Multidisciplinary team interventions for delirium in patients with chronic cognitive impairment

Patient Profile and Management of Delirium in Older Adults Hospitalized Due to COVID-19

SARS-CoV-2 can cause neurologic symptoms, as well as respiratory ones. Older adults are at risk of developing acute delirium in older persons (ADOP). The combination of experiencing respiratory isolation due to COVID-19, as well as other associated risk factors for older adults, may have had an impact on ADOP and ADOP management in the acute hospital setting. This study aimed to analyze the characteristics of ADOP in patients admitted to a COVID-19 unit. An observational prospective study on a sample of 108 patients was carried out between November 2020 and May 2021. The following data were collected: sociodemographic characteristics, risk factors for ADOP, management of ADOP, and impact on ADOP on both functional and cognitive deterioration. A 29.6% proportion of older adults admitted to an acute COVID-19 unit presented hyperactive ADOP, mainly during the night. Management of ADOP in our sample involved mainly pharmacological treatment and had a serious impact on hospital stay and both functional and cognitive deterioration. Preventive strategies and being accompanied by a relative or a carer may be useful to manage ADOP during hospital admission due to COVID-19.

Delirium in hospitalized patients: implications of current evidence on clinical practice and future avenues for research--a systematic evidence review

BACKGROUND

Despite the significant burden of delirium among hospitalized adults, critical appraisal of systematic data on delirium diagnosis, pathophysiology, treatment, prevention, and outcomes is lacking.

PURPOSE

To provide evidence-based recommendations for delirium care to practitioners, and identify gaps in delirium research.

DATA SOURCES

Medline, PubMed, the Cochrane Library, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) information systems from January 1966 to April 2011.

STUDY SELECTION

All published systematic evidence reviews (SERs) on delirium were evaluated.

DATA EXTRACTION

Three reviewers independently extracted the data regarding delirium risk factors, diagnosis, prevention, treatment, and outcomes, and critically appraised each SER as good, fair, or poor using the United States Preventive Services Task Force criteria.

DATA SYNTHESIS

Twenty-two SERs graded as good or fair provided the data. Age, cognitive impairment, depression, anticholinergic drugs, and lorazepam use were associated with an increased risk for developing delirium. The Confusion Assessment Method (CAM) is reliable for delirium diagnosis outside of the intensive care unit. Multicomponent nonpharmacological interventions are effective in reducing delirium incidence in elderly medical patients. Low-dose haloperidol has similar efficacy as atypical antipsychotics for treating delirium. Delirium is associated with poor outcomes independent of age, severity of illness, or dementia.

CONCLUSION

Delirium is an acute, preventable medical condition with short- and long-term negative effects on a patient's cognitive and functional states.

Care coordination for cognitively impaired older adults and their caregivers

Dementia and delirium, the most common causes of cognitive impairment (CI) among hospitalized older adults, are associated with higher mortality rates, increased morbidity and higher health care costs. A growing body of science suggests that these older adults and their caregivers are particularly vulnerable to systems of care that either do not recognize or meet their needs. The consequences can be devastating for these older adults and add to the burden of hospital staff and caregivers, especially during the transition from hospital to home. Unfortunately, little evidence exists to guide optimal care of this patient group. Available research findings suggest that hospitalized cognitively impaired elders may benefit from interventions aimed at improving care management of both CI and co-morbid conditions but the exact nature and intensity of interventions needed are not known. This article will explore the need for improved transitional care for this vulnerable population and their caregivers.

Delirium: The clinical concept

Delirium is a common syndrome complicating terminal illness. It is underrecognized partly because it is a difficult clinical concept. Consciousness, awareness, alertness, arousal, awakeness, vigilance, and attention are some of the terms used to describe the deficits occurring in delirium. Though interconnected, they are often loosely defined. Alertness is the primary impairment, and attentional deficits are objective clinical indices of the cognitive impairments of delirium. Simple bedside assessments of delirium are considered. The “deliriant” threshold and the symptomatic fluctuations of delirium are important concepts in the understanding of delirium. Jackson's conceptualization of the nervous system is relevant to delirium. Raising the deliriant threshold by multicomponent interventions is the intent of the palliative management of terminal delirium.

Incomplete functional recovery after delirium in elderly people: a prospective cohort study

BACKGROUND

Delirium often has a poor outcome, but why some people have incomplete recovery is not well understood. Our objective was to identify factors associated with short-term (by discharge) and long-term (by 6 month) incomplete recovery of function following delirium.

METHODS

In a prospective cohort study of elderly patients with delirium seen by geriatric medicine services, function was assessed at baseline, at hospital discharge and at six months.

RESULTS

Of 77 patients, vital and functional status at 6 months was known for 71, of whom 21 (30%) had died. Incomplete functional recovery, defined as > or =10 point decline in the Barthel Index, compared to pre-morbid status, was present in 27 (54%) of the 50 survivors. Factors associated with death or loss of function at hospital discharge were frailty, absence of agitation (hypoactive delirium), a cardiac cause and poor recognition of delirium by the treating service. Frailty, causes other than medications, and poor recognition of delirium by the treating service were associated with death or poor functional recovery at 6 months.

CONCLUSION

Pre-existing frailty, cardiac cause of delirium, and poor early recognition by treating physicians are associated with worse outcomes. Many physicians view the adverse outcomes of delirium as intractable. While in some measure this might be true, more skilled care is a potential remedy within their grasp.

Clinical pharmacology of old age syndromes

Several syndromes occur in old age. They are often associated with increased mortality and in all there is a paucity of basic and clinical research. The recent developments in the clinical pharmacology of three common syndromes of old age (delirium, urinary incontinence, and falls) are discussed along with directions for future research.

Rehabilitation practice: challenges to effective team working

Effective rehabilitation depends on multiple inputs from a variety of skilled multi-professional team members. This paper explores perceptions of the nurse's role within the multi-professional rehabilitation team and challenges for effective team working. It draws on findings from a 2-year qualitative study exploring the role of the nurse within rehabilitation. Substantial differences in the nurse's role were evident, depending on their and others' perceptions, especially in relation to the nurse's carry-on role. Many nurses felt their contributions were not valued and others desired greater reciprocity within the team. Blurring of role boundaries could bring benefits to clients but also led to professional tensions and rivalry.