The PREvention Program for Alzheimer's RElated Delirium (PREPARED) cluster randomized trial: a study protocol.

BACKGROUND: Delirium is a significant cause of morbidity and mortality among older people admitted to both acute and long-term care facilities (LTCFs). Multicomponent interventions have been shown to reduce delirium incidence in the acute care setting (30-73%) by acting on modifiable risk factors. Little work, however, has focused on using this approach to reduce delirium incidence in LTCFs. METHODS: The objective is to assess the effectiveness of the multicomponent PREPARED Trial intervention in reducing the following primary outcomes: incidence, severity, duration, and frequency of delirium episodes in cognitively impaired residents. This 4-year, parallel-design, cluster randomized study will involve nursing staff and residents in 45-50 LTCFs in Montreal, Canada. Participating public and private LTCFs (clusters) that provide 24-h nursing care will be assigned to either the PREPARED Trial intervention or the control (usual care) arm of the study using a covariate constrained randomization procedure. Approximately 400-600 LTC residents aged 65 and older with dementia and/or cognitive impairment will be enrolled in the study and followed for 18 weeks. Residents must be at risk of delirium, delirium-free at baseline and have resided at the facility for at least 2 weeks. Residents who are unable to communicate verbally, have a history of specific psychiatric conditions, or are receiving end-of-life care will be excluded. The PREPARED Trial intervention consists of four main components: a decision tree, an instruction manual, a training package, and a toolkit. Primary study outcomes will be assessed weekly. Functional autonomy and cognitive levels will be assessed at the beginning and end of follow-up, while information pertaining to modifiable delirium risk factors, medical consultations, and facility transfers will be collected retrospectively for the duration of the follow-up period. Primary outcomes will be reported at the level of intervention assignment. All researchers analyzing the data will be blinded to group allocation. DISCUSSION: This large-scale intervention study will contribute significantly to the development of evidence-based clinical guidelines for delirium prevention in this frail elderly population, as it will be the first to evaluate the efficacy of a multicomponent delirium prevention program translated into LTC clinical practice on a large scale. TRIAL REGISTRATION: NCT03718156 , ClinicalTrials.gov .

Effectiveness of collaborative care in reducing suicidal ideation: An individual participant data meta-analysis.

To assess whether CC is more effective at reducing suicidal ideation in people with depression compared with usual care, and whether study and patient factors moderate treatment effects. METHOD: We searched Medline, Embase, PubMed, PsycINFO, CINAHL, CENTRAL from inception to March 2020 for Randomised Controlled Trials (RCTs) that compared the effectiveness of CC with usual care in depressed adults, and reported changes in suicidal ideation at 4 to 6 months post-randomisation. Mixed-effects models accounted for clustering of participants within trials and heterogeneity across trials. This study is registered with PROSPERO, CRD42020201747. RESULTS: We extracted data from 28 RCTs (11,165 patients) of 83 eligible studies. We observed a small significant clinical improvement of CC on suicidal ideation, compared with usual care (SMD, -0.11 [95%CI, -0.15 to -0.08]; I2, 0·47% [95%CI 0.04% to 4.90%]). CC interventions with a recognised psychological treatment were associated with small reductions in suicidal ideation (SMD, -0.15 [95%CI -0.19 to -0.11]). CC was more effective for reducing suicidal ideation among patients aged over 65 years (SMD, - 0.18 [95%CI -0.25 to -0.11]). CONCLUSION: Primary care based CC with an embedded psychological intervention is the most effective CC framework for reducing suicidal ideation and older patients may benefit the most.

Latent class analysis of the multivariate Delirium Index in long-term care settings.

ABSTRACTBackground:A few studies examine the time evolution of delirium in long-term care (LTC) settings. In this work, we analyze the multivariate Delirium Index (DI) time evolution in LTC settings. METHODS: The multivariate DI was measured weekly for six months in seven LTC facilities, located in Montreal and Quebec City. Data were analyzed using a hidden Markov chain/latent class model (HMC/LC). RESULTS: The analysis sample included 276 LTC residents. Four ordered latent classes were identified: fairly healthy (low "disorientation" and "memory impairment," negligible other DI symptoms), moderately ill (low "inattention" and "disorientation," medium "memory impairment"), clearly sick (low "disorganized thinking" and "altered level of consciousness," medium "inattention," "disorientation," "memory impairment" and "hypoactivity"), and very sick (low "hypoactivity," medium "altered level of consciousness," high "inattention," "disorganized thinking," "disorientation" and "memory impairment"). Four course types were also identified: stable, improvement, worsening, and non-monotone. Class order was associated with increasing cognitive impairment, frequency of both prevalent/incident delirium and dementia, mortality rate, and decreasing performance in ADL. CONCLUSION: Four ordered latent classes and four course types were found in LTC residents. These results are similar to those reported previously in acute care (AC); however, the proportion of very sick residents at enrolment was larger in LTC residents than in AC patients. In clinical settings, these findings could help identify participants with a chronic clinical disorder. Our HMC/LC approach may help understand coexistent disorders, e.g. delirium and dementia.

Pilot Study of a Transitional Intervention for Family Caregivers of Older Adults.

Objectif: Évaluation (faisabilité, acceptabilité, pertinence et bienfaits potentiels) d'une intervention de transition pour proches aidants. Méthode: L'intervention visait à fournir du soutien émotionnel, de l'information sur les ressources communautaires et du soutien au développement des capacités d'adaptation pour les proches aidants de patients de 65 ans et plus qui avaient reçu leur congé suite à une hospitalisation de courte durée. L'approche méthodologique a impliqué un seul groupe, qui a été évalué lors d'un pré-test et d'un post-test effectué trois mois après le début de l'intervention. Résultats: Quatre-vingt-onze dyades patients-proches ont été recrutées. Soixante-trois (69 %) proches aidants ont reçu les cinq séances d'intervention (tel que prévu) et 60 (66 %) proches aidants ont complété le test final. Une diminution significative de l'anxiété et de la dépression des proches aidants et un taux de satisfaction élevé ont été notés après l'intervention. Discussion: Cette intervention de transition pour les patients plus âgés et leurs proches aidants devrait faire l'objet d'une évaluation plus poussée, de préférence avec un groupe de contrôle, en tant qu'intervention autonome ou comme une composante d'une intervention de transition complète.Objective: To conduct a formative evaluation of a transitional intervention for family caregivers, with assessment of feasibility, acceptability, appropriateness, and potential benefits. Methods: The intervention aimed to provide emotional support, information on community resources, and information and support for development of coping skills for the caregivers of patients aged 65 and older who were to be discharged home from an acute medical hospital admission. We used a one-group, pre- and three-month post-test study design. Results: Ninety-one patient-caregiver dyads were recruited. Of these, 63 caregivers (69%) received all five planned intervention sessions, while 60 (66%) completed the post-test. There were significant reductions in caregiver anxiety and depression following the intervention, and high rates of satisfaction. Discussion: This transitional intervention should be further evaluated, preferably with a control group, either as a stand-alone intervention or as one component of a comprehensive transitional intervention for older patients and their caregivers.

Partial and no recovery from delirium after hospital discharge predict increased adverse events.

Background: The implications of partial and no recovery from delirium after hospital discharge are not clear. We sought to explore whether partial and no recovery from delirium among recently discharged patients predicted increased adverse events (emergency room visits, hospitalisations, death) during the subsequent 3 months. Method: Prospective study of recovery from delirium in older hospital inpatients. The Confusion Assessment Method was used to diagnose delirium in hospital and determine recovery status after discharge (T0). Adverse events were determined during the 3 months T0. Survival analysis to the first adverse event and counting process modelling for one or more adverse events were used to examine associations between recovery status (ordinal variable, 0, 1 or 2 for full, partial or no recovery, respectively) and adverse events. Results: Of 278 hospital inpatients with delirium, 172 were discharged before the assessment of recovery status (T0). Delirium recovery status at T0 was determined for 152: 25 had full recovery, 32 had partial recovery and 95 had no recovery. Forty-four patients had at least one adverse event during the subsequent 3 months. In multivariable analysis of one or more adverse events, poorer recovery status predicted increased adverse events; the hazard ratio (HR) (95% confidence interval, CI) was 1.72 (1.09, 2.71). The association of recovery status with adverse events was stronger among patients without dementia. Conclusion: Partial and no recovery from delirium after hospital discharge appear to predict increased adverse events during the subsequent 3 months These findings have potentially important implications for in-hospital and post-discharge management and policy.

Use of medications that antagonize mediators of inflammatory responses may reduce the risk of delirium in older adults: a nested case-control study.

OBJECTIVE: The objective of this study is to explore whether the use of medications that antagonize mediators of inflammatory responses reduces the risk of delirium in older adults. METHODS: A nested case-control study was conducted using data from a prospective study of delirium in older long-term care residents from 7 long-term care facilities in Montreal and Quebec City, Canada. The Confusion Assessment Method was used to diagnose incident delirium. The use of medications that antagonize mediators of inflammatory responses was determined by examining facility pharmacy databases and coding medications received daily by each resident. Risk sets were built using incidence density sampling: each risk set consisted of a case with incident delirium and all controls without incident delirium at the same date and facility. Conditional logistic regression was used to assess the association of exposure to inflammation antagonist medications with the incidence of delirium. RESULTS: Of 254 residents, 95 developed incident delirium during 24 weeks (cases); each case was matched with up to 35 controls. Unadjusted and adjusted odds ratios (95% CI) of delirium for residents exposed to at least one inflammation antagonist medication were 0.53 (0.34, 0.81) and 0.60 (0.38, 0.92), respectively. Estimates of the risk of incident delirium associated with specific medications and medication classes were mostly protective but not statistically significant. CONCLUSION: The use of medications that antagonize mediators of inflammatory responses may reduce the risk of delirium in older adults. Despite study limitations, the findings merit further investigation using larger patient samples, more precise measures of exposure and better control of potential confounding variables. Copyright © 2016 John Wiley & Sons, Ltd.

Longitudinal patterns of delirium severity scores in long-term care settings.

BACKGROUND: The delirium index (DI) is a valid measure of delirium severity. We proposed to describe longitudinal patterns of severity scores in older long-term care (LTC) residents. METHODS: A prospective cohort study of 280 residents in seven LTC facilities in Montreal and Quebec City, Canada, was conducted. DI, Barthel Index, Mini-Mental State Examination, Charlson Comorbidity Index, Cornell Scale for Depression in Dementia, dementia assessment by an MD, and prevalent or incident probable delirium defined according to the Confusion Assessment Method were completed at baseline. The DI was also assessed weekly for 6 months. Demographic characteristics were abstracted from resident charts. Cluster analysis for longitudinal data was used to describe longitudinal patterns of DI scores. RESULTS: During the 24 weeks following enrolment, 28 (10.0%) of 280 residents who had prevalent delirium and 76 (27.1%) who had incident delirium were included in our analysis. Average observation period was 18.3 weeks. Four basic types of time evolution patterns were discovered: Improvement, Worsening, Fluctuating, and Steady, including 22%, 18%, 25%, and 35%, of the residents, respectively. With the exception of the Worsening pattern, the average trajectory was stabilized at the 4th week or earlier. Poor baseline cognitive and physical function and greater severity of delirium predicted worse trajectories over 24 weeks. CONCLUSIONS: The longitudinal patterns of DI scores found in LTC residents resemble those found in an earlier study of delirium in acute care (AC) settings. However, compared to AC patients, LTC residents have a smaller DI variability over time, a less frequent Improvement pattern, and more frequent Worsening and Fluctuating patterns.

Association Between Chronic Physical Conditions and the Effectiveness of Collaborative Care for Depression: An Individual Participant Data Meta-analysis.

IMPORTANCE: Collaborative care is an intensive care model involving several health care professionals working together, typically a physician, a case manager, and a mental health professional. Meta-analyses of aggregate data have shown that collaborative care is particularly effective in people with depression and comorbid chronic physical conditions. However, only participant-level analyses can rigorously test whether the treatment effect is influenced by participant characteristics, such as chronic physical conditions. OBJECTIVE: To assess whether the effectiveness of collaborative care for depression is moderated by the presence, type, and number of chronic physical conditions. DATA SOURCES: Data were obtained from MEDLINE, EMBASE, PubMed, PsycINFO, CINAHL Complete, and Cochrane Central Register of Controlled Trials, and references from relevant systematic reviews. The search and collection of eligible studies was ongoing until May 22, 2015. STUDY SELECTION: This was an update to a previous meta-analysis. Two independent reviewers were involved in the study selection process. Randomized clinical trials that compared the effectiveness of collaborative care with usual care in adults with depression and reported measured changes in depression severity symptoms at 4 to 6 months after randomization were included in the analysis. Key search terms included depression, dysthymia, anxiety, panic, phobia, obsession, compulsion, posttraumatic, care management, case management, collaborative care, enhanced care, and managed care. DATA EXTRACTION AND SYNTHESIS: Individual participant data on baseline demographics and chronic physical conditions as well as baseline and follow-up depression severity symptoms were requested from authors of the eligible studies. One-step meta-analysis of individual participant data using appropriate mixed-effects models was performed. MAIN OUTCOMES AND MEASURES: Continuous outcomes of depression severity symptoms measured using self-reported or observer-rated measures. RESULTS: Data sets from 31 randomized clinical trials including 36 independent comparisons (N = 10 962 participants) were analyzed. Individual participant data analyses found no significant interaction effects, indicating that the presence (interaction coefficient, 0.02 [95% CI, -0.10 to 0.13]), numbers (interaction coefficient, 0.01 [95% CI, -0.01 to 0.02]), and types of chronic physical conditions do not influence the treatment effect. CONCLUSIONS AND RELEVANCE: There is evidence that collaborative care is effective for people with depression alone and also for people with depression and chronic physical conditions. Existing guidance that recommends limiting collaborative care to people with depression and physical comorbidities is not supported by this individual participant data meta-analysis.

Delirium in older adults: a chronic cognitive disorder?

Delirium is defined as a neurocognitive disorder characterized by sudden onset, fluctuating course, and disturbances in level of consciousness, attention, orientation, memory, thought, perception, and behavior (American Psychiatric Association, 2013). It occurs in hyperactive, hypoactive, or mixed forms in up to 50% of older hospital patients (Inouye et al., 2014) and 70% of older long-term care residents (McCusker et al., 2011), many with pre-existing dementia (Fick et al., 2002).

Activation and Self-Efficacy in a Randomized Trial of a Depression Self-Care Intervention.

OBJECTIVES: In a sample of primary care participants with chronic physical conditions and comorbid depressive symptoms: to describe the cross-sectional and longitudinal associations of activation and self-efficacy with demographic, physical and mental health status, health behaviors, depression self-care, health care utilization, and use of self-care tools; and to examine the effects of a depression self-care coaching intervention on these two outcomes. Design/Study Setting. A secondary analysis of activation and self-efficacy data collected as part of a randomized trial to compare the effects of a telephone-based coached depression self-care intervention with a noncoached intervention. Activation (Patient Activation Measure) was measured at baseline and 6 months. Depression self-care self-efficacy was assessed at baseline, at 3 months, and at 6 months. PRINCIPAL FINDINGS: In multivariable cross-sectional analyses (n = 215), activation and/or self-efficacy were associated with language, birthplace, better physical and mental health, individual exercise, specialist visits, and antidepressant nonuse. In longitudinal analyses (n = 158), an increase in activation was associated with increased medication adherence; an increase in self-efficacy was associated with use of cognitive self-care strategies and increases in social and solitary activities. There were significant improvements from baseline to 6 months in activation and self-efficacy scores both among coached and noncoached groups. The self-care coaching intervention did not affect 6-month activation or self-efficacy but was associated with quicker improvement in self-efficacy. CONCLUSIONS: Overall, the results for activation and self-efficacy were similar, although self-efficacy correlated more consistently than activation with depression-specific behaviors and was responsive to a depression self-care coaching intervention.

A randomized trial of a depression self-care toolkit with or without lay telephone coaching for primary care patients with chronic physical conditions.

OBJECTIVE: The aim of this study was to compare outcomes of use of a depression self-care toolkit with and without lay telephone coaching among primary care patients 40 years and older with depressive symptoms and comorbid chronic physical conditions. METHOD: A single blind, individually randomized, pragmatic trial of a depression self-care toolkit (Toolkit) with or without lay telephone coaching was conducted among primary care adults with depressive symptoms and comorbid chronic physical conditions. Eligible patients were randomized to receive the Toolkit with (intervention) or without (control) telephone coaching provided by trained lay coaches. The primary outcome was depression severity [Patient Health Questionnaire (PHQ-9)] at 6 months. Secondary outcomes were self-efficacy, satisfaction, and use of health services at 6 months. RESULTS: A total of 223 patients were randomized, and 172 (77.1%) completed 6-month follow-ups. PHQ-9 scores improved significantly in both groups over the 6-month follow-up; the differences in PHQ-9 scores between intervention and control groups were statistically significant at 3 months [effect size = 0.43; 95% confidence interval (CI) = 0.15-0.70] but not at 6 months (effect size = 0.23; 95% CI = -0.04-0.59). Patients with moderate depression severity (PHQ-9 10-19) and high self-efficacy at baseline were most likely to benefit from the intervention. There was no significant effect of the intervention on the secondary outcomes. CONCLUSIONS: The incremental value of lay telephone coaching of a Toolkit appears short-lived. Targeting of coaching to those with moderate depression severity may be indicated.

Frequency of full, partial and no recovery from subsyndromal deliriumin older hospital inpatients.

OBJECTIVES: To determine the frequencies of full, partial and no recovery from subsyndromal delirium (SSD) in older hospital inpatients. A secondary objective was to compare the recovery status of patients with SSD or delirium. METHODS: SSD was defined as acute onset of one or more Confusion Assessment Method core symptoms of delirium (fluctuation, inattention, disorganized thinking and altered level of consciousness) not meeting criteria for delirium and not progressing to delirium. The recovery status of medical or surgical inpatients aged 65 and older with SSD was assessed approximately 1 and 3 months after enrolment. Primary outcome categories were full recovery (no core symptoms of delirium), partial recovery (presence of one or more core symptoms but fewer symptoms than at enrolment), no recovery (same number of core symptoms as at enrolment) or death. Nominal logistic regression was used to compare the recovery status of patients with SSD or delirium. RESULTS: Twenty-eight patients with SSD were enrolled. At the first follow-up, the frequencies of full, partial and no recovery and death were 40%, 12%, 32% and 16%, respectively; at the second follow-up, the frequencies were 54%, 8%, 21% and 17%, respectively. The frequency of full recovery was much higher in patients with SSD than delirium. CONCLUSION: Small study sample size notwithstanding, the majority (54%) of patients with SSD recovered fully, but a substantial proportion (29%) had a protracted course. It may be important to monitor the longer-term course of SSD and develop strategies to ensure full recovery in all patients.

Six-month trajectories of self-reported depressive symptoms in long-term care.

BACKGROUND: Depression is a common problem in long-term care (LTC) settings. We sought to characterize depression symptom trajectories over six months among older residents, and to identify resident characteristics at baseline that predict symptom trajectory. METHODS: This study was a secondary analysis of data from a six-month prospective, observational, and multi-site study. Severity of depressive symptoms was assessed with the 15-item Geriatric Depression Scale (GDS) at baseline and with up to six monthly follow-up assessments. Participants were 130 residents with a Mini-Mental State Examination score of 15 or more at baseline and of at least two of the six monthly follow-up assessments. Individual resident GDS trajectories were grouped using hierarchical clustering. The baseline predictors of a more severe trajectory were identified using the Proportional Odds Model. RESULTS: Three clusters of depression symptom trajectory were found that described "lower," "intermediate," and "higher" levels of depressive symptoms over time (mean GDS scores for three clusters at baseline were 2.2, 4.9, and 9.0 respectively). The GDS scores in all groups were generally stable over time. Baseline predictors of a more severe trajectory were as follows: Initial GDS score of 7 or more, female sex, LTC residence for less than 12 months, and corrected visual impairment. CONCLUSIONS: The six-month course of depressive symptoms in LTC is generally stable. Most residents who experience a more severe symptom trajectory can be identified at baseline.

Partial and No Recovery from Delirium in Older Hospitalized Adults: Frequency and Baseline Risk Factors.

OBJECTIVES: To determine the frequency and baseline risk factors for partial and no recovery from delirium in older hospitalized adults. DESIGN: Cohort study with assessment of recovery status approximately 1 and 3 months after enrollment. SETTING: University-affiliated, primary, acute-care hospital. PARTICIPANTS: Medical or surgical inpatients aged 65 and older with delirium (N = 278). MEASUREMENTS: The Mini-Mental State Examination (MMSE), Confusion Assessment Method (CAM), Delirium Index (DI), and activities of daily living (ADLs) were completed at enrollment and each follow-up. Primary outcome categories were full recovery (absence of CAM core symptoms of delirium), partial recovery (presence of ≥1 CAM core symptoms but not meeting criteria for delirium), no recovery (met CAM criteria for delirium), or death. Secondary outcomes were changes in MMSE, DI, and ADL scores between the baseline and last assessment. Potential risk factors included many clinical and laboratory variables. RESULTS: In participants with dementia, frequencies of full, partial, and no recovery and death at first follow-up were 6.3%, 11.3%, 74.6%, and 7.7%, respectively; in participants without dementia, frequencies were 14.3%, 17%, 50.9%, and 17.9%, respectively. In participants with dementia, frequencies at the second follow-up were 7.9%, 15.1%, 57.6%, and 19.4%, respectively; in participants without dementia, frequencies were 19.2%, 20.2%, 31.7%, and 28.8%, respectively. Frequencies were similar in participants with prevalent and incident delirium and in medical and surgical participants. The DI, MMSE, and ADL scores of many participants with partial and no recovery improved. Independent baseline risk factors for delirium persistence were chart diagnosis of dementia (odds ratio (OR) = 2.51, 95% confidence interval (CI) =1.38, 4.56), presence of any malignancy (OR = 5.79, 95% CI = 1.51, 22.19), and greater severity of delirium (OR =9.39, 95% CI = 3.95, 22.35). CONCLUSION: Delirium in many older hospitalized adults appears to be much more protracted than previously thought, especially in those with dementia, although delirium symptoms, cognition, and function improved in many participants with partial and no recovery. It may be important to monitor the longer-term course of delirium in older hospitalized adults and develop strategies to ensure full recovery.

A randomized trial of a depression self-care toolkit with or without lay telephone coaching for primary care patients with chronic physical conditions.

OBJECTIVE: The aim of this study was to compare outcomes of use of a depression self-care toolkit with and without lay telephone coaching among primary care patients 40 years and older with depressive symptoms and comorbid chronic physical conditions. METHOD: A single blind, individually randomized, pragmatic trial of a depression self-care toolkit (Toolkit) with or without lay telephone coaching was conducted among primary care adults with depressive symptoms and comorbid chronic physical conditions. Eligible patients were randomized to receive the Toolkit with (intervention) or without (control) telephone coaching provided by trained lay coaches. The primary outcome was depression severity [Patient Health Questionnaire (PHQ-9)] at 6 months. Secondary outcomes were self-efficacy, satisfaction, and use of health services at 6 months. RESULTS: A total of 223 patients were randomized, and 172 (77.1%) completed 6-month follow-ups. PHQ-9 scores improved significantly in both groups over the 6-month follow-up; the differences in PHQ-9 scores between intervention and control groups were statistically significant at 3 months [effect size = 0.44; 95% confidence interval (CI) = 0.16-0.72] but not at 6 months (effect size = 0.24; 95% CI = -0.01 to 0.60). Patients with moderate depression severity (PHQ-9 10-19) and high self-efficacy at baseline were most likely to benefit from the intervention. There was no significant effect of the intervention on the secondary outcomes. CONCLUSIONS: The incremental value of lay telephone coaching of a Toolkit appears short-lived. Targeting of coaching to those with moderate depression severity may be indicated.

Behavioral and psychological symptoms of dementia: how long does every behavior last, and are particular behaviors associated with PRN antipsychotic agent use?

Behavioral and psychological symptoms of dementia (BPSD) affect approximately all residents in nursing homes at some point; however, the course of BPSD among this group is not well known. The goal of the current study was to describe the course of each measured BPSD over a period of 6 months. A secondary explorative objective was to identify which BPSD are associated with as-needed (PRN) antipsychotic drug use. This secondary analysis study of 146 nursing home residents was drawn from a prospective, observational, multisite (N = 7) cohort study. Results showed that BPSD lasted for an average of 2.3 months, and the BPSD saying things that do not make sense had the longest duration, with 3.6 months. PRN antipsychotic drug administration was associated with nocturnal BPSD and requesting help unnecessarily. Within 3 months, most BPSD were resolved by usual care; use of PRN antipsychotic medication was not associated with behaviors that put the residents or their caregivers at risk.

Six-month outcomes of co-occurring delirium, depression, and dementia in long-term care.

OBJECTIVES: 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. DESIGN: Observational, prospective cohort study with 6-month follow-up conducted from 2005 to 2009. SETTING: Seven LTC facilities in the province of Quebec, Canada. PARTICIPANTS: Newly admitted and long-term residents recruited consecutively from lists of residents aged 65 and older admitted for LTC, with stratification into groups with and without severe cognitive impairment. The study sample comprised 274 residents with complete data at baseline on delirium, dementia, and depression. MEASUREMENTS: Outcomes were 6-month mortality, functional decline (10-point decline from baseline on 100-point Barthel scale), and cognitive decline (3-point decline on 30-point Mini-Mental State Examination). Predictors included delirium (full syndrome or subsyndromal symptoms, using the Confusion Assessment Method), depression (Cornell Scale for Depression in Dementia), and dementia (chart diagnosis). RESULTS: The baseline prevalences of delirium, subsyndromal symptoms of delirium (SSD), depression, and dementia were 11%, 44%, 19%, and 66%, respectively. By 6 months, 10% of 274 had died, 19% of 233 had experienced functional decline, and 17% of 246 had experienced cognitive decline. An analysis using multivariable generalized linear models found the following significant interaction effects (P < .15): between depression and dementia for mortality, between delirium and depression for functional decline, and between SSD and dementia for cognitive decline. CONCLUSION: Co-occurrence of delirium, SSD, depression, and dementia in LTC residents appears to affect some 6-month outcomes. Because of limited statistical power, it was not possible to draw conclusions about the effects of the co-occurrence of some syndromes on poorer outcomes.

Core symptoms not meeting criteria for delirium are associated with cognitive and functional impairment and mood and behavior problems in older long-term care residents.

BACKGROUND: The immediate clinical significance of Confusion Assessment Method (CAM)-defined core symptoms of delirium not meeting criteria for delirium is unclear. This study proposed to determine if such symptoms are associated with cognitive and functional impairment, mood and behavior problems and increased Burden of Care (BOC) in older long-term care (LTC) residents. METHODS: The study was a secondary analysis of data collected for a prospective cohort study of delirium. Two hundred and fifty-eight LTC residents aged 65 years and older in seven LTC facilities had monthly assessments (for up to six months) of CAM - defined core symptoms of delirium (fluctuation, inattention, disorganized thinking, and altered level of consciousness) and five outcome measures: Mini-Mental State Exam, Barthel Index, Cornell Scale for Depression, Nursing Home Behavioral Problems Scale, and Burden of Care. Associations between core symptoms and the five outcome measures were analyzed using generalized estimating equations. RESULTS: Core symptoms of delirium not meeting criteria for delirium among residents with and without dementia were associated with cognitive and functional impairment and mood and behavior problems but not increased BOC. The associations appear to be intermediate between those of full delirium and no core symptoms and were greater for residents with than without dementia. CONCLUSION: CAM-defined core symptoms of delirium not meeting criteria for delirium appear to be associated with cognitive and functional impairment and mood and behavior problems in LTC residents with or without dementia. These findings may have implications for the prevention and management of such impairments and problems in LTC settings.