Development of a complex intervention to prevent delirium in older hospitalized patients by optimizing discharge and transfer processes and involving caregivers: A multi-method study

BACKGROUND

Delirium is a common yet challenging condition in older hospitalized patients, associated with various adverse outcomes. Environmental factors, such as room changes, may contribute to the development or severity of delirium. Most previous research has focused on preventing and reducing this condition by addressing risk factors and facilitating reorientation during hospital stay.

OBJECTIVE

We aimed to systematically develop a complex intervention to prevent delirium in older hospitalized patients by optimizing discharge and transfer processes and involving caregivers during and after these procedures. The intervention combines stakeholder and expert opinions, evidence, and theory. This article provides guidance and inspiration to research groups in developing complex interventions according to the recommendations in the Medical Research Council framework for complex interventions.

DESIGN AND METHODS

A stepwise multi-method study was conducted. The preparation phase included analysis of the context and current practice via focus groups. Based on these results, an expert workshop was organized, followed by a Delphi survey. Finally, the intervention was modeled and a program theory was developed, including a logic model.

RESULTS

A complex intervention was developed in an iterative process, involving healthcare professionals, delirium experts, researchers, as well as caregiver and patient representatives. The key intervention component is an 8-point-program, which provides caregivers with recommendations for preventing delirium during the transition phase and in the post-discharge period. Information materials (flyers, handbook, videos, posters, defined "Dos and Don'ts", discharge checklist), training for healthcare professionals, and status analyses are used as implementation strategies. In addition, roles were established for gatekeepers to act as leaders, and champions to serve as knowledge multipliers and trainers for the multi-professional team in the hospitals.

CONCLUSIONS

This study serves as an example of how to develop a complex intervention. In an additional step, the intervention and implementation strategies will be investigated for feasibility and acceptability in a pilot study with an accompanying process evaluation.

TWEETABLE ABSTRACT

Delirium prevention can benefit from optimizing discharge and transfer processes and involving caregivers of older patients in these procedures.

STUDY REGISTRATION

DRKS00017828, German Register of Clinical Studies, date of registration 17.09.2019.

Artificial Intelligence-Based Clinical Decision Support Systems in Geriatrics: An Ethical Analysis

OBJECTIVES

To provide an ethical analysis of the implications of the usage of artificial intelligence-supported clinical decision support systems (AI-CDSS) in geriatrics.

DESIGN

Ethical analysis based on the normative arguments regarding the use of AI-CDSS in geriatrics using a principle-based ethical framework.

SETTING AND PARTICIPANTS

Normative arguments identified in 29 articles on AI-CDSS in geriatrics.

METHODS

Our analysis is based on a literature search that was done to determine ethical arguments that are currently discussed regarding AI-CDSS. The relevant articles were subjected to a detailed qualitative analysis regarding the ethical considerations Supplementary Datamentioned therein. We then discussed the identified arguments within the frame of the 4 principles of medical ethics according to Beauchamp and Childress and with respect to the needs of frail older adults.

RESULTS

We found a total of 5089 articles; 29 articles met the inclusion criteria and were subsequently subjected to a detailed qualitative analysis. We could not identify any systematic analysis of the ethical implications of AI-CDSS in geriatrics. The ethical considerations are very unsystematic and scattered, and the existing literature has a predominantly technical focus emphasizing the technology's utility. In an extensive ethical analysis, we systematically discuss the ethical implications of the usage of AI-CDSS in geriatrics.

CONCLUSIONS AND IMPLICATIONS

AI-CDSS in geriatrics can be a great asset, especially when dealing with patients with cognitive disorders; however, from an ethical perspective, we see the need for further research. By using AI-CDSS, older patients' values and beliefs might be overlooked, and the quality of the doctor-patient relationship might be altered, endangering compliance to the 4 ethical principles of Beauchamp and Childress.

Supporting SURgery with GEriatric Co-Management and AI (SURGE-Ahead): A study protocol for the development of a digital geriatrician

INTRODUCTION

Geriatric co-management is known to improve treatment of older adults in various clinical settings, however, widespread application of the concept is limited due to restricted resources. Digitalization may offer options to overcome these shortages by providing structured, relevant information and decision support tools for medical professionals. We present the SURGE-Ahead project (Supporting SURgery with GEriatric co-management and Artificial Intelligence) addressing this challenge.

METHODS

A digital application with a dashboard-style user interface will be developed, displaying 1) evidence-based recommendations for geriatric co-management and 2) artificial intelligence-enhanced suggestions for continuity of care (COC) decisions. The development and implementation of the SURGE-Ahead application (SAA) will follow the Medical research council framework for complex medical interventions. In the development phase a minimum geriatric data set (MGDS) will be defined that combines parametrized information from the hospital information system with a concise assessment battery and sensor data. Two literature reviews will be conducted to create an evidence base for co-management and COC suggestions that will be used to display guideline-compliant recommendations. Principles of machine learning will be used for further data processing and COC proposals for the postoperative course. In an observational and AI-development study, data will be collected in three surgical departments of a University Hospital (trauma surgery, general and visceral surgery, urology) for AI-training, feasibility testing of the MGDS and identification of co-management needs. Usability will be tested in a workshop with potential users. During a subsequent project phase, the SAA will be tested and evaluated in clinical routine, allowing its further improvement through an iterative process.

DISCUSSION

The outline offers insights into a novel and comprehensive project that combines geriatric co-management with digital support tools to improve inpatient surgical care and continuity of care of older adults.

TRIAL REGISTRATION

German clinical trials registry (Deutsches Register für klinische Studien, DRKS00030684), registered on 21st November 2022.

Artificial neural networks for non-linear age correction of diffusion metrics in the brain

Human aging is characterized by progressive loss of physiological functions. To assess changes in the brain that occur with increasing age, the concept of brain aging has gained momentum in neuroimaging with recent advancements in statistical regression and machine learning (ML). A common technique to assess the brain age of a person is, first, fitting a regression model to neuroimaging data from a group of healthy subjects, and then, using the resulting model for age prediction. Although multiparametric MRI-based models generally perform best, models solely based on diffusion tensor imaging have achieved similar results, with the benefits of faster data acquisition and better replicability across scanners and field strengths. In the present study, we developed an artificial neural network (ANN) for brain age prediction based upon tract-based fractional anisotropy (FA). Consequently, we investigated if this age-prediction model could also be used for non-linear age correction of white matter diffusion metrics in healthy adults. The brain age prediction accuracy of the ANN (R 2 = 0.47) was similar to established multimodal models. The comparison of the ANN-based age-corrected FA with the tract-wise linear age-corrected FA resulted in an R 2 value of 0.90 [0.82; 0.93] and a mean difference of 0.00 [-0.04; 0.05] for all tract systems combined. In conclusion, this study demonstrated the applicability of complex ANN models to non-linear age correction of tract-based diffusion metrics as a proof of concept.

Comparison of delirium detection tools in acute care : A rapid review

Background

Delirium is a frequent psychopathological syndrome in geriatric patients. It is sometimes the only symptom of acute illness and bears a high risk for complications. Therefore, feasible assessments are needed for delirium detection.

Objective and methods

Rapid review of available delirium assessments based on a current Medline search and cross-reference check with a special focus on those implemented in acute care hospital settings.

Results

A total of 75 delirium detection tools were identified. Many focused on inattention as well as acute onset and/or fluctuating course of cognitive changes as key features for delirium. A range of assessments are based on the confusion assessment method (CAM) that has been adapted for various clinical settings. The need for a collateral history, time resources and staff training are major challenges in delirium assessment. Latest tests address these through a two-step approach, such as the ultrabrief (UB) CAM or by optional assessment of temporal aspects of cognitive changes (4 As test, 4AT). Most delirium screening assessments are validated for patient interviews, some are suitable for monitoring delirium symptoms over time or diagnosing delirium based on collateral history only.

Conclusion

Besides the CAM the 4AT has become well-established in acute care because of its good psychometric properties and practicability. There are several other instruments extending and improving the possibilities of delirium detection in different clinical settings.

Supplementary Information

The online version of this article (10.1007/s00391-021-02003-5) contains supplementary material, which is available to authorized users.

A complex intervention to promote prevention of delirium in older adults by targeting caregiver's participation during and after hospital discharge - study protocol of the TRAnsport and DElirium in older people (TRADE) project

Background

Among potentially modifiable risk factors for delirium, transfers between wards, hospitals and other facilities have been mentioned with low evidence. TRADE (TRAnsport and DElirium in older people) was set up to investigate i) the impact of transfer and/or discharge on the onset of delirium in older adults and ii) feasibility and acceptance of a developed complex intervention targeting caregiver’s participation during and after hospital discharge or transfer on cognition and the onset of delirium in older adults.

Methods

The study is designed according to the guidelines of the UK Medical Research Council (MRC) for development and evaluation of complex interventions and comprises two steps: development and feasibility/piloting. The development phase includes i) a multicenter observational prospective cohort study to assess delirium incidence and cognitive decline associated with transfer and discharge, ii) a systematic review of the literature, iii) stakeholder focus group interviews and iv) an expert workshop followed by a Delphi survey. Based on this information, a complex intervention to better and systematically involve family caregivers in discharge and transport was developed. The intervention will be tested in a pilot study using a stepped wedge design with a detailed process and health economic evaluation. The study is conducted at four acute care hospitals in southwest Germany. Primary endpoints are the delirium incidence and cognitive function. Secondary endpoints include prevalence of caregiver companionship, functional decline, cost and cost effectiveness, quality of discharge management and quality of admission management in admitting hospitals or nursing homes. Data will be collected prior to discharge as well as after 3, 7 and 90 days.

Discussion

TRADE will help to evaluate transfer and discharge as a possible risk factor for delirium. In addition, TRADE evaluates the impact and modifiability of caregiver’s participation during patient’s transfer or discharge on delirium incidence and cognitive decline providing the foundation for a confirmatory implementation study.

Trial registration

DRKS (Deutsches Register für klinische Studien) DRKS00017828. Registered on 17th September 2019. Retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02585-0.

Microbial translocation in simian immunodeficiency virus (SIV)-infected rhesus monkeys (Macaca mulatta)

BACKGROUND

Chronic immune activation is a hallmark of HIV infection and has been postulated as major factor in the pathogenesis of AIDS. Recent evidence suggests that activation of immune cells is triggered by microbial translocation through the impaired gastrointestinal barrier.

METHODS

To determine the association between microbial translocation and disease progression, we have retrospectively analyzed microbial products, viral load and markers of immune activation in a cohort of 37 simian immunodeficiency virus-infected rhesus monkeys, divided in two groups with distinct disease courses.

RESULTS

As seen in HIV-infected patients, we found elevated levels of lipopolysaccharide (LPS) in infected animals. However, LPS levels or LPS control mechanisms like endotoxin core antibodies or LPS-binding protein did not differ between groups with different disease progression. In contrast, neopterin, a metabolic product of activated macrophages, was higher in fast progressors than in slow progressors.

CONCLUSION

Our data indicate that translocation of microbial products is not the major driving force of immune activation in HIV infection.

Simulation of the effects of atmospheric turbulence on mid-infrared visibility measurements with the mid-infrared interferometric instrument for the very large telescope interferometer

The mid-infrared interferometric instrument is one of three instruments that will equip the focus of the Very Large Telescope Interferometer. During the design phase of the instrument we made use of a program of simulations to define the constraints imposed by atmospheric turbulence. We present our results for the estimated fringe motion, during a typical sampling time of 100 ms, and for the estimated fringe visibility with and without tip-tilt correction. Our simulations were run assuming an outer scale of turbulence of 25 m against an infinite value as strictly implied by Kolmogorov statistics. The results show that this has positive consequences for our applications, above all as far as fringe motion is concerned. We also take into consideration the effect of background noise on the accuracy of the fringe visibility measurements and the effect of self-fringe tracking, which has been simulated by a linear fringe-tracker algorithm.

Properties of fiber optics for application in astronomical interferometry

We tested such properties of single-mode and multimode fiber optics that are relevant for use in a long-baseline astronomical interferometer, and we give quantitative values for modulation, transmission, and stability of the fiber optics as measured in a Mach-Zehnder interferometer configuration. Only polarization-maintaining single-mode fibers gave satisfying results. Good preservation of modulation and ease of beam combining are strong features of these fibers, whereas the light losses that are due to imperfect coupling may present a serious problem.

Astro 7 zodiacal light uv polychromator and its absolute radiometric calibration

The uv polychromator, flown in 1975 on the Astro 7 zodiacal light rocket experiment, and its absolute radiometric calibration are described. The instrument is essentially a broadband double polychromator with high stray light suppression. The spectral ranges of +/-20-nm width are cenyered at 180 nm, 220 nm, and 260 nm, respectively. The absolute calibration is based on the synchrotron radiation of the Deutsches Elektronen Synchrotron, Hamburg with deuterium lamps as transfer standards.

Stray light suppression in optical space experiments

Measurements of stray light suppression with mirrors, lenses, and baffle systems from four zodiacal light and one noctilucent cloud space experiments are reported. The method used to derive the total stray light suppression from these measurements is given. The predicted residual stray light intensity of about 10(-11) sr(-1) to 10(-10) sr(-1) corresponds to approximately 1% of the zodiacal light intensity and is confirmed by the available inflight results. Therefore accurate photometry of the zodiacal light is possible from a sunlit rocket or satellite.