An approach to the patient with cognitive impairment: delirium and dementia

Prevalence and Progression of Cognitive Impairment in Atrial Fibrillation Patients after Treatment with Catheter Ablation or Drug Therapy

Purpose

In atrial fibrillation (AF) patients, the effect of catheter ablation or drug therapy on cognition is currently not well investigated. Therefore, we prospectively evaluated AF patients who were either treated 'with drug therapy or underwent catheter ablation for the prevalence and progression of cognitive impairment (CI).

Methods

Randomized participants of the CABANA trial (catheter ablation versus antiarrhythmic drug therapy for atrial fibrillation) and the CASTLE-AF (catheter ablation versus standard conventional treatment in patients with left ventricular dysfunction and atrial fibrillation) study were assessed twice within 6 months by Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE) in our institution.

Results

Forty-five patients from both trials were investigated, and twenty-eight patients received catheter ablation, whereas seventeen patients received drug therapy for rhythm or rate control. The mean age of the twenty-one CABANA trial patients (AF group) was 68.8 ± 7.0 years and of the twenty-four CASTLE-AF study patients (AF/HF group) was 66.8 ± 8.1 years, respectively. Mean time from ablation/randomization to the first interview was 16.8 ± 11 months in the AF group and 28.3 ± 18.4 months in the AF/HF group, respectively. All patients investigated were classified as cognitively impaired with mean cutoff scores <24 by MoCA. Overall, we could not detect significant differences in medically treated versus catheter ablation patients within both groups in mean MMSE or MoCA scores between the first and the second interview (p > 0.09). Moreover, patients who received catheter ablation did not show statistically significant differences in the prevalence or progression of cognitive impairment compared to patients who were treated medically, neither within the two groups nor between AF and AF/HF patients (p > 0.05).

Conclusions

Prevalence of cognitive impairment in AF patients with comorbidities is substantial. However, in this preliminary prospective study, no apparent impact of AF pretreatment on the prevalence and course of cognitive impairment could be observed.

Differentiation of delirium, dementia and delirium superimposed on dementia in the older person

Delirium is an acute clinical emergency that requires prompt clinical intervention. A predisposing factor for delirium is dementia, and delirium may highlight the vulnerability of a patient to developing dementia. However, delirium also occurs during an acute illness in patients diagnosed with dementia; this is classified as delirium superimposed on dementia. This complex interplay of both dementia syndromes and the condition of delirium has been extensively studied. However, delirium continues to be under-recognised in the acute setting, which impacts negatively on patient outcomes. Nurses are the health professionals best placed to recognise a change in a patient's cognitive symptoms, but nurses caring for the older person have suggested the identification of and differentiation between delirium, dementia and delirium superimposed on dementia remains very confusing. A need for further education with supportive guidelines and protocols is required to empower nurses caring for an older person to verbalise changes in patients' cognitive status in a reliable, robust and systematic manner.

Dementia in elderly inpatients admitted to medical wards in Brazil: diagnosis and comorbidity with other clinical diseases

BACKGROUND

Specific comorbidities affect older patients with dementia admitted to general hospitals and may complicate the recognition of dementia. The aim of the present study was to estimate the prevalence of dementia among elderly inpatients admitted to hospital medical wards and to identify its distribution across clinical and sociodemographic conditions.

METHODS

From June 2011 to May 2012, a sample of elderly inpatients (≥60 years old) were screened for dementia with the Mini-Mental State Examination and the Bayer Activities of Daily Living Scale to identify cognitive and functional impairment (CFI). Subjects with CFI underwent a diagnostic procedure for dementia using the Cambridge Mental Disorders of the Elderly Examination and the Diagnostic and Statistical Manual of Mental Disorders, 4th edition. The elderly inpatients also completed a standard questionnaire to investigate sociodemographic and clinical variables and a screening procedure for depression and delirium. The data obtained were submitted to univariate and multivariate analyses.

RESULTS

The sample of 224 subjects had a mean age of 71.5 years and was mostly men (62.2%), poorly educated (≤4 years of schooling: 74.6%), and married (53.4%). CFI was observed in 84 subjects (prevalence: 37.4%; 95% confidence interval: 31.1-43.7), and dementia was observed in 31 subjects (prevalence: 17.2%; 95% confidence interval: 12.3-22.1). Dementia was related to older age and the presence of delirium, stroke, and pneumonia.

CONCLUSIONS

The prevalence of CFI and dementia was high among the elderly inpatients examined. The identification of medical and sociodemographic conditions associated with a dementia diagnosis in a general hospital may be useful in the development of preventative actions.

How do doctors and nurses manage delirium in intensive care units? A qualitative study using focus groups

OBJECTIVES

The aim of this study was to explore the experiences of doctors and nurses caring for patients with delirium in the intensive care unit (ICU) and to describe the process of delirium management.

SETTING

This study was performed in 5 ICUs located within 4 hospitals in Madrid (Spain).

PARTICIPANTS

Purposeful sampling was performed which included (1) doctors and nurses working in ICUs, (2) with >1 year experience in the ICU and (3) clinical experience with delirium. 38 professionals participated (19 doctors, 19 nurses), including 22 women and 16 men. The total mean age was 39 years.

DESIGN

A qualitative study using focus groups.

METHODS

7 focus groups were held to collect data: 3 nurse focus groups, 3 doctor focus groups and 1 mixed focus group. Each group comprised 6-10 participants. A semistructured questions guide was used. Thematic analysis methods were used to analyse the data.

RESULTS

3 themes were identified: (1) the professional perspective on delirium; (2) implementing pharmacological and non-pharmacological treatment for delirium and (3) work organisation in the ICU. The professionals regarded patients with delirium with uncertainty, and felt they were often underdiagnosed and poorly managed. Doctors displayed discrepancies regarding pharmacological prescriptions and decision-making. The choice of medication was determined by experience. Nurses felt that, for many doctors, delirium was not considered a matter of urgency in the ICU. Nurses encountered difficulties when applying verbal restraint, managing sleep disorders and providing early mobilisation. The lack of a delirium protocol generates conflicts regarding what type of care management to apply, especially during the night shift. A degree of group pressure exists which, in turn, influences the decision-making process and patient care.

CONCLUSIONS

Patients with delirium represent complex cases, requiring the implementation of specific protocols. These results serve to improve the process of care in patients with delirium.

Managing delirium in the acute care setting: a pilot focus group study

BACKGROUND

Delirium frequently occurs in hospitalised older adults leading to poor outcomes and frequent adverse events. Proper recognition and management of delirium by acute care nurses can minimise the effects of negative sequelae associated with delirium.

AIM

This pilot study used focus group methodology to: (i) describe acute care nurse's experience and knowledge regarding assessment and management of delirium in hospitalised older adults; (ii) illustrate potential facilitators and barriers to non-drug management of delirium; and (iii) to explicate the use of non-drug interventions by acute care nurses to manage delirium in hospitalised older adults.

DESIGN

Qualitative, pilot study.

METHODS

A total of 16 nurse participants, working on medical, surgical and orthopaedic units from one acute care hospital participated in two focus groups.

RESULTS

Main themes included the following: confusion is normal; our duty is to protect; and finding a balance. Nurses were able to identify non-pharmacological interventions for delirium and facilitators and barriers to using these in clinical practice.

CONCLUSIONS

Findings from this pilot study illustrate the need for regular assessment of cognitive status in hospitalised older adults and nursing staff education regarding the use of non-pharmacological management of delirium. Based on their experience, nurses have a wealth of ideas for managing delirium. Areas for future research and policy are also highlighted.

IMPLICATIONS FOR PRACTICE

More research is needed on how to improve delirium management by acute care nurses to increase the efficacy and use of non-pharmacological interventions in the management of delirium in hospitalised older adults. To translate these findings into practice, nursing care needs to be guided by evidence-based guidelines to implement non-pharmacological strategies in the acute care setting.