Minh Vu

Prevalence and incidence of delirium in long‐term care

(1) To describe the prevalence and 6‐month incidence of delirium in long‐term care facility (LTCF) residents age 65 and over; (2) To describe differences in these measures by resident baseline characteristics.

Subsyndromal Delirium in Older Long‐Term Care Residents: Incidence, Risk Factors, and Outcomes

To determine the incidence of, risk factors for, and outcomes of subsyndromal delirium (SSD) in older long‐term care (LTC) residents and, secondarily, to explore the use of a more‐restrictive definition of SSD.

Use of nurse-observed symptoms of delirium in long-term care: effects on prevalence and outcomes of delirium.

BACKGROUND Previous studies have reported that nurse detection of delirium has low sensitivity compared to a research diagnosis. As yet, no study has examined the use of nurse-observed delirium symptoms combined with research-observed delirium symptoms to diagnose delirium. Our specific aims were: (1) to describe the effect of using nurse-observed symptoms on the prevalence of delirium symptoms and diagnoses in long-term care (LTC) facilities, and (2) to compare the predictive validity of delirium diagnoses based on the use of research-observed symptoms alone with those based on research-observed and nurse-observed symptoms. METHODS Residents aged 65 years and over of seven LTC facilities were recruited into a prospective study. Using the Confusion Assessment Method (CAM), research assistants (RAs) interviewed residents and nurses to assess delirium symptoms. Delirium symptoms were also abstracted independently from nursing notes. Outcomes measured at five month follow-up were: death, the Hierarchic Dementia Scale (HDS), the Barthel ADL scale, and a composite outcome measure (death, or a 10-point decline in either the HDS or the ADL score). RESULTS The prevalence of delirium among 235 LTC residents increased from 14.0% (using research-observed symptoms only) to 24.7% (using research- and nurse-observed symptoms). The relative risks (and 95% confidence intervals) for prediction of the composite outcome, after adjustment for covariates, were: 1.43 (0.88, 1.96) for delirium using research-observed symptoms only; 1.77 (1.13, 2.28) for delirium using research- and nurse-observed symptoms, in comparison with no delirium. CONCLUSIONS The inclusion of delirium symptoms observed by nurses not only increases the detection of delirium in LTC facilities but improves the prediction of outcomes.

Observer-rated depression in long-term care: frequency and risk factors.

The objectives of this study were: (1) to describe the prevalence and 6-month incidence of observer-rated depression in residents age 65 and over of long-term care (LTC) facilities; (2) to describe risk factors for depression, at baseline and over time. A multisite, prospective observational study was conducted in residents aged 65 and over of 7 LTC facilities. The Cornell Scale for Depression in Dementia (CSDD) was completed by nurses monthly for 6 months. We measured demographic, medical, and functional factors at baseline and monthly intervals, using data from research assessments, nurse interviews, and chart reviews. 274 residents were recruited and completed baseline depression assessments. The prevalence of depression (CSDD score of 6+) was 19.0%. The incidence of depression among those without prevalent depression was 73.3 per 100 person-years. A delirium diagnosis, pain, and diabetes were independently associated with prevalent depression. CSDD score at baseline and development of severe cognitive impairment at follow-up were independent risk factors for incident depression. A diagnosis of delirium and uncorrected visual impairment at follow-up occurred concurrently with incident depression. The results of this study have implications for the detection and prevention of depression in LTC. Delirium diagnosis, pain and diabetes at baseline were associated with prevalent depression; depression symptoms at baseline and development of severe cognitive impairment at follow-up were risk factors for incident depression.

The course of delirium in older long-term care residents.

The purpose of this study was to determine the course of delirium in older long‐term care (LTC) residents.

Environmental factors predict the severity of delirium symptoms in long-term care residents with and without delirium.

To identify potentially modifiable environmental factors (including number of medications) associated with changes over time in the severity of delirium symptoms and to explore the interactions between these factors and resident baseline vulnerability.

Symptoms of Delirium Occurring Before and After Episodes of Delirium in Older Long-Term Care Residents

To describe Confusion Assessment Method (CAM) core symptoms of delirium occurring before and after incident episodes of delirium in older long‐term care (LTC) residents. A secondary objective was to describe the mean number of symptoms before and after episodes by dementia status.

The Course of Subsyndromal Delirium in Older Long-Term Care Residents

OBJECTIVE To determine the course of incident subsyndromal delirium (SSD) in older long-term care (LTC) residents. A secondary objective was to explore the use of a more restrictive definition of SSD on the findings of the study. DESIGN Cohort study with repeated weekly assessments for up to 6 months. SETTING Seven LTC facilities in Montreal and Quebec City, Canada. PARTICIPANTS LTC residents aged 65 and more and free of delirium core symptoms at baseline. MEASURES The Mini-Mental State Examination (MMSE), Confusion Assessment Method (CAM), Delirium Index (DI), Hierarchic Dementia Scale, and Barthel Index were completed at baseline. The MMSE, CAM, and DI were repeated weekly for 6 months. SSD1 required one or more CAM core symptoms; SSD2, a more restrictive definition, required two or more CAM core symptoms. RESULTS Sixty-eight residents had 129 incident episodes of SSD1: 32 had one episode and 36 had two or more episodes. Episodes lasted 7 - 133 days, mean 13.7 (SD: 14.8) days; mean number of symptoms per episode was 1.1 (SD: 0.4). Rates of recovery at 1, 2, and 4 weeks and 6 months were 45.7%, 61.2%, 64.6%, and 78.3%, respectively. Thirty-three residents had 49 episodes of SSD2: 21 had 1 episode and 12 had 2 or more episodes. Use of the more restrictive definition significantly increased time to recovery and reduced rate of recovery. CONCLUSION Episodes of SSD in older LTC residents appeared to last 7-133 days (mean: 13.7) and were often recurrent. Use of a more restrictive definition resulted in a more protracted course.

Six‐Month Outcomes of Co‐Occurring Delirium, Depression, and Dementia in Long‐Term Care

To describe the 6‐month outcomes of co‐occurring delirium (full syndrome and subsyndromal symptoms), depression, and dementia in a long‐term care (LTC) population.

Symptoms of delirium predict incident delirium in older long-term care residents

BACKGROUND Detection of long-term care (LTC) residents at risk of delirium may lead to prevention of this disorder. The primary objective of this study was to determine if the presence of one or more Confusion Assessment Method (CAM) core symptoms of delirium at baseline assessment predicts incident delirium. Secondary objectives were to determine if the number or the type of symptoms predict incident delirium. METHODS The study was a secondary analysis of data collected for a prospective study of delirium among older residents of seven LTC facilities in Montreal and Quebec City, Canada. The Mini-Mental State Exam (MMSE), CAM, Delirium Index (DI), Hierarchic Dementia Scale, Barthel Index, and Cornell Scale for Depression were completed at baseline. The MMSE, CAM, and DI were repeated weekly for six months. Multivariate Cox regression models were used to determine if baseline symptoms predict incident delirium. RESULTS Of 273 residents, 40 (14.7%) developed incident delirium. Mean (SD) time to onset of delirium was 10.8 (7.4) weeks. When one or more CAM core symptoms were present at baseline, the Hazard Ratio (HR) for incident delirium was 3.5 (95% CI = 1.4, 8.9). The HRs for number of symptoms present ranged from 2.9 (95% CI = 1.0, 8.3) for one symptom to 3.8 (95% CI = 1.3, 11.0) for three symptoms. The HR for one type of symptom, fluctuation, was 2.2 (95% CI = 1.2, 4.2). CONCLUSION The presence of CAM core symptoms at baseline assessment predicts incident delirium in older LTC residents. These findings have potentially important implications for clinical practice and research in LTC settings.