Donna M. Fick

Delirium Superimposed on Dementia: A Systematic Review

Delirium in a patient with preexisting dementia is a common problem that may have serious complications and poor prognostic implications. The purpose of this paper was to conduct a systematic review of the medical literature on delirium superimposed on dementia, specifically to review studies on prevalence, associated features, outcomes, and management. Areas of controversy and gaps in our knowledge of this problem are highlighted. Finally, an agenda for future research is proposed. Fourteen studies were reviewed, including seven prospective studies, three retrospective studies, two cross‐sectional studies, and two clinical trials. For the review of the literature on delirium superimposed on dementia, we searched MEDLINE from January 1966 through February 2002 for research studies with primary sources of data. Selection criteria for inclusion of articles in this study were inclusion of data on subjects with delirium superimposed on dementia, inclusion of a validated operational definition/measures of dementia and delirium, actual data on persons with delirium and dementia reported in the paper, and reporting of primary data. MEDLINE was searched using the following key search terms: delirium, acute confusion, cognitive impairment, Alzheimers disease, dementia, delirium superimposed on dementia, and elderly. The prevalence of delirium superimposed on dementia ranged from 22% to 89% of hospitalized and community populations aged 65 and older with dementia. To date, only one reported study systematically identified associated factors and interventions for delirium superimposed on dementia, but several studies examining outcomes have found that adverse events are associated with delirium in persons with dementia, including accelerated and long‐term cognitive and functional decline, need for institutionalization, rehospitalization, and increased mortality. This paper highlights the dearth of research on delirium superimposed on dementia and stresses the importance of early recognition and prevention of delirium in persons with dementia.

The cognitive impact of anticholinergics:a clinical review

Context: The cognitive side effects of medications with anticholinergic activity have been documented among older adults in a variety of clinical settings. However, there has been no systematic confirmation that acute or chronic prescribing of such medications lead to transient or permanent adverse cognitive outcomes. Objective: Evaluate the existing evidence regarding the effects of anticholinergic medications on cognition in older adults. Data sources: We searched the MEDLINE, OVID, and CINAHL databases from January, 1966 to January, 2008 for eligible studies. Study selection: Studies were included if the anticholinergic activity was systematically measured and correlated with standard measurements of cognitive performance. Studies were excluded if they reported case studies, case series, editorials, and review articles. Data extraction: We extracted the method used to determine anticholinergic activity of medications and its association with cognitive outcomes. Results: Twenty-seven studies met our inclusion criteria. Serum anticholinergic assay was the main method used to determine anticholinergic activity. All but two studies found an association between the anticholinergic activity of medications and either delirium, cognitive impairment or dementia. Conclusions: Medications with anticholinergic activity negatively affect the cognitive performance of older adults. Recognizing the anticholinergic activity of certain medications may represent a potential tool to improve cognition.

Health outcomes associated with potentially inappropriate medication use in older adults.

The purpose of this study was to examine the prevalence of potentially inappropriate medication use (PIMs) among community-dwelling older adults and the association between PIMs and health care outcomes. Participants were 17,971 individuals age 65 years and older. PIM use was defined by the Beers criteria. Drug-related problems (DRPs) were defined using ICD-9 codes. Forty percent of the 17,971 individuals filled at least 1 PIM prescription, and 13% filled 2 or more PIM prescriptions. Overall DRP prevalence among those with at least 1 PIM prescription was 14.3% compared to 4.7% in the non-PIM group (p < .001). In conclusion, preventing PIM use may be important for decreasing medication-related problems, which are increasingly being recognized as requiring an integrated interdisciplinary approach.

Consequences of Not Recognizing Delirium Superimposed on Dementia in Hospitalized Elderly Individuals

OBJECTIVE The purpose of this study was to describe the recognition and management of delirium in hospitalized patients with and without dementia. DESIGN A descriptive, exploratory design was used with a convenience sample of 20 hospitalized older patients who were observed indepth using qualitative interviews and observations of 13 family members and 11 staff members. SETTING This research was conducted on the medical-surgical units of a 550-bed, nonprofit, state-supported teaching hospital in the southeastern United States. The facility provides primary and tertiary care with five intensive care units and eight medical-surgical units. PARTICIPANTS This study did not exclude individuals with dementia or pre-existing delirium. Subjects were not excluded on the basis of race or gender. Twenty patients in the sample underwent observation and mental and functional status testing. Thirteen family members and 11 staff members were interviewed and observed. MEASUREMENTS In Phase 1 of the study, patients had daily mental status testing performed by the investigator. In Phase 2, family members and staff members were interviewed about the confusion event. For each patient, demographics and information regarding their health status and current diagnosis and treatment were obtained. The Mini-Mental State Examination (MMSE) and the Confusion Assessment Method were completed on each subject within 36 hours of being admitted to the hospital. The Cornell Depression Scale and Katz Activities of Daily Living scale were completed within 48 hours of admission. RESULTS The prevalence of delirium in this study was 60%. The incidence, or new onset of delirium, was 30%. The presence of delirium was associated with new onset incontinence, lower baseline MMSE scores, depression, weight loss, and comorbidity. Of the eight individuals with delirium superimposed on dementia, 63% (n = 5) were re-admitted to the hospital within 30 days, compared to none of the individuals with delirium in the absence of dementia. Delirium superimposed on dementia also was less likely to be recognized by nurses and physicians. CONCLUSIONS Delirium in individuals with dementia should be assessed and treated routinely because the failure to recognize delirium superimposed on dementia promptly has significant negative personal, social and financial consequences.

Postoperative Delirium in Older Adults: Best Practice Statement from the American Geriatrics Society

Disclosure Information: Disclosures for the members of t Geriatrics Society Postoperative Delirium Panel are listed in Support: Supported by a grant from the John A Hartford Fou to the Geriatrics-for-Specialists Initiative of the American Geri (grant 2009-0079). This article is a supplement to the American Geriatrics Soci Practice Guidelines for Postoperative Delirium in Older Adu at the American College of Surgeons 100 Annual Clinic San Francisco, CA, October 2014.

American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults

The abstracted set of recommendations presented here provides essential guidance both on the prevention of postoperative delirium in older patients at risk of delirium and on the treatment of older surgical patients with delirium, and is based on the 2014 American Geriatrics Society (AGS) Guideline. The full version of the guideline, American Geriatrics Society Clinical Practice Guideline for Postoperative Delirium in Older Adults is available at the website of the AGS. The overall aims of the study were twofold: first, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the prevention of postoperative delirium in older adults; and second, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the treatment of postoperative delirium in older adults. Prevention recommendations focused on primary prevention (i.e., preventing delirium before it occurs) in patients who are at risk for postoperative delirium (e.g., those identified as moderate‐to‐high risk based on previous risk stratification models such as the National Institute for Health and Care Excellence (NICE) guidelines, Delirium: Diagnosis, Prevention and Management. Clinical Guideline 103; London (UK): 2010 July 29). For management of delirium, the goals of this guideline are to decrease delirium severity and duration, ensure patient safety and improve outcomes.

Delirium superimposed on dementia is associated with prolonged length of stay and poor outcomes in hospitalized older adults

BACKGROUND Current literature does not identify the significance of underlying cognitive impairment and delirium in older adults during and 30 days following acute care hospitalization. OBJECTIVE Describe the incidence, risk factors, and outcomes associated with incident delirium superimposed on dementia. DESIGN A 24-month prospective cohort study. SETTING Community hospital. PATIENTS A total of 139 older adults (>65 years) with dementia. METHODS This prospective study followed patients daily during hospitalization and 1 month posthospital. Main measures included dementia (Modified Blessed Dementia Rating score, Informant Questionnaire on Cognitive Decline in the Elderly), daily mental status change, dementia stage/severity (Clinical Dementia Rating, Global Deterioration Scale), delirium (Confusion Assessment Method), and delirium severity (Delirium Rating Scale-Revised-98). All statistical analysis was performed using SAS 9.3, and significance was an α level of 0.05. Logistic regression, analysis of covariance, or linear regression was performed controlling for age, gender, and dementia stage. RESULTS The overall incidence of new delirium was 32% (44/139). Those with delirium had a 25% short-term mortality rate, increased length of stay, and poorer function at discharge. At 1 month follow-up, subjects with delirium had greater functional decline. Males were more likely to develop delirium, and for every 1 unit increase in dementia severity (Global Deterioration Scale), subjects were 1.5 times more likely to develop delirium. CONCLUSIONS Delirium prolongs hospitalization for persons with dementia. Thus, interventions to increase early detection of delirium have the potential to decrease the severity and duration of delirium and to prevent unnecessary suffering and costs from the complications of delirium and unnecessary readmissions to the hospital.

Tools to Detect Delirium Superimposed on Dementia: A Systematic Review

To identify valid tools to diagnose delirium superimposed on dementia.

2012 American Geriatrics Society Beers Criteria:: New Year, New Criteria, New Perspective

Mark Beers, MD, recognized more than 2 decades ago that the prevention of adverse drug events in older adults is crucial to the public health of this vulnerable population. The Beers Criteria remain simultaneously one of the most used and most controversial sets of medication criteria in the world. Although not without limitations, the Beers Criteria have done more than any other tool in the past decade to improve the awareness of and clinical outcomes for older adults with polypharmacy and for the most vulnerable older adults at risk of adverse drug events. They have accomplished this because of their explicit nature, simple application for nonpharmacy experts, and wide dissemination. The continued development of explicit lists of medications to avoid in older adults, such as the Beers Criteria, is a critical component, albeit not the only one, in the public health imperative to decrease drug-related problems and improve the health of older adults. Nevertheless, continuing challenges include evaluating and communicating a drug’s risks and benefits in older adults to individual clinicians across all settings of care and developing an explicit list of these medications as part of a concise document that meets the needs of patients, clinicians, educators, researchers, policy-makers, and regulators. This article provides a perspective from the co-chairs of the 2012 American Geriatrics Society (AGS) Beers Criteria by addressing these issues, exploring the major differences and intended use of the criteria in this AGS-sponsored update, and proposing an agenda for future work. The authors believe the 2012 criteria are vastly improved from previous iterations because they include important updates to the established method for developing the explicit list of medications to avoid in older adults and consider the challenges of guiding individual clinicians in avoiding certain drugs in older adults or using them with caution. Most importantly, the quality of the criteria has been improved by the application of an evidence-based approach and the support of AGS. The decision to follow the Institute of Medicine standards for evidence and transparency was an important benchmark—one that was clearly a transition for criteria that have been traditionally developed using a Delphi consensus process. Because of the nature of clinical drug trials in older adults, evidence was at times difficult to find and to apply cleanly. The literature search was complex because of the large number and diversity of search terms required, the extended time period searched, and the lack of clinical trial data in older adults often resulting in reliance on observational data. With AGS support, the development of databases to support more-frequent updates of the criteria and continual grading of the evidence as it emerges will continue to enhance this process. Past criticisms of the Beers Criteria correctly pointed out that many of the drugs were off the market or not in widespread use, lessening their relevance to clinicians and their association with health outcomes. The support of AGS has made this list more dynamic and relevant to the real-world practice of medicine. Still, caveats in their recommendation or rationale complicate some of the resulting criteria. These caveats offer additional guidance to clinicians about when to avoid a drug but at times cannot be used as a performance measure if extracted from a large database or by surveyors without sufficient clinical insight to discern these nuances. The Beers Criteria are situated within a larger perspective of strategies to improve medication safety in older adults. Previous studies have found that a small number of medications are responsible for most adverse drug events in older adults. In a recent study, four medications or medication classes (warfarin, insulin, oral antiplatelet agents, and oral hypoglycemic agents) were associated with most

Reframing person-centered nursing care for persons with dementia.

Alzheimer’s dementia manifests in a complex clinical presentation that has been addressed from both biomedical and phenomenological perspectives. Although each of these paradigmatic perspectives has contributed to advancement of the science, neither is adequate for theoretically framing a person-centered approach to nursing care. The need-driven dementia-compromised behavior (NDB) model is discussed as an exemplar of midrange nursing theory that promotes the integration of these paradigmatic views to promote a new level of excellence in person-centered dementia care. Clinical application of the NDB promotes a new level of praxis, or thoughtful action, in the care of persons with dementia.