Incidence and associations of hospital delirium diagnoses in 85,979 people with severe mental illness: A data linkage study.

INTRODUCTION: Delirium is an acute neuro-psychiatric disturbance precipitated by a range of physical stressors, with high morbidity and mortality. Little is known about its relationship with severe mental illness (SMI). METHODS: We conducted a retrospective cohort study using linked data analyses of the UK Clinical Practice Research Datalink (CPRD) and Hospital Episodes Statistics (HES) databases. We ascertained yearly hospital delirium incidence from 2000 to 2017 and used logistic regression to identify associations with delirium diagnosis in a population with SMI. RESULTS: The cohort included 249,047 people with SMI with median follow-up time in CPRD of 6.4 years. A total of 85,979 patients were eligible for linkage to HES. Delirium incidence increased from 0.04 (95% CI 0.02-0.07) delirium associated admissions per 100 person-years in 2000 to 1.05 (95% CI 0.93-1.17) per 100 person-years in 2017, increasing most notably from 2010 onwards. Delirium was associated with older age at study entry (OR 1.05 per year, 95% CI 1.05-1.06), SMI diagnosis of bipolar affective disorder (OR 1.66, 95% CI 1.44-1.93) or other psychosis (OR 1.56, 95% CI 1.35-1.80) relative to schizophrenia, and more physical comorbidities (OR 1.08 per additional comorbidity of the Charlson Comorbidity Index, 95% CI 1.02-1.14). Patients with delirium received more antipsychotic medication during follow-up (1-2 antipsychotics OR 1.65, 95% CI 1.44-1.90; >2 antipsychotics OR 2.49, 95% CI 2.12-2.92). CONCLUSIONS: The incidence of recorded delirium diagnoses in people with SMI has increased in recent years. Older people prescribed more antipsychotics and with more comorbidities have a higher incidence. Linked electronic health records are feasible for exploring hospital diagnoses such as delirium in SMI.

'I've never drunk very much water and I still don't, and I see no reason to do so': a qualitative study of the views of community-dwelling older people and carers on hydration in later life.

BACKGROUND: dehydration is associated with significant adverse outcomes in older people despite being largely preventable and treatable. Little research has focused on the views of community-dwelling older people on hydration, healthy drinking and the perceived importance of drinking well in later life. OBJECTIVES: to understand community-dwelling older people and informal carers' views on hydration in later life and how older people can be supported to drink well. METHODS: qualitative study using interviews and a focus group exploring hydration and nutrition in later life (24 older people at risk of malnutrition and dehydration, 9 informal carers) and thematic analysis. RESULTS: this article presents the findings on hydration alone. Four themes are presented: perceptions of healthy drinking, barriers to and facilitators of drinking in later life and supporting older people to drink well. The perceived importance of adequate hydration in later life was polarised. Concerns about urinary incontinence and knowledge gaps were significant barriers. Consideration of individual taste preference and functional capacity acted as facilitators. Distinct habitual drinking patterns with medications and meals exist within individuals. Many relied on thirst at other times or when fluid demands are greater (such as hot weather), a known unreliable prompt in later life. CONCLUSIONS: older people could be supported to drink well by building upon existing habitual drinking patterns. Primary care and public health should consider individual barriers, facilitators and tailored education. A multidisciplinary approach to promote hydration should be incorporated into care for older people with more complex needs.

Exploring the Views and Dietary Practices of Older People at Risk of Malnutrition and Their Carers: A Qualitative Study.

BACKGROUND: While malnutrition is an important cause of morbidity and mortality in older people, it is commonly under-recognised. We know little on the views of community-dwelling older people and their carers regarding the management of malnutrition. The aim of the study was: (a) to explore views and dietary practices of older people at risk of malnutrition and their carers; (b) to identify gaps in knowledge, barriers and facilitators to healthy eating in later life; (c) to explore potential interventions for malnutrition in primary care. METHODS: A qualitative study was performed using semi-structured interviews with participants recruited from four general practices and a carers' focus group in London. Community-dwelling people aged ≥75, identified as malnourished or at risk of malnutrition (n = 24), and informal carers of older people (n = 9) were interviewed. Data were analysed using thematic analysis. RESULTS: Older people at risk of malnutrition rarely recognise appetite or weight loss as a problem. Commonly held perceptions include that being thin is healthy and 'snacking' is unhealthy. Changes in household composition, physical or mental health conditions and cognitive impairment can lead to inadequate food intake. Most carers demonstrate an awareness of malnutrition, but also a lack of knowledge of what constitutes a nutritious diet. Although older people rarely seek any help, most would value advice from their GP/practice nurse, a dietitian or another trained professional. CONCLUSION: Older people at risk of malnutrition and their carers lack knowledge on nutritional requirements in later life but are receptive to intervention. Training for health professionals in delivering tailored dietary advice should be considered.

Non-pharmacological interventions for depression/anxiety in older adults with physical comorbidities affecting functioning: systematic review and meta-analysis.

OBJECTIVE: To review the effectiveness of non-pharmacological interventions in older adults with depression or anxiety and comorbidities affecting functioning. DESIGN: Systematic review and meta-analysis of randomized controlled trials, including searches of 10 databases (inception-Jul 2017). SETTING: Home/community. PARTICIPANTS: People aged 60 and over experiencing functional difficulties from physical or cognitive comorbidities and have symptoms or a diagnosis of depression and/or anxiety. INTERVENTIONS: Non-pharmacological interventions targeted at depression/anxiety. MEASUREMENTS: We extracted outcome data on depressive symptoms, quality of life, functioning, and service use. We used random effects meta-analysis to pool study data where possible. Two authors assessed the risk of bias using the Cochrane Risk of Bias tool. RESULTS: We identified 14 eligible trials including 2099 randomized participants and two subgroup analyses. Problem-solving therapy (PST) reduced short-term clinician-rated depressive symptoms (n = 5 trials, mean difference in Hamilton Depression Rating Scale score -4.94 [95% CI -7.90 to -1.98]) but not remission, with limited evidence for effects on functioning and quality of life. There was limited high-quality evidence for other intervention types. Collaborative care did not appear to affect depressive symptoms, functioning, or quality of life; and had mixed evidence for effects upon remission. No intervention consistently affected service use, but trials were limited by small sample sizes and short follow-up periods. No anxiety interventions were identified. CONCLUSION: PST may reduce depressive symptoms post-intervention in older people with depression and functional impairments. Collaborative care appears to have few effects in this population. Future research needs to assess cost-effectiveness, long-term outcomes, and anxiety interventions for this population.

TIME to think about delirium: improving detection and management on the acute medical unit.

Delirium affects 18%-35% patients in the acute hospital setting, yet is often neither detected nor managed appropriately. It is associated with increased risk of falls, longer hospital stay and increased morbidity and mortality rates. It is a frightening and unpleasant experience for both patients and their families. We used quality improvement tools and a multicomponent intervention to promote detection and improve management of delirium on the acute medical unit (AMU). We reviewed whether a delirium screening tool (4AT) had been completed for all patients aged over 65 years admitted to the AMU over 1 week. If delirium was detected, we assessed whether investigation and management was adequate as per national guidance. After baseline data collection, we delivered focused sessions of delirium education for doctors and nursing staff, including training on use of the 4AT tool and the TIME (Triggers, Investigate, Manage, Engage) management bundle. We introduced TIME checklists, an online delirium order set and created a bedside orientation tool. We collected data following the interventions and identified areas for further improvement. Following our first PDSA (Plan, Do, Study, Act) cycle, use of the 4AT screening tool improved from 40% to 61%. Adequate assessment for the causes of and exacerbating factors for delirium increased from 73% to 94% of cases. Use of personal orientation tools improved from 0% to 38%. In summary, a targeted staff education programme and practical aids for the ward have improved the screening and management of delirium on the AMU. This may be improved further through more frequent training sessions to account for regular change-over of junior doctors and through implementing a nursing champion for delirium.

Generation of osteoclasts from type 1 Gaucher patients and correlation with clinical and genetic features of disease.

Gaucher disease (GD) is a rare autosomal recessive disorder caused by deficient activity of ß-glucocerebrosidase resulting in the accumulation of glucosylceramide. Bone disease is a common feature with radiological evidence in up to 93% of patients. Severity of bone involvement ranges from osteoporosis to pathological fractures. The progressive course of type 1 GD is largely mitigated by treatment with enzyme replacement therapy (ERT) or substrate reduction. A number of studies have shown some patients suffer bone events while receiving ERT. Studies of biochemical markers of bone turnover have generated varied results and as a consequence are not generally used to assess bone disease in GD. In vitro osteoclast generation from peripheral blood samples of 74 Gaucher patients followed over a period of up to 10 years was correlated with bone events, reports of bone pain, anaemia, spleen status, bone mineral density, chitotriosidase activity, treatment with Gaucher specific therapies, bisphosphonates, mutation status and severity. Osteoclast generation, enumerated when cultured on glass, was significantly higher when differentiated from the peripheral blood of Gaucher patients which reported bone pain (116.4 ±â€¯18.0 vs 69.0 ±â€¯8.6, p < 0.01), had anaemia (153.7 ±â€¯34.9 vs 78.5 ±â€¯8.8, p < 0.01), had a splenectomy (137.6 ±â€¯41.1 vs 60.8 ±â€¯13.0, p < 0.05), versus those who did not. Osteoclast generation was also indicative of in vivo Gaucher specific therapy response as those naïve to therapy generated significantly more osteoclasts than those on therapy (111.2 ±â€¯35.8 vs 45.1 ±â€¯10.3, p < 0.05), as did patients receiving therapy but still suffering bone events (125.1 ±â€¯31.37 vs 45.1 ±â€¯10.33, p < 0.05). These findings demonstrate that the in vitro osteoclast assay may be a useful method for following bone disease progression in Gaucher patients.

Primary hyperparathyroidism presenting as acute psychosis secondary to hypercalcaemia requiring curative parathyroidectomy.

Primary hyperparathyroidism (PHPT) can cause hypercalcaemia secondary to a pathologically high secretion of parathyroid hormone. Rarely this can first manifest as acute psychosis. It is imperative to exclude organic causes of psychosis before labelling the psychosis as primarily psychological. If hypercalcaemia is revealed, investigation is required to elucidate the underlying cause whilst instigating treatment to lower serum calcium levels. If PHPT is the underlying pathology, subsequent treatment involves surgical exploration and resection of the parathyroid adenoma or hyperplasia.