Delirium in the Long-Term Care Setting: Clinical and Research Challenges

The methodological challenges faced when conducting hydration research in UK care homes

BACKGROUND

The evidence base for hydration practice in care homes is underdeveloped. High-quality research is therefore needed to determine what practices support older people with dementia in drinking sufficient fluid. However, methodological developments are needed to be able to do this.

AIM

To highlight the methodological issues researchers encountered during a feasibility cluster, randomised controlled trial of ThinkDrink, a hydration care guide for people with dementia living in UK care homes.

DISCUSSION

This is a challenging area because of the complexity of recruitment, participation and data collection in care homes. Researchers must pay extra attention to rigour and quality in the design of their studies. There may be multiple challenges, so various strategies may be required.

CONCLUSION

It is important that researchers continue to reflect on rigorous approaches to develop evidence in a crucial area of care, despite these challenges.

IMPLICATIONS FOR PRACTICE

Researchers working in complex environments face a variety of challenges to complete methodologically rigorous research. It is important for researchers to be critical of research processes and data, to mitigate and overcome these challenges.

Challenges of conducting research in long-term care facilities: a systematic review

Background

The aim of this review is to describe the challenges and barriers to conducting research in long-term care facilities.

Methods

A literature search was conducted in Ovid MEDLINE, Embase, Cochrane Central, PsycINFO and CINAHL. Keywords used included “long term care”, “nursing home”, “research”, “trial”, “challenge” and “barrier”, etc. Resulting references were screened in order to identify relevant studies that reported on challenges derived from first-hand experience of empirical research studies. Challenges were summarized and synthesized.

Results

Of 1723 references, 39 articles were selected for inclusion. To facilitate understanding we proposed a classification framework of 8 main themes to categorize the research challenges presented in the 39 studies, relating to the characteristics of facility/owner/administrator, resident, staff caregiver, family caregiver, investigator, ethical or legal concerns, methodology, and budgetary considerations.

Conclusions

Conducting research in long-term care facilities is full of challenges which can be categorized into 8 main themes. Investigators should be aware of all these challenges and specifically address them when planning their studies. Stakeholders should be involved from an early stage and flexibility should be built into both the methodology and research budget.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0934-9) contains supplementary material, which is available to authorized users.

Italian intersociety consensus on prevention, diagnosis, and treatment of delirium in hospitalized older persons

Delirium is a severe neuropsychiatric syndrome characterized by inattention and global cognitive dysfunction in the setting of an acute medical illness, medical complication, drug intoxication, or drug withdrawal. The most important risk factors are advanced age and dementia, whereas pain, dehydration, infections, stroke, metabolic disturbances, and surgery are the most common triggering factors. Although delirium is a common clinical syndrome in different settings of care (acute care hospitals, inpatient rehabilitation facilities, nursing homes, and hospices), it often remains under-recognized, poorly understood, and inadequately managed. There exists a clear need for improved understanding to overcome cultural stereotypes, and for the development and dissemination of a comprehensive model of implementation of general good practice points. A network of Italian national scientific societies was thus convened (1) to develop a collaborative multidisciplinary initiative report on delirium in elderly hospitalized patients, (2) to focus the attention of health care personnel on prevention, diagnosis, and therapy of patients suffering from delirium, and (3) to make the health services research community and policy-makers more aware of the potential risks of this condition providing a reference for training activities and data collection.

Dehydration, Hypernatremia, and Hyponatremia

Disturbances of serum sodium are one of the most common findings in older persons. They are also a major cause of hospital admissions and delirium and are associated with frailty, falls, and hip fractures. Both hypernatremia and hyponatremia are potentially preventable. Treatment involves treating the underlying cause and restoring sodium and volume status to normal. The arginine vasopressin antagonists, vaptans, have increased the therapeutic armamentarium available to physicians.

Antipsychotic Prescribing Patterns, and the Factors and Outcomes Associated with Their Use, among Patients Requiring Prolonged Mechanical Ventilation in the Long-Term Acute Care Hospital Setting

BACKGROUND:

Administration of scheduled antipsychotic therapy to mechanically ventilated patients to prevent or treat delirium is common, despite the lack of evidence to support its use. Among long-term acute care hospital (LTACH) patients requiring prolonged mechanical ventilation (PMV), the frequency of scheduled antipsychotic therapy use, and the factors and outcomes associated with it, have not been described.

OBJECTIVE:

To identify scheduled antipsychotic therapy prescribing practices, and the factors and outcomes associated with the use of antipsychotics, among LTACH patients requiring PMV.

METHODS:

Consecutive patients without major psychiatric disorders or dementia who were admitted to an LTACH for PMV over 1 year were categorized as those receiving scheduled antipsychotic therapy (≥24 hours of use) and those not receiving scheduled antipsychotic therapy. Presence of delirium, use of psychiatric evaluation, nonscheduled antipsychotic therapy, and scheduled antipsychotic therapy—related adverse effects were extracted and compared between the 2 groups and when significant (p ≤ 0.05), were entered into a regression analysis using generalized estimating equation techniques.

RESULTS:

Among 80 patients included, 39% (31) received scheduled antipsychotic therapy and 61% (49) did not. Baseline characteristics, including age, sex, illness severity, and medical history, were similar between the 2 groups. Scheduled antipsychotic therapy was administered on 52% of LTACH days for a median (interquartile range [IQR]) of 25 (6–38) days and, in the antipsychotic group, was initiated at an outside hospital (45%) or on day 2 (1–6; median [IQR]) of the LTACH stay (55%). Quetiapine was the most frequently administered scheduled antipsychotic (77%; median dose 50 [37–72] mg/day). Use of scheduled antipsychotic therapy was associated with a greater incidence of psychiatric evaluation (OR 5.7; p = 0.01), delirium (OR 2.4; p = 0.05), as-needed antipsychotic use (OR 4.1; p = 0.005) and 1:1 sitter use (OR 7.3; p = 0.001), but not benzodiazepine use (p = 0.19).

CONCLUSIONS:

Among LTACH patients requiring PMV, scheduled antipsychotic therapy is used frequently and is associated with a greater incidence of psychiatric evaluation, delirium, as-needed psychotic use, and sitter use. Although scheduled antipsychotic therapy—related adverse effects are uncommon, these effects are infrequently monitored.

Medical care in the nursing home

With the advent of the graying of the baby boomers, there is an urgent need to enhance care in the nursing home. This article focuses on the areas where high-quality care can improve outcomes.

Clinical practice in nursing homes as a key for progress

With the aging of the world's population there has become a major need for the development of nursing homes throughout the world. While some countries provide high quality care for the disabled elderly, in others this is not the case. Education of a medical director has been shown to improve the quality of the nursing home. Physicians need to have knowledge of how to implement continuous quality improvement and culture change. Key medical issues include moving to a restraint free environment, subsyndromal delirium, behavioral disturbances, weight loss, pain management, pressure ulcers, falls, hip fractures, polypharmacy, depression and frailty.

Detecting delirium and subsyndromal delirium using different diagnostic criteria among demented long-term care residents

OBJECTIVES

To evaluate the impact of using different diagnostic criteria on prevalence rates of delirium and subsyndromal delirium (SSD) among demented long-term care (LTC) residents.

DESIGN

Descriptive study.

SETTING

LTC settings in Quebec City, Canada.

PARTICIPANTS

Participants were 155 individuals aged 65 and older, with dementia.

MEASUREMENTS

(1) Prevalence rates of delirium according to: (a) the Diagnostic and Statistical Manual of Mental Disorders (DSM-III, DSM-III-R, and DSM-IV) and (b) the Confusion Assessment Method (CAM) algorithms for definite and probable delirium; and (2) prevalence rates of SSD employing 2 definitions described in previous studies.

RESULTS

Prevalence rates of delirium according to each set of criteria were 26.5% for DSM-III; 29% for DSM-IV-TR; 41.3% for DSM-III-R; 45.8% for CAM algorithm for definite delirium; and 70.3% for CAM algorithm for probable delirium. A total of 109 subjects (70.3%) were identified as delirious consistent with at least one classification and 37 (23.9%) met all the sets of criteria considered. Prevalence rates for SSD were 75 (48.4%) and 78 (50.3%) depending on the definition employed.

CONCLUSION

Prevalence rates for delirium are much affected by the diagnostic formulations used. The use of DSM-IV-TR among this population could result in fewer cases being identified as delirious and thus compromise proper care for those individuals. Considering that SSD was prevalent among this population, a systematic implementation of protocols targeting risk factors of delirium might be beneficial among demented LTC residents.