Risk for Acute Confusion in Sensory-Impaired, Rural, Long-Term-Care Elders

Delirium in Nursing Home Residents: A Narrative Review

Delirium is an important component of the geriatric syndromes and has been recognized to negatively influence the prognosis of older people in hospital and in a post-acute setting. About 2–5% of older people world-wide live in nursing homes and are characterized by functional impairment, cognitive decline, dementia, comorbidities, and polypharmacotherapy, all factors which influence the development of delirium. However, in this setting, delirium remains often understudied. Therefore, in this narrative review, we aimed to describe the latest evidence regarding delirium screening tools, epidemiology characteristics, outcomes, risk factors, and preventions strategies in nursing homes.

Examining Face Validity of Visual Stimuli Used in Preference Assessments for Older Adults With Communication Impairments

PURPOSE

Preference assessment is integral to person-centered treatment planning for older adults with communication impairments. There is a need to validate photographs used in preference assessment for this population. Therefore, this study aimed to establish preliminary face validity of photographs selected to enhance comprehension of questions from the Preferences for Everyday Living Inventory-Nursing Home (PELI-NH) and describe themes in older adults' recommendations for revising photographic stimuli.

METHOD

This qualitative, cognitive interviewing study included 21 participants with an average age of 75 years and no known cognitive or communication deficits. Photographic stimuli were randomized and evaluated across one to two interview sessions. Participants were asked to describe what the preference stimuli represented to them. Responses were scored to assess face validity. Participants were then shown the PELI-NH written prompt and asked to evaluate how well the photograph(s) represented the preference. A semideductive thematic analysis was conducted on interview transcripts to summarize themes in participant feedback.

RESULTS

Forty-six (64%) stimuli achieved face validity criteria without revisions. Six (8%) stimuli achieved face validity after one partial revision. Twenty (28%) stimuli required multiple revisions and reached feedback saturation, requiring team review for finalization. Thematic analysis revealed challenges interpreting stimuli (e.g., multiple meanings) and participant preferences for improving photographs (e.g., aesthetics).

CONCLUSIONS

Cognitive interviewing was useful for improving face validity of stimuli pertaining to personal care topics. Abstract and subjective preferences (e.g., cultural traditions) may be more challenging to represent. This study provides a framework for further testing with older adults with cognitive, communication, and hearing impairments.

Hearing Screening for Residents in Long-Term Care Homes Who Live with Dementia: A Scoping Review

BACKGROUND

Hearing loss is highly prevalent in older adults, particularly among those living with dementia and residing in long-term care homes (LTCHs). Sensory declines can have deleterious effects on functioning and contribute to frailty, but the hearing needs of residents are often unrecognized or unaddressed.

OBJECTIVE

To identify valid and reliable screening measures that are effective for the identification of hearing loss and are suitable for use by nursing staff providing care to residents with dementia in LTCHs.

METHODS

Electronic databases (Embase, Medline, PsycINFO, CENTRAL, and CINAHL) were searched using comprehensive search strategies, and a stepwise approach based on Arksey & O'Malley's scoping review and appraisal process was followed.

RESULTS

There were 193 scientific papers included in the review. Pure-tone audiometry was the most frequently reported measure to test hearing in older adults living with dementia. However, measures including self- or other-reports and questionnaires, review of medical records, otoscopy, and the whisper test were found to be most suitable for use by nurses working with older adults living with dementia in LTCHs.

CONCLUSION

Although frequently used, the suitability of pure-tone audiometry for use by nursing staff in LTCHs is limited, as standardized audiometry presents challenges for many residents, and specific training is needed to successfully adapt test administration procedures and interpret results. The whisper test was considered to be more suitable for use by staff in LTCH; however, it yields a limited characterization of hearing loss. There remains an urgent need to develop new approaches to screen hearing in LTCHs.

Social Engagement, Cognition, Depression, and Comorbidity in Nursing Home Residents With Sensory Impairment

Sensory impairment, explicitly vision and hearing impairment, among nursing home (NH) residents decreases their ability to socially engage. However, it is not known to what extent visual, hearing, or dual impairment is associated with social engagement. The aims of the current retrospective, cross-sectional descriptive study were to determine the relationship between social engagement and (a) levels of sensory impairment (vision, hearing, and dual); (b) depression; and (c) cognition. The authors analyzed baseline data from 213 NH residents with sensory impairment from the I-SEE study. Multivariable model results demonstrated that sensory impairment was not associated with social engagement when adjusting for all covariates. Greater social engagement was associated with less depression, better cognition, and greater comorbidity. Clinicians should be aware of these risks to social engagement in NH residents with sensory impairment and monitor for decreased social engagement and isolation in residents with less comorbidities, higher depression levels, and poorer cognition. [Res Gerontol Nurs. 2019; 12(5):217-226.].

Acceptance and adjustment: A qualitative study of experiences of hearing and vision impairments and daily life among oldest old recipients of home care

INTRODUCTION

The severity of age-related hearing and vision impairments increases with age. Such sensory impairments are risk factors for functional decline, reduced social participation, withdrawal, depression and accidents, and hence they make people vulnerable and adversely affect their quality of life.

AIM

The aim of this study was to explore how the oldest old recipients of home care experience sensory impairments in daily life.

DESIGN

An inductive, descriptive research design was used.

METHOD

Ten recipients of home care with a mean age of 89 years were interviewed in their homes. The study was implemented in accordance with the suggestions from Elo and Kyngäs for inductive content analysis.

FINDINGS

The main theme concerned acceptance and adjustment in daily life. Subcategories concerning the category of reduced hearing were identified as "acceptable though annoying" and "hesitant about using hearing aids." Subcategories concerning the category of reduced vision were "reading is increasingly challenging" and "living with vision diseases." The third category of feeling weak was elucidated in the subcategories "troublesome bodily changes" and "strenuous days with limited energy."

CONCLUSIONS

It is imperative to recognise that the oldest old are in a distinct phase of the lifespan. Despite this population being aware of their hearing and vision impairments, they do not always have the strength to alter the situation. Instead they accept it; they often struggle with more serious health challenges. Therefore, they are not prioritising using their limited energy reserves to try to improve or optimise their hearing and vision impairments themselves.

IMPLICATIONS FOR PRACTICE

The oldest old with sensory impairments cannot be expected to perform all the necessary activities of daily living or address their functional sensory impairments. Close monitoring and assistance need to be applied to the oldest old.

Clinical characteristics associated with the onset of delirium among long-term nursing home residents

Background

Nursing home residents are frail, have multiple medical comorbidities, and are at high risk for delirium. Most of the existing evidence base on delirium is derived from studies in the acute in-patient population. We examine the association between clinical characteristics and medication use with the incidence of delirium during the nursing home stay.

Methods

This is a retrospective cohort study of 1571 residents from 12 nursing homes operated by a single care provider in Ontario, Canada. Residents were over the age of 55 and admitted between February 2010 and December 2015 with no baseline delirium and a minimum stay of 180 days. Residents with moderate or worse cognitive impairment at baseline were excluded. The baseline and follow-up characteristics of residents were collected from the Resident Assessment Instrument-Minimal Data Set 2.0 completed at admission and repeated quarterly until death or discharge. Multivariate logistic regression was used to identify characteristics and medication use associated with the onset of delirium.

Results

The incidence of delirium was 40.4% over the nursing home stay (mean LOS: 32 months). A diagnosis of dementia (OR: 2.54, p < .001), the presence of pain (OR: 1.64, p < .001), and the use of antipsychotics (OR: 1.87, p < .001) were significantly associated with the onset of delirium. Compared to residents who did not develop delirium, residents who developed a delirium had a greater increase in the use of antipsychotics and antidepressants over the nursing home stay.

Conclusions

Dementia, the presence of pain, and the use of antipsychotics were associated with the onset of delirium. Pain monitoring and treatment may be important to decrease delirium in nursing homes. Future studies are necessary to examine the prescribing patterns in nursing homes and their association with delirium.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0733-3) contains supplementary material, which is available to authorized users.

Differential associations between sensory loss and neuropsychiatric symptoms in adults with and without a neurocognitive disorder

BACKGROUND

To investigate the differential associations between sensory loss and neuropsychiatric symptoms among older adults with and without diagnosed neurocognitive disorder.

METHODS

The sample comprised 1,393 adults (52.3% men) aged between 72 and 79 years from a community-based cohort study. There were 213 cases of mild and 64 cases of major neurocognitive disorders. The main outcome was number of informant reported symptoms on the Neuropsychiatric Inventory (NPI). Sensory loss was defined by visual acuity worse the 0.3 logMAR (6/12 or 20/40) and self-reported hearing problems.

RESULTS

Clinically relevant NPI symptoms were reported in 182 (13.1%) participants, but no individual symptom occurred in more than 5% of the total sample. Among participants diagnosed with a major neurocognitive disorder, those with any sensory loss had over three times (95%CI: 1.72-11.78) greater rates of NPI symptoms than those with unimpaired levels of sensory functioning. There were no differences in the number of neuropsychiatric symptoms by type of sensory loss, and no additional risk associated with a dual sensory loss compared to a single sensory loss. There was no evidence of an association between sensory loss and number of neuropsychiatric symptoms among cognitively healthy adults.

CONCLUSIONS

The extent to which this association is the result of underlying neuropathology, unmet need, or interpersonal factors is unclear. These findings have significant implications for dementia care settings, including hospitals and respite care, as patients with sensory loss are at increased risk of neuropsychiatric symptoms and may require additional psychosocial support. Interventions to manage sensory loss and reduce the impact of sensory limitations on neuropsychiatric symptoms are needed.

Deafblindness: a review of the literature

BACKGROUND

Deafblindness or dual sensory loss is a rare condition among young people, but more frequent among older people. Deafblindness is a heterogeneous condition that varies with regard to time of onset and degree of vision and hearing impairment, as well as communication mode, medical aetiology, and number and severity of co-morbidity.

METHOD

We conducted a comprehensive review of public health issues related to deafblindness.

RESULTS

Deafblindness often lead to barriers in language and communication, access to information and social interaction, which can lead to a number of health-related difficulties. Some of the reported consequences are a higher risk of depression, cognitive decline, developmental disorder in children and psychological distress.

CONCLUSIONS

Deafblindness is associated with a number of health-related issues and more knowledge is needed about the impact of dual sensory loss to be able to offer the best support.

Dual sensory loss: development of a dual sensory loss protocol and design of a randomized controlled trial

Background

Dual sensory loss (DSL) has a negative impact on health and wellbeing and its prevalence is expected to increase due to demographic aging. However, specialized care or rehabilitation programs for DSL are scarce. Until now, low vision rehabilitation does not sufficiently target concurrent impairments in vision and hearing. This study aims to 1) develop a DSL protocol (for occupational therapists working in low vision rehabilitation) which focuses on optimal use of the senses and teaches DSL patients and their communication partners to use effective communication strategies, and 2) describe the multicenter parallel randomized controlled trial (RCT) designed to test the effectiveness and cost-effectiveness of the DSL protocol.

Methods/design

To develop a DSL protocol, literature was reviewed and content was discussed with professionals in eye/ear care (interviews/focus groups) and DSL patients (interviews). A pilot study was conducted to test and confirm the DSL protocol. In addition, a two-armed international multi-center RCT will evaluate the effectiveness and cost-effectiveness of the DSL protocol compared to waiting list controls, in 124 patients in low vision rehabilitation centers in the Netherlands and Belgium.

Discussion

This study provides a treatment protocol for rehabilitation of DSL within low vision rehabilitation, which aims to be a valuable addition to the general low vision rehabilitation care.

Trial registration

Netherlands Trial Register (NTR) identifier: NTR2843

Prevalence, presentation and prognosis of delirium in older people in the population, at home and in long term care: a review

OBJECTIVE

The aim of this study is to provide an overview of prevalence, symptoms, risk factors and prognosis of delirium in primary care and institutionalized long-term care.

DESIGN

The method used in this study is a systematic PubMed search and literature review.

RESULTS

The prevalence of delirium in the population among the elderly aged 65+ years is 1-2%. Prevalence rises with age: 10% among a "general" population aged 85+ years. Prevalence rises up to 22% in populations with higher percentages of demented elder. In long-term care, prevalence ranges between 1.4% and 70%, depending on diagnostic criteria and on the prevalence of dementia. There is a significant increase of the risk of delirium with age and cognitive decline in all groups. Concerning prognosis, most studies agree that older people who previously experienced delirium have a higher risk of dementia and a higher mortality rate. Population and long-term care studies show the same tendency.

CONCLUSIONS

Delirium in a non-selected population aged 65+ years is uncommon. However, prevalence rises very quickly in selected older groups. Primary care doctors should be aware of a relatively high risk of delirium among the elderly in long-term care, those older than 85 years and those with dementia.

Providing delirium education for family caregivers of older adults

Using the Knowledge to Action Process, an education session was developed to teach families of older adults about delirium. Seven sessions were held with 16 eligible participants. A significant increase in delirium knowledge was found following education, and many participants believed others should receive similar education. At follow up, most participants were able to recall information related to risk factors and signs of delirium. Families of older adults form a common communication link for their relatives between health care providers across settings; providing education to family caregivers may in part provide a solution to the problem of delirium.

Twelve-month fall outcomes among delirium subtypes

PURPOSE

The purpose of this study was to examine falls as an outcome measure at 12 months for two-group comparison (delirium cases and noncases) and five-group comparison (noncases, hypoactive, hyperactive, mixed delirium cases, and subsyndromal delirium cases).

DESIGN

Three hundred and twenty patients enrolled in the Delirium in Rural Long-Term Care Facilities Study, which examined subjects for delirium during a 28-day surveillance period, were followed longitudinally for fall events for 12 months. Fall events were recorded and data analyzed using date of "first fall" as the referent for statistical analysis.

METHODS

Fall reports were completed for all subjects for 12 months following delirium surveillance. Fall records were reviewed and the number of days until the first fall event was calculated. Data were censored for deaths that occurred during the 12-month period.

FINDINGS

Five group analysis of variance (noncases, hyperactive delirium, hypoactive delirium, mixed delirium, and subsyndromal delirium) showed significant differences in Functional Independence Measure scores (p = .001) and number of medications (p = .001). The percentage of patients who fell was higher in all delirium subtypes than in noncases at 12 months and was statistically significant for subsyndromal subjects. Two patients, one each from the subsyndromal and mixed delirium subtypes, died from injuries sustained during falls.

CONCLUSIONS

Delirium appears to increase the risk for falls.

CLINICAL RELEVANCE

Increased surveillance and fall prevention strategies are needed for patients who experience transient cognitive changes such as delirium and subsyndromal delirium, even after delirium resolution.

Twelve-month mortality among delirium subtypes

This study used data from the Delirium Among the Elderly in Rural Long-Term Care Facilities Study and data from the National Death Index (NDI) to examine mortality among 320 individuals. Individuals were grouped into noncases, subsyndromal cases, hypoactive delirium, hyperactive delirium, and mixed delirium on the basis of scoring using the Confusion Assessment Method (CAM), NEECHAM Scale, Mini-Mental State Examination (MMSE), Clinical Assessment of Confusion-A (CAC-A), and Vigilance A instruments. Risk ratios of mortality using "days of survival" did not reach statistical significance (α = .05) for any subgroup. Underlying cause of death (UCD) using International Classification of Disease, 10th version (ICD-10), showed typical UCD among older adults. There appeared to be clinical differences in UCD between delirium subgroups. Findings supported the conclusion that careful monitoring of patients with delirium and subsyndromal delirium is needed to avoid complications and injuries that could increase mortality.

Dual Sensory Impairment in Older Age

Objectives: Hearing and visual impairments are commonly viewed separately in research and service provision, but they often occur together as dual sensory impairment or DSI in older populations. This article examines the frequency and effects of DSI in older age and notes limitations in the evidence. Methods: Search of electronic databases of published papers. Results: DSI diminishes communication and well-being and can cause social isolation, depression, reduced independence, mortality, and cognitive impairment. Discussion: Although intuitively DSI may be expected to have additional impacts over single sensory impairment, research findings are inconclusive. Services and supports required by people with DSI are simply a combination of those required by people with single vision and hearing loss, taking account of the unique communication difficulties posed by DSI.

Delirium in care homes

Delirium is a distressing but preventable condition associated with increased morbidity and mortality, and significant financial costs. Most research on delirium has focused on high-risk patients in hospitals. Another group also at high risk are residents in care homes for older people. This report reviews the literature on the occurrence, aetiology, outcomes, prevention and treatment of delirium in long-term care. Delirium appears to be common in this setting, with a median point prevalence estimate of 14.2% in studies comparable to the UK. However, there is a paucity of high-quality studies, likely to reflect the difficulty in conducting research in this population and the particular challenges of investigating delirium. Addressing delirium successfully in care homes presents an opportunity to improve care standards and to reduce inequalities in health and social care. Well-designed prospective cohort studies and robust evaluations of interventions to prevent and treat delirium are needed.

Predisposing factors associated with delirium among demented long-term care residents

This was a cross-sectional study to investigate predisposing factors associated with delirium among demented long-term-care residents and to assess the cumulative effect of these factors on the likelihood of having delirium. Of the 155 participants, 109 (70.3%) were found delirious according to the confusion assessment method. Among these individuals, age (OR = 1.07; 95% CI = 1.05-1.10) and severity of dementia (OR = 1.05; 95% CI = 1.03-1.07) were the most associated factors of delirium. The likelihood of being in delirium increased with the number of associated predisposing factors present (OR = 1.67; 95% CI = 1.11-2.51). Associated factors identified were level of functional autonomy, pain, depression, behavioral disturbances, number of medications, dehydration, fever, and malnutrition. Identification of predisposing factors will help nurses in detecting those residents in long-term care settings who are at high-risk for delirium, as well as in designing preventive intervention strategies for delirium, based on these factors.

Educating staff working in long-term care about delirium: the Trojan horse for improving quality of care?

OBJECTIVE

This study aimed to design a multicomponent intervention to improve delirium care in long-term care facilities for older people in the UK and to identify the levers and barriers to its implementation in practice.

METHODS

The research incorporated the theoretical phase and Phase 1 of the Medical Research Council's framework. We designed a multicomponent intervention based on the evidence for effective interventions for delirium and for changing practice. We refined the intervention with input from care home staff and field visits to homes. Our intervention incorporated the following features: targeting risk factors for delirium, a 'delirium practitioner' functioning as a facilitator, an education package for care home staff, staff working groups at each home to identify barriers to improving delirium care and to produce tailored solutions, a local champion identified from the working groups, consultation, liaison with other professionals, and audit or feedback. The delirium practitioner recorded her experiences of delivering the intervention in a contemporaneous log. This was analysed using framework analysis to determine the levers and barriers to implementation.

RESULTS

We introduced a multicomponent intervention for delirium in six care homes in Leeds. Levers to implementation included flexibility, tailoring training to staff needs, engendering pride and ownership amongst staff, and minimising extra work. Barriers included time constraints, poor organization, and communication problems.

CONCLUSION

We were able to design and deliver an evidence-based multicomponent intervention for delirium that was acceptable to staff. The next steps are to establish its feasibility and effectiveness in modifying outcomes for residents of care homes.

Nutritional status and delirium in long-term care elderly individuals

Delirium is physiologically plausible in elderly individuals with a poor nutritional status. We explored body composition, serum protein levels, and delirium in a multicenter long-term care study using bioelectrical impedance analysis (BIA). Estimates from the BIA procedure included the body cell mass and fat-free mass (FFM) of nursing home elderly residents (N = 312). Increased delirium was identified in men and women who were leaner and had lower FFM. Clinical surveillance for delirium in frail elderly individuals with low serum albumin levels and polypharmacy is recommended because of their increased likelihood of having drug toxicities for medications with protein-binding properties.