Barbara Kamholz

Vulnerability: The Crossroads of Frailty and Delirium

Frailty and delirium, although seemingly distinct syndromes, both result in significant negative health outcomes in older adults. Frailty and delirium may be different clinical expressions of a shared vulnerability to stress in older adults, and future research will determine whether this vulnerability is age related, pathological, genetic, environmental, or most likely, a combination of all of these factors. This article explores the clinical overlap of frailty and delirium, describes possible pathophysiological mechanisms linking the two, and proposes research opportunities to further knowledge of the interrelationships between these important geriatric syndromes. Frailty, a diminished ability to compensate for stressors, is generally viewed as a chronic condition, whereas delirium is an acute change in attention and cognition, but there is a developing literature on transitions in frailty status around acute events, as well as on delirium as a chronic, persistent condition. If frailty predisposes an individual to delirium, and delirium delays recovery from a stressor, then both syndromes may contribute to a downward spiral of declining function, increasing risk, and negative outcomes. In addition, frailty and delirium may have shared pathophysiology, such as inflammation, atherosclerosis, and chronic nutritional deficiencies, which will require further investigation. The fields of frailty and delirium are rapidly evolving, and future research may help to better define the interrelationship of these common and morbid geriatric syndromes. Because of the heterogeneous pathophysiology and presentation associated with frailty and delirium, typical of all geriatric syndromes, multicomponent prevention and treatment strategies are most likely to be effective and should be developed and tested.

Recorded delirium in a national sample of elderly inpatients: potential implications for recognition.

This retrospective study examined delirium and related confusional diagnoses recorded in patients older than age 60 discharged from Veterans Affairs (VA) acute inpatient units nationally in 1996 (n = 267,947). Only 4% of patients had delirium or related confusional diagnoses recorded. Patients with recorded delirium had significantly higher mortality than did those without recorded delirium or those with other confusional diagnoses (“organic psychoses”); the most common delirium types were dementia with delirium and alcohol intoxication/withdrawal delirium. Organic psychoses patients had the longest lengths of stay and significantly more admissions to nonmedical/surgical units and discharges to nursing homes; almost 20% were African American. The recorded rate of delirium in the VA health system likely underestimates true prevalence and possibly reflects nonrecognition of delirium in many older veterans. Certain motoric and etiologic types of delirium may be more commonly diagnosed and recorded. Future research should prospectively examine recognition of motoric and etiologic delirium subtypes and racial differences in delirium diagnoses. (J Geriatr Psychiatry Neurol 2003; 16:32-38)

Consensus and variations in opinions on delirium care: a survey of European delirium specialists

Background: There are still substantial uncertainties over best practice in delirium care. The European Delirium Association (EDA) conducted a survey of its members and other interested parties on various aspects of delirium care. Methods: The invitation to participate in the online survey was distributed among the EDA membership. The survey covered assessment, treatment of hyperactive and hypoactive delirium, and organizational management. Results: A total of 200 responses were collected (United Kingdom 28.6%, Netherlands 25.3%, Italy 15%, Switzerland 9.7%, Germany 7.1%, Spain 3.8%, Portugal 2.5%, Ireland 2.5%, Sweden 0.6%, Denmark 0.6%, Austria 0.6%, and others 3.2%). Most of the responders were doctors (80%), working in geriatrics (45%) or internal medicine (14%). Ninety-two per cent of the responders assessed patients for delirium daily. The most commonly used assessment tools were the Confusion Assessment Method (52%) and the Delirium Observation Screening Scale (30%). The first-line choice in the management of hyperactive delirium was a combination of non-pharmacological and pharmacological approaches (61%). Conversely, non-pharmacological management was the first-line choice in hypoactive delirium (67%). Delirium awareness (34%), knowledge (33%), and lack of education (13%) were the most commonly reported barriers to improving the detection of delirium. Interestingly, 63% of the responders referred patients after an episode of delirium to a follow-up clinic. Conclusions: This is the first systematic survey involving an international group of specialists in delirium. Several areas of lack of consensus were found. These results emphasise the importance of further research to improve care of this major unmet medical need.

The Diagnosis of Delirium Superimposed on Dementia: An Emerging Challenge

Delirium occurring in patients with dementia is referred to as delirium superimposed on dementia (DSD). People who are older with dementia and who are institutionalized are at increased risk of developing delirium when hospitalized. In addition, their prior cognitive impairment makes detecting their delirium a challenge. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision are considered the standard reference for the diagnosis of delirium and include criteria of impairments in cognitive processes such as attention, additional cognitive disturbances, or altered level of arousal. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision does not provide guidance regarding specific tests for assessment of the cognitive process impaired in delirium. Importantly, the assessment or inclusion of preexisting cognitive impairment is also not addressed by these standards. The challenge of DSD gets more complex as types of dementia, particularly dementia with Lewy bodies, which has features of both delirium and dementia, are considered. The objective of this article is to critically review key elements for the diagnosis of DSD, including the challenge of neuropsychological assessment in patients with dementia and the influence of particular tests used to diagnose DSD. To address the challenges of DSD diagnosis, we present a framework for guiding the focus of future research efforts to develop a reliable reference standard to diagnose DSD. A key feature of a reliable reference standard will improve the ability to clinically diagnose DSD in facility-based patients and research studies.

Delirium: a strategic plan to bring an ancient disease into the 21st century.

Hippocrates described delirium in the fourth century BC and Marcus Aurelius Antoninus in the second century AD. Since then (and probably beforehand), delirium has continued to plague ill and vulnerable people with morbidity and mortality. In the past 20 years, the science of delirium has greatly expanded, with better methods for diagnosis, risk identification, and prevention, but important areas such as risk modification, early recognition and treatment strategies, pathophysiology, and neuropsychology remain underdeveloped, underfunded, and understudied. Most importantly, clinical implementation of delirium programs is trailing scientific understanding, so delirium continues to affect more older adults than need be. As the country and world face the impending “age wave,” the prevalence of age-related diseases is likely to increase. For example, the Alzheimer’s Association predicts that the number of cases of Alzheimer’s disease will nearly double by 2050. Because delirium is more likely to occur in hospitalized older adults with cognitive impairment, it is safe to assume that delirium incidence and prevalence will increase in the future as well. The Centers for Medicare and Medicaid Services predicts that expenditures for hospitalization will nearly double over the next 10 years, exceeding

Delirium superimposed on dementia: a survey of delirium specialists shows a lack of consensus in clinical practice and research studies

1.3 trillion annually, in part because of the aging of the population. The cost of delirium to the healthcare system is estimated to be between

DEPRESSION AFTER HIP FRACTURE

38 billion and

Preliminary Data from the Caring for Older Adults and Caregivers at Home (COACH) Program: A Care Coordination Program for Home‐Based Dementia Care and Caregiver Support in a Veterans Affairs Medical Center

152 billion annually, in addition to patient costs in terms of compromised functional and cognitive performance. Advances in prevention and treatment and improved care for individuals with delirium are needed to minimize the morbidity, mortality, and healthcare costs associated with delirium. Delirium is a geriatric syndrome characterized by an acute change in mental status. As a geriatric syndrome, delirium does not have a single causal pathway, but instead has many predisposing and precipitating factors and therefore multiple presentations, treatments, and prevention strategies. Thus, many individuals who are focused on the patient (e.g., patients, caregivers, nurses, nursing assistants, social workers, rehabilitation staff, providers, and physicians) working together as a healthcare team can best provide optimal care for individuals who are vulnerable to delirium. The growing paradigm shift to patient-focused models of care suggests new possibilities for more effectively using current knowledge of delirium risk and presentation to modify the healthcare delivery environment with the goal of decreasing the incidence of this highly prevalent and costly syndrome. The purpose of this article is to offer a framework for improving the care of individuals with delirium. Even as we recognize progress in delirium science, the field is early in its development, and much more work is required to minimize the effect of delirium on individuals and the healthcare system. Our framework therefore begins by outlining the goals for delirium progress in education, research, quality improvement, policy, and implementation science necessary to bring delirium care into this century. Following the goals are examples of steps that may be required to achieve the goals. The critical underlying principle is that the individual (and caregiver) bears the burdens of delirium and the consequences thereafter. Therefore, the focus of this framework is to put the individual at the forefront of all recommendations by focusing on improving the delivery of clinical care. From the Geriatric Research, Education, and Clinical Center, Veterans Affairs Boston Healthcare System, Boston, Massachusetts; Regenstrief Institute, Indiana University Center for Aging Research, Indianapolis, Indiana; Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina; Geriatric Research, Education, and Clinical Center, Veterans Affairs Baltimore Medical Center, Baltimore, Maryland; and Office of Geriatrics and Extended Care, Veterans Health Administration, Washington, District of Columbia.

THE MENTAL STATUS VITAL SIGN

BACKGROUND Despite advances in delirium knowledge and the publication of best practice guidelines, uncertainties exist regarding assessment of Delirium Superimposed on Dementia (DSD). An international survey of delirium specialists was undertaken to evaluate current practice. METHODS Invitations to participate in an online survey were distributed by email among members of four international delirium associations with additional publication on their websites. The survey covered the assessment and diagnosis of DSD in clinical practice and research studies. Questions were structured around current practice and attitudes. RESULTS The 205 responders were mostly confident that they could detect DSD with 60% rating their confidence at 7 or above on a likert scale of 0 (none) to 10 (excellent). Seventy-six percent felt that Dementia with Lewy Bodies (DLB) was the most challenging dementia subtype in which to diagnose DSD. Several scales were used to assess for the presence of DSD including the Confusion Assessment Method (CAM) (54%), DSM-5 criteria (25%) and CAM-ICU (15%). Responders stated that attention (71%), fluctuation in cognitive status (65%), and arousability (41%) were the most clinically useful features to assess when diagnosing DSD. Motor fluctuations were also deemed important but 61% had no specific test to monitor these. CONCLUSIONS The largest survey of DSD practice to date demonstrates that despite good levels of confidence in recognizing DSD, there exists a lack of consensus concerning assessment and diagnosis globally. These findings suggest the need for the development of more research leading to precise diagnostic criteria and comprehensive guidelines regarding the assessment and diagnosis of DSD.

Progress in Delirium

Two reports in this edition of the Journal of the American Geriatrics Society (JAGS) address the incidence, prevention, and treatment of depression after hip fracture, which has been reported over the wide range of 9% to 47%. Although prevalence rates of depression in older adults with hip fractures seem similar to rates in other comorbid medical disorders, it is clear that these two prominent medical conditionsFdepression and hip fractureFaccount for a significant amount of morbidity and mortality in the elderly population and that depression in this context carries a significant risk of poorer outcomes or mortality. Even without depression, only 20% of hip fracture patients return to their preoperative functional level after hip repair. Recent data from the National Health and Nutrition Examination Survey suggest that depression is associated with a greater risk of hip fracture, with a hazard ratio of 1.9. Depression has also been associated with a greater risk of falls; 30% to 60% of community-dwelling older patients and 43% of institutionalized older persons fall each year. In institutionalized persons, 50% of fractures involve the hip, and 96% of hip fractures involve a fall. Data summarized in the American Geriatrics Society guidelines suggest that depression confers a higher mean relative risk for falls (2.2) than cognitive impairment (1.8) or age of 80 and older (1.7), which are far less modifiable. Depression is a highly disabling condition in itself, and when it is associated with significant medical illness, it can have a profound effect on capacity to recover. Depression also affects patients’ daily function, their ability to sustain social networks and their quality of life and mortality from other causes. Poor physical function, such as during the prolonged recovery from a fracture, can predispose to depression. In turn, depressive symptoms and cognitive impairment have been associated with poorer participation in rehabilitation. Recovery from falls is often associated with risk for institutional placement, partly due to fear of further injury. Persons suffering hip fracture who had few depressive symptoms were three times as likely to achieve independence in walking and nine times as likely to return to their prior level of function. It appears that this is a specific effect of depression itself, not the effect of depression on related psychosocial factors. In another study, patients with high positive affect had better performance-based functioning after hip fracture. Thankfully, depression is a relatively modifiable condition no matter whether it is a cause or result of disability, but until now, there have been no studies identifying predictors of depression post hip fracture and none that address methods of prevention and intervention. As reported in this issue of JAGS, Dr. Lenze and his coworkers carefully examined clinical and demographic variables associated with the development of depression after hip fracture. They found that 18 of 126 (14%) elderly hip fracture patients in a large urban hospital developed major depression (MDD). The majority (61%) of these patients had the onset of MDD before discharge from the hospital, and no new cases of MDD were identified after 14 weeks until study termination at 26 weeks. Features of the injury itself, such as type or location of fracture, degree of disability at discharge, and type of surgery were not associated with the development of MDD; apathy was the only variable significantly associated with developing MDD in this study, giving us only limited clinical guidance for the treatment of patients at risk for developing depression after a hip fracture. In another publication Dr. Lenze reported an association between hip fracture, depression, and the 5-HTTLPR genotype. More research is needed to help identify patients at high risk for depression after hip fracture. The treatment and prevention of depression in the context of hip fracture have also received little attention. Dr. Burns and his coworkers report here a pioneering study of structured nurse-led interventions to treat and prevent depression in patients with hip fractures. The study confirms high rates of depression in this population, but the results of the interventions tested are largely disappointing. Although more depressed patients improved in the intervention group (52%) than in the controls (34%), and fewer intervention patients (6%) developed depression than control patients (16%), these differences were not statistically significant. The two interventions also did not improve length of stay, functional outcomes, or pain. Given the relatively low incidence rates of depression observed, the authors may have had limited statistical power to identify a significant difference in their prevention study. Finally, the low participation rate in this trial (49%) suggests how difficult it can be to implement interventions for such a frail and vulnerable population. It has become well known that depression can complicate recovery from common medical illnesses in older people, but few reports so far have addressed preventive strategies or early interventions in this context. The reports in this month’s JAGS break important new ground in this area but also suggest that more research is needed to give clinicians tools to help identify, prevent, and treat depression in such high-risk groups.