Delirium superimposed on dementia

Drug prescriptions in elderly hospitalized patients with cognitive impairment in the Italian Dementia Friendly Hospital project

Objective

The aim of the study was to characterize drug prescription patterns in elderly patients hospitalized in acute wards as a function of cognitive status and staff training.

Methods

We recorded clinical parameters reflecting health status and drug prescriptions at admission, during hospital stay, and at discharge before and after a short staff training on the needs of aged cognitively impaired patients. Participants aged 65 and older had a Mini-Mental State Examination (MMSE) score ≥16. The number of prescriptions, sedative and anticholinergic load, and drug-drug interactions were evaluated. Of the 116 older patients analyzed, 59 patients were cognitively impaired, and 57 were cognitively normal with an MMSE value > 24. Fifty-nine patients (28 CN, 31 CI) were assisted by the hospital health staff after training.

Results

Participants presented a widespread polypharmacy. Cognitively impaired patients received more prescriptions, more inappropriate prescriptions, had a greater sedative load, and were exposed to more interactions. Staff training had no effect on the prescription pattern.

Conclusion

The results suggest that hospitalized cognitively impaired patients are overprescribed psychotropic drugs and have an excessive sedative and anticholinergic load. Interventions designed to improve dementia care practices in health staff that are not also designed to manage drug polypharmacy do not modify prescription patterns.

Validation of the Delirium Observation Screening Scale in long-term care facilities in Flanders

AIM

The aim of this study was to validate the Delirium Observation Screening Scale (DOSS) in a population of long-term care facility (LTCF) residents in Flanders. Currently there is no validated screening tool for delirium available for the population in this setting in Flanders.

METHODS

A multisite, cross-sectional study was conducted in six LTCFs. A total of 338 residents aged 65 years and older were included. Sociodemographic and clinical data, including data from the Montreal Cognitive Assessment (MoCA), Confusion Assessment Method (CAM) and DOSS, were obtained by three trained nurse researchers. For the DOSS, internal consistency was determined, and inter-rater reliability was calculated. To validate the DOSS, the sensitivity, specificity, and positive and negative predictive value of the DOSS relative to the CAM were determined through receiver operating characteristic analysis. This article adheres to the Strengthening the Reporting of Observational Studies (STROBE) checklist for observational research.

RESULTS

For 338 residents, delirium assessments were completed during an early or late shift. The prevalence of delirium was 14.2% as measured with the DOSS. The reliability (α) for the CAM and DOSS was assessed, as was the inter-rater reliability (κ) and the area under the curve. The sensitivity and specificity for a cut-off value of 3 on the DOSS by Youden's index were very high, as was the negative predictive value. The positive predictive value was good.

CONCLUSIONS

This study showed that the DOSS is a reliable and valid instrument to screen for delirium in LTCF residents in Flanders. Geriatr Gerontol Int 2024; 24: 619-625.

Factors associated with delirium in a real-world acute-care setting: analysis considering the interdependence of clinical variables with the frailty syndrome

PURPOSE

Delirium risk assessment in the acute-care setting generally does not account for frailty. The objective of this retrospective study was to identify factors associated with delirium, considering the interdependency of clinical variables with frailty syndrome in complex older patients.

METHODS

The clinical records of 587 participants (248 M, median age 84) were reviewed, collecting clinical, anamnestic and pharmacological data. Frailty syndrome was assessed with the Clinical Frailty Scale (CFS). Delirium was the main study endpoint. The correlations of the considered anamnestic and clinical variables with delirium and its subtypes were investigated selecting only those variables not showing a high overlap with frailty. Correlations associated with a 25% excess of frequency of delirium in comparison with the average of the population were considered as statistically significant.

RESULTS

Delirium was detected in 117 (20%) participants. The presence of one among age > 85 years old, CFS > 4 and invasive devices explained 95% of delirium cases. The main factors maximizing delirium incidence at the individual level were dementia, other psychiatric illness, chronic antipsychotic treatment, and invasive devices. The coexistence of three of these parameters was associated with a peak frequency of delirium, ranging from 57 to 61%, mostly hypoactive forms.

CONCLUSIONS

In acute-care wards, frailty exhibited a strong association with delirium during hospitalization, while at the individual level, dementia and the use of antipsychotics remained important risk factors. Modern clinical prediction tools for delirium should account for frailty syndrome.

Does the Etiology, Phenomenology and Motor Subtype of Delirium Differ When It Occurs in Patients With An Underlying Dementia?: A Multi-Site, International Study

OBJECTIVES

To compare the etiology, phenomenology and motor subtype of delirium in patients with and without an underlying dementia.

METHODS

A combined dataset (n = 992) was collated from two databases of older adults (>65 years) from liaison psychiatry and palliative care populations in Ireland and India. Phenomenology and severity of delirium were analysed using the Delirium Symptom Rating Scale Revised (DRS-R98) and contributory etiologies for the delirium groups were ascertained using the Delirium Etiology Checklist (DEC). Delirium motor subtype was documented using the abbreviated version of the Delirium Motor Subtype Scale (DMSS4).

RESULTS

Delirium superimposed on dementia (DSD) showed greater impairment in short term memory, long term memory and visuospatial ability than the delirium group but showed significantly less perceptual disturbance, temporal onset and fluctuation. Systemic infection, cerebrovascular and other Central nervous system etiology were associated with DSD while metabolic disturbance, organ insufficiency and intracranial neoplasm were associated with the delirium only group.

CONCLUSION

The etiology and phenomenology of delirium differs when it occurs in the patient with an underlying dementia. We discuss the implications in terms of identification and management of this complex condition.

Delirium Prevention in Early Rehabilitation During Acute Hospitalization and Implementation of Programs Specifically Tailored to Older Patients with Cognitive Impairment: A Scoping Review with Meta-Analysis

BACKGROUND

No systematic review on delirium prevention within early, hospital-based rehabilitation on implementation of approaches specifically tailored for patients with cognitive impairment (PwCI), such as Alzheimer's disease or vascular dementia, has been published despite the high relevance of specific medical care in this vulnerable population.

OBJECTIVE

To document design and effectiveness of delirium prevention programs by early rehabilitation during acute, hospital-based medical care and implementation of programs specifically tailored to PwCI.

METHODS

In a three-step approach, we first identified published systematic reviews of hospital-based, early rehabilitation interventions for older persons (>65 years) in relevant databases. In a second step, we screened each single trial of included reviews according to predefined inclusion criteria. In a third step, we analyzed studies with focus on delirium prevention.

RESULTS

Among n = 25 studies identified, almost all intervention programs did not specifically target cognitive impairment (CI). Interventions were heterogeneous (modules: n = 2-19); almost all study samples were mixed/unspecified for cognitive status with more affected patients excluded. Only one study exclusively included delirium patients, and only one included CI patients. Results of random effect meta-analysis showed significant effects of generic programs to reduce delirium incidence during hospitalization by 41% (p < 0.001, odds ratio, 95% confidence interval: 0.59 [0.49, 0.71] with modest heterogeneity (I2: 30%).

CONCLUSIONS

Study results document a lack of implementation for delirium prevention programs specifically tailored to PwCI by early, hospital-based rehabilitation. Specifying existing rehab concepts or augmenting them by CI-specific modules may help to develop, optimize, and implement innovative delirium prevention in PwCI in acute medical care.

[Delirium superimposed on dementia : Early detection and treatment]

BACKGROUND

Delirium superimposed on dementia (DSD) is a widespread but often undetected problem. Additional delirium significantly reduces the quality of life in patients with dementia. Awareness of this condition must be increased among professionals to recognize its development at an early stage, distinguish it from dementia and treat it accordingly.

OBJECTIVE

This review describes the current state of diagnostic, preventive, and therapeutic methods in dealing with DSD.

MATERIAL AND METHODS

A comprehensive literature search was conducted in the PubMed database using the terms "dementia", "delirium", "delirium superimposed on dementia" and "DSD". An additional literature search was performed via Google Scholar.

RESULTS

The diagnostic techniques for detecting DSD are currently limited to delirium-only diagnostic tools, such as the confusion assessment method. A multiprofessional screening of high-risk patients on a regular basis is essential for the early detection and prevention of this disease. An interdisciplinary approach is also required for treatment. Pharmacological therapy is indicated when nonpharmacological measures are insufficient or to treat delirium-inducing causes. The focus lies on the mental and physical care of the patient and on the elimination of risk factors for developing DSD.

CONCLUSION

DSD is a serious syndrome, however, there is still no gold standard for diagnosis and treatment. Multicomponent nonpharmacological intervention programs have been shown to reduce the incidence of delirium. Their benefit in DSD must be verified in large multicenter studies.

Occurrence and predictors of delirium in critically ill older patients: a prospective cohort study

Objectives

This study aims to analyze the occurrence of delirium in critically ill older patients and to identify predictors of delirium.

Methods

This prospective study included critically ill older patients admitted into level II units of Intensive Care Medicine Department of a University Hospital. Patients with Glasgow Coma Scale score ≤11, traumatic brain injury, terminal disease, history of psychosis, blindness/deafness, or inability to understanding/speaking Portuguese were excluded. The Confusion Assessment Method-Short Form (CAM-4) was used to assess the presence of delirium.

Results

The final sample (n = 105) had a median age of 80 years, most being female (56.2%), widowed (49.5%), and with complete primary education (53%). Through CAM-4, 36.2% of the patients had delirium. The delirium group was more likely to have previous cognitive decline (48.6% vs 19.6%, P = .04) and severe dependency in instrumental activities of daily living (34.3% vs 14.8%, P = .032), comparing with patients without delirium. The final multiple logistic regression model explained that patients with previous cognitive decline presented a higher risk for delirium (odds ratio: 4.663, 95% confidence Interval: 1.055-20.599, P = .042).

Conclusions

These findings corroborate previous studies, showing that cognitive decline is an independent predictor for delirium in older patients. This study is an important contribution for the knowledge regarding the predictors of delirium. The recognition of these factors will help to identify patients who are at high risk for this syndrome and implement early screening and prevention strategies. However, further studies with larger samples, recruited from other clinical settings as well as analyzing other potential factors for delirium, will be needed.

Aesthetic ways of knowing: exploring mental health nurses' experiences of delirium superimposed on dementia

BACKGROUND

In the UK, people with delirium superimposed on dementia may be cared for by mental health nurses, however there is little in the literature about the experience of caring for people with the condition from the perspective of mental health nurses.

AIM

To illuminate the experiences of mental health nurses caring for people with delirium superimposed on dementia and to explore how mental health nurses 'know' the people they care for using 'aesthetic ways of knowing'.

METHOD

A mixed-methods design was used guided by the principles of activity theory. Participants were registered mental health nurses with experience of caring for people with delirium superimposed on dementia within a 24-hour care environment, including an NHS mental health foundation trust and care homes. Data were collected in two ways and at two different time points: first via semi-structured interviews (n=7), second via a questionnaire (n=25). Thematic analysis of the qualitative data was paired with simple descriptive statistics of the quantitative data to describe participants' experience.

FINDINGS

This article discusses one finding from the larger study, which was undertaken as part of the author's PhD, in relation to the way in which mental health nurses 'know' the people they care for. Overall, participants showed a preference for aesthetic ways of knowing, rather than the use of formal assessment tools or scores. Participants experienced caring for people with delirium superimposed on dementia by valuing the person and concentrating on their behaviours, responses and personality, thus enabling them to anticipate and/or recognise potential triggers, precipitating factors and any changes in behaviours.

CONCLUSION

The ways in which mental health nurses know the people they care for influences their care delivery. Mental health nurses' use of aesthetic ways of knowing should be recognised and valued as a way of better understanding and supporting the person with delirium superimposed on dementia.

Association of drug burden index with delirium in community-dwelling older adults with dementia: a longitudinal observational study

BACKGROUND

The Drug Burden Index (DBI) is a validated tool for assessing the dose-dependent cumulative exposure to sedative and anticholinergic medications. However, the increased risk of delirium superimposed dementia (DSD) with high DBI levels has not yet been investigated.

AIM

This study aimed to examine the potential association between DBI scores and delirium in community-dwelling older adults with dementia.

METHOD

A total of 1105 participants with cognitive impairment underwent a comprehensive geriatric assessment. Experienced geriatricians made the final diagnosis of delirium based on DSM-IV-TR and DSM-V. We calculated the DBI as the sum of all sedatives and anticholinergics taken continuously for at least four weeks before admission. Polypharmacy was defined as regular use of five or more medications. We classified the participants as having no exposure (DBI = 0), low exposure (0 < DBI < 1), and high exposure (DBI ≥ 1).

RESULTS

Of the 721 patients with dementia, the mean age was 78.3 ± 6.7 years, and the majority were female (64.4%). In the whole sample, low and high exposures to anticholinergic and sedative medications at admission were 34.1% (n = 246) and 38.1% (n = 275), respectively. Patients in the high-exposure group had higher physical impairment (p = 0.01), higher polypharmacy (p = 0.01), and higher DBI scores (p = 0.01). In the multivariate Cox regression analysis, high exposure to anticholinergic and sedative medications increased the risk of delirium 4.09-fold compared to the no exposure group (HR = 4.09, CI: 1.63-10.27, p = 0.01).

CONCLUSION

High exposure to drugs with sedative and anticholinergic properties was common in community-dwelling older adults. A high DBI was associated with DSD, highlighting the need for an optimal prescription in this vulnerable population.

TRIAL REGISTRATION

The trial was retrospectively registered at ClinicalTrials.gov. Identifier: NCT04973709 Registered on 22 July 2021.

Contribution of Different Brain Disorders and Multimorbidity to Delirium Superimposed Dementia (DSD)

Delirium, an acute neuropsychiatric disorder characterized by a disturbance of attention and awareness, is often superimposed on dementia with its progressive cognitive decline. Despite the high frequency and clinical relevance of this condition, often called delirium-superimposed dementia (DSD), little is known about possible triggers. In this study using the GePsy-B databank, we investigated the impact of the underlying brain disorder and multimorbidity (MM) on DSD. MM was measured by CIRS and the number of ICD-10 diagnoses. Dementia was diagnosed by CDR, and delirium by DSM IV TR criteria. A total of 218 patients were diagnosed with DSD and these were compared to 105 patients with only dementia, 46 with only delirium, and 197 patients suffering from other psychiatric diseases, mainly depression. No significant differences between groups were found concerning CIRS scores. Based on CT scans, DSD cases were grouped into those with cerebral atrophy only (probably pure neurodegenerative), with brain infarction, or with white matter hyperintensities (WMH), but no between-group differences regarding the MM indices could be found. Regression analysis only revealed age and dementia stage as influencing factors. Conclusion: Our results suggest that neither MM nor morphologic changes in the brain are predisposing factors for DSD.

Neurologic Complications of COVID-19

OBJECTIVE

This article describes the spectrum of neurologic complications occurring in acute or postacute infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as well as the neurologic risks and benefits of vaccination against SARS-CoV-2.

LATEST DEVELOPMENTS

Early in the COVID-19 pandemic, reports of neurologic complications of COVID-19 began to surface. A variety of neurologic conditions have since been reported in association with COVID-19. Understanding of the underlying mechanism of COVID-19 neurologic involvement continues to evolve; however, the evidence seems to suggest that aberrant inflammatory responses may play a role. In addition to neurologic symptoms in acute COVID-19, neurologic post-COVID-19 conditions are increasingly recognized. The development of COVID-19 vaccines has been essential in preventing the spread of COVID-19. With increasing numbers of vaccine doses administered, various neurologic adverse events have been reported.

ESSENTIAL POINTS

Neurologists must be aware of the potential acute, postacute, and vaccine-associated neurologic complications associated with COVID-19 and be poised to serve as integral members of multidisciplinary care teams for patients with COVID-19-related conditions.

The possible role of gut microbiota dysbiosis in the pathophysiology of delirium in older persons

Delirium is a clinical syndrome characterized by an acute change in attention, awareness and cognition with fluctuating course, frequently observed in older patients during hospitalization for acute medical illness or after surgery. Its pathogenesis is multifactorial and still not completely understood, but there is general consensus on the fact that it results from the interaction between an underlying predisposition, such as neurodegenerative diseases, and an acute stressor acting as a trigger, such as infection or anesthesia. Alterations in brain insulin sensitivity and metabolic function, increased blood-brain barrier permeability, neurotransmitter imbalances, abnormal microglial activation and neuroinflammation have all been involved in the pathophysiology of delirium. Interestingly, all these mechanisms can be regulated by the gut microbiota, as demonstrated in experimental studies investigating the microbiota-gut-brain axis in dementia. Aging is also associated with profound changes in gut microbiota composition and functions, which can influence several aspects of disease pathophysiology in the host. This review provides an overview of the emerging evidence linking age-related gut microbiota dysbiosis with delirium, opening new perspectives for the microbiota as a possible target of interventions aimed at delirium prevention and treatment.

The longitudinal patterns of psychotropic drug prescriptions for subpopulations of community-dwelling older people with dementia: electronic health records based retrospective study

BACKGROUND

Studies focusing on patterns of psychotropic drug prescriptions (PDPs) for subpopulations of community-dwelling older people with dementia are lacking.

OBJECTIVE

The aim of this study was to identify the longitudinal patterns of PDPs in subpopulations.

METHODS

This retrospective study used electronic health records from general practitioners (GPs) in the Netherlands. People (N = 1278) firstly diagnosed with dementia between 2013 and 2015, aged 65 years or older, were selected and categorized into four subpopulations: community-dwelling (CD) group throughout follow-up, ultimately admitted to nursing homes (NH) group, ultimately died (DIE) group, and ultimately deregistered for unclear reasons (DeR) group. Generalised estimating equations were used to estimate the patterns of psychotropic drug prescriptions, after the diagnosis of dementia for a five-year follow-up, and 0-3 months before institutionalisation or death.

RESULTS

Over the five-year follow-up, antipsychotic prescriptions increased steadily in CD (OR = 1.07 [1.04-1.10]), NH (OR = 1.10 [1.04-1.15]), and DIE (OR = 1.05 [1.02-1.08]) groups. Similarly, prescriptions of antidepressants also showed upward trends in CD (OR = 1.04 [1.02-1.06]), NH (OR = 1.10 [1.02-1.18]), and DIE (OR = 1.04 [1.00-1.08]) groups. The other psychotropic drugs did not show clear changes over time in most of the subpopulations. In the three months before institutionalisation, antipsychotic prescriptions increased (OR = 2.12 [1.26-3.57]) in the NH group compared to prior periods. Likewise, before death, prescriptions of antipsychotics (OR = 1.74 [1.28-2.38]) and hypnotics and sedatives (OR = 2.11 [1.54-2.90]) increased in the DIE group, while anti-dementia drug prescriptions decreased (OR = 0.42 [0.26-0.69]).

CONCLUSIONS

After community-dwelling older people are diagnosed with dementia, all subpopulations' prescriptions of antipsychotics and antidepressants increase continuously during the follow-up. While we cannot judge whether these prescriptions are appropriate, GPs might consider a more reluctant use of psychotropic drugs and use alternative psychosocial interventions. Additionally, antipsychotic prescriptions rise considerably shortly before institutionalisation or death, which might reflect that older people experience more neuropsychiatric symptoms during this period.

Prescriptions of Antipsychotics in Younger and Older Geriatric Patients with Polypharmacy, Their Safety, and the Impact of a Pharmaceutical-Medical Dialogue on Antipsychotic Use

Geriatric patients are a particularly vulnerable and, at the same time, very heterogeneous group due to their multimorbidity and polypharmacy. Antipsychotics are often prescribed in their complex drug regimens, whereby the prescription of antipsychotics is not without controversy. To date, questions remain as to whether there are differences in the prescribing pattern, safety, and impact of a consultant pharmacist regarding antipsychotic use between younger and older geriatric patients in the heterogenic geriatric group. This monocentric study of 744 patients was based on the analysis of routine data collected from January 2018 to June 2020 in a geriatric department during a weekly pharmaceutical and medical consultation. The frequency of the prescription of antipsychotics in our study was 30.7%. Regarding antipsychotic safety and/or adverse drug reaction (ADR) antipsychotics, only a difference in terms of overuse in younger geriatric patients was found. The binary logistic regression analyses of geriatric patients with antipsychotics revealed that ADRs and drug-drug interactions (DDIs) were particularly related to the number of medications prescribed. The higher the number of prescribed drugs, the higher the risk of ADRs and DDIs. In 26.7% of geriatric patients on antipsychotics, the pharmacist made recommendations that were almost exclusively implemented by the physician, with no difference made between the two age groups. The prescriptions of antipsychotics in geriatric patients with polypharmacy, their safety, and the impact of a pharmaceutical-medical dialogue on the use of antipsychotics seem comparable between younger and older geriatric patients in the geriatric setting. Antipsychotics should always be critically considered and used cautiously, whereby a regular pharmaceutical-medical dialogue is recommended in geriatric settings.

Persistent delirium in older hospital patients: an updated systematic review and meta-analysis

Introduction

Delirium is associated with future dementia progression. Yet whether this occurs subclinically over months and years, or persistent delirium merges into worsened dementia is not understood. Our objective was to estimate the prevalence of persistent delirium and understand variation in its duration.

Methods

We adopted an identical search strategy to a previous systematic review, only including studies using a recognised diagnostic framework for ascertaining delirium at follow-up (persistent delirium). Studies included hospitalised older patients outside critical and palliative care settings. We searched MEDLINE, EMBASE, PsycINFO and the Cochrane Database of Systematic Reviews on 11th January 2022. We applied risk of bias assessments based on Standards of Reporting of Neurological Disorders criteria and assessed strength of recommendations using the grading of recommendation, assessment, development and evaluation (GRADE) approach. Estimates were pooled across studies using random-effects meta-analysis, and we estimated associations with follow-up duration using robust error meta-regression.

Results

We identified 13 new cohorts, which we added to 10 from the previous systematic review (23 relevant studies, with 39 reports of persistent delirium at 7 time-points in 3186 individuals admitted to hospital care (mean age 82 years and 41% dementia prevalence). Studies were mainly at moderate risk of bias. Pooled delirium prevalence estimates at discharge were 36% (95% CI 22% to 51%, 13 studies). Robust error meta-regression did not show variation in prevalence of persistent delirium over time (-1.6% per month, 95% CI -4.8 to 1.6, p=0.08). Margins estimates for this model indicate a prevalence of persistent delirium of 16% (95% CI 6% to 25%) at 12 months.

Conclusions

This systematic review emphasises the importance of delirium as a persistent and extensive problem (GRADE certainty = moderate), raising questions on chronic delirium as a clinical entity and how it might evolve into dementia. Addressing persistent delirium will require a whole-system, integrated approach to detect, follow-up and implement opportunities for recovery across all healthcare settings.

Prevalence and features of delirium in older patients admitted to rehabilitation facilities: a multicenter study

BACKGROUND

Delirium is thought to be common across various settings of care; however, still little research has been conducted in rehabilitation.

AIM

We investigated the prevalence of delirium, its features and motor subtypes in older patients admitted to rehabilitation facilities during the three editions of the "Delirium Day project".

METHODS

We conducted a cross-sectional study in which 1237 older patients (age ≥ 65 years old) admitted to 50 Italian rehabilitation wards during the three editions of the "Delirium Day project" (2015 to 2017) were included. Delirium was evaluated through the 4AT and its motor subtype with the Delirium Motor Subtype Scale.

RESULTS

Delirium was detected in 226 patients (18%), and the most recurrent motor subtype was mixed (37%), followed by hypoactive (26%), hyperactive (21%) and non-motor one (16%). In a multivariate Poisson regression model with robust variance, factors associated with delirium were: disability in basic (PR 1.48, 95%CI: 1.17-1.9, p value 0.001) and instrumental activities of daily living (PR 1.58, 95%CI: 1.08-2.32, p value 0.018), dementia (PR 2.10, 95%CI: 1.62-2.73, p value < 0.0001), typical antipsychotics (PR 1.47, 95%CI: 1.10-1.95, p value 0.008), antidepressants other than selective serotonin reuptake inhibitors (PR 1.3, 95%CI: 1.02-1.66, p value 0.035), and physical restraints (PR 2.37, 95%CI: 1.68-3.36, p value < 0.0001).

CONCLUSION

This multicenter study reports that 2 out 10 patients admitted to rehabilitations had delirium on the index day. Mixed delirium was the most prevalent subtype. Delirium was associated with unmodifiable (dementia, disability) and modifiable (physical restraints, medications) factors. Identification of these factors should prompt specific interventions aimed to prevent or mitigate delirium.

Detecting delirium in nursing home residents using the Informant Assessment of Geriatric Delirium (I-AGeD): a validation pilot study

Aim

The aims of this study were to record the prevalence of delirium in residents with the DSM-5, to investigate the feasibility of the I-AGeD in a Swiss nursing home and to compare the results of the I-AGeD with the DSM-5 criteria as the reference standard.

Findings

This study shows that the I-AGeD is suitable for detecting delirium in nursing home residents with a sensitivity of 60% and a specificity of 94%.

Message

The I-AGeD is a simple, brief and feasible assessment tool for the detection of delirium in nursing home residents.

Purpose

Early delirium detection in nursing home residents is vital to prevent adverse outcomes. Despite the potential of structured delirium screening tools to enhance delirium detection, they are rarely used in nursing homes. To promote delirium screening tools in nursing homes, they should be easy to integrate into the daily routine of care workers. The I-AGeD, was developed as a simple and easily understandable tool to detect delirium in older adults. The aims of this study were to record the prevalence of delirium, to investigate the feasibility of the I-AGeD, and to compare these results with the DSM-5 as the reference standard.

Methods

This is a cross-sectional prospective single-center pilot study. Seven registered nurses assessed the participants with the I-AGeD. The research assistant conducted delirium assessments based on the DSM-5 criteria, to identify delirium symptoms for the same participants. The feasibility test was verified using a five-point Likert scale ranging from very easy to very difficult.

Results

85 nursing home residents participated in the study. A delirium prevalence of 5.9% was found. The sensitivity was 60% and specificity 94% at a cut point of ≥ 4 to indicate delirium. The feasibility test showed that the 10 items of the I-AGeD were easy or very easy to answer.

Conclusion

The I-AGeD showed an acceptable performance to assess delirium in nursing home residents. Additionally, it was found feasible and due to its brevity the I-AGeD could easily be integrated into the routine of daily care in nursing homes.

Diagnostic accuracy and clinical applicability of the Swedish version of the 4AT assessment test for delirium detection, in a mixed patient population and setting

BACKGROUND

Delirium is common in older hospitalized patients. It has serious consequences e.g., poor health outcomes, mortality and increased costs. Despite that, many cases are undetected. Early detection of delirium is important in improving outcomes and use of assessment tools improves detection rates. The 4AT is a brief screening tool for delirium detection, which has not previously been translated into Swedish. The study aim was to evaluate diagnostic accuracy and clinical applicability of a Swedish version of the screening tool 4AT for delirium detection.

METHOD

This diagnostic test accuracy study used a quantitative and a qualitative approach and evaluated the patients' and the health care professionals' experiences of the tool. Study included 200 patients ≥65 years from a university hospital and a county hospital in two Swedish regions. Medical specialties were geriatric stroke/neurology, geriatric multimorbidity, severe cognitive impairment, orthopaedic, and urology. The translated 4AT was tested against the reference standard DSM-IV-TR criteria, based on the Organic Brain Syndrome scale and patient records. The 4AT was assessed simultaneously and independently by two assessors. Additionally, data was collected through patient record reviews, and questions about applicability to the patients (n = 200) and the assessors (n = 37). Statistical analyses, and qualitative content analyses were conducted.

RESULTS

By reference standard 18% had delirium, and by 4AT 19%. The overall percent agreement was 88%, AUROC 0.808, sensitivity 0.70 (95% CI 0.51-0.84) and specificity 0.92 (95% CI 0.87-0.96). In the ward for severe cognitive impairment (n = 63) the 4AT was less sensitive and less specific. In the other wards (n = 132) sensitivity was 0.77 (95% CI 0.50-0.93), specificity 0.93 (95% CI 0.87-0.97), and AUROC 0.848. Interrater reliability (Kappa) was 0.918, p = < 0.001 (n = 144). The 4AT was well tolerated by patients, easy to use for health care professionals, and took a few minutes to conduct.

CONCLUSION

The Swedish version of 4AT is an accurate and applicable tool to use in clinical practice for detecting delirium in hospitalized patients across different medical specialities, and to use by different professionals and levels of seniority. To improve patient outcomes, we recommend the 4AT to be incorporated in clinical practice in health care settings in Sweden.

Delirium is a good predictor for poor outcomes from coronavirus disease 2019 (COVID-19) pneumonia: A systematic review, meta-analysis, and meta-regression

AIM

Delirium is a common presenting symptom among older patients. Patients who presented with delirium may have a higher morbidity and mortality rate due to older age, other comorbidities, and atypical COVID-19 presentation. Currently, the evidence supporting delirium as one of the predictors of poor outcome of COVID-19 is still insufficient. This study aims to explore the potential association between delirium and poor outcomes from COVID-19.

METHODS

We systematically searched the PubMed and Google Scholar databases using specific keywords related to our aims until January 30th, 2021. All articles published on COVID-19 and delirium were retrieved. The quality of the study was assessed using the Newcastle Ottawa Scale (NOS) tool for observational studies and Joanna Briggs Institute (JBI) Critical Appraisal Tools for case-series studies. Statistical analysis was done using Review Manager 5.4 software.

RESULTS

Our meta-analysis of 20 studies showed that delirium symptoms on admission was associated with poor outcomes from COVID-19 [OR 2.36 (95% CI 1.80-3.09), p < 0.00001, I² = 76%, random-effect models] and its subgroup which consist of severe COVID-19 [OR 3.89 (95% CI 1.72-8.75), p = 0.001, I² = 91%, random-effect models], and mortality from COVID-19 [OR 1.90 (95% CI 1.55-2.33), p < 0.00001, I² = 36%, random-effect models]. Meta-regression showed that the association was influenced by age (p = 0.005).

CONCLUSIONS

Our study suggests delirium as an important marker to identify patients at higher risk for developing poor COVID-19 outcomes. The physicians should add delirium as one of the common presenting symptoms of COVID-19 in older populations.

The 4-DSD: A New Tool to Assess Delirium Superimposed on Moderate to Severe Dementia

OBJECTIVES

The purpose of this study was to create, standardize, and validate a new instrument, named 4-DSD, and determine its diagnostic accuracy in the diagnosis of delirium in subjects with moderate to severe dementia.

DESIGN

Multicenter cross-sectional observational study.

SETTING AND PARTICIPANTS

Older patients consecutively admitted to acute and rehabilitation hospital wards.

MEASURES

The DSM-5 was used as the reference standard delirium assessment. The presence and severity of dementia was defined using the AD8 and the Global Deterioration Scale (GDS). The 4-DSD is a 4-item tool that ranges from 0 to 12. Item 1 measures alertness, item 2 altered function, item 3 attention, and item 4 acute change or fluctuation in mental status.

RESULTS

A total of 134 patients were included in the study. Most of the patients were enrolled in acute hospital wards (60%), with 40% in rehabilitation settings. A minority of the patients were categorized with moderate dementia, with a GDS score of 5 (4%). Most of the patients were in the moderate-severe stage with a GDS score ≤6 (77%); 19% were classed as severe, with a GDS score of 7. A 4-DSD cutoff score ≥5 had a sensitivity of 80% and specificity of 80% with a positive predictive value (PPV) of 67% and a negative predictive value (NPV) of 89%. In the subgroup with moderate-severe dementia (n = 108), the sensitivity and the specificity were 79% and 82%, respectively, with a PPV and NPV of 62% and 92%. In the subgroup with severe dementia (n = 26) the sensitivity was 82% and the specificity 56% with a PPV of 78% and a NPV of 63%.

CONCLUSIONS AND IMPLICATIONS

The availability of a specific tool to detect delirium in patients with moderate-severe dementia has important clinical and research implications, allowing all health care providers to improve their ability to identify it.

Centenarians in nursing homes during the COVID-19 pandemic

Background: Centenarians are known to be successful agers compared to other older adults.Objective: The objective of the present study was to compare coronavirus disease (COVID-19) symptoms and outcomes in centenarians and other residents living in nursing homes.

Design-Setting-Subjects-Methods: A retrospective multicenter cohort study was conducted using data from 15 nursing homes in the Marseille area. Older residents with confirmed COVID-19 between March and June 2020 were enrolled. The clinical and biological characteristics, the treatment measures, and the outcomes in residents living in these nursing homes were collected from the medical records.

Results: A total of 321 residents were diagnosed with COVID-19 including 12 centenarians. The median age was 101 years in centenarians and 89 years in other residents. The most common symptoms were asthenia and fever. Three centenarians (25%) experienced a worsening of pre-existing depression (vs. 5.5% of younger residents; p = 0.032). Mortality was significantly higher in centenarians than in younger residents (50% vs. 21.3%, respectively; p = 0.031). A quarter of the younger residents and only one centenarian were hospitalized. However, 33.3% of the centenarians received treatment within the context of home hospitalization.

Conclusion: Worsening of pre-existing depression seems to be more frequent in centenarians with COVID-19 in nursing homes. This population had a higher mortality rate but a lower hospitalization rate than younger residents.

Delirium in your house: a survey during General Practitioner-programmed home visits

OBJECTIVES

To assess the prevalence of delirium (DEL) among older patients living at home and periodically visited by their General Practitioners (GPs).

DESIGN

Observational study.

SETTING

In Italy, programmed home visits by the GPs are regularly scheduled for their vulnerable and frail patients who are often on poly-drug regimens and suffering from dementia.

PARTICIPANTS

N = 102 patients among those receiving programmed home visits by n = 6 GP based in the Brianza area (Lombardy).

MEASUREMENTS

Patients were screened for delirium with the Italian version of the 4AT, with a score ≥ 4 considered as a positive indicator for DEL. The Charlson Comorbidity Index (CCI), the Short Physical Performance Battery (SPPB), the presence of dementia, and benzodiazepine (BZD) use were recorded.

RESULTS

DEL+ was detected in almost half of the recruited sample (44.1%), and it was clearly associated with increased comorbidity and decreased motor abilities. Pre-existing dementia was documented in most of DEL+ patients (71.1%), while this was the case for only a minority of DEL- (5.2%, p < 0.00001). Analogously, BZD use was over-represented in the DEL+ group with respect to the DEL- one (73.3% vs. 22.8%, p < 0.00001).

CONCLUSIONS

DEL prevalence as detected by GP during programmed home visits is surprisingly high, and related to motor impairment, comorbidities (among which dementia), and BZD use. DEL prompt recognition should be one of the goals of GP-programmed home visits, since this treatable and preventable condition is associated to an elevated burden of frailty and risk of death.

COVID-19 in seniors: Findings and lessons from mass screening in a nursing home

BACKGROUND/OBJECTIVE

The COVID-19 epidemic is particularly serious in older adults. The symptomatology and epidemic profile remain little known in this population, especially in disabled oldest-old people with chronic diseases living in nursing homes. The objective of the present study was to comprehensively describe symptoms and chronological aspects of the diffusion of the SARS-CoV-2 virus in a nursing home, among both residents and caregivers.

DESIGN

Five-week retrospective cohort study.

SETTING

A middle-sized nursing home in Maine-et-Loire, west of France.

PARTICIPANTS

Eighty-seven frail older residents (87.9 ± 7.2years; 71 % female) and 92 staff members (38.3 ± 11.7years; 89 % female) were included.

MEASUREMENTS

Mass screening for SARS-CoV-2 was performed in both residents and staff. Attack rate, mortality rate, and symptoms among residents and staff infected with SARS-CoV-2 were recorded.

RESULTS

The attack rate of COVID-19 was 47 % in residents (case fatality rate, 27 %), and 24 % in staff. Epidemic curves revealed that the epidemic started in residents before spreading to caregivers. Residents exhibited both general and respiratory signs (59 % hyperthermia, 49 % cough, 42 % polypnea) together with geriatric syndromes (15 % falls, 10 % altered consciousness). The classification tree revealed 100 % COVID-19 probability in the following groups: i) residents younger than 90 with dyspnea and falls; ii) residents older than 90 with anorexia; iii) residents older than 90 without anorexia but with altered consciousness. Finally, 41 % of staff members diagnosed with COVID-19 were asymptomatic.

CONCLUSIONS

The pauci-symptomatic expression of COVID-19 in older residents, together with the high prevalence of asymptomatic forms in caregivers, justifies mass screening in nursing homes, possibly prioritizing residents with suggestive combinations of clinical signs including dyspnea, falls, anorexia and/or altered consciousness.

Delirium in COVID-19: epidemiology and clinical correlations in a large group of patients admitted to an academic hospital

BACKGROUND

Delirium incidence and clinical correlates in coronavirus disease-19 (COVID-19) pneumonia are still poorly investigated.

AIM

To describe the epidemiology of delirium in patients hospitalized for suspect COVID-19 pneumonia during the pandemic peak in an academic hospital of Northern Italy, identify its clinical correlations and evaluate the association with mortality.

METHODS

The clinical records of 852 patients admitted for suspect COVID-19 pneumonia, defined as respiratory symptoms or fever or certain history of contact with COVID-19 patients, plus chest CT imaging compatible with alveolar-interstitial pneumonia, were retrospectively analyzed. Delirium was defined after careful revision of daily clinical reports in accordance with the Confusion Assessment Method criteria. Data on age, clinical presentation, comorbidities, drugs, baseline lab tests and outcome were collected. The factors associated with delirium, and the association of delirium with mortality, were evaluated through binary logistic regression models.

RESULTS

Ninety-four patients (11%) developed delirium during stay. They were older (median age 82, interquartile range, IQR 78-89, vs 75, IQR 63-84, p < 0.001), had more neuropsychiatric comorbidities and worse respiratory exchanges at baseline. At multivariate models, delirium was independently and positively associated with age [odds ratio (OR) 1.093, 95% confidence interval (CI) 1.046-1.143, p < 0.001], use of antipsychotic drugs (OR 4.529, 95% CI 1.204-17.027, p = 0.025), serum urea and lactate-dehydrogenase at admission. Despite a higher mortality in patients with delirium (57% vs 30%), this association was not independent of age and respiratory parameters.

CONCLUSIONS

Delirium represents a common complication of COVID-19 and a marker of severe disease course, especially in older patients with neuropsychiatric comorbidity.

Top Ten Tips Palliative Care Clinicians Should Know About Cognitive Impairment and Institutional Care

Most long-term care (LTC) residents are of age >65 years and have multiple chronic health conditions affecting their cognitive and physical functioning. Although some individuals in nursing homes return home after receiving therapy services, most will remain in a LTC facility until their deaths. This article seeks to provide guidance on how to assess and effectively select treatment for delirium, behavioral and psychological symptoms for patients with dementia, and address other common challenges such as advanced care planning, decision-making capacity, and artificial hydration at the end of life. To do so, we draw upon a team of physicians with training in various backgrounds such as geriatrics, palliative medicine, neurology, and psychiatry to shed light on those important topics in the following "Top 10" tips.