Prevalence and management of delirium in community dwelling older people with dementia referred to a memory clinic

OBJECTIVE

Our aim was to measure the prevalence of delirium, its clinical features, and outcomes in older patients referred to a memory clinic.

METHODS

A retrospective cohort study of 109 older outpatients with delirium referred to a memory clinic with a home care service. Delirium was diagnosed using the confusion assessment method and dementia with the DSM-5 criteria. We collected information on cognitive and functional status, mortality, institutionalization, and hospitalization during 6 months following the delirium episode.

RESULTS

Delirium prevalence was 3.6%, mostly of hyperactive type. Delirium worsened functional (ADL 2.95 ± 1.95 vs. 2.16 ± 1.84) and cognitive (MMSE 13.88 ± 8.96 vs.11.0 ± 9.49) status after 6 months compared to the baseline. The mortality rate was 29.4%, and 28.3% were admitted to a long-term facility after the episode of delirium. Of these patients, more than half were hospitalized during the follow-up. Of the 109 patients with delirium, 85 were managed at home and 24 were hospitalized. Patients who were hospitalized had more severe behavioral symptoms during the delirium episode. There was no difference in mortality and institutionalization according to the home or hospital management.

CONCLUSIONS

This retrospective cohort study adds novel information to the existing literature of an understudied setting and population. The study supports the need to further investigate the feasibility and efficacy of the hospital at home models for the prevention and management of delirium in a high-risk population.

Occupational therapy in special respite care: a new multicomponent model for challenging behavior in people with dementia

People with dementia experience a cognitive and functional decline and besides Behavioral and Psychological Symptoms (BPSD). BPSD represent the main cause of the dramatic deterioration in the quality of life and stress for patients and their families. BPSD can benefit from psychosocial and environment approach; in particular the tailor made treatment has proved the best results in literature. The intervention of Occupational Therapist (OT) at home (CotiD-Method) and in Nursing Home on elderly people with moderate dementia can improve BPSD. OT is the trigger figure that can understand the intricate relationship between person, environment and occupation that is required for successful task performance. Our prospective cohort study analyzed a sample of 14 People (aged 82±5.88) With moderate-severe (MMSE mean 9.29/30 sd=6.88) Dementia (PWD) and severe BPSD (NPI=31.79±7.62) in a Temporary Special Respite Care (SRC) in Modena. We test how a multi-professional approach and a Personal Care Planning including occupational therapy could be effective in challenging behaviors. The method includes formal and informal caregivers reflecting CotiD method. Our results show that occupational therapy can significantly improve BPSD and quality con life in PWD. The multiprofessional approach permitted to reduce number of psychotropic drugs and also falls. The general positive mood reflects on professionals working in SRC in the sense of improvement,even if not significantly, of psychological load and personal fulfillment. In the same way even formal caregivers who assist PWD at home, learned skills in managing the exacerbation of BPSD.

Insulin-like growth factor-1 (IGF-1): relation with cognitive functioning and neuroimaging marker of brain damage in a sample of hypertensive elderly subjects

IGF-1 decline has been related to age-dependent cognitive impairment and dementia. No study examined IGF-1 levels in subjects with a risk factor for brain damage such as hypertension. We investigated the relationship between IGF-1, cognitive functioning and neuroimaging in a sample of 75 hypertensive elderly subjects aged > 65. Cognitive performance were tested by mini mental state examination (MMSE), Cambridge cognitive examination (CAMDEX-R), and the frontal assessment battery (FAB). Among other indices, free IGF-1 in serum was assayed. The radial width of the temporal horn (rWTH) evaluates medial cerebral temporal lobe atrophy. Significant correlations between IGF-1 levels and both total and sub-domain scores of cognition were found. IGF-1 level was significantly lower in cognitively declined group. The lowest IGF-1 -percentile subgroup was significantly cognitively impaired. A statistically non-significant, but lower IGF-1 level was found in the sub-sample with pathologically wider rWTH. Levels of IGF-1 below 79.4 microg/l are associated with cognitive decline, whereas a level above 118 microg/l seems to be a marker of normal cognitive performance. A decreasing of IGF-1 related to a widening of the rWTH suggests an involvement of this hormone in hippocampus atrophy.

[The noninvasive quantitative evaluation of the acute hemodynamic effects of sublingual and transdermal nitroglycerin in man]

BACKGROUND

Organic nitrates are complex vasodilators: the hemodynamic action of these drugs is different in the venous and arterial resistance and capacitance beds. The aim of our study was to obtain a quantitative, noninvasive evaluation of the acute effects of sublingual and transdermal (td) nitroglycerin (NTG).

METHODS

Twenty-one pts (mean age 49 years) underwent strain-gauge plethysmography and digital photoplethysmography under control conditions, 5 min after sublingual NTG (0.4 mg), 1 hour thereafter and 2 hours after NTG td (10 mg patch). Forearm venous capacitance (CV, ml.100 ml-1) and arteriolar resistance (RA, mmHg.ml-1.100 ml.min) and the b/a ratio of arterial pulse wave (%) were measured.

RESULTS

After sublingual NTG, CV increased (+24%, p < 0.01) and b/a was reduced (-35%, p < 0.01), while heart rate and RA increased (+9% and +36% respectively, both p < 0.01). Two hours after NTG td, CV increase was not statistically significant (+11%, p = 0.056), b/a was reduced (-31%, p < 0.01), heart rate and RA did not change.

CONCLUSIONS

The combined use of plethysmography and digital photoplethysmography is suitable for the evaluation of vasoactive drugs such as nitrates, which have a complex profile of action on arterial and venous beds. By this method we have shown that NTG td 10 mg dilates venous beds to a low extent; this approach will be utilized in future studies aimed at elucidating dose-response and regimen effect of these drugs.