Delirium in people living with dementia: a call for global solutions

What older people and their relatives say is important during acute hospitalisation: a qualitative study

BACKGROUND

Due to the growing population of older people across the world, providing safe and effective care is an increasing concern. Older persons in need for hospitalisation often have, or are susceptible to develop, cognitive impairment. Hospitals need to adapt to ensure high-quality care for this vulnerable patient group. Several age-friendly frameworks and models aiming at reducing risks and complications have been promoted. However, care for older people must be based on the persons' reported needs, and relatives are often an important part of older persons' social support. The primary aim of this study was to explore older peoples' and their relatives' experiences of acute hospitalisation and determine what is important for them to experience a good hospital stay. The study was not limited to patients with cognitive impairment; but included a wider group of older individuals vulnerable to developing delirium, with or without an underlying chronic cognitive impairment.

METHODS

This study had a qualitative research design in which people aged 75 years or older and their relatives were interviewed during an acute hospitalisation. The study was conducted at two medical wards at a large university hospital in Norway, and included a total of 60 participants. All interviews were informed by a semi-structured interview guide and were thematically analysed.

RESULTS

Four major themes were identified in the older people's and the relatives' descriptions of how they experienced the hospital stay and what was important for them during the hospital stay: being seen and valued as a person, individualised care, patient-adapted communication and information, and collaboration with relatives. The themes span both positive and negative experiences, reflecting great variability in the experiences described. The presence of these four characteristics promoted positive experiences among patients and relatives, whereas the absence or negative valuation of them promoted negative experiences.

CONCLUSIONS

The findings underscore the interrelatedness of older people and their relatives and that patients and relatives are quite consistent in their experiences and opinions. This suggests that listening to the concerns of relatives is important, as they can voice the older patient's needs and concerns in situations where older people might find it difficult to do so. Furthermore, the results underscore how 'small things' matter in relation to how health professionals capture the patient's individual values, need for care, information and involvement of relatives and that these are essential to ensure predictability and security and a good stay for older people and their relatives.

Impact of a dementia-friendly program on detection and management of patients with cognitive impairment and delirium in acute-care hospital units: a controlled clinical trial design

Background

Frail older persons with cognitive impairment (CI) are at special risk of experiencing delirium during acute hospitalisation. The purpose of this study was to investigate whether a dementia-friendly hospital program contributes to improved detection and management of patients with CI and risk of delirium at an acute-care hospital in Norway. Furthermore, we aimed to explore whether the program affected the detection of delirium, pharmacological treatment, 30-day re-hospitalisation, 30-day mortality and institutionalisation afterwards.

Methods

This study was part of a larger quality improvement project aiming at developing and implementing a new program for early screening and management of patients with CI. This study, evaluating the program are designed as a controlled clinical trial with a historical control group. It was conducted at two different medical wards at a large acute-care hospital in Norway from September 2018 to December 2019. A total of 423 acute hospitalised patients 75 years of age or older were included in the study. Delirium screening and cognitive tests were recorded by research staff with the 4 ‘A’s Test (4AT) and the Confusion Assessment Measure (CAM), while demographic and medical information was recorded from the electronic medical records (EMR).

Results

Implementation of the dementia-friendly hospital program did not show any significant changes in the identification of patients with CI. However, the share of patients screened with 4AT within 24 h increased from 0% to 35.5% (P < .001). The proportion of the patients with CI identified by the clinical staff, who received measures to promote “dementia-friendly” care and reduce the risk for delirium increased by 32.2% (P < .001), compared to the control group. Furthermore, the number of patients with CI who were prescribed antipsychotic, hypnotic or sedative medications was reduced by 24.5% (P < .001). There were no differences in delirium detection, 30-day readmission or 30-day mortality.

Conclusions

A model for early screening and multifactorial non-pharmacological interventions for patients with CI and delirium may improve management of this patient group, and reduce prescriptions of antipsychotic, hypnotic and sedative medications. The implementation in clinical practice of early screening using quality improvement methodology deserves attention.

Trial registration

The protocol of this study was retrospectively registered in the ClinicalTrials.gov Protocol Registration and Results System with the registration number: NCT04737733 and date of registration: 03/02/2021.

Development and Evaluation of Clinical Practice Guideline for Delirium in Long-Term Care

Delirium is highly prevalent and leads to several bad outcomes for older long-term care (LTC) residents. For a more successful translation of delirium knowledge, Clinical Practice Guidelines (CPGs) tailored to LTC should be developed and applied based on the understanding of the barriers to implementation. This study was conducted to develop a CPG for delirium in LTC and to determine the barriers perceived by healthcare professionals related to the implementation of the CPG. We followed a structured, evidence- and theory-based procedure during the development process. After a systematic search, quality appraisal, and selection for eligible up-to-date CPGs for delirium, the recommendations applicable to the LTC were drafted, evaluated, and confirmed by an external group of experts. To evaluate the barriers to guideline uptake from the users' perspectives, semi-structured interviews were conducted which resulted in four major themes: (1) a lack of resources, (2) a tendency to follow mindlines rather than guidelines, (3) passive attitudes, and (4) misunderstanding delirium care in LTC. To minimize adverse prognoses through prompt delirium care, the implementation of a CPG with an approach that comprehensively considers various barriers at the system, practice, healthcare professional, and patients/family levels is necessary.