Ultra-brief Screeners for Detecting Delirium Superimposed on Dementia

[Delirium superimposed on dementia : Early detection and treatment]

BACKGROUND

Delirium superimposed on dementia (DSD) is a widespread but often undetected problem. Additional delirium significantly reduces the quality of life in patients with dementia. Awareness of this condition must be increased among professionals to recognize its development at an early stage, distinguish it from dementia and treat it accordingly.

OBJECTIVE

This review describes the current state of diagnostic, preventive, and therapeutic methods in dealing with DSD.

MATERIAL AND METHODS

A comprehensive literature search was conducted in the PubMed database using the terms "dementia", "delirium", "delirium superimposed on dementia" and "DSD". An additional literature search was performed via Google Scholar.

RESULTS

The diagnostic techniques for detecting DSD are currently limited to delirium-only diagnostic tools, such as the confusion assessment method. A multiprofessional screening of high-risk patients on a regular basis is essential for the early detection and prevention of this disease. An interdisciplinary approach is also required for treatment. Pharmacological therapy is indicated when nonpharmacological measures are insufficient or to treat delirium-inducing causes. The focus lies on the mental and physical care of the patient and on the elimination of risk factors for developing DSD.

CONCLUSION

DSD is a serious syndrome, however, there is still no gold standard for diagnosis and treatment. Multicomponent nonpharmacological intervention programs have been shown to reduce the incidence of delirium. Their benefit in DSD must be verified in large multicenter studies.

Comparative Implementation of a Brief App-Directed Protocol for Delirium Identification by Hospitalists, Nurses, and Nursing Assistants : A Cohort Study

BACKGROUND

Systematic screening improves delirium identification among hospitalized older adults. Little data exist on how to implement such screening.

OBJECTIVE

To test implementation of a brief app-directed protocol for delirium identification by physicians, nurses, and certified nursing assistants (CNAs) in real-world practice relative to a research reference standard delirium assessment (RSDA).

DESIGN

Prospective cohort study.

SETTING

Large urban academic medical center and small rural community hospital.

PARTICIPANTS

527 general medicine inpatients (mean age, 80 years; 35% with preexisting dementia) and 399 clinicians (53 hospitalists, 236 nurses, and 110 CNAs).

MEASUREMENTS

On 2 study days, enrolled patients had an RSDA. Subsequently, CNAs performed an ultra-brief 2-item screen (UB-2) for delirium, whereas physicians and nurses performed a 2-step protocol consisting of the UB-2 followed in those with a positive screen result by the 3-Minute Diagnostic Assessment for the Confusion Assessment Method.

RESULTS

Delirium was diagnosed in 154 of 924 RSDAs (17%) and in 114 of 527 patients (22%). The completion rate for clinician protocols exceeded 97%. The CNAs administered the UB-2 in a mean of 62 seconds (SD, 51). The 2-step protocols were administered in means of 104 seconds (SD, 99) by nurses and 106 seconds (SD, 105) by physicians. The UB-2 had sensitivities of 88% (95% CI, 72% to 96%), 87% (CI, 73% to 95%), and 82% (CI, 65% to 91%) when administered by CNAs, nurses, and physicians, respectively, with specificities of 64% to 70%. The 2-step protocol had overall accuracy of 89% (CI, 83% to 93%) and 87% (CI, 81% to 91%), with sensitivities of 65% (CI, 48% to 79%) and 63% (CI, 46% to 77%) and specificities of 93% (CI, 88% to 96%) and 91% (CI, 86% to 95%), for nurses and physicians, respectively. Two-step protocol sensitivity for moderate to severe delirium was 78% (CI, 54% to 91%).

LIMITATION

Two sites; limited diversity.

CONCLUSION

An app-directed protocol for delirium identification was feasible, brief, and accurate, and CNAs and nurses performed as well as hospitalists.

PRIMARY FUNDING SOURCE

National Institute on Aging.

Prevalence, Risk Factors, and Impact of Delirium on Hospitalized Older Adults With Dementia: A Systematic Review and Meta-Analysis

OBJECTIVES

High prevalence of delirium superimposed on dementia (DSD) was previously reported, with associated negative impact on hospitalized older adults. However, data were conflicting, and no meta-analysis has been conducted. Although dementia is the leading risk factor for delirium, risk factors for DSD have not been adequately studied. This systematic review and meta-analysis aims to elucidate the prevalence, risk factors, and impact of DSD in hospitalized older adults. Comparisons were made between older adults with DSD and persons with dementia alone (PWDs).

DESIGN

Systematic review and meta-analysis.

SETTING AND PARTICIPANTS

Observational studies reporting prevalence, risk factors, or impact of DSD in hospitalized older adults.

METHODS

Database search was conducted till December 2020 in PubMed, Embase, CENTRAL, PsycINFO, CINAHL, Scopus, Web of Science, ProQuest, and OpenGrey for relevant primary and secondary studies. A piloted data collection form was used for data extraction, and methodological quality was assessed using Joanna Briggs Institute critical appraisal checklists. Meta-analyses, with risk ratio and mean differences as effect measures, were performed using random effects model with Review Manager software. Cochran's Q and I² statistics were used to assess heterogeneity, which was investigated using subgroup analyses.

RESULTS

A total of 81 studies were eligible. The pooled prevalence of DSD was 48.9%, with the highest prevalence found in the Americas and orthopedic wards. Risk factors, including nonmodifiable hospital-, illness-, and medication-related factors, were found to precipitate DSD. Patients with DSD had longer length of hospitalization, disclosed worse cognitive and functional outcomes, and a higher risk of institutionalization and mortality than patients with dementia.

CONCLUSIONS AND IMPLICATIONS

These findings suggested high prevalence and detrimental impact of DSD in hospitalized older adults, highlighting a need for early identification, prevention, and treatments. Further research on risk factors of DSD should be conducted as data were sparse and conflicting. Future high-quality studies regarding DSD are warranted to improve knowledge of this common but under-recognized phenomenon.

Delirium awareness day: a portuguese perspective

Delirium is a syndrome characterized by impairment of awareness and inattention, that represents a change from the patient's baseline cognitive functioning. It is triggered by an underlying medical condition, reaching a prevalence of 24.7% in geriatric wards. However, undiagnosed delirium remains a reality among inpatient individuals, with an estimated frequency of 24.1%. The inappropriate knowledge of diagnostic criteria and standard screening tools was pointed out as a relevant contributing factor to this paradigm.

Liaison Psychiatry Services guarantee psychiatric approach and treatment to patients attending general hospitals. Considering that older adult patient care requires a well-trained and skilled team, the Centro Hospitalar e Universitário de Coimbra has a Geriatric Psychiatry Liaison Service, where delirium is one of the prevailing clinical conditions assessed by this team. The International Delirium Awareness Day is going to be worldwide celebrated on the 11th of March. Given that delirium has been consistently associated with the economic burden and adverse outcomes this symbolic day works as a huge opportunity to raise insight into the preventive strategies that could be implemented among healthcare professionals, patients, and caregivers. Within the Portuguese National Health System there is a need to build a set of systematic epidemiological data about delirium prevalence and incidence in the different settings and it would be essential the employment of a multicomponent intervention package delivered by a multidisciplinary team trained and competent in delirium prevention into routine care.

Current Challenges in the Recognition and Management of Delirium Superimposed on Dementia

Delirium occurring in a patient with preexisting dementia is referred to as delirium superimposed on dementia (DSD). DSD commonly occurs in older hospitalized patients and is associated with worse outcomes, including higher rates of mortality and institutionalization, compared to inpatients with delirium or dementia alone. This narrative review summarizes the screening, diagnosis, management, and pathophysiology of DSD and concludes by highlighting opportunities for future research. Studies were identified via Medline and PsycINFO keyword search, and handsearching reference lists. Conceptually, DSD could be considered an "acute exacerbation" of dementia precipitated by a noxious insult akin to an acute exacerbation of heart failure or acute on chronic renal failure. However, unlike other organ systems, there are no established biomarkers for delirium, so DSD is diagnosed and monitored clinically. Because cognitive dysfunction is common to both delirium and dementia, the diagnosis of DSD can be challenging. Inattention, altered levels of arousal, and motor dysfunction may help distinguish DSD from dementia alone. An informant history suggestive of an acute change in cognition or alertness should be investigated and managed as delirium until proven otherwise. The key management principles include prevention, identifying and treating the underlying precipitant(s), implementing multicomponent interventions to create an ideal environment for brain recovery, preventing complications, managing distress, and monitoring for resolution. Informing and involving family members or caregivers throughout the patient journey are essential because there is significant prognostic uncertainty, including the risk of persistent cognitive and functional decline following DSD and relapse. Furthermore, informal carers can provide significant assistance in management. Emerging evidence demonstrates that increased exposure to delirium is associated with neuronal injury and worse cognitive outcomes although the mechanisms through which this occurs remain unclear. Given the clinical overlap between delirium and dementia, studying shared pathophysiological pathways may uncover diagnostic tests and is an essential step in therapeutic innovation.

Delirium: A Marker of Vulnerability in Older People

Delirium is an acute neuropsychiatric syndrome and one of the most common presenting symptoms of acute medical illnesses in older people. Delirium can be triggered by a single cause, but in most cases, it is multifactorial as it depends on the interaction between predisposing and precipitating factors. Delirium is highly prevalent in older patients across various settings of care and correlates with an increased risk of adverse clinical outcomes. Several pathophysiological mechanisms may contribute to its onset, including neurotransmitter imbalance, neuroinflammation, altered brain metabolism, and impaired neuronal network connectivity. Several screening and diagnostic tools for delirium exist, but they are unfortunately underutilized. Additionally, the diagnosis of delirium superimposed on dementia poses a formidable challenge – especially if dementia is severe. Non-pharmacological approaches for the prevention and multidomain interventions for the treatment of delirium are recommended, given that there is currently no robust evidence of drugs that can prevent or resolve delirium. This article aims to review the current understanding about delirium in older people. To achieve this goal, we will describe the epidemiology and outcomes of the syndrome, the pathophysiological mechanisms that are supposed to be involved, the most commonly used tools for screening and diagnosis, and prevention strategies and treatments recommended. This review is intended as a brief guide for clinicians in hospital wards to improve their knowledge and practice. At the end of the article, we propose an approach to improve the quality of care provided to older patients throughout a systematic detection of delirium.

The 4-DSD: A New Tool to Assess Delirium Superimposed on Moderate to Severe Dementia

OBJECTIVES

The purpose of this study was to create, standardize, and validate a new instrument, named 4-DSD, and determine its diagnostic accuracy in the diagnosis of delirium in subjects with moderate to severe dementia.

DESIGN

Multicenter cross-sectional observational study.

SETTING AND PARTICIPANTS

Older patients consecutively admitted to acute and rehabilitation hospital wards.

MEASURES

The DSM-5 was used as the reference standard delirium assessment. The presence and severity of dementia was defined using the AD8 and the Global Deterioration Scale (GDS). The 4-DSD is a 4-item tool that ranges from 0 to 12. Item 1 measures alertness, item 2 altered function, item 3 attention, and item 4 acute change or fluctuation in mental status.

RESULTS

A total of 134 patients were included in the study. Most of the patients were enrolled in acute hospital wards (60%), with 40% in rehabilitation settings. A minority of the patients were categorized with moderate dementia, with a GDS score of 5 (4%). Most of the patients were in the moderate-severe stage with a GDS score ≤6 (77%); 19% were classed as severe, with a GDS score of 7. A 4-DSD cutoff score ≥5 had a sensitivity of 80% and specificity of 80% with a positive predictive value (PPV) of 67% and a negative predictive value (NPV) of 89%. In the subgroup with moderate-severe dementia (n = 108), the sensitivity and the specificity were 79% and 82%, respectively, with a PPV and NPV of 62% and 92%. In the subgroup with severe dementia (n = 26) the sensitivity was 82% and the specificity 56% with a PPV of 78% and a NPV of 63%.

CONCLUSIONS AND IMPLICATIONS

The availability of a specific tool to detect delirium in patients with moderate-severe dementia has important clinical and research implications, allowing all health care providers to improve their ability to identify it.

Ultrabrief Screens for Detecting Delirium in Postoperative Cognitively Intact Older Adults

The authors' sought to develop an ultrabrief screen for postoperative delirium in cognitively intact patients older than 70 years undergoing major elective surgery. All possible combinations of one-, two- and three-item screens and their sensitivities, specificities, and 95% confidence intervals were calculated and compared with the delirium reference standard Confusion Assessment Method (CAM). Among the 560 participants (mean age, 77 years; 58% women), delirium occurred in 134 (24%). We considered 1,100 delirium assessments from postoperative days 1 and 2. The screen with the best overall performance consisted of three items: (1) Patient reports feeling confused, (2) Months of the year backward, and (3) "Does the patient appear sleepy?" with sensitivity of 92% and specificity of 72%. This brief, three-item screen rules out delirium quickly, identifies a subset of patients who require further testing, and may be an important tool to improve recognition of postoperative delirium.

Delirium superimposed on dementia

PURPOSE

Delirium superimposed on dementia (DSD) is a frequent and growing emerging clinical challenge, given the increasing prevalence of dementia.

METHODS

This narrative review focuses on and discusses the current knowledge on epidemiology, pathogenesis, diagnosis and management of DSD.

RESULTS

There is a close interaction between delirium and dementia since dementia is a risk factor for delirium and delirium is a known risk factor for newly developed dementia or worsening of dementia. The occurrence of DSD causes adverse clinical outcomes. However, DSD is often under-recognized or is frequently considered as the regular course of dementia. Indeed, especially in the advance stages of dementia, DSD diagnosis is challenging since a clear distinction between symptoms attributable to delirium and to dementia is difficult. Given the importance of DSD, it is essential to educate health care providers on the best approach for delirium management and treatment. It is now well recognized that delirium can be prevented using multicomponent interventions carried out by a multidisciplinary team targeting predisposing and precipitating risk factors for delirium. On the contrary, antipsychotics should only be used in patients with severe distressing symptoms and whose behavior means their safety or the safety of those around them is compromised, given the harmful of these medications in patients with pre-existing dementia.

CONCLUSIONS

It is essential to improve health care providers knowledge on DSD to improve the quality of care for an epidemiologically relevant though understudied population.