Adults with intellectual and developmental disabilities (I/DD) are increasingly presenting to their health care professionals with concerns related to growing older. One particularly challenging clinical question is related to the evaluation of suspected cognitive decline or dementia in older adults with I/DD, a question that most physicians feel ill-prepared to answer. The National Task Group on Intellectual Disabilities and Dementia Practices was convened to help formally address this topic, which remains largely underrepresented in the medical literature. The task group, comprising specialists who work extensively with adults with I/DD, has promulgated the following Consensus Recommendations for the Evaluation and Management of Dementia in Adults With Intellectual Disabilities as a framework for the practicing physician who seeks to approach this clinical question practically, thoughtfully, and comprehensively.

Hospitalized patients with advanced dementia often receive care that is of limited clinical benefit and inconsistent with preferences. We designed an Advanced Dementia Consult Service and conducted a pre and post pilot study to evaluate it in a Boston hospital. Consults were conducted by geriatricians and palliative care nurse practitioner. They consisted of structured consultation, counseling and provision of an information booklet to the family, and post-discharge follow-up with the family and primary care providers. Patients > 65 admitted with advanced dementia were identified and consults were solicited using pop-ups programmed into the computerized provider order entry (POE) system. In the initial 3-month period, patients received usual care (N=24). In the subsequent 3-month period, consults were provided to patients for whom it was requested (N=5). Data were obtained from the electronic medical record and proxies interviews (admission, 1-month post-discharge). The patients’ mean age in the combined sample (N=29) was 85.4, 58.6% were from nursing homes, and 86.2% of their proxies stated comfort was the goal of care. Nonetheless, their hospitalizations were characterized by high rates of intravenous antibiotics (86.2%), > 5 venipunctures (44.8%), and radiological exams (96.6%). Acknowledging the small sample size, there were trends towards better outcomes in the intervention group including: higher proxy knowledge of the disease, greater communication between proxies and providers, more advance care planning, lower re-hospitalization rates, and fewer feeding tube insertions after discharge. Targeted consultation for advanced dementia is feasible and may promote greater engagement of proxies and goal-directed care for patients after discharge.

No abstract

Background Computerized provider order entry (CPOE) systems in the electronic medical record and checklists may present opportunities to improve care in older hospitalized adults. Objectives To determine if a bundled intervention can increase detection of delirium and facilitate safer use of high risk medications. Design Pre-post interventional trial Setting Large academic medical center Participants Patients ≥ 70 years (n=19,949) admitted 5/1/2008 to 9/30/2011. Patients ≥ 80 years admitted after 4/26/2010 received the intervention; those admitted prior were primary controls. Patients aged 70–79 were concurrent controls. Intervention The intervention uses a checklist promoting delirium prevention, recognition and management, and modifies the CPOE system to provide elder focused care. Measurements Frequency of orders for activating the rapid response team for altered mental status, frequency of orders for haloperidol > 0.5 mg or IV morphine > 2 mg, and discharge disposition. Results Patients receiving the intervention were 86.1 ± 4.6 years old and 58.2% female. The number of orders to activate the rapid response team for altered mental status increased in both patients receiving the bundle and in controls [odds ratio (OR) for the difference of differences = 1.23 (95% CI 0.68–2.24, p=0.49)]. Patients receiving the bundle were less likely to receive haloperidol > 0.5 mg IV/IM/PO [OR=0.60 (0.39–0.91) p = 0.02] and morphine > 2 mg IV [OR=0.52 (0.42–0.63), p < 0.0001]. More patients who received the bundle were discharged home than to extended care facilities [OR 1.18 (CI 1.04–1.35) p = 0.01]. Conclusion An intervention focused on delirium prevention and recognition by bedside staff combined with computerized decision support facilitates safer prescribing of high risk medications, and possibly results in less need for extended care.