Study protocol for the recreational stimulation for elders as a vehicle to resolve delirium superimposed on dementia (Reserve For DSD) trial

Delirium superimposed on dementia in post-acute care: Nurse documentation of symptoms and interventions

Delirium superimposed on dementia (DSD) is common in older adults being discharged to post-acute care settings (PAC). Nurse documentation remains poorly understood. Aims were to describe nurse documentation and to determine associations in a secondary data analysis of a large, single-blinded randomized controlled trial (Recreational Stimulation For Elders As A Vehicle To Resolve DSD (Reserve For DSD). Just under 75% of the sample had at least one symptom of delirium documented by the nursing staff, while 25.9% had none despite being CAM positive by expert adjudication. Only 32% had an intervention documented. Number of documented interventions were significantly associated with number of documented symptoms. There is a need for research and innovation related to nurse documentation and communication of DSD symptoms and interventions in an efficient and accurate manner to impact care for vulnerable older adults in these settings.

Recreation for Psychosocial Rehabilitation of Clients with Mental Health Disorders: A Retropective Review

Recreation is considered as an important part of rehabilitation as it increases cognitive ability improves social and communication skills among clients with mental health disorders. As part of Psychiatric Rehabilitation Services NIMHANS, weekly recreational activities are conducted for clients with mental health disorders. A retrospective file review of clients' feedback (who participated offline and online) about the recreation session was conducted. Thematic analysis was carried out to analyze the data. Reasons and Benefits of participating in recreation challenges faced, and changes clients would want to bring in the sessions were the themes that emerged. There were differences in the structure of recreation activity conducted in online and offline mode. Overall clients were happy and interested to participate in recreation activities. Recreation should be an integral part of psychosocial rehabilitation for clients with mental health disorders.

Interventions to support recovery following an episode of delirium: A realist synthesis

OBJECTIVES

Persistent delirium is associated with poor outcomes in older adults but little is known about how to support longer-term recovery from delirium. The aim of this review was to identify and synthesise literature to understand mechanisms of recovery from delirium as a basis for designing an intervention that enables more effective recovery.

METHODS

A systematic search of literature relevant to the research question was conducted in two phases. Phase one focused on studies evaluating the efficacy of interventions to support recovery from delirium, and stage two used a wider search strategy to identify other relevant literature including similar patient groups and wider methodologies. Synthesis of the literature followed realist principles.

RESULTS

Phase one identified four relevant studies and stage two identified a further forty-six studies. Three interdependent recovery domains and four recovery facilitators were identified. Recovery domains were 1) support for physical recovery through structured exercise programmes; 2) support for cognitive recovery through reality orientation and cognitive stimulation; 3) support for emotional recovery through talking with skilled helpers. Recovery facilitators were 1) involvement and support of carers; 2) tailoring intervention to individual needs, preferences and abilities; 3) interpersonal connectivity and continuity in relationships and; 4) facilitating positive expressions of self.

CONCLUSIONS

Multicomponent interventions with elements that address all recovery domains and facilitators may have the most promise. Future research should build on this review and explore patients', carers', and professionals' tacit theories about the persistence of delirium or recovery from delirium in order to inform an effective intervention.

Genetic and environmental factors associated with delirium severity in older adults with dementia

OBJECTIVE

To determine (1) whether delirium severity was associated with Apolipoprotein E (APOE) genotype status and occupational complexity, a measure of cognitive reserve, in individuals with delirium superimposed on dementia; and (2) whether decline in delirium severity was associated with these same factors over a post-acute care (PAC) stay.

METHODS

Control group data (n = 142) from a completed randomized clinical trial were used to address the aims of the study. Delirium severity was calculated by combining items from the Confusion Assessment Method and the Montreal Cognitive Assessment. APOE ε4 carriers versus non-carriers were considered. Occupational complexity, a measure of cognitive reserve, was derived from the Lifetime of Experiences Questionnaire. Covariates examined included age, gender, education, Clinical Dementia Rating Scale, and the Charlson comorbidity score. Data were nested (i.e., days nested within persons) and analyzed using multilevel models.

RESULTS

The presence of an APOE ε4 allele and higher Clinical Dementia Rating Scale were associated with greater delirium severity at baseline. The presence of an APOE ε4 allele was also associated with greater delirium severity averaged across the PAC stay. Occupational complexity was not associated with baseline delirium severity or average daily delirium severity; however, individuals with low occupational complexity showed a significant decreased in delirium severity during the course of their PAC stay.

CONCLUSIONS

Individual differences, including genetic factors and level of cognitive reserve, contribute to the severity of delirium in older adults with dementia. Copyright © 2016 John Wiley & Sons, Ltd.

Delirium in elderly patients: association with educational attainment

OBJECTIVE

Among cognitive reserve markers, educational attainment is the most widely studied, with several studies establishing a strong association with risk of dementia. However, it has not yet been fully examined in delirium. This study aims to analyse the relationship between educational attainment and delirium.

METHODS

The study included elderly hospitalised patients admitted (≥48 h) into an intermediate care unit (IMCU) of Intensive Care Medicine Service. Exclusion criteria were as follows: Glasgow Coma Scale (total≤11), blindness/deafness, inability to communicate or to speak Portuguese. The European Portuguese Version of the Confusion Assessment Method (CAM) was used for delirium assessment.

RESULTS

The final sample (n=157) had a mean age of 78.8 (SD=7.6) the majority being female (52.2%), married (51.5%) and with low educational level (49%). According to CAM, 21% of the patients had delirium. The delirium group presented the fewest years of education (median 1 vs. 4), with statistical significance (p=0.003). Delirium was more frequent among male patients [odds ratio (OR) 0.32; 95% confidence interval (CI) 0.12-0.86; p=0.023], as well as those patients with lower education (OR 0.76; 95% CI 0.62-0.95; p=0.016), and with respiratory disease (OR 3.35; 95% CI 1.20-9.33; p=0.020), after controlling for age and medication.

CONCLUSION

Similar to previous studies, these findings point to a negative correlation between education and delirium. This study appears as an attempt to contribute to the knowledge about the role of cognitive reserve in risk of delirium, particularly because is the first one that has been carried out in an IMCU, with lower educated elderly patients. Further studies are needed to clarify this relationship considering other markers (e.g. cognitive activities), which can contribute to the definition of preventive strategies.

Anticholinergic Exposure During Rehabilitation: Cognitive and Physical Function Outcomes in Patients with Delirium Superimposed on Dementia

OBJECTIVES

We examined the association between anticholinergic medication exposure and subsequent cognitive and physical function in patients with delirium superimposed on dementia during rehabilitation. We also examined length of stay and discharge disposition by anticholinergic medication exposure.

DESIGN

In this secondary analysis we used control group data from an ongoing randomized clinical trial.

SETTING/PARTICIPANTS

Participants with delirium and dementia were enrolled at admission to post-acute care. These 99 participants had a mean age of 86.11 (±6.83) years; 67.6% were women; 98% were Caucasian; and 33% were positive for at least one APOE e4 allele.

MEASURES

We obtained daily measures of cognitive and physical function using: Digit Span; memory, orientation and attention items from the Montreal Cognitive Assessment; CLOX; the Confusion Assessment Method; and the Barthel Index. Anticholinergic medication exposure was measured weekly using the Anticholinergic Cognitive Burden Scale.

RESULTS

Using multilevel models for time we found that greater use of clinically relevant anticholinergic medications in the previous week reduced cognitive and physical function, as measured by Digit Span Backwards and the Barthel index, in the current week. There was no effect of anticholinergic medication use on delirium severity, and APOE status did not moderate any outcomes. Greater use of clinically relevant anticholinergic medications was related to longer length of stay but not discharge disposition.

CONCLUSIONS

For vulnerable older adults, anticholinergic exposure represents a potentially modifiable risk factor for poor attention, working memory, physical function, and greater length of stay during rehabilitation.

Licensed Nurse and Nursing Assistant Recognition of Delirium in Nursing Home Residents With Dementia

Many nursing home residents experience delirium. Nursing home personnel, especially nursing assistants, have the opportunity to become familiar with residents' normal cognitive function and to recognize changes in a resident's cognitive function over time. The purpose of this study was to determine the accuracy of delirium recognition by licensed nurses and nursing assistants from eight nursing homes over a 12-month period. Participants were asked to complete five case vignette assessments at three different time points (in 6-month intervals) to test their ability to identify different subtypes of delirium and delirium superimposed on dementia (DSD). A total of 760 case vignettes were completed across the different time points. Findings reveal that staff recognition of delirium was poor. The case vignette describing hyperactive DSD was correctly identified by the greatest number participants, and the case vignette describing hypoactive DSD was correctly identified by the least number of participants. Recognition of the case vignette describing hypoactive delirium improved over time. Nursing assistants performed similarly to the licensed nurses, indicating that all licensed nursing home staff require further education to correctly recognize delirium in older adults.

Using Standardized Case Vignettes to Evaluate Nursing Home Staff Recognition of Delirium and Delirium Superimposed on Dementia

The purpose of this study is to describe nursing home staff knowledge regarding delirium detection and the most common causes of delirium. Specific aims that guided this study include identifying the rate of nurse recognition of delirium and delirium superimposed on dementia (DSD), including different motoric subtypes of delirium, using standardized case vignettes, and exploring what nursing home staff describe as the potential causes of delirium. The study showed overall poor recognition of delirium and DSD, which did not improve over time. Interventions have the potential to increase the early detection of delirium and DSD by the staff and warrant development.

The triple challenge of recruiting older adults with dementia and high medical acuity in skilled nursing facilities

PURPOSE

To describe strategies, culled from experience, for responding to several recruitment challenges in an ongoing randomized clinical trial of delirium in persons with dementia.

ORGANIZING CONSTRUCT

Delirium in people with dementia is common across all cultures. Little research supports the use of specific interventions for delirium. Recruitment of an adequate sample is critical to the validity of findings from intervention studies that form the foundation for evidence-based practice.

METHODS

The trial referenced in this article tests the efficacy of cognitive stimulation for resolving delirium in people with dementia. Participants are recruited at the time of admission to one of eight community-based skilled nursing facilities (SNFs). Eligible participants are 65 years of age or older and community dwelling, and have a diagnosis of dementia and delirium. Recruitment challenges and strategies were identified during weekly team meetings over a 2-year period.

FINDINGS

Recruitment challenges include factors in the external and internal environment and the participants and their families. Strategies that address these challenges include early site evaluation and strong communication approaches with staff, participants, and families.

CONCLUSIONS

The recruitment of an adequate sample of acutely ill older adults with dementia in SNFs can pose a challenge to investigators and threaten the validity of findings. Recruitment strategies that help improve the validity of future studies are described.

CLINICAL RELEVANCE

Worldwide, over 100 million people will have dementia by 2050, placing them at increased risk for delirium. Recruitment strategies that improve the quality of nursing research and, by extension, the care and prevention of delirium in older adults with dementia during rehabilitation in SNFs are greatly needed.

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

BACKGROUND

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

AIM

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

DESIGN

Qualitative, pilot study.

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS FOR PRACTICE

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

Practical Protocol for Implementing Cognitive Stimulation in Persons with Delirium Superimposed on Dementia

Delirium is common in persons with dementia and often accompanies acute medical or surgical conditions. These individuals are at risk for an accelerated decline in their cognitive and physical function. For this reason, interventions that help resolve delirium are critically needed. We have developed a non-pharmacological intervention for delirium in persons with dementia based on our prior interdisciplinary work on delirium, dementia and cognitive stimulation. The intervention uses recreational activities that are alerting, capture attention, and provide cognitive stimulation that encourages cognitive processing in support of cognitive function. In this paper we describe the practical protocol we have developed for implementing these activities, and present a video that will enhance treatment fidelity for studies that replicate the approach.