to enroll 28 patients, 28 family caregivers, and 28 staff nurses. The intervention group significantly improved knowledge of delirium and attitudes toward partnership. Key to satisfaction were participation in decision making, communication, and respect. The NFCPM appears feasible for clinical practice and provides an innovative strategy for family and nurses to improve hospital outcomes for older adults.

Barriers and facilitators to implementing delirium rounds in a clinical trial across three diverse hospital settings

Delirium occurs in more than half of hospitalized older adults with dementia, substantially worsening outcomes. The use of multiple strategies and a local opinion leader, unit champion, has cumulative and lasting effects compared with single-strategy interventions. The purpose of this article is to describe the early barriers and facilitators to rounding with unit champions in a cluster randomized clinical trial in Year 2 of a 5-year trial (5R01NR011042-02). This is a mixed-method study nested within an ongoing multisite cluster-randomized, controlled clinical trial. Descriptive and comparative statistics were collected on N = 192 nursing rounds. Qualitative data were thematically analyzed. On average, rounds lasted 25.54 min (SD = 13.18) and were conducted with the unit champion 64% of the time. This is one of the first studies to systematically address quantitative and qualitative barriers and facilitators to nurse-led delirium rounds, demonstrating the gradual adoption of an intervention in diverse clinical settings.

Delirium superimposed on dementia is associated with prolonged length of stay and poor outcomes in hospitalized older adults

BACKGROUND

Current literature does not identify the significance of underlying cognitive impairment and delirium in older adults during and 30 days following acute care hospitalization.

OBJECTIVE

Describe the incidence, risk factors, and outcomes associated with incident delirium superimposed on dementia.

DESIGN

A 24-month prospective cohort study.

SETTING

Community hospital.

PATIENTS

A total of 139 older adults (>65 years) with dementia.

METHODS

This prospective study followed patients daily during hospitalization and 1 month posthospital. Main measures included dementia (Modified Blessed Dementia Rating score, Informant Questionnaire on Cognitive Decline in the Elderly), daily mental status change, dementia stage/severity (Clinical Dementia Rating, Global Deterioration Scale), delirium (Confusion Assessment Method), and delirium severity (Delirium Rating Scale-Revised-98). All statistical analysis was performed using SAS 9.3, and significance was an α level of 0.05. Logistic regression, analysis of covariance, or linear regression was performed controlling for age, gender, and dementia stage.

RESULTS

The overall incidence of new delirium was 32% (44/139). Those with delirium had a 25% short-term mortality rate, increased length of stay, and poorer function at discharge. At 1 month follow-up, subjects with delirium had greater functional decline. Males were more likely to develop delirium, and for every 1 unit increase in dementia severity (Global Deterioration Scale), subjects were 1.5 times more likely to develop delirium.

CONCLUSIONS

Delirium prolongs hospitalization for persons with dementia. Thus, interventions to increase early detection of delirium have the potential to decrease the severity and duration of delirium and to prevent unnecessary suffering and costs from the complications of delirium and unnecessary readmissions to the hospital.

Using Standardized Case Vignettes to Evaluate Nursing Home Staff Recognition of Delirium and Delirium Superimposed on Dementia

The purpose of this study is to describe nursing home staff knowledge regarding delirium detection and the most common causes of delirium. Specific aims that guided this study include identifying the rate of nurse recognition of delirium and delirium superimposed on dementia (DSD), including different motoric subtypes of delirium, using standardized case vignettes, and exploring what nursing home staff describe as the potential causes of delirium. The study showed overall poor recognition of delirium and DSD, which did not improve over time. Interventions have the potential to increase the early detection of delirium and DSD by the staff and warrant development.

Inappropriate medication prescriptions in elderly adults surviving an intensive care unit hospitalization

OBJECTIVES

To determine types of potentially (PIMs) and actually inappropriate medications (AIMs), which PIMs are most likely to be considered AIMs, and risk factors for PIMs and AIMs at hospital discharge in elderly intensive care unit (ICU) survivors.

DESIGN

Prospective cohort study.

SETTING

Tertiary care, academic medical center.

PARTICIPANTS

One hundred twenty individuals aged 60 and older who survived an ICU hospitalization.

MEASUREMENTS

Potentially inappropriate medications were defined according to published criteria; a multidisciplinary panel adjudicated AIMs. Medications from before admission, ward admission, ICU admission, ICU discharge, and hospital discharge were abstracted. Poisson regression was used to examine independent risk factors for hospital discharge PIMs and AIMs.

RESULTS

Of 250 PIMs prescribed at discharge, the most common were opioids (28%), anticholinergics (24%), antidepressants (12%), and drugs causing orthostasis (8%). The three most common AIMs were anticholinergics (37%), nonbenzodiazepine hypnotics (14%), and opioids (12%). Overall, 36% of discharge PIMs were classified as AIMs, but the percentage varied according to drug type. Whereas only 16% of opioids, 23% of antidepressants, and 10% of drugs causing orthostasis were classified as AIMs, 55% of anticholinergics, 71% of atypical antipyschotics, 67% of nonbenzodiazepine hypnotics and benzodiazepines, and 100% of muscle relaxants were deemed AIMs. The majority of PIMs and AIMs were first prescribed in the ICU. Preadmission PIMs, discharge to somewhere other than home, and discharge from a surgical service predicted number of discharge PIMs, but none of the factors predicted AIMs at discharge.

CONCLUSION

Certain types of PIMs, which are commonly initiated in the ICU, are more frequently considered inappropriate upon clinical review. Efforts to reduce AIMs in elderly ICU survivors should target these specific classes of medications.

Screening for delirium using family caregivers: convergent validity of the Family Confusion Assessment Method and interviewer-rated Confusion Assessment Method

OBJECTIVES

To explore agreement between the Family Confusion Assessment Method (FAM-CAM) for delirium identification and interviewer-rated CAM delirium ratings.

DESIGN

Exploratory analysis of agreement.

SETTING

Community.

PARTICIPANTS

Fifty-two family caregivers and 52 elderly adults with preexisting impairment according to standardized cognitive testing.

MEASUREMENTS

The interviewer-rating for delirium was determined by fulfillment of the CAM algorithm

RESULTS

The total sample included 52 paired CAM:FAM-CAM assessments completed across 52 dyads of elderly adults with preexisting cognitive impairment and family caregivers. The point prevalence of delirium was 13% (7/52). Characteristics did not differ significantly between the groups with and without delirium. The FAM-CAM questions that mapped directly to the original four-item CAM algorithm had the best overall agreement with the interviewer-rated CAM (kappa = 0.85, 95% confidence interval (CI) = 0.65-1.0), sensitivity of 88% (95% CI = 47-99%), and specificity of 98% (95% CI = 86-100%).

CONCLUSION

The FAM-CAM is a sensitive screening tool for detection of delirium in elderly adults with cognitive impairment using family caregivers, with relevance for research and clinical practice.

Pay attention! The critical importance of assessing attention in older adults with dementia

Attention is an important cognitive domain that is affected in Alzheimer's disease and other dementias. It influences performance in most other cognitive domains, as well as activities of daily living. Nurses are often unaware of the critical importance of assessing attention as part of the overall mental status examination. This article addresses an important gap in nurses' knowledge. The authors present a brief overview of attention as a critical cognitive domain in dementia; review instruments/methods for standardizing and enhancing the assessment of attention; and offer ways to help ensure that best practices in the assessment, recognition, and documentation of inattention are implemented in the clinical area. Clinical resources that practicing nurses may find helpful are included.

Tools to detect delirium superimposed on dementia: a systematic review

OBJECTIVES

To identify valid tools to diagnose delirium superimposed on dementia.

DESIGN

Systematic review of studies of delirium tools that explicitly included individuals with dementia.

SETTING

Hospital.

PARTICIPANTS

Studies were included if delirium assessment tools were validated against standard criteria, and the presence of dementia was assessed according to standard criteria that used validated instruments.

MEASUREMENTS

PubMed, Embase, and Web of Science databases were searched for articles in English published between January 1960 and January 2012.

RESULTS

Nine studies fulfilled the selection criteria. Of 1,569 participants, 401 had dementia, and 50 had delirium superimposed on dementia. Six delirium tools were evaluated. One study using the Confusion Assessment Method (CAM) with 85% of participants with dementia had high specificity (96-100%) and moderate sensitivity (77%). Two intensive care unit studies that used the CAM for the Intensive Care Unit (CAM-ICU) reported 100% sensitivity and specificity for delirium in 23 individuals with dementia. One study using electroencephalography reported sensitivity of 67% and specificity of 91% in a population with a 100% prevalence of dementia. No studies examined potential effects of dementia severity or subtype on diagnostic accuracy.

CONCLUSIONS

The evidence base on tools for detection of delirium superimposed on dementia is limited, although some existing tools show promise. Further studies of existing or refined tools with larger samples and more-detailed characterization of dementia are required to address the identification of delirium superimposed on dementia.

Physical activity promotion in primary care targeting the older adult

PURPOSE

This integrative review identifies and examines research literature focused on physical activity promotion provided in primary care settings to older adult patients in order to evaluate the effectiveness of provider-delivered interventions on elders short- and long-term activity levels.

DATA RESOURCES

A comprehensive review of original research published in English from all countries through May 2010 was performed. Relevant literature was identified through MEDLINE, CINAHL, and ProQuest on-line databases. Data from 11 unique studies were systematically extracted and summarized in table format.

CONCLUSIONS

Activity interventions delivered in primary care can produce at least short term increases in activity; however, there is limited evidence to evaluate whether long-term changes can be achieved and thus making the case for future longitudinal studies.

IMPLICATIONS FOR PRACTICE

Tailored activity prescriptions should be provided after holistic patient assessment. Activity counseling requires recognition as a billable service and further study is needed to identify the most efficient intervention. Inclusion of health-economic evaluations in future research could reveal if efforts to improve physical activity levels are an efficient use of resources.