Population-based analysis of non-operative management and treatment patterns in older women with estrogen receptor-positive breast cancer.

PURPOSE: To examine the proportion of older women with ER + HER2- breast cancer receiving non-operative management versus surgery, and to evaluate the use of axillary staging and adjuvant radiation in this population. METHODS: We queried the SEER database to identify all women aged 70 years or older with stage I-III ER + HER2- invasive breast cancer diagnosed between 2010 and 2016. We evaluated trends in non-operative management, breast surgery, axillary staging, and adjuvant radiation according to age at diagnosis. RESULTS: We identified 57,351 older women with ER + HER2- disease. Overall, 3538 (6.2%) of the cohort underwent non-operative management, 38,452 (67.0%) underwent breast-conserving surgery (BCS), and 15,361 (26.8%) underwent mastectomy. The proportion of patients undergoing non-operative management increased from 2.8% among 70-74-year-old women to 30.1% in those ≥ 90 years old (p < 0.001). In 53,813 women who underwent surgery, 36,850 (68.5%) underwent sentinel lymph node biopsy, while 10,861 (20.2%) underwent axillary lymph node dissection. Subgroup analysis of 29,032 older women undergoing BCS for stage I ER + HER2- breast cancer revealed a 14.2% rate of omission of axillary staging, increasing from 5.3% in those 70-74 years to 67.6% in those ≥ 90 years old (p < 0.001). Receipt of adjuvant radiation occurred in 63.3% of older women following BCS and 18% post-mastectomy, with similar trends towards omission in older age groups. CONCLUSION: Primary breast surgery remains the dominant management strategy for the majority of older women with ER + HER2- breast cancer. Omission of axillary staging and adjuvant radiation are used in a minority of eligible women undergoing breast conservation for early-stage disease.

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 .

A randomized phase II trial of geriatric assessment and management for older cancer patients.

PURPOSE: Geriatric assessment and management (GAM) can identify current health issues and recommend interventions to optimize well-being of older adults, but no randomized trial has yet been completed in oncology. Therefore, a randomized phase 2 trial was conducted. METHODS: A two-group parallel single-blinded randomized phase II trial ( ClinicalTrials.gov Identifier: NCT02222259) enrolled patients aged ≥70 years, diagnosed with stage 2-4 gastrointestinal, genitourinary, or breast cancer within 6 weeks of commencing chemotherapy at Princess Margaret Cancer Centre. The coprimary feasibility outcomes were the proportion of eligible patients enrolled and retained. The coprimary clinical outcomes were quality of life (QOL) (EORTC QLQ C30) and modification of cancer treatment. Descriptive and regression analyses using intent-to-treat analysis were conducted. RESULTS: Sixty-one persons (64%) agreed to participate (31 allocated to intervention arm and 30 to control group). In the control group, more participants died and refused follow-up. The benefit of intervention over control on QOL at 3 months was greater for those who survived 6 months (difference 9.28; 95% CI -10.35 to 28.91) versus those who survived only 3 months (difference 6.55; 95% CI -9.63 to 22.73). CONCLUSIONS: This trial showed that it was feasible to recruit and retain older adults for a GAM study. Those who survived at least 6 months seemed to receive a greater QOL benefit than those who died or withdrew.

The OptimaMed intervention to reduce inappropriate medications in nursing home residents with severe dementia: results from a quasi-experimental feasibility pilot study.

BACKGROUND: Medication regimens in nursing home (NH) residents with severe dementia should be frequently reviewed to avoid inappropriate medication, overtreatment and adverse drug events, within a comfort care approach. This study aimed at testing the feasibility of an interdisciplinary knowledge exchange (KE) intervention using a medication review guidance tool categorizing medications as either "generally", "sometimes" or "exceptionally" appropriate for NH residents with severe dementia. METHODS: A quasi-experimental feasibility pilot study with 44 participating residents aged 65 years or over with severe dementia was carried out in three NH in Quebec City, Canada. The intervention comprised an information leaflet for residents' families, a 90-min KE session for NH general practitioners (GP), pharmacists and nurses focusing on the medication review guidance tool, a medication review by the pharmacists for participating residents with ensuing team discussion on medication changes, and a post-intervention KE session to obtain feedback from team staff. Medication regimens and levels of pain and of agitation of the participants were evaluated at baseline and at 4 months post-intervention. A questionnaire for team staff explored perceived barriers and facilitators. Statistical differences in measures comparing pre and post-intervention were assessed using paired t-tests and Cochran's-Q tests. RESULTS: The KE sessions reached 34 NH team staff (5 GP, 4 pharmacists, 6 heads of care unit and 19 staff nurses). Forty-four residents participated in the study and were followed for a mean of 104 days. The total number of regular medications was 372 pre and 327 post-intervention. The mean number of regular medications per resident was 7.86 pre and 6.81 post-intervention. The odds ratios estimating the risks of using any regular medication or a "sometimes appropriate" medication post-intervention were 0.81 (95% CI: 0.71-0.92) and 0.83 (95% CI: 0.74-0.94), respectively. CONCLUSION: A simple KE intervention using a medication review guidance tool categorizing medications as being either "generally", "sometimes" or "exceptionally" appropriate in severe dementia was well received and accompanied by an overall reduction in medication use by NH residents with severe dementia. Levels of agitation were unaffected and there was no clinically significant changes in levels of pain. Staff feedback provided opportunities to improve the intervention.

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.

Assessment of inattention in the context of delirium screening: one size does not fit all!

BACKGROUND: Despite its high prevalence and deleterious consequences, delirium often goes undetected in older hospitalized patients and long-term care (LTC) residents. Inattention is a core symptom of this syndrome. The aim of this study was to explore the usefulness of ten simple and objective attention tests that would enable efficient delirium screening among this population. METHODS: This was a secondary analysis (n = 191) of a validation study conducted in one acute care hospital (ACH) and one LTC facility among older adults with, or without, cognitive impairment. The attention test tasks (n = 10) were drawn from the Concentration subscale the Hierarchic Dementia Scale (HDS). Delirium was defined as meeting the criteria for DSM-5 delirium. The Confusion Assessment Method (CAM) was used to determine the presence of delirium symptoms. RESULTS: The Months of the Year Backward (MOTYB) test, which 57% of participants completed successfully, showed the best balance between sensitivity and specificity (82.6%; 95% CI [61.2-95.0], and 62.5%; 95% CI [54.7-69.8] respectively) for the entire group. Subgroup analyses revealed that no test had both sensitivity and specificity over 50% in participants with cognitive impairment indicated in their medical chart. CONCLUSIONS: Our results revealed that these tests varied greatly in performance and none can be earmarked to become a single-item screening tool for delirium among older patients and residents with, or without, cognitive impairment. The presence of premorbid cognitive impairment may necessitate more extensive assessments of delirium, especially when a change in general status or mental state is observed.

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.

Recognizing acute delirium as part of your routine [RADAR]: a validation study.

BACKGROUND: Although detection of delirium using the current tools is excellent in research settings, in routine clinical practice, this is not the case. Together with nursing staff, we developed a screening tool (RADAR) to address certain limitations of existing tools, notably administration time, ease-of-use and generalizability. The purpose of this study was not only to evaluate the validity and reliability of RADAR but also to gauge its acceptability among the nursing staff in two different clinical settings. METHODS: This was a validation study conducted on three units of an acute care hospital (medical, cardiology and coronary care) and five units of a long-term care facility. A total of 142 patients and 51 residents aged 65 and over, with or without dementia, participated in the study and 139 nurses were recruited and trained to use the RADAR tool. Data on each patient/resident was collected over a 12-hour period. The nursing staff and researchers administered RADAR during the scheduled distribution of medication. Researchers used the Confusion Assessment Method to determine the presence of delirium symptoms. Delirium itself was defined as meeting the criteria for DMS-IV-TR delirium. Inter-rater reliability, convergent, and concurrent validity of RADAR were assessed. At study end, 103 (74%) members of the nursing staff completed the RADAR feasibility and acceptability questionnaire. RESULTS: Percentages of agreement between RADAR items that bedside nurses administered and those research assistants administered varied from 82% to 98%. When compared with DSM-IV-TR criterion-defined delirium, RADAR had a sensitivity of 73% and a specificity of 67%. Participating nursing staff took about seven seconds on average, to complete the tool and it was very well received (≥98%) overall. CONCLUSIONS: The RADAR tool proved to be efficient, reliable, sensitive and very well accepted by nursing staff. Consequently, it becomes an appropriate new option for delirium screening among older adults, with or without cognitive impairment, in both hospitals and nursing homes. Further projects are currently underway to validate the RADAR among middle-aged adults, as well as in newer clinical settings; home care, emergency department, medical intensive care unit, and palliative care.

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.

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.

The course of subsyndromal delirium in older long-term care residents.

OBJECTIVE: To determine the course of incident subsyndromal delirium (SSD) in older long-term care (LTC) residents. A secondary objective was to explore the use of a more restrictive definition of SSD on the findings of the study. DESIGN: Cohort study with repeated weekly assessments for up to 6 months. SETTING: Seven LTC facilities in Montreal and Quebec City, Canada. PARTICIPANTS: LTC residents aged 65 and more and free of delirium core symptoms at baseline. MEASURES: The Mini-Mental State Examination (MMSE), Confusion Assessment Method (CAM), Delirium Index (DI), Hierarchic Dementia Scale, and Barthel Index were completed at baseline. The MMSE, CAM, and DI were repeated weekly for 6 months. SSD1 required one or more CAM core symptoms; SSD2, a more restrictive definition, required two or more CAM core symptoms. RESULTS: Sixty-eight residents had 129 incident episodes of SSD1: 32 had one episode and 36 had two or more episodes. Episodes lasted 7 - 133 days, mean 13.7 (SD: 14.8) days; mean number of symptoms per episode was 1.1 (SD: 0.4). Rates of recovery at 1, 2, and 4 weeks and 6 months were 45.7%, 61.2%, 64.6%, and 78.3%, respectively. Thirty-three residents had 49 episodes of SSD2: 21 had 1 episode and 12 had 2 or more episodes. Use of the more restrictive definition significantly increased time to recovery and reduced rate of recovery. CONCLUSION: Episodes of SSD in older LTC residents appeared to last 7-133 days (mean: 13.7) and were often recurrent. Use of a more restrictive definition resulted in a more protracted course.

The fall rate of older community-dwelling cancer patients.

PURPOSE: Little is known about the incidence of falls in cancer patients receiving cancer treatment. The aims were to explore the number of falls older adults report in the 6 months after cancer diagnosis, and if those with a fall were more frail than those who did not fall. METHODS: Secondary data analysis of a prospective pilot study that recruited patients aged 65 and older with a new cancer diagnosis. At each interview (baseline, 3- and 6-month follow-up), participants were asked if they had a fall in the previous 3 months. The frailty markers and functional status were obtained at baseline, 3- and 6-month follow-up. Chi-square and t tests were used to compare those who had a fall to those who had no fall. Univariate logistic regression analysis was conducted to explore the association between sociodemographic and health characteristics and reporting a fall. RESULTS: Seventeen participants (18.7%) reported one or more falls in the first 6 months after cancer diagnosis. Fifteen participants reported one or more falls in the 3 months prior to the cancer diagnosis. Those who had a fall and those with no fall were not different in terms of health and functioning. None of the sociodemographic and health characteristics including the frailty markers were associated with a fall. CONCLUSION: A fall is common in cancer patients. More research is needed to examine the risk factors for a fall in older adults receiving cancer treatment.

Symptoms of delirium predict incident delirium in older long-term care residents.

BACKGROUND: Detection of long-term care (LTC) residents at risk of delirium may lead to prevention of this disorder. The primary objective of this study was to determine if the presence of one or more Confusion Assessment Method (CAM) core symptoms of delirium at baseline assessment predicts incident delirium. Secondary objectives were to determine if the number or the type of symptoms predict incident delirium. METHODS: The study was a secondary analysis of data collected for a prospective study of delirium among older residents of seven LTC facilities in Montreal and Quebec City, Canada. The Mini-Mental State Exam (MMSE), CAM, Delirium Index (DI), Hierarchic Dementia Scale, Barthel Index, and Cornell Scale for Depression were completed at baseline. The MMSE, CAM, and DI were repeated weekly for six months. Multivariate Cox regression models were used to determine if baseline symptoms predict incident delirium. RESULTS: Of 273 residents, 40 (14.7%) developed incident delirium. Mean (SD) time to onset of delirium was 10.8 (7.4) weeks. When one or more CAM core symptoms were present at baseline, the Hazard Ratio (HR) for incident delirium was 3.5 (95% CI = 1.4, 8.9). The HRs for number of symptoms present ranged from 2.9 (95% CI = 1.0, 8.3) for one symptom to 3.8 (95% CI = 1.3, 11.0) for three symptoms. The HR for one type of symptom, fluctuation, was 2.2 (95% CI = 1.2, 4.2). CONCLUSION: The presence of CAM core symptoms at baseline assessment predicts incident delirium in older LTC residents. These findings have potentially important implications for clinical practice and research in LTC settings.

Predictors and effects of toxicity experienced by older adults with cancer receiving systemic therapy in a randomized clinical trial of geriatric assessment.

INTRODUCTION: Older adults represent a large segment of the oncology population, however, they remain underrepresented in clinical research. Treatment of older adults is often extrapolated using data from younger and fitter patients, which may not be appropriate. Furthermore the implications of toxicity from treatment can be greater for this population. Predicting toxicity from treatment and its effect on quality of life and functional status for older adults therefore is important. MATERIALS AND METHODS: We analyzed data from a clinical trial of geriatric assessment and management for Canadian elders with cancer (5C study). We assessed whether the baseline Cancer and Aging Research Group (CARG) toxicity score, G8 score, and Eastern Cooperative Oncology Group (ECOG) performance predicted grade 3-5 toxicity using logistic regression and pattern mixture models. We also assessed the impact of toxicity on quality of life and functional decline. Patients were followed for six months. RESULTS: Three hundred sixteen patients were included. Mean age was 76 years old and 40% of patients were female. One hundred nineteen patients (38%) experienced at least one grade 3-5 toxicity. Neither the CARG toxicity score, G8, or ECOG were predictive of grade 3-5 toxicity. Patients who experienced grade 3-5 toxicity were more likely to have functional impairments over time (odds ratio 3.71, p = 0.03). However, they maintained their quality of life. DISCUSSION: In this secondary analysis of a randomized controlled trial of geriatric assessment and management we did not find any predictors of grade 3-5 toxicity. Patients who did experience toxicity were more likely to report functional decline over time. Older adults who do experience treatment related toxicity may benefit from increased supports. CLINICAL TRIAL INFORMATION: NCT0315467.

Implementing geriatric assessment and management for older Canadians with cancer: Adherence to and satisfaction with the intervention, results of the 5C study.

INTRODUCTION: Geriatric assessment and management (GAM) is recommended by professional organizations and recently several randomized controlled trials (RCTs) demonstrated benefits in multiple health outcomes. GAM typically leads to one or more recommendations for the older adult on how to optimize their health. However, little is known about how well recommendations are adhered to. Understanding these issues is vital to designing GAM trials and clinical programs. Therefore, the aim of this study was to examine the number of GAM recommendations made and adherence to and satisfaction with the intervention in a multicentre RCT of GAM for older adults with cancer. MATERIALS AND METHODS: The 5C study was a two-group parallel RCT conducted in eight hospitals across Canada. Each centre kept a detailed recruitment and retention log. The intervention teams documented adherence to their recommendations. Medical records were also reviewed to assess which recommendations were adhered to. Twenty-three semi-structured interviews were conducted with 12 members of the intervention teams and 11 oncology team members to assess implementation of the study and the intervention. RESULTS: Of the 350 participants who were enrolled, 173 were randomized to the intervention arm. Median number of recommendations was seven. Mean adherence to recommendations based on the GAM was 69%, but it varied by type of recommendation, ranging from 98% for laboratory tests to 28% for psychosocial/psychiatry oncology referrals. There was no difference in the number of recommendations or non-adherence to recommendations by sex, level of frailty, or functional status. Oncologists and intervention team members were satisfied with the study implementation and intervention delivery. DISCUSSION: Adherence to recommendations was variable. Adherence to laboratory investigations and further imaging were generally high but much lower for recommendations regarding psychosocial support. Further collaborative work with older adults with cancer is needed to understand how to optimize the intervention to be consistent with patient goals, priorities, and values to ensure maximal impact on health outcomes.

Impact of Geriatric Assessment and Management on Quality of Life, Unplanned Hospitalizations, Toxicity, and Survival for Older Adults With Cancer: The Randomized 5C Trial.

PURPOSE: American Society of Clinical Oncology recommends that older adults with cancer being considered for chemotherapy receive geriatric assessment (GA) and management (GAM), but few randomized controlled trials have examined its impact on quality of life (QOL). PATIENTS AND METHODS: The 5C study was a two-group parallel 1:1 single-blind multicenter randomized controlled trial of GAM for 6 months versus usual oncologic care. Eligible patients were age 70+ years, diagnosed with a solid tumor, lymphoma, or myeloma, referred for first-/second-line chemotherapy or immunotherapy or targeted therapy, and had an Eastern Cooperative Oncology Group performance status of 0-2. The primary outcome QOL was measured with the global health scale of the European Organisation for the Research and Treatment of Cancer QOL questionnaire and analyzed with a pattern mixture model using an intent-to-treat approach (at 6 and 12 months). Secondary outcomes included functional status, grade 3-5 treatment toxicity; health care use; satisfaction; cancer treatment plan modification; and overall survival. RESULTS: From March 2018 to March 2020, 350 participants were enrolled. Mean age was 76 years and 40.3% were female. Fifty-four percent started treatment with palliative intent. Eighty-one (23.1%) patients died. GAM did not improve QOL (global QOL of 4.4 points [95% CI, 0.9 to 8.0] favoring the control arm). There was also no difference in survival, change in treatment plan, unplanned hospitalization/emergency department visits, and treatment toxicity between groups. CONCLUSION: GAM did not improve QOL. Most intervention group participants received GA on or after treatment initiation per patient request. Considering recent completed trials, GA may have benefit if completed before treatment selection. The COVID-19 pandemic may have affected our QOL outcome and intervention delivery for some participants.

Development of a delirium risk screening tool for long-term care facilities.

OBJECTIVE: The aim of this study is to develop a delirium risk screening tool for use in long-term care (LTC) facilities. METHODS: The sample comprised residents aged 65 years and over of seven LTC facilities in Montreal and Quebec City, Canada, admitted for LTC. Primary analyses were conducted among residents without delirium at baseline. Incident delirium was diagnosed using multiple data sources during the 6-month follow-up. Risk factors, all measured at or prior to baseline, included the following six groups: sociodemographic, medical, cognitive status, physical function, agitated behavior, and symptoms of depression. Variables were analyzed individually and by group using Cox regression models. Clinical judgment was used to select the most feasible among similarly performing factors. RESULTS: The cohort comprised 206 residents without delirium at baseline; 69 cases of incident delirium were observed (rate 7.6 per 100 person weeks). The best-performing screening tool comprised five items, with an overall area under the curve of 0.82 (95% CI 0.76, 0.88). These items included brief measures of cognitive status, physical function, behavioral, and emotional problems. Using cut-points of 2 (or 3) over 5, the scale has a sensitivity of 90% (63%), specificity of 59% (85%), and positive predictive value of 52% (66%). CONCLUSIONS: This brief screening tool allows nurses to identify LTC residents at increased risk for delirium. These residents can be targeted for closer monitoring and preventive interventions.

The course of delirium in older long-term care residents.

OBJECTIVE: The purpose of this study was to determine the course of delirium in older long-term care (LTC) residents. METHODS: A prospective cohort study of 279 residents in seven LTC facilities in Montreal and Quebec City, Canada, was conducted. The Mini Mental State Examination (MMSE), Confusion Assessment Method (CAM), Delirium Index (DI), Hierarchic Dementia Scale, Barthel Index, and Cornell Scale for Depression were completed at baseline. The MMSE, CAM, and DI were repeated weekly for 6 months. Information on medical problems and medication was abstracted from resident charts. Data were analyzed using descriptive statistics, Cox proportional hazard regression, and logistic regression. RESULTS: Of the 279 residents, 41 (14.7%) had 61 CAM-defined incident episodes of delirium: 28 (10%) had one episode and 13 (4.7%) had two or more episodes. Episode duration was 7-63 days, mean, 11.3 (SD, 10.1) days. The mean episode DI score was 11.5 (SD, 3.5). Rates of recovery at 1, 2, 4, and 24 weeks were 57.4%, 67.2% 77.1%, and 80.3%, respectively. Most episodes were preceded or followed by one or more CAM core symptoms of delirium, sometimes lasting many weeks. CONCLUSIONS: Confusion Assessment Method-defined incident episodes of delirium in older LTC residents appear to last longer than episodes in acute care hospital patients, but rates of recovery at 4 and 24 weeks are similar. Notably, most episodes were preceded or followed by one or more CAM core symptoms of delirium. These findings have implications for clinical practice and research in LTC settings.

A long-term care center interdisciplinary education program for antipsychotic use in dementia: program update five years later.

BACKGROUND: While antipsychotic (AP) medications are frequently used in long-term care, current evidence suggests that the risks may offset the benefits, necessitating periodic reassessment of their use. The aims of this present study were: (1) to assess rates of AP use five years after our first intervention to determine the long-term impact; and (2) to implement an updated AP reduction educational intervention program at the same center five years later in order to determine whether AP use could be further reduced. METHODS: Participants were residents with dementia receiving AP medication. The educational program component included separate lectures on pharmacologic and non-pharmacologic treatment of behavioral and psychological symptoms of dementia (BPSD). Completion of the Nursing Home Behavior Problems Scale (NHBPS), physician interviews concerning AP treatment plans for subjects with dementia, and AP administration and dose assessment occurred both at baseline and again between four to five months after the educational program. RESULTS: Of 308 long-term residents with dementia, 53 (17.2%) were receiving regular APs, primarily for agitation, aggressivity, other behavioral problems and psychosis. Of these, six died and one was transferred, leaving 46 participants. At five months, ten (21.7%) residents were no longer receiving APs and seven (15.2%) were on a lower dose; thus, 17 (37.0%) were either discontinued or on a lower dose. There was no worsening of NHBPS scores. CONCLUSION: Despite the low prevalence (17.2%) of AP users at the beginning of the current study compared to that observed five years prior (30.5%), it is still possible to further decrease the proportion of users.

Prodrome of delirium among long-term care residents: what clinical changes can be observed in the two weeks preceding a full-blown episode of delirium?

BACKGROUND: Delirium among long-term care (LTC) residents is frequent and is associated with increased morbidity and mortality. Identification of clinical changes during the prodromal phase of delirium could lead to prevention of a full-blown episode and perhaps limit the deleterious consequences of this syndrome. The aim of the present study was to identify clinical changes observable in the 2-week period prior to the onset of full-blown delirium. METHODS: Long-term care (LTC) residents aged 65 years and over, with or without dementia were eligible for this nested case-control study. Delirium was assessed weekly over a 6-month period using the Confusion Assessment Method. Cases with incident delirium were matched by time since enrollment to one or more controls without delirium. RESULTS: When compared to the controls, LTC residents who developed delirium (cases = 85) were more likely to have new-onset perceptual disturbances (OR = 4.75; 95% CI 1.65-13.66) and disorganized thinking (OR = 3.09; 95% CI 1.33-7.19) and a worsening of the Mini-Mental State Examination (MMSE) item measuring registration (OR = 2.59; 95% CI 1.24-5.41) during the preceding 2 weeks. However, the frequency of these changes was low. Residents with at least 3 clinical changes were more likely to develop delirium than those without any clinical change (OR = 2.52; 95% CI 1.08-5.87). CONCLUSIONS: This study provides evidence of clinical changes during the prodromal phase of delirium among LTC residents. More studies are needed to further explore the role and relevance of these clinical changes as warning signs of imminent delirium.