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Hauer K, Dutzi I, Werner C, Bauer J, Ullrich P. Delirium Prevention in Early Rehabilitation During Acute Hospitalization and Implementation of Programs Specifically Tailored to Older Patients with Cognitive Impairment: A Scoping Review with Meta-Analysis. J Alzheimers Dis 2024; 97:3-29. [PMID: 38073387 DOI: 10.3233/jad-230644] [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] [Indexed: 01/09/2024]
Abstract
BACKGROUND No systematic review on delirium prevention within early, hospital-based rehabilitation on implementation of approaches specifically tailored for patients with cognitive impairment (PwCI), such as Alzheimer's disease or vascular dementia, has been published despite the high relevance of specific medical care in this vulnerable population. OBJECTIVE To document design and effectiveness of delirium prevention programs by early rehabilitation during acute, hospital-based medical care and implementation of programs specifically tailored to PwCI. METHODS In a three-step approach, we first identified published systematic reviews of hospital-based, early rehabilitation interventions for older persons (>65 years) in relevant databases. In a second step, we screened each single trial of included reviews according to predefined inclusion criteria. In a third step, we analyzed studies with focus on delirium prevention. RESULTS Among n = 25 studies identified, almost all intervention programs did not specifically target cognitive impairment (CI). Interventions were heterogeneous (modules: n = 2-19); almost all study samples were mixed/unspecified for cognitive status with more affected patients excluded. Only one study exclusively included delirium patients, and only one included CI patients. Results of random effect meta-analysis showed significant effects of generic programs to reduce delirium incidence during hospitalization by 41% (p < 0.001, odds ratio, 95% confidence interval: 0.59 [0.49, 0.71] with modest heterogeneity (I2: 30%). CONCLUSIONS Study results document a lack of implementation for delirium prevention programs specifically tailored to PwCI by early, hospital-based rehabilitation. Specifying existing rehab concepts or augmenting them by CI-specific modules may help to develop, optimize, and implement innovative delirium prevention in PwCI in acute medical care.
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Affiliation(s)
- Klaus Hauer
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Heidelberg, Germany
- Robert Bosch Gesellschaft für Medizinische Forschung mbH, Stuttgart, Germany
| | - Ilona Dutzi
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Heidelberg, Germany
| | - Christian Werner
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Heidelberg, Germany
| | - Jürgen Bauer
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Heidelberg, Germany
| | - Phoebe Ullrich
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Heidelberg, Germany
- Department of Thoracic Oncology, Thoraxklinik Heidelberg, Heidelberg University Hospital, Heidelberg, Germany
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Fong TG, Hshieh TT, Tabloski PA, Metzger ED, Arias F, Heintz HL, Patrick RE, Lapid MI, Schmitt EM, Harper DG, Forester BP, Inouye SK. Identifying Delirium in Persons With Moderate or Severe Dementia: Review of Challenges and an Illustrative Approach. Am J Geriatr Psychiatry 2022; 30:1067-1078. [PMID: 35581117 PMCID: PMC10413471 DOI: 10.1016/j.jagp.2022.04.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 04/02/2022] [Accepted: 04/06/2022] [Indexed: 01/25/2023]
Abstract
Delirium and dementia are common causes of cognitive impairment among older adults, which often coexist. Delirium is associated with poor clinical outcomes, and is more frequent and more severe in patients with dementia. Identifying delirium in the presence of dementia, also described as delirium superimposed on dementia (DSD), is particularly challenging, as symptoms of delirium such as inattention, cognitive dysfunction, and altered level of consciousness, are also features of dementia. Because DSD is associated with poorer clinical outcomes than dementia alone, detecting delirium is important for reducing morbidity and mortality in this population. We review a number of delirium screening instruments that have shown promise for use in DSD, including the 4-DSD, combined Six Item Cognitive Impairment Test (6-CIT) and 4 'A's Test (4AT), Confusion Assessment Method (CAM), and the combined UB2 and 3D-CAM (UB-CAM). Each has advantages and disadvantages. We then describe the operationalization of a CAM-based approach in a current ECT in dementia project as an example of modifying an existing instrument for patients with moderate to severe dementia. Ultimately, any instrument modified will need to be validated against a standard clinical reference, in order to fully establish its sensitivity and specificity in the moderate to severe dementia population. Future work is greatly needed to advance the challenging area of accurate identification of delirium in moderate or severe dementia.
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Affiliation(s)
- Tamara G Fong
- Departments of Neurology (TGF, FA), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School (TGF, TTH, FA, EMS, SKI), Boston, MA.
| | - Tammy T Hshieh
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School (TGF, TTH, FA, EMS, SKI), Boston, MA; Department of Medicine (TTH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | - Eran D Metzger
- Departments of Psychiatry (EDM), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Franchesca Arias
- Departments of Neurology (TGF, FA), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School (TGF, TTH, FA, EMS, SKI), Boston, MA
| | - Hannah L Heintz
- Division of Geriatric Psychiatry (HLH, REP, DGH, BPF), McLean Hospital, Harvard Medical School, Belmont, MA
| | - Regan E Patrick
- Division of Geriatric Psychiatry (HLH, REP, DGH, BPF), McLean Hospital, Harvard Medical School, Belmont, MA
| | | | - Eva M Schmitt
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School (TGF, TTH, FA, EMS, SKI), Boston, MA
| | - David G Harper
- Division of Geriatric Psychiatry (HLH, REP, DGH, BPF), McLean Hospital, Harvard Medical School, Belmont, MA
| | - Brent P Forester
- Division of Geriatric Psychiatry (HLH, REP, DGH, BPF), McLean Hospital, Harvard Medical School, Belmont, MA
| | - Sharon K Inouye
- Departments of Medicine (SKI), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School (TGF, TTH, FA, EMS, SKI), Boston, MA
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Dalkin SM, Lhussier M, Kendall N, Atkinson J, Tolman S. Namaste care in the home setting: developing initial realist explanatory theories and uncovering unintended outcomes. BMJ Open 2020; 10:e033046. [PMID: 31974087 PMCID: PMC7045233 DOI: 10.1136/bmjopen-2019-033046] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION The End-of-Life Namaste Care Program for People with Dementia, challenges the misconception that people with dementia are a 'shell'; it provides a holistic approach using the five senses, which can provide positive ways of communicating and emotional responses. It is proposed Namaste Care can improve communication and the relationships families and friends have with the person with dementia. Previously used in care homes, this study is the first to explore the pioneering use of Namaste Care in people's own homes. OBJECTIVE To develop initial programme theories detailing if, how and under which circumstances Namaste Care works when implemented at home. DESIGN A qualitative realist approach following the RAMESES II guidelines was employed to understand not only whether Namaste Care has positive outcomes, but also how these are generated, for whom they happen and in which circumstances. SETTING A hospice in the North East of England, operating in the community, through volunteers. PARTICIPANTS Programme theories were developed from three focus groups with volunteers implementing Namaste Care (n=8; n=8; n=11) and eight interviews with family carers (n=8). RESULTS Four refined explanatory theories are presented: increasing engagement, respite for family carers, importance of matched volunteers and increasing social interaction. It was identified that while Namaste Care achieved some of the same goals in the home setting as it does in the care home setting, it could also function in a different way that promoted socialisation. CONCLUSIONS Namaste Care provides holistic and personalised care to people with both moderate and advanced dementia, improving engagement and reducing social isolation. In the present study carers often chose to use Namaste Care sessions as respite. This was often linked to their frustration of the unavoidable dominance of task-focussed care in daily life. Individualised Namaste Care activities thus led to positive outcomes for both those with dementia and their carers.
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Affiliation(s)
- Sonia Michelle Dalkin
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, Tyne and Wear, UK
- Fuse (The Centre for Translational Research in Public Health), Newcastle Upon Tyne, UK
| | - Monique Lhussier
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, Tyne and Wear, UK
- Fuse (The Centre for Translational Research in Public Health), Newcastle Upon Tyne, UK
| | | | - Joanne Atkinson
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, Tyne and Wear, UK
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Holle CL, Turnquist MA, Rudolph JL. Safeguarding older adults with dementia, depression, and delirium in a temporary disaster shelter. Nurs Forum 2018; 54:157-164. [PMID: 30536416 DOI: 10.1111/nuf.12309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 10/11/2018] [Accepted: 10/28/2018] [Indexed: 11/27/2022]
Abstract
Natural disasters impact people of every age in the communities where they occur, with older adults being a vulnerable subset of the population. Most disaster shelter volunteer nurses are experienced in addressing common health needs of older adult clients such as diabetes, hypertension, and pulmonary disease. These nurses also have the requisite training to respond to more acute medical events, including the symptoms of a heart attack or stroke. They provide care and comfort to those suffering from the distress, anxiety, and fear caused by disasters. However, they may be less adept at triaging and caring for older adults with mental health conditions such as delirium, depression, or dementia. The trauma associated with a disaster and relocation will challenge cognitive abilities in those with dementia, may exacerbate existing depression, or lead to the onset of delirium, which is a medical emergency. Older adults experiencing these conditions are at risk for harm and deterioration with serious short and long-term consequences. Since disaster shelter volunteer health care staff may not be well-versed in distinguishing between dementia, depression, or delirium, behavior observation, and safety considerations are critical determinants of whether it is possible to support the older adult in the shelter environment or it is necessary to transition to a higher level of care.
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Affiliation(s)
- Cynthia L Holle
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, RI
| | - Mary A Turnquist
- Connecticut Department of Mental Health and Addiction Services, Hartford, CT
| | - James L Rudolph
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, RI.,Department of Medicine, Warren Alpert Medical School, Brown University, Providence, RI.,Center of Gerontology and Health Research, Brown University School of Public Health, Providence, RI
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