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Santervas LR, Wyller TB, Skovlund E, Jensen JL, Fjeld KG, Hove LH, Ringstad IB, Nordberg LB, Mellingen KM, Kristoffersen ES, Romskaug R. Cooperation across healthcare service levels for medication reviews in older people with polypharmacy admitted to a municipal in-patient acute care unit (The COOP II Study): study protocol for a randomized controlled trial. Trials 2024; 25:612. [PMID: 39272164 PMCID: PMC11396309 DOI: 10.1186/s13063-024-08442-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 09/02/2024] [Indexed: 09/15/2024] Open
Abstract
BACKGROUND Polypharmacy and inappropriate drug use are associated with adverse health outcomes in older people. Collaborative interventions between geriatricians and general practitioners have demonstrated effectiveness in improving clinical outcomes for complex medication regimens in home-dwelling patients. Since 2012, Norwegian municipalities have established municipal in-patient acute care (MipAC) units, designed to contribute towards reducing the number of hospital admissions. These units predominantly serve older people who typically benefit from multidisciplinary approaches. The primary objective of this study is to evaluate the effect of cooperative medication reviews conducted by MipAC physicians, supervised by geriatricians, and in collaboration with general practitioners, on health-related quality of life and clinical outcomes in MipAC patients ≥ 70 years with polypharmacy. Additionally, the study aims to assess the carbon footprint of the intervention. METHODS This is a randomized, single-blind, controlled superiority trial with 16 weeks follow-up. Participants will be randomly assigned to either the control group, receiving usual care at the MipAC unit, or to the intervention group which in addition receive clinical medication reviews that go beyond what is considered usual care. The medication reviews will evaluate medication appropriateness using a structured but individualized framework, and the physicians will receive supervision from geriatricians. Following the clinical medication reviews, the MipAC physicians will arrange telephone meetings with the participants' general practitioners to combine their assessments in a joint medication review. The primary outcome is health-related quality of life as measured by the 15D instrument. Secondary outcomes include physical and cognitive functioning, oral health, falls, admissions to healthcare facilities, and mortality. DISCUSSION This study aims to identify potential clinical benefits of collaborative, clinical medication reviews within community-level MipAC units for older patients with polypharmacy. The results may offer valuable insights into optimizing patient care in comparable municipal healthcare settings. TRIAL REGISTRATION The study was registered prospectively on ClinicalTrials.gov 30.08.2023 with identifier NCT06020391.
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Affiliation(s)
- Leonor Roa Santervas
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.
- City of Oslo Health Agency, Municipality of Oslo, Oslo, Norway.
- Department of Geriatric Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Torgeir Bruun Wyller
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Department of Geriatric Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Eva Skovlund
- Department of Public Health and Nursing, The Norwegian University of Science and Technology, Trondheim, Norway
| | - Janicke Liaaen Jensen
- Department of Oral Surgery and Oral Medicine, Institute of Clinical Dentistry, University of Oslo, Oslo, Norway
| | - Katrine Gahre Fjeld
- Department of Cariology and Gerodontology, Institute of Clinical Dentistry, University of Oslo, Oslo, Norway
| | - Lene Hystad Hove
- Department of Cariology and Gerodontology, Institute of Clinical Dentistry, University of Oslo, Oslo, Norway
| | - Ingrid Beate Ringstad
- Department of Oral Surgery and Oral Medicine, Institute of Clinical Dentistry, University of Oslo, Oslo, Norway
| | - Lena Bugge Nordberg
- REMEDY Centre for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
| | | | - Espen Saxhaug Kristoffersen
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Neurology, Akerhus University Hospital, Lørenskog, Norway
| | - Rita Romskaug
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
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Bonfichi A, Ceresa IF, Piccioni A, Zanza C, Longhitano Y, Boudi Z, Esposito C, Savioli G. A Lethal Combination of Delirium and Overcrowding in the Emergency Department. J Clin Med 2023; 12:6587. [PMID: 37892725 PMCID: PMC10607343 DOI: 10.3390/jcm12206587] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/25/2023] [Accepted: 09/28/2023] [Indexed: 10/29/2023] Open
Abstract
Delirium is a common public health concern that significantly impacts older patients admitted to the Emergency Department (ED). This condition is linked to adverse outcomes such as reduced long-term functionality, higher mortality rates, extended hospital stays, and increased medical costs. The identification of risk factors is crucial for the early recognition and management of delirium in ED patients. Aging, cognitive decline, polypharmacy, and sensory impairment are some of the most common general risk factors described in the literature. Although validated delirium assessment tools already exist, they are not practical for the fast-paced ED environment because of their extended evaluation period or specialized training request. Moreover, clear guidance is needed to select the most suitable tool for detecting delirium, balancing between the accuracy and the swiftness required in an overcrowded, high-stress, and understaffed healthcare setting. This narrative review aims to analyze the updated literature on delirium risk factors in older ED patients and focuses on the methods for better screening, managing, and treating this condition in the ED.
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Affiliation(s)
- Alessandra Bonfichi
- Department of Internal Medicine, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy;
| | - Iride Francesca Ceresa
- Department of Emergency Medicine, Humanitas University-Research Hospital, 20089 Rozzano, Italy; (I.F.C.); (Y.L.)
| | - Andrea Piccioni
- Department of Emergency, Fondazione Policlinico Universitario A. Gemelli, IRCCS Fondazione Policlinico San Matteo, 00168 Roma, Italy;
| | - Christian Zanza
- Italian Society of Pre-Hospital Emergency Medicine (SIS-118), 74121 Taranto, Italy;
| | - Yaroslava Longhitano
- Department of Emergency Medicine, Humanitas University-Research Hospital, 20089 Rozzano, Italy; (I.F.C.); (Y.L.)
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15260, USA
| | - Zoubir Boudi
- Department of Emergency Medicine, Dr Sulaiman Alhabib Hospital, Dubai 2542, United Arab Emirates;
| | - Ciro Esposito
- Nephrology and Dialysis Unit, ICS Maugeri, University of Pavia, 27100 Pavia, Italy;
| | - Gabriele Savioli
- Emergency Medicine and Surgery, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
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Caldwell C, Verghese J, Gong MN, Kim M, Hope AA. Frailty, Acute Brain Dysfunction, and Posthospitalization Disability Outcomes in Critically Ill Older Adults. Am J Crit Care 2023; 32:256-263. [PMID: 37391376 DOI: 10.4037/ajcc2023858] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
BACKGROUND Identifying potentially modifiable factors that mediate adverse outcomes in frail adults with critical illness may facilitate development of interventions to improve intensive care unit (ICU) survivorship. OBJECTIVES To estimate the relationship between frailty, acute brain dysfunction (as reflected by delirium or persistent coma), and 6-month disability outcomes. METHODS Older adults (aged ≥50 years) admitted to the ICU were enrolled prospectively. Frailty was identified with the Clinical Frailty Scale. Delirium and coma were assessed daily with the Confusion Assessment Method for the ICU and the Richmond Agitation-Sedation Scale, respectively. Disability outcomes (death and severe physical disability [defined as new dependence in 5 or more activities of daily living]) were assessed by telephone within 6 months after discharge. RESULTS In 302 older adults (mean [SD] age, 67.2 [10.8] y), both frail and vulnerable patients had a higher risk for acute brain dysfunction (adjusted odds ratio [AOR], 2.9 [95% CI, 1.5-5.6], and 2.0 [95% CI, 1.0-4.1], respectively) compared with fit patients. Both frailty and acute brain dysfunction were independently associated with death or severe disability at 6 months (AOR, 3.3 [95% CI, 1.6-6.5] and 2.4 [95% CI, 1.4 -4.0], respectively). The average proportion of the frailty effect mediated by acute brain dysfunction was estimated to be 12.6% (95% CI, 2.1%-23.1%; P = .02). CONCLUSION Frailty and acute brain dysfunction were important independent predictors of disability outcomes in older adults with critical illness. Acute brain dysfunction may be an important mediator of increased risk for physical disability outcomes after critical illness.
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Affiliation(s)
- Corrielle Caldwell
- Corrielle Caldwell was a critical care medicine fellow, Department of Medicine, Division of Critical Care Medicine, Montefiore Medical Center, Bronx, New York; she is currently an intensivist at Prisma Health, Sumter, South Carolina
| | - Joe Verghese
- Joe Verghese is a professor, Department of Medicine, Division of Cognitive and Motor Aging and Geriatrics, Albert Einstein College of Medicine, Bronx, New York
| | - Michelle N Gong
- Michelle N. Gong is a professor, Department of Medicine, Divisions of Pulmonary and Critical Care Medicine, Montefiore Medical Center, and a professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
| | - Mimi Kim
- Mimi Kim is a professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
| | - Aluko A Hope
- Aluko A. Hope is an associate professor, Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Oregon Health & Science University, Portland, Oregon, and this work was completed while he was at the Department of Medicine, Division of Critical Care Medicine, Montefiore Medical Center, Bronx, New York
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Kinchin I, Edwards L, Hosie A, Agar M, Mitchell E, Trepel D. Cost-effectiveness of clinical interventions for delirium: A systematic literature review of economic evaluations. Acta Psychiatr Scand 2022; 147:430-459. [PMID: 35596552 DOI: 10.1111/acps.13457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 05/13/2022] [Accepted: 05/17/2022] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Little is known about the economic value of clinical interventions for delirium. This review aims to synthesise and appraise available economic evidence, including resource use, costs, and cost-effectiveness of interventions for reducing, preventing, and treating delirium. METHODS Systematic review of published and grey literature on full and partial economic evaluations. Study quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS). RESULTS Fourteen economic evaluations (43% full, 57% partial) across nine multicomponent and nonpharmacological intervention types met inclusion criteria. The intervention costs ranged between US$386 and $553 per person in inpatient settings. Multicomponent delirium prevention intervention and the Hospital Elder Life Program (HELP) reported statistically significant cost savings or cost offsets somewhere else in the health system. Cost savings related to inpatient, outpatient, and out-of-pocket costs ranged between $194 and $6022 per person. The average CHEERS score was 74% (±SD 10%). CONCLUSION Evidence on a joint distribution of costs and outcomes of delirium interventions was limited, varied and of generally low quality. Directed expansion of health economics towards the evaluation of delirium care is necessary to ensure effective implementation that meets patients' needs and is cost-effective in achieving similar or better outcomes for the same or lower cost.
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Affiliation(s)
- Irina Kinchin
- Centre for Health Policy and Management, Trinity College Dublin, the University of Dublin, Dublin, Ireland.,Global Brain Health Institute, Trinity College Dublin, the University of Dublin, Dublin, Ireland.,Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT) Centre, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Layla Edwards
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT) Centre, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Annmarie Hosie
- School of Nursing Sydney, The University of Notre Dame Australia, Darlinghurst, NSW, Australia.,St Vincent's Health Network Sydney, Darlinghurst, NSW, Australia
| | - Meera Agar
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT) Centre, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Eileen Mitchell
- Global Brain Health Institute, Trinity College Dublin, the University of Dublin, Dublin, Ireland
| | - Dominic Trepel
- Global Brain Health Institute, Trinity College Dublin, the University of Dublin, Dublin, Ireland
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Ross EL, Weinberg MS, Arnold SE. Cost-effectiveness of Aducanumab and Donanemab for Early Alzheimer Disease in the US. JAMA Neurol 2022; 79:478-487. [PMID: 35344024 PMCID: PMC8961406 DOI: 10.1001/jamaneurol.2022.0315] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 01/28/2022] [Indexed: 12/13/2022]
Abstract
Importance Several anti-amyloid monoclonal antibodies have been developed for slowing the progression of Alzheimer disease (AD). Among the furthest developed are aducanumab, which received accelerated approval from the US Food and Drug Administration in 2021, and donanemab, which is currently undergoing phase 3 trials. The cost-effectiveness of these treatments has not been established. Objectives To estimate the cost-effectiveness of aducanumab and donanemab relative to standard care for early AD in the US. Design, Setting, and Participants A decision analytic model was used to estimate the lifetime health and economic outcomes of adults with early AD, from US healthcare sector and societal perspectives. Simulated patients had a mean (SD) age of 75.2 (5.5) years; 65% had mild cognitive impairment and 35% had mild dementia. Analyses were conducted from April 6, 2021, to January 20, 2022. Interventions Standard care, aducanumab (selected inputs including disease progression hazard ratio [HR] of 0.89 [95% CI, 0.63-1.15], annual price of $28 000, and twice-yearly monitoring with magnetic resonance imaging [MRI] of the brain), or donanemab (selected inputs including disease progression HR of 0.68 [95% CI, 0.44-0.99], annual price of $28 000, and twice-yearly monitoring with MRI of the brain and amyloid positron emission tomography [PET] monitoring). Donanemab was switched to placebo after substantial amyloid reduction on PET imaging, which occurred in 27% of patients at 6 months and 55% of patients at 12 months. Main Outcomes and Measures Quality-adjusted life-years (QALYs); costs, in 2020 US dollars; incremental cost-effectiveness ratios (ICERs); and value-based prices, defined as the maximum price at which a treatment would be cost-effective given a cost-effectiveness threshold of ICER of $150 000/QALY. Results Lifetime QALYs increased by 0.133 with aducanumab and 0.408 with donanemab. Total health care sector and societal costs increased by $130 100 and $127 800, respectively, with aducanumab and by $78 700 and $71 600, respectively, with donanemab, driven largely by drug costs ($119 000 for aducanumab and $44 600 for donanemab). Health care sector and societal ICERs relative to standard care were $981 000/QALY and $964 000/QALY, respectively, for aducanumab and $193 000/QALY and $176 000/QALY, respectively, for donanemab. In sensitivity analysis, aducanumab's value-based price remained less than $50 000/y, even when assuming a 90% reduction in disease progression. Donanemab's value-based price surpassed $50 000/y once its efficacy exceeded 50%. Conclusions and Relevance These findings suggest that at current expected prices, neither aducanumab nor donanemab would be cost-effective for early AD in the US. Donanemab's dosing scheme, in which patients suspend treatment on achieving substantial amyloid reductions, may provide a rubric by which sufficiently effective anti-amyloid antibody treatments could be cost-effective even when priced comparably to other biologics.
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Affiliation(s)
- Eric L. Ross
- Department of Psychiatry, Massachusetts General Hospital, Boston
- Department of Psychiatry, McLean Hospital, Belmont, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Marc S. Weinberg
- Department of Psychiatry, Massachusetts General Hospital, Boston
- Department of Psychiatry, McLean Hospital, Belmont, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Steven E. Arnold
- Department of Neurology, Massachusetts General Hospital, Boston
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
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6
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Chen Z, Ding Z, Chen C, Sun Y, Jiang Y, Liu F, Wang S. Effectiveness of comprehensive geriatric assessment intervention on quality of life, caregiver burden and length of hospital stay: a systematic review and meta-analysis of randomised controlled trials. BMC Geriatr 2021; 21:377. [PMID: 34154560 PMCID: PMC8218512 DOI: 10.1186/s12877-021-02319-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 05/23/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Comprehensive geriatric assessment (CGA) interventions can improve functional ability and reduce mortality in older adults, but the effectiveness of CGA intervention on the quality of life, caregiver burden, and length of hospital stay remains unclear. The study aimed to determine the effectiveness of CGA intervention on the quality of life, length of hospital stay, and caregiver burden in older adults by conducting meta-analyses of randomised controlled trials (RCTs). METHODS A literature search in PubMed, Embase, and Cochrane Library was conducted for papers published before February 29, 2020, based on inclusion criteria. Standardised mean difference (SMD) or mean difference (MD) with 95% confidence intervals (CIs) was calculated using the random-effects model. Subgroup analyses, sensitivity analyses, and publication bias analyses were also conducted. RESULTS A total of 28 RCTs were included. Overall, the intervention components common in different CGA intervention models were interdisciplinary assessments and team meetings. Meta-analyses showed that CGA interventions improved the quality of life of older people (SMD = 0.12; 95% CI = 0.03 to 0.21; P = 0.009) compared to usual care, and subgroup analyses showed that CGA interventions improved the quality of life only in participants' age > 80 years and at follow-up ≤3 months. The change value of quality of life in the CGA intervention group was better than that in the usual care group on six dimensions of the 36-Item Short-Form Health Survey questionnaire (SF-36). Also, compared to usual care, the CGA intervention reduced the caregiver burden (SMD = - 0.56; 95% CI = - 0.97 to - 0.15, P = 0.007), but had no significant effect on the length of hospital stay. CONCLUSIONS CGA intervention was effective in improving the quality of life and reducing caregiver burden, but did not affect the length of hospital stay. It is recommended that future studies apply the SF-36 to evaluate the impact of CGA interventions on the quality of life and provide supportive strategies for caregivers as an essential part of the CGA intervention, to find additional benefits of CGA interventions.
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Affiliation(s)
- Zhongyi Chen
- Research Office of Chronic Disease Management and Rehabilitation, Wuxi School of Medicine, Jiangnan University, No. 1800 Lihu Avenue, Wuxi, Jiangsu Province, China
| | | | - Caixia Chen
- Wuxi Tongren Rehabilitation Hospital, Wuxi, China
| | - Yangfan Sun
- Wuxi Tongren Rehabilitation Hospital, Wuxi, China
| | - Yuyu Jiang
- Research Office of Chronic Disease Management and Rehabilitation, Wuxi School of Medicine, Jiangnan University, No. 1800 Lihu Avenue, Wuxi, Jiangsu Province, China.
| | - Fenglan Liu
- Medical School, Liaocheng University, Liaocheng, China
| | - Shanshan Wang
- Research Office of Chronic Disease Management and Rehabilitation, Wuxi School of Medicine, Jiangnan University, No. 1800 Lihu Avenue, Wuxi, Jiangsu Province, China
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DeBolt CL, Gao Y, Sutter N, Soong A, Leard L, Jeffrey G, Kleinhenz ME, Calabrese D, Greenland J, Venado A, Hays SR, Shah R, Kukreja J, Trinh B, Kolaitis NA, Douglas V, Diamond JM, Smith P, Singer J. The association of post-operative delirium with patient-reported outcomes and mortality after lung transplantation. Clin Transplant 2021; 35:e14275. [PMID: 33682171 PMCID: PMC11098451 DOI: 10.1111/ctr.14275] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 01/16/2021] [Accepted: 02/22/2021] [Indexed: 12/14/2022]
Abstract
Post-operative delirium after lung transplantation is common. Its associations with health-related quality of life (HRQL), depression, and mortality remains unknown. In 236 lung transplant recipients, HRQL and depressive symptoms were assessed as part of a structured survey battery before and after transplantation. Surveys included the Geriatric Depressive Scale (GDS) and Short Form 12 (SF12). Delirium was assessed throughout the post-operative intensive care unit (ICU) stay with Confusion Assessment Method for ICU. Delirium and mortality data were extracted from electronic medical records. We examined associations between delirium and changes in depressive symptoms and HRQL using linear mixed effects models and association between delirium and mortality with Cox-proportional hazard models. Post-operative delirium occurred in 34 participants (14%). Delirium was associated with attenuated improvements in SF12-PCS (difference ₋4.0; 95%CI: -7.4, -0.7) but not SF12-MCS (difference 2.2; 95%CI: -0.7,5.7) or GDS (difference ₋0.4; 95%CI: -1.5,0.7). Thirty-two participants died during the study period. Delirium was associated with increased adjusted hazard risk of mortality (HR 17.9, 95%CI: 4.4,72.5). Delirium after lung transplantation identifies a group at increased risk for poorer HRQL and death within the first post-operative year. Further studies should investigate potential causal links between delirium, and poorer HRQL and mortality risk after lung transplantation.
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Affiliation(s)
- Claire L DeBolt
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Ying Gao
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Nicole Sutter
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Allison Soong
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Lorriana Leard
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Golden Jeffrey
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Mary Ellen Kleinhenz
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Daniel Calabrese
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- Department of Medicine, San Francisco VA Health Care System, San Francisco, CA, USA
| | - John Greenland
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- Department of Medicine, San Francisco VA Health Care System, San Francisco, CA, USA
| | - Aida Venado
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Steven R Hays
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Rupal Shah
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Jasleen Kukreja
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Binh Trinh
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Nicholas A Kolaitis
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Vanja Douglas
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Joshua M Diamond
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Patrick Smith
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Jonathan Singer
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
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Wilson JE, Mart MF, Cunningham C, Shehabi Y, Girard TD, MacLullich AMJ, Slooter AJC, Ely EW. Delirium. Nat Rev Dis Primers 2020; 6:90. [PMID: 33184265 PMCID: PMC9012267 DOI: 10.1038/s41572-020-00223-4] [Citation(s) in RCA: 414] [Impact Index Per Article: 103.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2020] [Indexed: 02/06/2023]
Abstract
Delirium, a syndrome characterized by an acute change in attention, awareness and cognition, is caused by a medical condition that cannot be better explained by a pre-existing neurocognitive disorder. Multiple predisposing factors (for example, pre-existing cognitive impairment) and precipitating factors (for example, urinary tract infection) for delirium have been described, with most patients having both types. Because multiple factors are implicated in the aetiology of delirium, there are likely several neurobiological processes that contribute to delirium pathogenesis, including neuroinflammation, brain vascular dysfunction, altered brain metabolism, neurotransmitter imbalance and impaired neuronal network connectivity. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) is the most commonly used diagnostic system upon which a reference standard diagnosis is made, although many other delirium screening tools have been developed given the impracticality of using the DSM-5 in many settings. Pharmacological treatments for delirium (such as antipsychotic drugs) are not effective, reflecting substantial gaps in our understanding of its pathophysiology. Currently, the best management strategies are multidomain interventions that focus on treating precipitating conditions, medication review, managing distress, mitigating complications and maintaining engagement to environmental issues. The effective implementation of delirium detection, treatment and prevention strategies remains a major challenge for health-care organizations globally.
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Affiliation(s)
- Jo Ellen Wilson
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Psychiatry and Behavioral Sciences, Division of General Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Matthew F Mart
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Colm Cunningham
- School of Biochemistry & Immunology, Trinity Biomedical Sciences Institute & Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin, Republic of Ireland
| | - Yahya Shehabi
- Monash Health School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
- Prince of Wales Clinical School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Timothy D Girard
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - E Wesley Ely
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
- Veteran's Affairs TN Valley, Geriatrics Research, Education and Clinical Center (GRECC), Nashville, TN, USA
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9
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Friedman JI, Li L, Kirpalani S, Zhong X, Freeman R, Cheng YT, Alfonso FL, McAlpine G, Vakil A, Macon B, Francaviglia P, Cassara M, LoPachin V, Reina K, Davis K, Reich D, Craven CK, Mazumdar M, Siu AL. A Multi-Phase Quality Improvement Initiative for the Treatment of Active Delirium in Older Persons. J Am Geriatr Soc 2020; 69:216-224. [PMID: 33150615 DOI: 10.1111/jgs.16897] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 09/22/2020] [Accepted: 09/26/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND/OBJECTIVES The Hospital Elder Life Program emerged 20 years ago as the reference model for delirium prevention in hospitalized older patients. However, implementation has been achieved at only 200 hospitals worldwide over the last 20 years. Among the barriers to implementation for some institutions is an unwillingness of hospital administration to assume the costs associated with implementing programs that service all hospitalized older patients at risk for delirium. Facing such a situation, we implemented a unique and self-evolving model of care of older hospitalized patients who had already developed delirium. DESIGN Hypothesis testing was carried out using a pretest-posttest design on program administrative data. SETTING Mount Sinai Hospital, New York, NY, a tertiary-care teaching facility. PARTICIPANTS A total of 9,214 consecutively admitted older patients to non-intensive care (ICU) inpatient units over a 5.5-year period, regardless of the suspected presence of delirium or risk status for developing delirium. INTERVENTION A delirium intervention program targeting patients in whom delirium has already developed, with a modified delirium team supported by extensive workflow automation with custom tools in our electronic medical records system. MEASUREMENTS Length of stay (LOS) for delirious and non-delirious patients on units where this program was piloted. Benzodiazepine, opiate, and antipsychotic use on the same units. RESULTS There was a significant drop in LOS by 1.98 days (95% confidence interval = .24-3.71), a decrease in the average morphine dose equivalents administered from .38 mg to .21 mg per patient hospital day, diazepam dose equivalents from .22 mg to .15 mg per patient hospital day, and quetiapine administered from .17 mg to .14 mg per patient hospital day for delirious patients on the program pilot units. CONCLUSION Elements of our unique active delirium treatment program may provide some direction to other program developers working on improving the care of older hospitalized delirious patients. However, the supporting evidence presented is limited, and a more rigorous prospective study is needed.
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Affiliation(s)
- Joseph I Friedman
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lihua Li
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York.,Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, 10029
| | | | - Xiaobo Zhong
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York.,Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, 10029
| | - Robert Freeman
- Clinical Operations, Mount Sinai Hospital, New York, New York
| | - Yim Tan Cheng
- EPIC Clinical Transformation Group, Mount Sinai Health System, New York, New York
| | - Francis L Alfonso
- EPIC Clinical Transformation Group, Mount Sinai Health System, New York, New York
| | - George McAlpine
- EPIC Clinical Transformation Group, Mount Sinai Health System, New York, New York
| | - Aditi Vakil
- EPIC Clinical Transformation Group, Mount Sinai Health System, New York, New York
| | - Bernard Macon
- EPIC Clinical Transformation Group, Mount Sinai Health System, New York, New York
| | - Paul Francaviglia
- EPIC Clinical Transformation Group, Mount Sinai Health System, New York, New York
| | - Margherita Cassara
- EPIC Clinical Transformation Group, Mount Sinai Health System, New York, New York
| | - Vicki LoPachin
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Katherine Reina
- Department of Nursing, Mount Sinai Hospital, New York, New York
| | - Kenneth Davis
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York.,President's Office, Mount Sinai Health System, New York, New York
| | - David Reich
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Catherine K Craven
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Madhu Mazumdar
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York.,Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, 10029
| | - Albert L Siu
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York.,Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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10
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Recognition, prevention, and treatment of delirium in emergency department: An evidence-based narrative review. Am J Emerg Med 2020; 38:349-357. [DOI: 10.1016/j.ajem.2019.158454] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 09/13/2019] [Accepted: 09/16/2019] [Indexed: 12/19/2022] Open
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11
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Heldmann P, Werner C, Belala N, Bauer JM, Hauer K. Early inpatient rehabilitation for acutely hospitalized older patients: a systematic review of outcome measures. BMC Geriatr 2019; 19:189. [PMID: 31288750 PMCID: PMC6617943 DOI: 10.1186/s12877-019-1201-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 07/02/2019] [Indexed: 01/11/2023] Open
Abstract
Background Selecting appropriate outcome measures for vulnerable, multimorbid, older patients with acute and chronic impairments poses specific challenges, which may have caused inconsistent findings of previous intervention trials on early inpatient rehabilitation in acutely hospitalized older patients. The aim of this review was to describe primary outcome measures that have been used in randomized controlled trials (RCTs) on early rehabilitation in acutely hospitalized older patients, to analyze their matching, and to evaluate the effects of matching on the main findings of these RCTs. Methods A systematic literature search was conducted in PubMed, Cochrane CENTRAL, CINAHL, and PEDro databases. Additional studies were identified through reference and citation tracking. Inclusion criteria were: RCT, patients aged ≥65 years, admission to an acute hospital medical ward (but not to an intensive medical care unit), physical exercise intervention (also as part of multidisciplinary programs), and primary outcome measure during hospitalization. Two independent reviewers extracted the data, assessed the methodological quality, and analyzed the matching of primary outcome measures to the intervention, study sample, and setting. Main study findings were related to the results of the matching procedure. Results Twenty-eight articles reporting on 24 studies were included. A total of 33 different primary outcome measures were identified, which were grouped into six categories: functional status, mobility status, hospital outcomes, adverse clinical events, psychological status, and cognitive functioning. Outcome measures differed considerably within each category and showed a large heterogeneity in their matching to the intervention, study sample, and setting. Outcome measures that specifically matched the intervention contents were more likely to document intervention-induced benefits. Mobility instruments seemed to be the most sensitive outcome measures to reveal such benefits. Conclusions This review highlights that the selection of outcome measures has to be highly specific to the intervention contents as this is a key factor to reveal benefits attributable to early rehabilitation in acutely hospitalized older patients. Inappropriate selection of outcome measures may represent a major cause of inconsistent findings reported on the effectiveness of early rehabilitation in this setting. Trial registration PROSPERO CRD42017063978. Electronic supplementary material The online version of this article (10.1186/s12877-019-1201-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Patrick Heldmann
- Network Aging Research (NAR), Heidelberg University, Bergheimer Str. 20, 69115, Heidelberg, Germany.
| | - Christian Werner
- Agaplesion Bethanien Hospital Heidelberg, Geriatric Center at the Heidelberg University, Heidelberg, Germany.,Center for Geriatric Medicine, Heidelberg University, Heidelberg, Germany
| | - Nacera Belala
- Network Aging Research (NAR), Heidelberg University, Bergheimer Str. 20, 69115, Heidelberg, Germany
| | - Jürgen M Bauer
- Agaplesion Bethanien Hospital Heidelberg, Geriatric Center at the Heidelberg University, Heidelberg, Germany.,Center for Geriatric Medicine, Heidelberg University, Heidelberg, Germany
| | - Klaus Hauer
- Agaplesion Bethanien Hospital Heidelberg, Geriatric Center at the Heidelberg University, Heidelberg, Germany
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12
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Liimatta HA, Lampela P, Kautiainen H, Laitinen-Parkkonen P, Pitkala KH. The Effects of Preventive Home Visits on Older People’s Use of Health Care and Social Services and Related Costs. J Gerontol A Biol Sci Med Sci 2019; 75:1586-1593. [DOI: 10.1093/gerona/glz139] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
We use data from a randomized controlled trial on preventive home visits exploring effectiveness on health-related quality of life. In this article, we examine the intervention’s cost-effectiveness and effects on quality-adjusted life years in older home-dwelling adults.
Methods
There were 422 independently home-dwelling participants in the randomized, controlled trial, all aged more than 75 years, with equal numbers in the control and intervention groups. The intervention took place in a municipality in Finland and consisted of multiprofessional preventive home visits. We gathered the data on health care and social services use from central registers and medical records during 1 year before the intervention and 2 years after the intervention. We analyzed the total health care and social services use and costs per person-years and the difference in change in health-related quality of life as measured using the 15D measure. We calculated quality-adjusted life years and incremental cost-effectiveness ratios.
Results
There was no significant difference in baseline use of services or in the total use and costs of health care and social services during the 2-year follow-up between the two groups. In the intervention group, health-related quality of life declined significantly more slowly compared with the control group (–0.015), but there was no significant difference in quality-adjusted life years gained between the groups. The cost-effectiveness plane showed 60% of incremental cost-effectiveness ratios lying in the dominant quadrant, representing additional effects with lower costs.
Conclusions
This multiprofessional preventive home visit intervention appears to have positive effects on health-related quality of life without accruing additional costs.
The clinical trial registration number
ACTRN12616001411437.
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Affiliation(s)
- Heini A Liimatta
- Hyvinkää City Health Center, University of Helsinki, Uusimaa, Finland
- Department of General Practice and Primary Health Care, University of Helsinki, Uusimaa, Finland
| | - Pekka Lampela
- Hyvinkää City Health Center, University of Helsinki, Uusimaa, Finland
| | - Hannu Kautiainen
- Department of General Practice and Primary Health Care, University of Helsinki, Uusimaa, Finland
- Unit of Primary Health Care, Helsinki University Hospital, Uusimaa, Finland
| | - Pirjo Laitinen-Parkkonen
- Keski-Uusimaa Joint Municipality Authority for Health Care and Social Services, Uusimaa, Finland
| | - Kaisu H Pitkala
- Department of General Practice and Primary Health Care, University of Helsinki, Uusimaa, Finland
- Unit of Primary Health Care, Helsinki University Hospital, Uusimaa, Finland
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Liimatta H, Lampela P, Laitinen-Parkkonen P, Pitkala KH. Effects of preventive home visits on health-related quality-of-life and mortality in home-dwelling older adults. Scand J Prim Health Care 2019; 37:90-97. [PMID: 30810457 PMCID: PMC6452824 DOI: 10.1080/02813432.2019.1569372] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE We explored the effectiveness of preventive home visits on the health-related quality-of-life (HRQoL) and mortality among independently community-dwelling older adults. DESIGN A randomised controlled trial. SUBJECTS Independently home-dwelling older adults 75 years and older, consisting of 211 in the intervention and 211 in the control group. SETTING Hyvinkää town municipality, Finland. MAIN OUTCOME MEASURES We used the change in HRQoL measured by the 15D scale as our primary outcome. Mortality at two years was retrieved from central registers. RESULTS At the one-year time point, the HRQoL according to the 15D scores deteriorated in the control group, whereas we found no change in the intervention group. The difference between the 15D score changes between the groups was -0.015 (95% CI -0.029 to -0.0016; p = 0.028, adjusted for age, sex, and baseline value). At the two-year time point as the visits ended, that difference diminished. There was no difference in mortality between the groups during the 24-month follow-up. CONCLUSION Preventive home visits implemented by a multidisciplinary team with CGA appear to help slow down the decline in HRQoL among older adults, although the effect diminishes when the visits end. Key points We are exploring preventive home visits as means to support the health-related quality-of-life (HRQoL) of home-dwelling older adults Multiprofessional preventive home visits in this intervention study helped to maintain the HRQoL when measured using 15D The effects on HRQoL diminished when the intervention ended, so could further benefits be attained with a longer intervention?The clinical trial registration number: ACTRN12616001411437.
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Affiliation(s)
- Heini Liimatta
- Hyvinkää City Health Centre, Hyvinkää, Finland;
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland;
- CONTACT Heini Liimatta , Hyvinkää City Health Center, Sandelininkatu 1, 05800Hyvinkää, Finland
| | | | | | - Kaisu H. Pitkala
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland;
- Unit of Primary Health Care, Helsinki University Hospital, Helsinki, Finland
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14
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Kallio EL, Öhman H, Hietanen M, Soini H, Strandberg TE, Kautiainen H, Pitkälä KH. Effects of Cognitive Training on Cognition and Quality of Life of Older Persons with Dementia. J Am Geriatr Soc 2018; 66:664-670. [DOI: 10.1111/jgs.15196] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Eeva-Liisa Kallio
- Department of General Practice and Primary Health Care; University of Helsinki; and Unit of Primary Health Care; Helsinki University Hospital; Helsinki Finland
- Clinical Neurosciences; Neuropsychology; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - Hannareeta Öhman
- Department of General Practice and Primary Health Care; University of Helsinki; and Unit of Primary Health Care; Helsinki University Hospital; Helsinki Finland
- City of Helsinki; Hospital; Rehabilitation; and Care Services; Helsinki Finland
| | - Marja Hietanen
- Clinical Neurosciences; Neuropsychology; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - Helena Soini
- City of Helsinki; Social Services and Health Care Department; Helsinki Finland
| | - Timo E. Strandberg
- University of Helsinki and Helsinki University Hospital; Helsinki Finland
- Center for Life Course Health Research; University of Oulu; Oulu Finland
| | - Hannu Kautiainen
- Department of General Practice and Primary Health Care; University of Helsinki; and Unit of Primary Health Care; Helsinki University Hospital; Helsinki Finland
| | - Kaisu H. Pitkälä
- Department of General Practice and Primary Health Care; University of Helsinki; and Unit of Primary Health Care; Helsinki University Hospital; Helsinki Finland
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15
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Liimatta H, Lampela P, Laitinen-Parkkonen P, Pitkala K. Preventive home visits to promote the health-related quality of life of home-dwelling older people: Baseline findings and feasibility of a randomized, controlled trial. Eur Geriatr Med 2017. [DOI: 10.1016/j.eurger.2017.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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16
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Cooperation between geriatricians and general practitioners for improved pharmacotherapy in home-dwelling elderly people receiving polypharmacy - the COOP Study: study protocol for a cluster randomised controlled trial. Trials 2017; 18:158. [PMID: 28372591 PMCID: PMC5379709 DOI: 10.1186/s13063-017-1900-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 03/14/2017] [Indexed: 11/28/2022] Open
Abstract
Background Polypharmacy and inappropriate drug use is associated with negative health outcomes among older people. Various interventions for improving drug treatment have been evaluated, but the majority of studies are limited by the use of surrogate outcomes or suboptimal design. Thus, the potential for clinically significant improvements from different interventions is still unclear. The main objective of this study is therefore to evaluate the effect upon patient-relevant endpoints of a cooperation between geriatricians and general practitioners on complex drug regimens in home-dwelling elderly people. Methods This is a cluster randomised, single-blind, controlled trial where general practitioners are invited to participate with patients from their lists. The patients must be 70 years or older, use at least seven different medications and have their medications administered by the home nursing service. We plan to recruit 200 patients, with randomisation at physician level. The intervention consists of three main parts: (1) clinical geriatric assessment of the patient, combined with a thorough review of their medications; (2) a meeting between the geriatrician and general practitioner, where the two physicians combine their competence and knowledge and discuss the drug list systematically; (3) clinical follow-up, depending on the medication changes that have been done. The study period is 24 weeks, and the patients are assessed at baseline, 16 and 24 weeks. The primary outcome measure is health-related quality of life according to the 15D instrument. Secondary outcome measures include physical and cognitive functioning, medication appropriateness, falls, carer burden, use of health services (hospital or nursing home admissions, use of home nursing services) and mortality. Discussion Our choice of patient-relevant outcome measures will hopefully provide new knowledge on the potential for clinical improvements after performing comprehensive medication reviews in home-dwelling elderly people receiving polypharmacy. Trial registration ClinicalTrials.gov, NCT02379455. Registered on 27 February 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1900-0) contains supplementary material, which is available to authorized users.
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Angel C, Brooks K, Fourie J. Standardizing Management of Adults with Delirium Hospitalized on Medical-Surgical Units. Perm J 2016; 20:16-002. [PMID: 27644045 DOI: 10.7812/tpp/16-002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
CONTEXT Delirium is common among inpatients aged 65 years and older and is associated with multiple adverse consequences, including increased length of stay (LOS). However, delirium is frequently unrecognized and poorly understood. At one hospital, baseline management of delirium on medical-surgical units varied greatly, and psychiatric consultations focused exclusively on crisis management. OBJECTIVE To implement a multidisciplinary program for rapid identification and proactive management of patients with delirium on medical-surgical units. DESIGN A pilot from September 2010 to July 2012 included 920 unique patients, of whom 470 were seen by the delirium management team. A delirium management team included a redesigned role for consulting psychiatrists and a new clinical nurse specialist role; the team provided assistance with diagnosis and recommendations for nonpharmacologic and pharmacologic management of delirium. Multidisciplinary education focused on delirium identification and management and nurses' use of appropriate assessment tools. Electronic health record functions supported accurate problem list coding, referrals to the team, and standardized documentation. MAIN OUTCOME MEASURE Length of stay. RESULTS During the study period, average LOS in the target population decreased from 8.5 days to 6.5 days (p = 0.001); average LOS for the Medical Center remained stable. Compared with patients whose delirium was diagnosed during the baseline period, patients who received a delirium diagnosis during the pilot period had a higher illness burden and were likelier to have a history of delirium and diagnosed dementia. CONCLUSION Program implementation was associated with reduced LOS among older inpatients with delirium. The delirium team is an effective model that can be quickly implemented with few additional resources.
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Affiliation(s)
- Clay Angel
- Chief of Service for Skilled Nursing Facilities at the San Rafael Medical Center in CA.
| | - Kristen Brooks
- Consultant Liaison in Psychiatry for the San Rafael Medical Center in CA.
| | - Julie Fourie
- Clinical Consulting Manager at the San Rafael Medical Center in CA.
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18
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Australian and New Zealand Society for Geriatric Medicine Position Statement Abstract: Delirium in older people. Australas J Ageing 2016; 35:292. [DOI: 10.1111/ajag.12254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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19
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Laakkonen ML, Kautiainen H, Hölttä E, Savikko N, Tilvis RS, Strandberg TE, Pitkälä KH. Effects of Self-Management Groups for People with Dementia and Their Spouses--Randomized Controlled Trial. J Am Geriatr Soc 2016; 64:752-60. [PMID: 27060101 DOI: 10.1111/jgs.14055] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To investigate the effect of self-management group rehabilitation for persons with dementia (PwD) and their spouses on their health-related quality of life (HRQoL), the cognition of the PwD, and the costs of health and social services. DESIGN A randomized controlled trial. SETTING Primary care and memory clinics in the Helsinki metropolitan area, Finland. PARTICIPANTS PwD (N = 136) and their spouses (N = 136). INTERVENTION Couples were randomized to usual care or eight-session self-management groups for PwD and concurrently for their spouses. Sessions aim to enhance self-efficacy and problem-solving skills and to provide peer support. MEASUREMENTS The primary outcome measures were the HRQoL of PwD (measured using a generic, comprehensive (15-dimensional), self-administered instrument (15D)) and spouses (measured using the RAND-36) and the spousal Sense of Competence Questionnaire (SCQ). Secondary outcome measures were PwD cognition (Verbal Fluency (VF), Clock Drawing Test (CDT)) and costs of health and social services during 24 months. RESULTS At 3 months, the spouse physical component of the RAND-36 improved (mean change 1.0, 95% confidence interval (CI) = -0.5 to 2.4) for those undergoing the intervention and worsened for controls (mean change -2.0, 95% CI = -3.5 to -0.4) (P = .006 adjusted for age, sex, baseline value of the physical component of the RAND-36). There were no differences between the groups on the mental component of the RAND-36, the SCQ, or the 15D. At 9 months, PwD change in VF was -0.38 (95% CI = -1.03 to 0.27) in intervention group and -1.60 (95% CI = -2.26 to -0.94) for controls (P = .011 adjusted for age, sex, baseline MMSE score). CDT changes were similar to VF changes. Differences in incremental costs between the groups was -436 € per person per year (95% CI = -4,986 to 4,115) for PwD (P = .35 adjusted for age, CDR) and -896 € per person per year (95% CI = -3,657 to 1,864) for spouses (P = .51 adjusted for PwD age, CDR). CONCLUSIONS The intervention had beneficial effects on the HRQoL of spouses and the cognitive function of PwD without increasing total costs. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12611001173987.
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Affiliation(s)
- Marja-Liisa Laakkonen
- Geriatric Clinic, Department of Social Services and Health Care, Laakso Hospital, Helsinki, Finland.,Department of General Practice, University of Helsinki, Helsinki, Finland.,Unit of Primary Health Care, Helsinki University Central Hospital, Helsinki, Finland
| | - Hannu Kautiainen
- Department of General Practice, University of Helsinki, Helsinki, Finland.,Unit of Primary Health Care, Helsinki University Central Hospital, Helsinki, Finland
| | - Eeva Hölttä
- Department of General Practice, University of Helsinki, Helsinki, Finland.,Unit of Primary Health Care, Helsinki University Central Hospital, Helsinki, Finland.,Geriatric Psychiatric Clinics, Department of Social Services and Health Care, Laakso Hospital, Helsinki, Finland
| | - Niina Savikko
- Department of General Practice, University of Helsinki, Helsinki, Finland.,Unit of Primary Health Care, Helsinki University Central Hospital, Helsinki, Finland.,Department of Home Care, Espoo, Finland
| | - Reijo S Tilvis
- Department of General Internal Medicine and Geriatrics, University of Helsinki, Helsinki, Finland.,General Internal Medicine, Helsinki University Central Hospital, Helsinki, Finland.,Geriatrics Clinics, Helsinki University Central Hospital, Helsinki, Finland
| | - Timo E Strandberg
- Department of General Internal Medicine and Geriatrics, University of Helsinki, Helsinki, Finland.,General Internal Medicine, Helsinki University Central Hospital, Helsinki, Finland.,Geriatrics Clinics, Helsinki University Central Hospital, Helsinki, Finland.,Division of Geriatrics, Institute of Health Sciences, University of Oulu, Oulu, Finland.,Unit of General Practice, Oulu University Hospital, Oulu, Finland
| | - Kaisu H Pitkälä
- Department of General Practice, University of Helsinki, Helsinki, Finland.,Unit of Primary Health Care, Helsinki University Central Hospital, Helsinki, Finland
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Bulamu NB, Kaambwa B, Ratcliffe J. A systematic review of instruments for measuring outcomes in economic evaluation within aged care. Health Qual Life Outcomes 2015; 13:179. [PMID: 26553129 PMCID: PMC4640110 DOI: 10.1186/s12955-015-0372-8] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 10/22/2015] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND This paper describes the methods and results of a systematic review to identify instruments used to measure quality of life outcomes in older people. The primary focus of the review was to identify instruments suitable for application with older people within economic evaluations conducted in the aged care sector. METHODS Online databases searched were PubMed, Medline, Scopus, and Web of Science, PsycInfo, CINAHL, Embase and Informit. Studies that met the following criteria were included: 1) study population exclusively above 65 years of age 2) measured health status, health related quality of life or quality of life outcomes more broadly through use of an instrument developed for this purpose, 3) used a generic preference based instrument or an older person specific preference based or non-preference based instrument or both, and 4) published in journals in the English language after 2000. RESULTS The most commonly applied generic preference based instrument in both the community and residential aged care context was the EuroQol - 5 Dimensions (EQ-5D), followed by the Adult Social Care Outcomes Toolkit (ASCOT) and the Health Utilities Index (HUI2/3). The most widely applied older person specific instrument was the ICEpop CAPability measure for Older people (ICECAP-O) in both community and residential aged care. CONCLUSION In the absence of an ideal instrument for incorporating into economic evaluations in the aged care sector, this review recommends the use of a generic preference based measure of health related quality of life such as the EQ-5D to obtain quality adjusted life years, in combination with an instrument that has a broader quality of life focus like the ASCOT, which was designed specifically for evaluating interventions in social care or the ICECAP-O, a capability measure for older people.
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Affiliation(s)
- Norma B Bulamu
- Flinders Health Economics Group, School of Medicine, Flinders University, A Block, Repatriation General Hospital, 202-16 Daws Road, Daw Park, SA, 5041, Australia.
| | - Billingsley Kaambwa
- Flinders Health Economics Group, School of Medicine, Flinders University, A Block, Repatriation General Hospital, 202-16 Daws Road, Daw Park, SA, 5041, Australia.
| | - Julie Ratcliffe
- Flinders Health Economics Group, School of Medicine, Flinders University, A Block, Repatriation General Hospital, 202-16 Daws Road, Daw Park, SA, 5041, Australia.
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21
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Do Postoperative Pain Management Techniques Influence Postoperative Delirium? CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-014-0089-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lee E, Kim J. Cost-benefit analysis of a delirium prevention strategy in the intensive care unit. Nurs Crit Care 2014; 21:367-373. [PMID: 25351583 DOI: 10.1111/nicc.12124] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Revised: 04/23/2014] [Accepted: 07/07/2014] [Indexed: 11/27/2022]
Abstract
AIMS The aim of this study was to evaluate the effect of a delirium prevention strategy. BACKGROUND A high prevalence has been reported for delirium after liver transplantation surgery in the intensive care unit (ICU). Delirium increases treatment costs because of treatment delays, prolonged hospital stays and other associated complications. Despite all those problems associated with delirium, a systemic prevention strategy does not exist yet. DESIGN This study used an economic evaluation design by reviewing relevant medical records. METHODS Study objects were 130 patients who were admitted to the ICU after liver transplantation surgery. After looking at the medical records of these patients, we divided them into two groups according to the application of the prevention strategy. This study analysed the costs and benefits of the prevention strategy between the groups. RESULTS The prevalence rate of delirium was 35·3% in the prevention-care group and 51·6% in the usual-care group. A sum of $38·4 was invested for the prevention strategy in opposite to the expected total costs of $5578 for a probable treatment. Thus, the net benefit was $5539·6 with a benefit ratio of 145·3 CONCLUSIONS: A strategy is necessary for the delirium prevention of patients in the ICU to decrease the economic burden. RELEVANCE TO CLINICAL PRACTICE This study demonstrated that a prevention strategy was cost-effective because of its low input costs. With low additional investment, it is expected that this prevention strategy will be more available to other patients in the future.
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Affiliation(s)
- Eunhee Lee
- College of Nursing, The Research Institute of Nursing Science, Seoul National University, Seoul, Republic of Korea
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Chong MS, Chan M, Tay L, Ding YY. Outcomes of an innovative model of acute delirium care: the Geriatric Monitoring Unit (GMU). Clin Interv Aging 2014; 9:603-12. [PMID: 24748778 PMCID: PMC3986297 DOI: 10.2147/cia.s60259] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objective Delirium is associated with poor outcomes following acute hospitalization. The Geriatric Monitoring Unit (GMU) is a specialized five-bedded unit for acute delirium care. It is modeled after the Delirium Room program, with adoption of core interventions from the Hospital Elder Life Program and use of evening light therapy to consolidate circadian rhythms and improve sleep in older inpatients. This study examined whether the GMU program improved outcomes in delirious patients. Method A total of 320 patients, including 47 pre-GMU, 234 GMU, and 39 concurrent control subjects, were studied. Clinical characteristics, cognitive status, functional status (Modified Barthel Index [MBI]), and chemical restraint-use data were obtained. We also looked at in-hospital complications of falls, pressure ulcers, nosocomial infection rate, and discharge destination. Secondary outcomes of family satisfaction (for the GMU subjects) were collected. Results There were no significant demographic differences between the three groups. Pre-GMU subjects had longer duration of delirium and length of stay. MBI improvement was most evident in the GMU compared with pre-GMU and control subjects (19.2±18.3, 7.5±11.2, 15.1±18.0, respectively) (P<0.05). The GMU subjects had a zero restraint rate, and pre-GMU subjects had higher antipsychotic dosages. This translated to lower pressure ulcer and nosocomial infection rate in the GMU (4.1% and 10.7%, respectively) and control (1.3% and 7.7%, respectively) subjects compared with the pre-GMU (9.1% and 23.4%, respectively) subjects (P<0.05). No differences were observed in mortality or discharge destination among the three groups. Caregivers of GMU subjects felt the multicomponent intervention to be useful, with scheduled activities voted the most beneficial in patient’s recovery from the delirium episode. Conclusion This study shows the benefits of a specialized delirium management unit for older persons. The GMU model is thus a relevant system of care for rapidly “graying” nations with high rates of frail elderly hospital admissions, which can be easily transposed across acute care settings.
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Affiliation(s)
- Mei Sian Chong
- Department of Geriatric Medicine, Institute of Geriatrics and Active Ageing, Tan Tock Seng Hospital, Singapore
| | - Mark Chan
- Department of Geriatric Medicine, Institute of Geriatrics and Active Ageing, Tan Tock Seng Hospital, Singapore
| | - Laura Tay
- Department of Geriatric Medicine, Institute of Geriatrics and Active Ageing, Tan Tock Seng Hospital, Singapore
| | - Yew Yoong Ding
- Department of Geriatric Medicine, Institute of Geriatrics and Active Ageing, Tan Tock Seng Hospital, Singapore
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Sonntag M, König HH, Konnopka A. The estimation of utility weights in cost-utility analysis for mental disorders: a systematic review. PHARMACOECONOMICS 2013; 31:1131-54. [PMID: 24293216 DOI: 10.1007/s40273-013-0107-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
OBJECTIVE To systematically review approaches and instruments used to derive utility weights in cost-utility analyses (CUAs) within the field of mental disorders and to identify factors that may have influenced the choice of the approach. METHODS We searched the databases DARE (Database of Abstracts of Reviews of Effects), NHS EED (National Health Service Economic Evaluation Database), HTA (Health Technology Assessment), and PubMed for CUAs. Studies were included if they were full economic evaluations and reported quality-adjusted life-years as the health outcome. Study characteristics and instruments used to estimate utility weights were described and a logistic regression analysis was conducted to identify factors associated with the choice of either the direct (e.g. standard gamble) or the preference-based measure (PBM) approach (e.g. EQ-5D). RESULTS We identified 227 CUAs with a maximum in 2009, 2010, and 2012. Most CUAs were conducted in depression, dementia, or psychosis, and came from the US or the UK, with the EQ-5D being the most frequently used instrument. The application of the direct approach was significantly associated with depression, psychosis, and model-based studies. The PBM approach was more likely to be used in recent studies, dementia, Europe, and empirical studies. Utility weights used in model-based studies were derived from only a small number of studies. LIMITATIONS We only searched four databases and did not evaluate the quality of the included studies. CONCLUSIONS Direct instruments and PBMs are used to elicit utility weights in CUAs with different frequencies regarding study type, mental disorder, and country.
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Affiliation(s)
- Michael Sonntag
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany,
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Allen VJ, Methven L, Gosney MA. Use of nutritional complete supplements in older adults with dementia: Systematic review and meta-analysis of clinical outcomes. Clin Nutr 2013; 32:950-7. [DOI: 10.1016/j.clnu.2013.03.015] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Revised: 02/08/2013] [Accepted: 03/19/2013] [Indexed: 10/27/2022]
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The clinical and economic costs of delirium after surgical resection for esophageal malignancy. Ann Surg 2013; 258:77-81. [PMID: 23426343 DOI: 10.1097/sla.0b013e31828545c1] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The aim of this study was to identify preoperative risk factors and postoperative consequences that are associated with the occurrence of delirium after esophagectomy for malignancy. BACKGROUND Delirium is an underdiagnosed, serious complication after major surgery, particularly in the elderly population. METHODS All patients undergoing esophagectomy for cancer (1991-2011) were included. Patients with and without delirium were compared with respect to medical comorbidities, use of neoadjuvant therapy, operative outcomes, postoperative complications, overall cost, and survival. RESULTS Of the 500 patients included in this analysis, 46 (9.2%) patients developed postoperative delirium. Patients with delirium had higher ASA and Charlson comorbidity index scores. Delirium was associated with a longer hospital (14 ± 7.5 vs 10.9 ± 5.7; P < 0.05) and intensive care unit stay (3.6 ± 3.8 vs 2.7 ± 16.9; P < 0.05) and an increased incidence of pulmonary complications and increased hospital costs. Delirium was preceded by another complication in 32.6% of cases but by a septic complication in only 19.6% of cases. Age was the only preoperative predictor of postoperative delirium in multivariate modeling (P < 0.05). No differences were noted in the use of neoadjuvant chemoradiotherapy or survival. CONCLUSIONS This study demonstrates that postoperative delirium is associated with a more complicated and costly recovery after esophagectomy and that age is independently predictive of its development. Delirium has often been thought to be the sequela of other complications; however, this study demonstrates that it presents in isolation or precedes other complications in 67.4% of cases. Focused screening will likely allow targeted preventative strategies to be used in the perioperative period to reduce complications and costs associated with delirium.
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Chong MS, Tan KT, Tay L, Wong YM, Ancoli-Israel S. Bright light therapy as part of a multicomponent management program improves sleep and functional outcomes in delirious older hospitalized adults. Clin Interv Aging 2013; 8:565-72. [PMID: 23723696 PMCID: PMC3666546 DOI: 10.2147/cia.s44926] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective Delirium is associated with poor outcomes following acute hospitalization. A specialized delirium management unit, the Geriatric Monitoring Unit (GMU), was established. Evening bright light therapy (2000–3000 lux; 6–10 pm daily) was added as adjunctive treatment, to consolidate circadian activity rhythms and improve sleep. This study examined whether the GMU program improved sleep, cognitive, and functional outcomes in delirious patients. Method A total of 228 patients (mean age = 84.2 years) were studied. The clinical characteristics, delirium duration, delirium subtype, Delirium Rating Score (DRS), cognitive status (Chinese Mini–Mental State Examination), functional status (modified Barthel Index [MBI]), and chemical restraint use during the initial and predischarge phase of the patient’s GMU admission were obtained. Nurses completed hourly 24-hour patient sleep logs, and from these, the mean total sleep time, number of awakenings, and sleep bouts (SB) were computed. Results The mean delirium duration was 6.7 ± 4.6 days. Analysis of the delirium subtypes showed that 18.4% had hypoactive delirium, 30.2% mixed delirium, and 51.3% had hyperactive delirium. There were significant improvements in MBI scores, especially for the hyperactive and mixed delirium subtypes (P < 0.05). Significant improvements were noted on the DRS sleep–wake disturbance subscore, for all delirium-subtypes. The mean total sleep time (7.7 from 6.4 hours) (P < 0.05) and length of first SB (6.0 compared with 5.3 hours) (P < 0.05) improved, with decreased mean number of SBs and awakenings. The sleep improvements were mainly seen in the hyperactive delirium subtype. Conclusion This study shows initial evidence for the clinical benefits (longer total sleep time, increased first SB length, and functional gains) of incorporating bright light therapy as part of a multicomponent delirium management program. The benefits appear to have occurred mainly in patients with hyperactive delirium, which merits further in-depth, randomized controlled studies.
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Affiliation(s)
- Mei Sian Chong
- Department of Geriatric Medicine, Tan Tock Seng Hospital, Singapore.
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Irwin SA, Pirrello RD, Hirst JM, Buckholz GT, Ferris FD. Clarifying delirium management: practical, evidenced-based, expert recommendations for clinical practice. J Palliat Med 2013; 16:423-35. [PMID: 23480299 PMCID: PMC3612281 DOI: 10.1089/jpm.2012.0319] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2013] [Indexed: 12/30/2022] Open
Abstract
Delirium is highly prevalent in those with serious or advanced medical illnesses. It is associated with many adverse consequences, including significant patient, family, and health care provider distress. This article suggests a novel approach to delirium assessment and management and provides useful, practical guidance for clinicians based on a complete review of the existing literature and the expert clinical opinion of the authors and their colleagues, derived from over a decade of collective bedside experience. Comprehensive assessment includes careful description of observed symptoms, signs, and behaviors; and an understanding of the patient's situation, including primary diagnosis, associated comorbidities, functional status, and prognosis. The importance of incorporating goals of care for the patient and family is discussed. The concepts of potential reversibility versus irreversible delirium and delirium subtype are proffered, with a description of how diagnostic and management strategies follow from these concepts. Pharmacological interventions that provide rapid, effective, and safe relief are presented. Employing both pharmacological and nonpharmacological interventions, including patient and family education, improves symptoms and relieves patient and family distress, whether the delirium is reversible or irreversible, hyperactive or hypoactive. All interventions can be provided in any setting of care, including patients' homes.
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Affiliation(s)
- Scott A Irwin
- San Diego Hospice and The Institute for Palliative Medicine, San Diego, CA 92103, USA.
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Abstract
Altered mental status is a common chief compliant among older patients in the emergency department (ED). Acute changes in mental status are more concerning and are usually secondary to delirium, stupor, and coma. Although stupor and coma are easily identifiable, the clinical presentation of delirium can be subtle and is often missed without actively screening for it. For patients with acute changes in mental status the ED evaluation should focus on searching for the underlying etiology. Infection is one of the most common precipitants of delirium, but multiple causes may exist concurrently.
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Affiliation(s)
- Jin H. Han
- Center for Quality Aging, Assistant Professor of Emergency Medicine, Vanderbilt University School of Medicine, Department of Emergency Medicine, 703 Oxford House, Nashville, TN 37232-4700, Phone: 615-936-1434, Fax: 615-936-1316
| | - Scott T. Wilber
- Emergency Medicine Research Center, Associate Professor of Emergency Medicine, Summa Akron City Hospital, Northeastern Ohio Medical University, 525 East Market Street, Akron, Ohio 44309, Phone: 330-375-7530, Fax: 330-375-7564
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Breitbart W, Alici Y. Evidence-based treatment of delirium in patients with cancer. J Clin Oncol 2012; 30:1206-14. [PMID: 22412123 PMCID: PMC3646320 DOI: 10.1200/jco.2011.39.8784] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2011] [Accepted: 01/10/2012] [Indexed: 12/18/2022] Open
Abstract
Delirium is the most common neuropsychiatric complication seen in patients with cancer, and it is associated with significant morbidity and mortality. Increased health care costs, prolonged hospital stays, and long-term cognitive decline are other well-recognized adverse outcomes of delirium. Improved recognition of delirium and early treatment are important in diminishing such morbidity. There has been an increasing number of studies published in the literature over the last 10 years regarding delirium treatment as well as prevention. Antipsychotics, cholinesterase inhibitors, and alpha-2 agonists are the three groups of medications that have been studied in randomized controlled trials in different patient populations. In patients with cancer, the evidence is most clearly supportive of short-term, low-dose use of antipsychotics for controlling the symptoms of delirium, with close monitoring for possible adverse effects, especially in older patients with multiple medical comorbidities. Nonpharmacologic interventions also appear to have a beneficial role in the treatment of patients with cancer who have or are at risk for delirium. This article presents evidence-based recommendations based on the results of pharmacologic and nonpharmacologic studies of the treatment and prevention of delirium.
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Affiliation(s)
- William Breitbart
- Memorial Sloan-Kettering Cancer Center and Weill Medical College of Cornell University, New York, NY, USA.
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Quinlan N, Marcantonio ER, Inouye SK, Gill TM, Kamholz B, Rudolph JL. Vulnerability: the crossroads of frailty and delirium. J Am Geriatr Soc 2012; 59 Suppl 2:S262-8. [PMID: 22091571 DOI: 10.1111/j.1532-5415.2011.03674.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Frailty and delirium, although seemingly distinct syndromes, both result in significant negative health outcomes in older adults. Frailty and delirium may be different clinical expressions of a shared vulnerability to stress in older adults, and future research will determine whether this vulnerability is age related, pathological, genetic, environmental, or most likely, a combination of all of these factors. This article explores the clinical overlap of frailty and delirium, describes possible pathophysiological mechanisms linking the two, and proposes research opportunities to further knowledge of the interrelationships between these important geriatric syndromes. Frailty, a diminished ability to compensate for stressors, is generally viewed as a chronic condition, whereas delirium is an acute change in attention and cognition, but there is a developing literature on transitions in frailty status around acute events, as well as on delirium as a chronic, persistent condition. If frailty predisposes an individual to delirium, and delirium delays recovery from a stressor, then both syndromes may contribute to a downward spiral of declining function, increasing risk, and negative outcomes. In addition, frailty and delirium may have shared pathophysiology, such as inflammation, atherosclerosis, and chronic nutritional deficiencies, which will require further investigation. The fields of frailty and delirium are rapidly evolving, and future research may help to better define the interrelationship of these common and morbid geriatric syndromes. Because of the heterogeneous pathophysiology and presentation associated with frailty and delirium, typical of all geriatric syndromes, multicomponent prevention and treatment strategies are most likely to be effective and should be developed and tested.
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Affiliation(s)
- Nicky Quinlan
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Boston Healthcare System, Boston, MA 02130, USA
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González Tugas M, Uslar Nawrath W, Villarroel del Pino L, Calderón Pinto J, Palma Onetto C, Carrasco Gorman M. [Hospital costs associated with delirium in older medical patients]. Rev Esp Geriatr Gerontol 2012; 47:23-26. [PMID: 21719151 DOI: 10.1016/j.regg.2011.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Revised: 03/17/2011] [Accepted: 03/24/2011] [Indexed: 05/31/2023]
Abstract
INTRODUCTION Delirium is a common and serious complication in older patients, associated with increased, potentially preventable, morbidity and mortality. The aim of this study was to evaluate the associated costs of delirium during hospitalization in a university affiliated hospital in Chile. MATERIALS AND METHODS Prospective cohort study of consecutive patients 65 years and older, admitted to a medical ward. A psychogeriatric team assessed patients during the first and every 48h until discharge using the Confusion Assessment Method (CAM-S), length of hospital stay, pharmacy and total hospitalization costs were analyzed. Statistical analysis was performed using bivariate and multivariate analysis according to delirium diagnosis. RESULTS Data from 454 patients was analyzed, 160 of them in a delirium cohort (35.2%) and 294 in a non-delirium cohort (64.8%). The delirium cohort had a longer hospital stay (DATA) and higher mortality (7.0% versus 1.7%). The median of total costs of delirium during hospital stay was 38.7% higher than the non-delirium cohort (P<.001). Total costs were significantly higher in the delirium cohort after adjustment of covariables (P=.01). CONCLUSIONS This study confirms that delirium is associated with significantly greater costs. Considering that effective delirium prevention is possible, the knowledge of associated costs can help health care providers to justify prevention strategies and finally give better care for older patients.
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Affiliation(s)
- Matías González Tugas
- Departamento de Psiquiatría, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile
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Rathier MO, Baker WL. A review of recent clinical trials and guidelines on the prevention and management of delirium in hospitalized older patients. Hosp Pract (1995) 2011; 39:96-106. [PMID: 22056829 DOI: 10.3810/hp.2011.10.928] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Treatment of acute illness in older adults is frequently complicated by the presence of delirium. Delirium is characterized by the development of an altered mental status over the course of hours to days, and can have a fluctuating course. Patients with delirium have difficulty paying attention to their environment, have disorganized thinking, and usually have an altered level of consciousness. While scientists continue to elucidate the pathophysiologic mechanisms associated with delirium, clinicians can identify patients at risk for delirium and diagnose it using valid instruments, such as the Confusion Assessment Method and Confusion Assessment Method for the Intensive Care Unit. Delirium is an independent risk factor for death, institutionalization, and dementia, and resolves in many patients by the time of hospital discharge. For patients admitted to medical units, optimal management of delirium includes reassessment of medications, pain, sleep, nutrition, mobility, need for physical restraints, and bowel and bladder function. The use of antipsychotic medication to sedate delirious patients should be restricted to patients in danger of harming themselves or others and should be used when nonpharmacologic means fail. Multicomponent interventions performed by the hospital care team that address risk factors can prevent delirium in patients in medical units and those undergoing hip fracture repair. This includes attention to the depth of sedation during spinal anesthesia and the addition of regional nerve blocks to patient-controlled analgesia in orthopedic patients, both of which may reduce postoperative delirium. Perioperative use of antipsychotics may further reduce the incidence of delirium, although hospital length of stay has not been routinely reduced. Appropriate management of analgesia, sedation, and delirium in the intensive care unit is also associated with reduced duration of mechanical ventilation, as well as intensive care unit and hospital length of stay. The use of dexmedetomidine, an α-adrenergic receptor agonist, for sedation may reduce intensive care unit length of stay when compared with use of benzodiazepines.
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Affiliation(s)
- Margaret O Rathier
- University of Connecticut Health Center, Center on Aging, Farmington, CT, USA.
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Chong MS, Chan MPC, Kang J, Han HC, Ding YY, Tan TL. A new model of delirium care in the acute geriatric setting: geriatric monitoring unit. BMC Geriatr 2011; 11:41. [PMID: 21838912 PMCID: PMC3166896 DOI: 10.1186/1471-2318-11-41] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Accepted: 08/13/2011] [Indexed: 11/23/2022] Open
Abstract
Background Delirium is a common and serious condition, which affects many of our older hospitalised patients. It is an indicator of severe underlying illness and requires early diagnosis and prompt treatment, associated with poor survival, functional outcomes with increased risk of institutionalisation following the delirium episode in the acute care setting. We describe a new model of delirium care in the acute care setting, titled Geriatric Monitoring Unit (GMU) where the important concepts of delirium prevention and management are integrated. We hypothesize that patients with delirium admitted to the GMU would have better clinical outcomes with less need for physical and psychotropic restraints compared to usual care. Methods/Design GMU models after the Delirium Room with adoption of core interventions from Hospital Elder Life Program and use of evening bright light therapy to consolidate circadian rhythm and improve sleep in the elderly patients. The novelty of this approach lies in the amalgamation of these interventions in a multi-faceted approach in acute delirium management. GMU development thus consists of key considerations for room design and resource planning, program specific interventions and daily core interventions. Assessments undertaken include baseline demographics, comorbidity scoring, duration and severity of delirium, cognitive, functional measures at baseline, 6 months and 12 months later. Additionally we also analysed the pre and post-GMU implementation knowledge and attitude on delirium care among staff members in the geriatric wards (nurses, doctors) and undertook satisfaction surveys for caregivers of patients treated in GMU. Discussion This study protocol describes the conceptualization and implementation of a specialized unit for delirium management. We hypothesize that such a model of care will not only result in better clinical outcomes for the elderly patient with delirium compared to usual geriatric care, but also improved staff knowledge and satisfaction. The model may then be transposed across various locations and disciplines in the acute hospital where delirious patients could be sited. Trial Registration Current Controlled Trials ISRCTN52323811
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Affiliation(s)
- Mei Sian Chong
- Department of Geriatric Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore.
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Effects of socially stimulating group intervention on lonely, older people's cognition: a randomized, controlled trial. Am J Geriatr Psychiatry 2011; 19:654-63. [PMID: 21709611 DOI: 10.1097/jgp.0b013e3181f7d8b0] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Loneliness may predict impaired cognition among older people. The aim of this study was to determine the effects of socially stimulating group intervention on cognition among older individuals suffering from loneliness. DESIGN A randomized controlled trial. SETTING AND PARTICIPANTS Two hundred thirty-five participants (≥75 years) in seven day care centers in Finland. INTERVENTION Group intervention was based on the effects of closed-group dynamics and peer support. The three-month intervention was aimed to enhance interaction and friendships between participants and to socially stimulate them. Each group was facilitated by two specifically trained professionals. In addition to active discussions, the groups included three types of activities depending on the participants' interests: 1) therapeutic writing; 2) group exercise; and 3) art experiences. MEASUREMENTS Cognition was measured by the Alzheimer's Disease Assessment Scale (ADAS-Cog), and mental function was measured by the 15D measure. RESULTS The intervention and control groups were similar at baseline with respect to their demographics, disease burden, depression, and cognition. The ADAS-Cog scale improved more in the intervention group than in the control group within the three-month period, with mean changes being -2.6 points (95% confidence interval [CI]: -3.4 to -1.8) and -1.6 points (95% CI: -2.2 to -1.0), respectively. The dimension of mental function in the 15D showed significant improvement at 12 months in the intervention group (+0.048, 95% CI: +0.013 to +0.085) compared with the control group (-0.027, 95% CI: -0.063 to +0.010). CONCLUSION Psychosocial group intervention improved lonely older people's cognition.
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Carpenter CR, Bassett ER, Fischer GM, Shirshekan J, Galvin JE, Morris JC. Four sensitive screening tools to detect cognitive dysfunction in geriatric emergency department patients: brief Alzheimer's Screen, Short Blessed Test, Ottawa 3DY, and the caregiver-completed AD8. Acad Emerg Med 2011; 18:374-84. [PMID: 21496140 DOI: 10.1111/j.1553-2712.2011.01040.x] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cognitive dysfunction, including dementia and delirium, is prevalent in geriatric emergency department (ED) patients, but often remains undetected. One barrier to reliable identification of acutely or chronically impaired cognitive function is the lack of an acceptable screening tool. While multiple brief screening instruments have been derived, ED validation trials have not previously demonstrated tools that are appropriately sensitive for clinical use. OBJECTIVES The primary objective was to evaluate and compare the Ottawa 3DY (O3DY), Brief Alzheimer's Screen (BAS), Short Blessed Test (SBT), and caregiver-completed AD8 (cAD8) diagnostic test performance for cognitive dysfunction in geriatric ED patients using the Mini Mental Status Exam (MMSE) as the criterion standard. A secondary objective was to assess the diagnostic accuracy for the cAD8 (which is an informant-based instrument) when used in combination with the other performance-based screening tools. METHODS In an observational cross-sectional cohort study at one urban academic university-affiliated medical center, trained research assistants (RAs) collected patients' responses on the Confusion Assessment Method for the Intensive Care Unit, BAS, and SBT. When available, reliable caregivers completed the cAD8. The MMSE was then obtained. The O3DY was reconstructed from elements of the MMSE and the BAS. Consenting subjects were non-critically ill, English-speaking adults over age 65 years, who had not received potentially sedating medications prior to or during cognitive testing. Using an MMSE score of ≤23 as the criterion standard for cognitive dysfunction, the sensitivity, specificity, likelihood ratios, and receiver operating characteristic (ROC) area under the curve (AUC) were computed. Venn diagrams were constructed to quantitatively compare the degree of overlap among positive test results between the performance-based instruments. RESULTS The prevalence of cognitive dysfunction for the 163 patients enrolled with complete data collection was 37%, including 5.5% with delirium. Dementia was self-reported in 3%. Caregivers were available to complete the cAD8 for 56% of patients. The SBT, BAS, and O3DY each demonstrated 95% sensitivity, compared with 83% sensitivity for the cAD8. The SBT had a superior specificity of 65%. No combination of instruments with the cAD8 significantly improved diagnostic accuracy. The SBT provided the optimal overlap with the MMSE. CONCLUSIONS The SBT, BAS, and O3DY are three brief performance-based screening instruments to identify geriatric patients with cognitive dysfunction more rapidly than the MMSE. Among these three instruments, the SBT provides the best diagnostic test characteristics and overlap with MMSE results. The addition of the cAD8 to the other instruments does not enhance diagnostic accuracy.
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Affiliation(s)
- Christopher R Carpenter
- Division of Emergency Medicine, Washington University in St. Louis School of Medicine, MO, USA.
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Rösler A, Hofmann W, von Renteln-Kruse W, Flesch P, Greuel HW, Hoffmann J, Hofmann W, Kopf D, Meyer AK, Merk B, Nehen HG, Püllen R, Schwab J, von Renteln-Kruse W, Weil K. [Special care units for the treatment of acutely ill, cognitively impaired geriatric patients in Germany]. Z Gerontol Geriatr 2011; 43:249-53. [PMID: 20848262 DOI: 10.1007/s00391-010-0132-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
During recent years, specialized wards have been established in geriatric hospital departments as a consequence of the growing need of special care for acutely ill older patients, who are also cognitively impaired. However, there are neither established standards nor any commonly agreed concept of care. A written survey among 12 specialized wards in Germany revealed some characteristics of these wards: extended geriatric assessment, special education of staff including validation and gerontopsychiatric issues, and particular equipment/architecture, such as hidden doors and group rooms, and in some cases loop tracks for walking, therapeutic facilities, and 'living rooms' on the wards. There is a wide variability with respect to the designation of these wards, the number of beds, length of stay, and admission criteria. It appears from this survey that there should be an exchange of empirical experience made on these wards, and there is a need of collaborative research on its usefulness.
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Affiliation(s)
- A Rösler
- Medizinisch-Geriatrische Klinik, Albertinen-Haus, Zentrum für Geriatrie und Gerontologie, Wissenschaftliche Einrichtung an der Universität Hamburg, Sellhopsweg 18-22, 22459 Hamburg.
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Abstract
The psychosocial and psychiatric sequelae of cancer are highly prevalent, diverse, and challenging for clinicians to manage. A growing body of literature has generated methods for the reliable screening, assessment, and management of these sequelae, including the treatment of psychiatric disorders that may complicate the course of cancer. To meet the specific needs of this patient population, psycho-oncologists worldwide have begun to train more and more social workers, psychologists, and psychiatrists who can provide consultative services in support of the psychiatric care of cancer patients and their families at all stages of disease, including cancer survivorship. This review presents an overview of the history of psycho-oncology, common psychological responses to cancer, factors in adapting to cancer, epidemiology, the assessment and management of major psychiatric disorders in cancer patients, cancer-related fatigue, the cognitive effects of cancer and cancer treatment, issues related to the psychosocial care of families (including bereavement), and psychological issues for staff caring for cancer patients.
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van Munster BC, de Rooij SEJA, Yazdanpanah M, Tienari PJ, Pitkälä KH, Osse RJ, Adamis D, Smit O, van der Steen MS, van Houten M, Rahkonen T, Sulkava R, Laurila JV, Strandberg TE, Tulen JHM, Zwang L, MacDonald AJD, Treloar A, Sijbrands EJG, Zwinderman AH, Korevaar JC. The association of the dopamine transporter gene and the dopamine receptor 2 gene with delirium, a meta-analysis. Am J Med Genet B Neuropsychiatr Genet 2010; 153B:648-655. [PMID: 19739106 DOI: 10.1002/ajmg.b.31034] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Delirium is the most common neuropsychiatric syndrome in elderly ill patients. Previously, associations between delirium and the dopamine transporter gene (solute carrier family 6, member 3 (SLC6A3)) and dopamine receptor 2 gene (DRD2) were found. The aim of this study was to validate whether markers of the SLC6A3 and DRD2 genes are were associated with delirium in independent populations. Six European populations collected DNA of older delirious patients. Associations were determined per population and results were combined in a meta-analysis. In total 820 medical inpatients, 185 cardiac surgery patients, 134 non-cardiac surgery patients and 502 population-based elderly subjects were included. Mean age was 82 years (SD 7.5 years), 598 (36%) were male, 665 (41%) had pre-existing cognitive impairment, and 558 (34%) experienced delirium. The SLC6A3 rs393795 homozygous AA genotype was more frequent in patients without delirium in all populations. The meta-analysis showed an Odds Ratio (OR) for delirium of 0.4 (95% confidence interval (C.I.) 0.2-0.6, P = 0.0003) for subjects with AA genotype compared to the AG and GG genotypes. SLC6A3 marker rs1042098 showed no association with delirium. In meta-analysis the DRD2 rs6276 homozygous GG genotype showed an OR of 0.8 for delirium (95% C.I. 0.6-1.1, P = 0.24). When subjects were stratified for cognitive status the rs6276 GG genotype showed ORs of 0.6 (95% C.I. 0.4-1.0, P = 0.06) and 0.8 (95% C.I. 0.5-1.5, P = 0.51) for delirium in patients with and without cognitive impairment, respectively. In independent cohorts, a variation in the SLC6A3 gene and possibly the DRD2 gene were found to protect for delirium.
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Affiliation(s)
- Barbara C van Munster
- Department of Clinical Epidemiology and Biostatistics, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.,Department of Internal Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - Sophia E J A de Rooij
- Department of Internal Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | | | - Pentti J Tienari
- Department of Neurology, Helsinki University Central Hospital and Molecular Neurology Programme, Biomedicum, University of Helsinki, Helsinki, Finland
| | - Kaisu H Pitkälä
- Helsinki University Central Hospital, Unit of General Practice, Helsinki, Finland
| | - Robert J Osse
- Department of Psychiatry, Erasmus MC, Rotterdam, the Netherlands
| | - Dimitrios Adamis
- Psychiatry, Research and Academic Institute of Athens, Athens, Greece
| | - Orla Smit
- Department of Internal Medicine, VU Medical Center, Amsterdam, the Netherlands
| | | | | | - Terhi Rahkonen
- Department of Geriatrics, School of Public Health and Clinical Nutrition, University of Kuopio, Kuopio, Finland
| | - Raimo Sulkava
- Department of Geriatrics, School of Public Health and Clinical Nutrition, University of Kuopio, Kuopio, Finland
| | - Jouko V Laurila
- Helsinki University Central Hospital, Clinics of General Internal Medicine and Geriatrics, Helsinki, Finland
| | | | - Joke H M Tulen
- Department of Psychiatry, Erasmus MC, Rotterdam, the Netherlands
| | - Louwerens Zwang
- Department of Clinical Chemistry, Erasmus MC, Rotterdam, the Netherlands
| | | | | | | | - Aeilko H Zwinderman
- Department of Clinical Epidemiology and Biostatistics, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Johanna C Korevaar
- Department of Clinical Epidemiology and Biostatistics, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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Kuikka LK, Salminen S, Ouwehand A, Gueimonde M, Strandberg TE, Finne-Soveri UH, Sintonen H, Pitkälä KH. Inflammation Markers and Malnutrition as Risk Factors for Infections and Impaired Health-Related Quality of Life Among Older Nursing Home Residents. J Am Med Dir Assoc 2009; 10:348-53. [DOI: 10.1016/j.jamda.2009.02.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2008] [Revised: 02/12/2009] [Accepted: 02/12/2009] [Indexed: 10/20/2022]
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Monitoring Delirium in the ICU. Intensive Care Med 2009. [DOI: 10.1007/978-0-387-92278-2_82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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