Current Challenges in the Recognition and Management of Delirium Superimposed on Dementia

Nitchingham, Anita; Caplan, Gideon A.

doi:10.2147/ndt.s247957

Cited by 22 publications

(10 citation statements)

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“…Delirium superimposed on dementia also seems to be challenging to evaluate for the participants of our study. This seems to reflect current clinical practice [ 42 ]. Low detection rates of hypoactive delirium and delirium superimposed on dementia in case vignettes, as seen in our study and previous studies, point towards gaps in nurses’ knowledge of delirium and suggest better training of health care professionals on delirium [ 16 ].…”

Section: Discussionmentioning

confidence: 67%

Nurses’ competence in recognition and management of delirium in older patients: development and piloting of a self-assessment tool

et al. 2022

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Background Delirium is a common condition in elderly inpatients. Health care professionals play a crucial role in recognizing delirium, initiating preventive measures and implementing a multicomponent treatment strategy. Yet, delirium often goes unrecognized in clinical routine. Nurses take an important role in preventing and managing delirium. This study assesses clinical reasoning of nurses using case vignettes to explore their competences in recognizing, preventing and managing delirium. Methods The study was conducted as an online survey. The questionnaire was based on five case vignettes presenting cases of acutely ill older patients with different subtypes of delirium or diseases with overlapping symptoms. In a first step, case vignettes were developed and validated through a multidisciplinary expert panel. Scoring of response options were summed up to a Geriatric Delirium Competence Questionnaire (GDCQ) score including recognition and management tasks The questionnaire was made available online. Descriptive analyses and group comparisons explores differences between nurses from different settings. Factors explaining variance in participants’ score were evaluated using correlations and linear regression models. Results The questionnaire demonstrated good content validity and high reliability (kappa = 0.79). The final sample consisted of 115 nurses. Five hundred seventy-five case vignettes with an accuracy of 0.71 for the correct recognition of delirium presence or absence were solved. Nurses recognized delirium best in cases describing hyperactive delirium (79%) while hypoactive delirium was recognized least (44%). Nurses from geriatric and internal medicine departments had significantly higher GDCQ-score than the other subgroups. Management tasks were correctly identified by most participants. Conclusions Overall, nurses’ competence regarding hypoactive delirium should be strengthened. The online questionnaire might facilitate targeting training opportunities to nurses’ competence.

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Section: Discussionmentioning

confidence: 67%

Nurses’ competence in recognition and management of delirium in older patients: development and piloting of a self-assessment tool

et al. 2022

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“…The three key search terms were: 1) transitional care programs; 2) older adults; and 3) cognitive impairment. In this review, cognitive impairment includes dementia, delirium, and non-specified cognitive impairment, as differentiating between them can be challenging [ 23 ]. Long-term care includes long-term care homes, nursing homes, and care homes [ 24 ].…”

Section: Methodsmentioning

confidence: 99%

The impact of facility-based transitional care programs on function and discharge destination for older adults with cognitive impairment: a systematic review

Cumal

Colella²,

Puts³

et al. 2022

BMC Geriatr

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Background Older adults with cognitive impairment are frequently hospitalized and discharged to facility-based transitional care programs (TCPs). However, it is unknown whether TCPs are effective in improving their functional status and promoting discharge home rather than to long-term care. The aims of this systematic review were to examine the effectiveness of facility-based TCPs on functional status, patient and health services outcomes for older adults (≥ 65 years) with cognitive impairment and to determine what proportion post TCP are discharged home compared to long-term care. Methods The Joanna Briggs Institute Critical Appraisal Manual for Evidence Synthesis was used to guide the methodology for this review. The protocol was published in PROSPERO (registration number CRD42021257870). MEDLINE, CINAHL, PsycINFO, the Cochrane Library, and EMBASE databases, and ClinicalTrials.gov and the World Health Organization Trials Registry were searched for English publications. Studies that met the following criteria were included: community-dwelling older adults ≥ 65 years who participated in facility-based TCPs and included functional status and/or discharge destination outcomes. Studies with participants from nursing homes and involved rehabilitation programs or transitional care in the home or in acute care, were excluded. Risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Checklists. Results are in narrative form. Results Twenty-two studies (18 cohort and four cross sectional studies) involving 4,013,935 participants met inclusion criteria. The quality of the studies was mostly moderate to good. Improvement in activities of daily living (ADLs) was reported in eight of 13 studies. Between 24.4%-68% of participants were discharged home, 20–43.9% were hospitalized, and 4.1–40% transitioned to long-term care. Review limitations included the inability to perform meta-analysis due to heterogeneity of outcome measurement tools, measurement times, and patient populations. Conclusions Facility-based TCPs are associated with improvements in ADLs and generally result in a greater percentage of participants with cognitive impairment going home rather than to long-term care. However, gains in function were not as great as for those without cognitive impairment. Future research should employ consistent outcome measurement tools to facilitate meta-analyses. The level of evidence is level III-2 according to the National Health and Medical Research Council for cohort and cross-sectional studies.

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“…In this sense, the DSM-5 diagnostic criteria for DSD may be useful because they focus on abrupt worsening of the confusional state in the presence of easily recognizable stressors [10]. However, patients to whom these criteria apply (most of whom are hospitalized) [6, 7] may only represent the tip of an iceberg of elderly people with varying degrees of cognitive and/or behavioral impairment, who do not yet meet the diagnostic criteria or are undergoing a clinical procedure that excludes delirium a priori. A common case is that of confused elderly people treated to control sleep and/or behavior disorders using drugs (usually benzodiazepines, neuroleptics, or analgesics) that act simultaneously as treatment and stressor, which means that their sedative effect can be considered both a success of care and a failure of therapy.…”

Section: Discussionmentioning

confidence: 99%

Delirium and Dementia in the Elderly: Sometimes Associated or Always Together?

Bugiani

2023

Eur Neurol

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Background – In the elderly, the association of delirium and dementia can cause diagnostic problems because they share the same symptom of confusion. Delirium is often misdiagnosed as dementia and treated inappropriately, ignoring that it could be successfully addressed, which can lead to increased health risks up to death. Summary – Confusion indicates that functional reserve fails to compensate for the action of stressors. The decline in reserve is linked to aging-related changes in blood flow, mitochondria, cerebrospinal fluid, and immune function, as well as the appearance of structural precursors of disease. It is greater in dementia that adds a large burden of pathology, especially degenerative and vascular. Key Messages – Based on their common background linking normal and pathological brain aging, it can be argued that delirium and dementia are always associated to some extent and can aggravate each other. The clinical approach to their association, which currently relies on the preliminary diagnosis of delirium according to ad hoc protocols, could be simplified by taking delirium for granted so that its causative stressors, usually the most common diseases of old age and/or drug abuse, could be addressed immediately. This approach would benefit all demented patients: not only those who are in such a serious condition that they need to be hospitalized due to the risk of death, but also those with clouded delirium.

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Current Challenges in the Recognition and Management of Delirium Superimposed on Dementia

Cited by 22 publications

References 100 publications

Nurses’ competence in recognition and management of delirium in older patients: development and piloting of a self-assessment tool

Nurses’ competence in recognition and management of delirium in older patients: development and piloting of a self-assessment tool

The impact of facility-based transitional care programs on function and discharge destination for older adults with cognitive impairment: a systematic review

Delirium and Dementia in the Elderly: Sometimes Associated or Always Together?

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