Delirium in Nursing Home Residents: A Narrative Review

Komici, Klara; Guerra, Germano; Addona, Franco; Fantini, Carlo

doi:10.3390/healthcare10081544

Cited by 16 publications

(16 citation statements)

References 81 publications

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“…As highlighted previously, adversities such as dysphagia and delirium are complications of multimorbidity and resulting frailty, 3 , 4 and are both independently associated with mortality. 8 , 54 As such, both of these conditions may be rightly viewed as late signals of end-of-life decline in LTC residents because they are indicators of severe cognitive and physical dysregulation or impairment in an already frail and vulnerable population. However, this interpretation is limited in the current study because of a lack of context.…”

Section: Discussionmentioning

confidence: 99%

Nutrition and Non-Nutrition-Related Challenges Predict Time to Death in Long-Term Care Residents: A Retrospective Chart Review

Morrison-Koechl,

Liu,

Banerjee

et al. 2023

JMDH

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Purpose Signals of end-of-life decline observed in daily habits, such as mealtime participation, are important for moving towards comfort-focused goals of care in the final months of life of long-term care (LTC) residents. It is unclear how eating issues observed in real-time in LTC homes are used as indicators of suspected end of life. The study quantifies nutrition and key non-nutrition related signals (eg, general decline, unstable vitals) documented to describe end-of-life decline and the subsequent time to death. Patients and Methods A retrospective chart review identified the first documented conversation where end-of-life decline was considered by members of the care team (eg, nurses, physicians, dietitian, family member) for 76 randomly selected decedents from 9 LTC homes in southwestern Ontario, Canada. Time (days) to death was calculated. A directed content analysis of the free-text description of the suspected end-of-life decline was used to categorize signals. Cox proportional hazards regression analysis tested the risk of mortality associated with each categorized signal. Results Time to death of residents (mean age = 88 ± 7 years; 60% female) from the first documentation of potential end-of-life decline ranged from 0 days to over 2 years prior to death (median = 27.5 days). Seven nutrition-related and 18 non-nutrition related signals were identified. Swallowing difficulty (HR = 2.99; 95% CI = 1.41, 6.33), cognitive decline (HR = 0.40; 95% CI = 0.20, 0.77), delirium (HR = 13.23; 95% CI = 1.57, 111.69), and cancer (HR = 0.18; 95% CI = 0.07, 0.48) were associated with time to death. Conclusion This study provides insight into the signals used by care providers in LTC to suspect that residents are declining towards the end of life and identifies four signals that were associated with time to death. When identified by care providers as indicators of end-of-life decline, swallowing difficulty and delirium predicted a shorter time to death, while cancer and cognitive decline predicted a longer time to death. Recognition of nutrition and non-nutrition related signals may be leveraged to systematically introduce timely comfort care conversations.

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Section: Discussionmentioning

confidence: 99%

Nutrition and Non-Nutrition-Related Challenges Predict Time to Death in Long-Term Care Residents: A Retrospective Chart Review

Morrison-Koechl,

Liu,

Banerjee

et al. 2023

JMDH

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“…Estimates of the prevalence of delirium in long-term care settings vary widely (1%-70%), with heterogeneity due to methods to ascertain delirium and case-mix of residents (e.g., age, % with dementia). 33,34 Among nursing home residents with acute illness, delirium onset is common (17.7% within 14 days). 35 Delirium is stressful to families 36 and creates additional stress and strain on nurses caring for those patients.…”

Section: Discussionmentioning

confidence: 99%

“…We found that the rate of delirium in nursing home residents on short‐acting opioids was ~20 per 100 person‐years. Estimates of the prevalence of delirium in long‐term care settings vary widely (1%–70%), with heterogeneity due to methods to ascertain delirium and case‐mix of residents (e.g., age, % with dementia) 33,34 . Among nursing home residents with acute illness, delirium onset is common (17.7% within 14 days) 35 .…”

Section: Discussionmentioning

confidence: 99%

Comparative safety of adding serotonin and norepinephrine reuptake inhibitors (SNRIs) versus nonsteroidal anti‐inflammatory drugs (NSAIDs) to short‐acting opioids for non‐malignant pain in nursing homes

Liu,

Yuan,

Baek

et al. 2023

J American Geriatrics Society

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BackgroundThe comparative safety of serotonin and norepinephrine reuptake inhibitors (SNRIs) as adjuvants to short‐acting opioids in older adults is unknown even though SNRIs are commonly used. We compared the effects of SNRIs versus nonsteroidal anti‐Inflammatory drugs (NSAIDs) on delirium among nursing home residents when SNRIs or NSAIDs were added to stable regimens of short‐acting opioids.MethodsUsing 2011–2016 national Minimum Data Set (MDS) 3.0 and Medicare claims data to implement a new‐user design, we identified a cohort of nursing home residents receiving short‐acting opioids who initiated either an SNRI or an NSAID. Delirium was defined from the Confusion Assessment Method in MDS 3.0 assessments and ICD9/10 codes using Medicare hospitalization claims. Propensity score matching balanced underlying differences for initiating treatments on 39 demographic and clinical characteristics (nSNRIs = 5350; nNSAIDs = 5350). Fine and Gray models provided hazard ratios (HRs) and 95% confidence intervals (CIs) adjusting for the competing risk of death.ResultsHydrocodone was the most commonly used short‐acting opioid (48%). Residents received ~23 mg daily oral morphine equivalent at the time of SNRIs/NSAIDs initiation. The majority were women, non‐Hispanic White, and aged ≥75 years. There were no differences in any of the confounders after propensity matching. Over 1 year, 10.8% of SNRIs initiators and 8.9% of NSAIDs initiators developed delirium. The rate of delirium onset was similar in SNRIs and NSAID initiators (HR(delirium in nursing home or hospitalization for delirium):1.10; 95% CI: 0.97–1.24; HR(hospitalization for delirium): 1.06; 95% CI: 0.89–1.25), and were similar regardless of baseline opioid daily dosage.ConclusionsAmong nursing home residents, adding SNRIs to short‐acting opioids does not appear to increase risk of delirium relative to initiating NSAIDs. Understanding the comparative safety of pain regimens is needed to inform clinical decisions in a medically complex population often excluded from clinical research.

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Section: Introduction and Pathophysiologymentioning

confidence: 99%

“…Other significant risk factors associated with delirium in these settings include dehydration, falls, use of physical restraints, and SARS-CoV-2 infection. In nursing homes, 10 delirium increases risks of re-hospitalization, mortality, and worse functional outcomes, yet delirium remains understudied in these settings. To address delirium burden in older adults, national guidelines in the US and UK outline risk factors, clinical indicators, prevention strategies, and management recommendations.…”

Section: Introduction and Pathophysiologymentioning

confidence: 99%

Preventing and treating delirium in clinical settings for older adults

Faeder,

Hale,

Hedayati

et al. 2023

Therapeutic Advances in Psychopharmacology

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Delirium is a serious consequence of many acute or worsening chronic medical conditions, a side effect of medications, and a precipitant of worsening functional and cognitive status in older adults. It is a syndrome characterized by fluctuations in cognition and impaired attention that develops over a short period of time in response to an underlying medical condition, a substance (prescribed, over the counter, or recreational), or substance withdrawal and can be multi-factorial. We present a narrative review of the literature on nonpharmacologic and pharmacologic approaches to prevention and treatment of delirium with a focus on older adults as a vulnerable population. Older adult patients are most at risk due to decreasing physiologic reserves, with delirium rates of up to 80% in critical care settings. Presentation of delirium can be hyperactive, hypoactive, or mixed, making identification and study challenging as patients with hypoactive delirium are less likely to come to attention in an inpatient or long-term care setting. Studies of delirium focus on prevention and treatment with nonpharmacological or medication interventions, with the preponderance of evidence favoring multi-component nonpharmacological approaches to prevention as the most effective. Though use of antipsychotic medication in delirium is common, existing evidence does not support routine use, showing no clear benefit in clinically significant outcome measures and with evidence of harm in some studies. We therefore suggest that antipsychotics be used to treat agitation, psychosis, and distress associated with delirium at the lowest effective doses and shortest possible duration and not be considered a treatment of delirium itself. Future studies may clarify the use of other agents, such as melatonin and melatonin receptor agonists, alpha-2 receptor agonists, and anti-epileptics.

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Delirium in Nursing Home Residents: A Narrative Review

Cited by 16 publications

References 81 publications

Nutrition and Non-Nutrition-Related Challenges Predict Time to Death in Long-Term Care Residents: A Retrospective Chart Review

Nutrition and Non-Nutrition-Related Challenges Predict Time to Death in Long-Term Care Residents: A Retrospective Chart Review

Comparative safety of adding serotonin and norepinephrine reuptake inhibitors (SNRIs) versus nonsteroidal anti‐inflammatory drugs (NSAIDs) to short‐acting opioids for non‐malignant pain in nursing homes

Preventing and treating delirium in clinical settings for older adults

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