Sylvie Richard

Detecting Delirium and Subsyndromal Delirium Using Different Diagnostic Criteria among Demented Long-Term Care Residents

OBJECTIVES To evaluate the impact of using different diagnostic criteria on prevalence rates of delirium and subsyndromal delirium (SSD) among demented long-term care (LTC) residents. DESIGN Descriptive study. SETTING LTC settings in Quebec City, Canada. PARTICIPANTS Participants were 155 individuals aged 65 and older, with dementia. MEASUREMENTS (1) Prevalence rates of delirium according to: (a) the Diagnostic and Statistical Manual of Mental Disorders (DSM-III, DSM-III-R, and DSM-IV) and (b) the Confusion Assessment Method (CAM) algorithms for definite and probable delirium; and (2) prevalence rates of SSD employing 2 definitions described in previous studies. RESULTS Prevalence rates of delirium according to each set of criteria were 26.5% for DSM-III; 29% for DSM-IV-TR; 41.3% for DSM-III-R; 45.8% for CAM algorithm for definite delirium; and 70.3% for CAM algorithm for probable delirium. A total of 109 subjects (70.3%) were identified as delirious consistent with at least one classification and 37 (23.9%) met all the sets of criteria considered. Prevalence rates for SSD were 75 (48.4%) and 78 (50.3%) depending on the definition employed. CONCLUSION Prevalence rates for delirium are much affected by the diagnostic formulations used. The use of DSM-IV-TR among this population could result in fewer cases being identified as delirious and thus compromise proper care for those individuals. Considering that SSD was prevalent among this population, a systematic implementation of protocols targeting risk factors of delirium might be beneficial among demented LTC residents.

Predisposing Factors Associated With Delirium Among Demented Long-Term Care Residents

This was a cross-sectional study to investigate predisposing factors associated with delirium among demented long-term-care residents and to assess the cumulative effect of these factors on the likelihood of having delirium. Of the 155 participants, 109 (70.3%) were found delirious according to the confusion assessment method. Among these individuals, age (OR = 1.07; 95% CI = 1.05-1.10) and severity of dementia (OR = 1.05; 95% CI = 1.03-1.07) were the most associated factors of delirium. The likelihood of being in delirium increased with the number of associated predisposing factors present (OR = 1.67; 95% CI = 1.11-2.51). Associated factors identified were level of functional autonomy, pain, depression, behavioral disturbances, number of medications, dehydration, fever, and malnutrition. Identification of predisposing factors will help nurses in detecting those residents in long-term care settings who are at high-risk for delirium, as well as in designing preventive intervention strategies for delirium, based on these factors.

Detection of delirium by nurses among long-term care residents with dementia

BackgroundDelirium is a prevalent problem in long-term care (LTC) facilities where advanced age and cognitive impairment represent two important risk factors for this condition. Delirium is associated with numerous negative outcomes including increased morbidity and mortality. Despite its clinical importance, delirium often goes unrecognized by nurses. Although rates of nurse-detected delirium have been studied among hospitalized older patients, this issue has been largely neglected among demented older residents in LTC settings. The goals of this study were to determine detection rates of delirium and delirium symptoms by nurses among elderly residents with dementia and to identify factors associated with undetected cases of delirium.MethodsIn this prospective study (N = 156), nurse ratings of delirium were compared to researcher ratings of delirium. This procedure was repeated for 6 delirium symptoms. Sensitivity, specificity, positive and negative predictive values were computed. Logistic regressions were conducted to identify factors associated with delirium that is undetected by nurses.ResultsDespite a high prevalence of delirium in this cohort (71.5%), nurses were able to detect the delirium in only a minority of cases (13%). Of the 134 residents not identified by nurses as having delirium, only 29.9% of them were correctly classified. Detection rates for the 6 delirium symptoms varied between 39.1% and 58.1%, indicating an overall under-recognition of symptoms of delirium. Only the age of the residents (≥ 85 yrs) was associated with undetected delirium (OR: 4.1; 90% CI: [1.5–11.0]).ConclusionDetection of delirium is a major issue for nurses that clearly needs to be addressed. Strategies to improve recognition of delirium could result in a reduction of adverse outcomes for this very vulnerable population.

Detection of delirium and its symptoms by nurses working in a long term care facility.

OBJECTIVE To investigate the ability of nurses to recognize delirium and its symptoms and to investigate the factors associated with undetected delirium. DESIGN A prospective, observational study with repeated measurements over a 6-month period. SETTING Seven long term care settings in Montreal and Quebec City, Canada. PARTICIPANTS Residents aged 65 and older, with or without dementia, admitted to long term care (not respite care) and able to communicate in English or French. MEASUREMENTS Delirium and its symptoms were assessed using the Confusion Assessment Method. Ratings of delirium by nurses based on their observations during routine care were compared with delirium ratings by trained research assistants based on a one-time formal structured evaluation (Confusion Assessment Method and Mini Mental State Examination). This procedure was repeated for 10 delirium symptoms. Sensitivity, specificity, and positive and negative predictive values were calculated. The method of generalized estimating equations was used to identify factors associated with undetected delirium. RESULTS Research assistants identified delirium in 43 (21.3%) of the 202 residents. Nurses identified delirium in 51% of the cases identified by the research assistants. However, for cases without delirium according to the research assistants, nurses identified 90% of them correctly. Detection rates for delirium symptoms ranged from 25% to 66.7%. Undetected delirium was associated with lower number of depressive symptoms manifested by the resident. CONCLUSION Detection of delirium is a major issue for nurses. Strategies to improve nurse recognition of delirium could well reduce adverse outcomes for this vulnerable population.

Isolation and characterization of a cDNA clone encoding a putative white spruce glycine-rich RNA binding protein

A presumably full-length cDNA encoding a putative glycine-rich RNA binding protein was isolated from a lambdaZAP cDNA library prepared from mRNAs extracted from needles of 2year old white spruce seedlings, which had been either wounded or jasmonate-treated. The cDNA, designated PgRNP (Picea glauca RNP protein), presents a 468bp open reading frame encoding a 155 amino acid protein. This polypeptide possesses an RNA binding domain (RNP-CS) and a glycine-rich domain. Comparative alignment reveals extensive homologies to glycine-rich RNA binding proteins containing an RNP-CS found in other angiosperm species. Genomic hybridization experiments suggest that the PgRNP gene is part of a small multigene family with at least four members. RNA blot analysis revealed that the PgRNP transcript is expressed in all tissues from non-stressed plants. Constitutive mRNA level was found in needle tissue from control as well as methyl-jasmonate treated plants. Wounding had no clear induction effect. Jasmonic acid treatment and systemic wound response had a positive effect on transcript accumulation. Transcript accumulation was slightly induced by cold in needles, and repressed by drought stress in both needle and root tissues of 2year old plants. Finally, the level of PgRNP accumulation was induced by wounding and repressed in 2week old dark-grown seedlings upon jasmonate treatments.

Factors associated with delirium severity among older persons with dementia.

ABSTRACT Delirium is a common cause of functional and cognitive decline, morbidity, and mortality among hospitalized elderly individuals. Several studies reveal that the prognosis of delirium is worse among elderly individuals with severe delirium. In light of these findings, it is important to identify which factors are associated with delirium severity: individual (predisposing) or environmental (precipitating) factors. This study wanted to investigate individual and environmental factors associated with delirium severity among older persons with delirium superimposed on dementia. This study is a secondary analysis of a cross-sectional study (N = 71) on delirium carried out in three long-term care facilities and one long-term care unit of a large regional hospital. Of the 29 potential risk factors considered, researchers found 6 to be significantly associated with delirium severity in univariate analysis: marital status (being married), severity of dementia, lower functional autonomy, less medication consumption, presence of behavioral problems, and inadequacy of the physical environment. In multivariate analysis, only marital status (being married) and severity of dementia remained statistically associated with delirium severity. Results of this study provide further evidence that the weakened brain functions of persons with dementia increases not only the risk of delirium but also its severity. Given the poor outcomes associated with delirium severity, nurses need to pay closer attention to the predisposing and precipitating factors of delirium severity.

Recognizing acute delirium as part of your routine (RADAR): a validation study

BackgroundAlthough detection of delirium using the current tools is excellent in research settings, in routine clinical practice, this is not the case. Together with nursing staff, we developed a screening tool (RADAR) to address certain limitations of existing tools, notably administration time, ease-of-use and generalizability. The purpose of this study was not only to evaluate the validity and reliability of RADAR but also to gauge its acceptability among the nursing staff in two different clinical settings.MethodsThis was a validation study conducted on three units of an acute care hospital (medical, cardiology and coronary care) and five units of a long-term care facility. A total of 142 patients and 51 residents aged 65 and over, with or without dementia, participated in the study and 139 nurses were recruited and trained to use the RADAR tool. Data on each patient/resident was collected over a 12-hour period. The nursing staff and researchers administered RADAR during the scheduled distribution of medication. Researchers used the Confusion Assessment Method to determine the presence of delirium symptoms. Delirium itself was defined as meeting the criteria for DMS-IV-TR delirium. Inter-rater reliability, convergent, and concurrent validity of RADAR were assessed. At study end, 103 (74%) members of the nursing staff completed the RADAR feasibility and acceptability questionnaire.ResultsPercentages of agreement between RADAR items that bedside nurses administered and those research assistants administered varied from 82% to 98%. When compared with DSM-IV-TR criterion-defined delirium, RADAR had a sensitivity of 73% and a specificity of 67%. Participating nursing staff took about seven seconds on average, to complete the tool and it was very well received (≥98%) overall.ConclusionsThe RADAR tool proved to be efficient, reliable, sensitive and very well accepted by nursing staff. Consequently, it becomes an appropriate new option for delirium screening among older adults, with or without cognitive impairment, in both hospitals and nursing homes. Further projects are currently underway to validate the RADAR among middle-aged adults, as well as in newer clinical settings; home care, emergency department, medical intensive care unit, and palliative care.

Precipitating factors associated with delirium among long-term care residents with dementia.

This cross-sectional study (N = 155) investigated precipitating factors associated with delirium among long-term-care residents with dementia and assessed their cumulative effect on the likelihood of having delirium. Use of physical restraints (odds ratio [OR] = 4.64, 95% confidence interval [CI] = 2.61-8.27) was the factor most associated, and the likelihood of being in delirium increased with the number of associated precipitating factors present (OR = 2.53, 95% CI = 1.42-4.49). Given their frailty, only a few precipitating factors need be present to increase the likelihood of these residents being in delirium, hence the need for increased nurse awareness of the risks posed by use of physical restraints with respect to the cognitive function of elderly residents with dementia.

Assessment of inattention in the context of delirium screening: one size does not fit all!

BACKGROUND Despite its high prevalence and deleterious consequences, delirium often goes undetected in older hospitalized patients and long-term care (LTC) residents. Inattention is a core symptom of this syndrome. The aim of this study was to explore the usefulness of ten simple and objective attention tests that would enable efficient delirium screening among this population. METHODS This was a secondary analysis (n = 191) of a validation study conducted in one acute care hospital (ACH) and one LTC facility among older adults with, or without, cognitive impairment. The attention test tasks (n = 10) were drawn from the Concentration subscale the Hierarchic Dementia Scale (HDS). Delirium was defined as meeting the criteria for DSM-5 delirium. The Confusion Assessment Method (CAM) was used to determine the presence of delirium symptoms. RESULTS The Months of the Year Backward (MOTYB) test, which 57% of participants completed successfully, showed the best balance between sensitivity and specificity (82.6%; 95% CI [61.2-95.0], and 62.5%; 95% CI [54.7-69.8] respectively) for the entire group. Subgroup analyses revealed that no test had both sensitivity and specificity over 50% in participants with cognitive impairment indicated in their medical chart. CONCLUSIONS Our results revealed that these tests varied greatly in performance and none can be earmarked to become a single-item screening tool for delirium among older patients and residents with, or without, cognitive impairment. The presence of premorbid cognitive impairment may necessitate more extensive assessments of delirium, especially when a change in general status or mental state is observed.

Nursing documentation in long-term care settings: New empirical evidence demands changes be made.

In this study on nursing documentation in long-term care facilities, a set of 9 delirium symptoms was used to evaluate the agreement between symptoms reported by nurses during monthly interviews and those documented in the nursing notes for the same 7-day observation period. Residents aged 65 and above (N = 280) were assessed monthly over a 6-month period for the presence of delirium and its symptoms using the Confusion Assessment Method. The proportion of symptoms documented in the nursing notes ranged from 1.9% to 53.5%. A trend toward a lower proportion of documented symptoms for higher resident−nurse ratios was observed, although the difference was not statistically significant. Efforts should be made to improve the situation by revisiting the content of academic and clinical training given to nurses in addition to exploring innovative ways to make nursing documentation more efficient and less time-consuming within the current context of nurses’ work overload.