Exploring Antipsychotic Use for Delirium Management in Adults in Hospital, Sub-Acute Rehabilitation and Aged Care Settings: A Systematic Literature Review.

BACKGROUND: International guidelines discourage antipsychotic use for delirium; however, concerns persist about their continued use in clinical practice. OBJECTIVES: We aimed to describe the prevalence and patterns of antipsychotic use in delirium management with regard to best-practice recommendations. Primary outcomes investigated were prevalence of use, antipsychotic type, dosage and clinical indication. METHODS: Eligibility criteria: studies of any design that examined antipsychotic use to manage delirium in adults in critical care, acute care, palliative care, rehabilitation, and aged care were included. Studies of patients in acute psychiatric care, with psychiatric illness or pre-existing antipsychotic use were excluded. INFORMATION SOURCES: we searched five health databases on 16 August, 2023 (PubMed, CINAHL, Embase, APA PsycInfo, ProQuest Health and Medical Collection) using MeSH terms and relevant keywords, including 'delirium' and 'antipsychotic'. Risk of bias: as no included studies were randomised controlled trials, all studies were assessed for methodological quality using the Mixed Methods Appraisal Tool. SYNTHESIS OF RESULTS: descriptive data were extracted in Covidence and synthesised in Microsoft Excel. RESULTS: Included studies: 39 studies published between March 2004 and August 2023 from 13 countries (n = 1,359,519 patients). Most study designs were retrospective medical record audits (n = 16). SYNTHESIS OF RESULTS: in 18 studies, participants' mean age was ≥65 years (77.79, ±5.20). Palliative care had the highest average proportion of patients with delirium managed with antipsychotics (70.87%, ±33.81%); it was lower and varied little between intensive care unit (53.53%, ±19.73%) and non-intensive care unit settings [medical, surgical and any acute care wards] (56.93%, ±26.44%) and was lowest in in-patient rehabilitation (17.8%). Seventeen different antipsychotics were reported on. In patients aged ≥65 years, haloperidol was the most frequently used and at higher than recommended mean daily doses (2.75 mg, ±2.21 mg). Other antipsychotics commonly administered were olanzapine (mean 11 mg, ±8.54 mg), quetiapine (mean 64.23 mg, ±43.20 mg) and risperidone (mean 0.97 mg, ±0.64 mg). CONCLUSIONS: The use of antipsychotics to manage delirium is strongly discouraged in international guidelines. Antipsychotic use in delirium care is a risk for adverse health outcomes and a longer duration of delirium, especially in older people. However, this study has provided evidence that clinicians continue to use antipsychotics for delirium management, the dose, frequency and duration of which are often outside evidence-based guideline recommendations. Clinicians continue to choose antipsychotics to manage delirium symptoms to settle agitation and maintain patient and staff safety, particularly in situations where workload pressures are high. Sustained efforts are needed at the individual, team and organisational levels to educate, train and support clinicians to prioritise non-pharmacological interventions early before deciding to use antipsychotics. This could prevent delirium and avert escalation in behavioural symptoms that often lead to antipsychotic use.

Appraisal of the quality of care of older adults with cognitive impairment in the emergency department.

The medical records of 273 patients 75 years and older were reviewed to evaluate quality of emergency department (ED) care through the use of quality indicators. One hundred fifty records contained evidence of an attempt to carry out a cognitive assessment. Documented evidence of cognitive impairment (CI) was reported in 54 cases. Of these patients, 30 had no documented evidence of an acute change in cognitive function from baseline; of 26 patients discharged home with preexisting CI (i.e., no acute change from baseline), 15 had no documented evidence of previous consideration of this issue by a health care provider; and 12 of 21 discharged patients who screened positive for cognitive issues for the first time were not referred for outpatient evaluation. These findings suggest that the majority of older adults in the ED are not receiving a formal cognitive assessment, and more than half with CI do not receive quality of care according to the quality indicators for geriatric emergency care. Recommendations for improvement are discussed.

Characteristics of older people with cognitive impairment attending emergency departments: A descriptive study.

OBJECTIVE: The objective of this paper is to describe the profile of older people with cognitive impairment (CI) presenting to emergency departments (EDs). METHODS: This was a multi-centre (n=8) observational study of a convenience sample of older (≥70y) ED patients (n=579). Participants were prospectively assessed for CI and surveyed for the duration of their ED stay (n=191). A picture of patients' health status and ED responses to care needs was obtained through application of standardised assessment tools. Additionally, observations of care processes in ED were undertaken. Demographic data were collected through both ED's information system and survey. Outcome data were collected 28 days post-ED visit using follow-up telephone interviews. RESULTS: Of 579 older persons, 191 (33%) persons met criteria for CI. The majority of older ED patients with CI in ED lived in the community (157/177, 88.7%), arrived by ambulance (116/172, 67%), were accompanied by a support person (94/149, 63%), were triaged as urgent to semi-urgent (157/191, 82%), and were hospitalised (108/172, 57%). The median ED length of stay was 6h. In ED, 53% of the sample experienced pain (92/173). Older ED patients with CI pose the following characteristics: prior hospital admissions (43/129, 33%), incontinence (61/178, 34%), dependence in activities in daily living (81/190, 43%), issues in nutrition (73/182, 40%), vision and hearing impairment (93% (160/172) and 26% (44/171) respectively). CONCLUSION: Increased understanding of these presenting characteristics and their impacts on patient risk facilitates tailoring the quality of emergency care to better suit the needs and improve outcomes of this increasing ED population.

Structural quality indicators to support quality of care for older people with cognitive impairment in emergency departments.

OBJECTIVES: The purpose of this study was to identify the structural quality of care domains and to establish a set of structural quality indicators (SQIs) for the assessment of care of older people with cognitive impairment in emergency departments (EDs). METHODS: A structured approach to SQI development was undertaken including: 1) a comprehensive search of peer-reviewed and gray literature focusing on identification of evidence-based interventions targeting structure of care of older patients with cognitive impairment and existing SQIs; 2) a consultative process engaging experts in the care of older people and epidemiologic methods (i.e., advisory panel) leading to development of a draft set of SQIs; 3) field testing of drafted SQIs in eight EDs, leading to refinement of the SQI set; and 4) an independent voting process among the panelists for SQI inclusion in a final set, using preestablished inclusion and exclusion criteria. RESULTS: At the conclusion of the process, five SQIs targeting the management of older ED patients with cognitive impairment were developed: 1) the ED has a policy outlining the management of older people with cognitive impairment during the ED episode of care; 2) the ED has a policy outlining issues relevant to carers of older people with cognitive impairment, encompassing the need to include the (family) carer in the ED episode of care; 3) the ED has a policy outlining the assessment and management of behavioral symptoms, with specific reference to older people with cognitive impairment; 4) the ED has a policy outlining delirium prevention strategies, including the assessment of patients' delirium risk factors; and 5) the ED has a policy outlining pain assessment and management for older people with cognitive impairment. CONCLUSIONS: This article presents a set of SQIs for the evaluation of performance in caring for older people with cognitive impairment in EDs.

Process quality indicators targeting cognitive impairment to support quality of care for older people with cognitive impairment in emergency departments.

OBJECTIVES: The objective of this study was to develop process quality indicators (PQIs) to support the improvement of care services for older people with cognitive impairment in emergency departments (ED). METHODS: A structured research approach was taken for the development of PQIs for the care of older people with cognitive impairment in EDs, including combining available evidence with expert opinion (phase 1), a field study (phase 2), and formal voting (phase 3). A systematic review of the literature identified ED processes targeting the specific care needs of older people with cognitive impairment. Existing relevant PQIs were also included. By integrating the scientific evidence and clinical expertise, new PQIs were drafted and, along with the existing PQIs, extensively discussed by an advisory panel. These indicators were field tested in eight hospitals using a cohort of older persons aged 70 years and older. After analysis of the field study data (indicator prevalence, variability across sites), in a second meeting, the advisory panel further defined the PQIs. The advisory panel formally voted for selection of those PQIs that were most appropriate for care evaluation. RESULTS: In addition to seven previously published PQIs relevant to the care of older persons, 15 new indicators were created. These 22 PQIs were then field tested. PQIs designed specifically for the older ED population with cognitive impairment were only scored for patients with identified cognitive impairment. Following formal voting, a total of 11 PQIs were included in the set. These PQIs targeted cognitive screening, delirium screening, delirium risk assessment, evaluation of acute change in mental status, delirium etiology, proxy notification, collateral history, involvement of a nominated support person, pain assessment, postdischarge follow-up, and ED length of stay. CONCLUSIONS: This article presents a set of PQIs for the evaluation of the care for older people with cognitive impairment in EDs. The variation in indicator triggering across different ED sites suggests that there are opportunities for quality improvement in care for this vulnerable group. Applied PQIs will identify an emergency services' implementation of care strategies for cognitively impaired older ED patients. Awareness of the PQI triggers at an ED level enables implementation of targeted interventions to improve any suboptimal processes of care. Further validation and utility of the indicators in a wider population is now indicated.