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 .

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.

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.

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.

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.

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.

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).

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.

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.

Subsyndromal delirium in older people: a systematic review of frequency, risk factors, course and outcomes.

OBJECTIVE: To determine the frequency, risk factors, course and outcomes of subsyndromal delirium (SSD) in older people by systematically reviewing evidence on these topics. METHODS: Subsyndromal delirium was defined as the presence of one or more symptoms of delirium, not meeting criteria for delirium and not progressing to delirium. MEDLINE, EMBASE, PsycINFO and the Web of Science were searched for potentially relevant articles published from 1996 to June 2011. The bibliographies of relevant articles were searched for additional references. Twelve studies met the inclusion criteria. The validity of included studies was assessed according to Evidence-Based Medicine criteria. Information about the study population and methods, age, gender, proportion with dementia, diagnostic criteria, period and frequency of observation, and the topics above was systematically abstracted, tabulated and synthesized using standard meta-analysis techniques. RESULTS: The combined prevalence of SSD was 23% (95% CI, 9-42%); the combined incidence was 13% (95% CI, 6-23%). Risk factors were similar to those for delirium. Episodes lasted up to 133 days and were often recurrent. Outcomes were poor and often intermediate between those of older people with or without delirium. Of note, there was significant unexplained heterogeneity in the results of studies of prevalence, incidence and some risk factors. CONCLUSIONS: SSD in older people may be a frequent and clinically important condition that falls on a continuum between no symptoms and full delirium. Because of significant unexplained heterogeneity in the results of studies of SSD, however, the results of this review must be interpreted cautiously. Further research is necessary.

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.

Risk factors for the late-onset psychoses: a systematic review of cohort studies.

BACKGROUND: Psychoses with onset in late adulthood are challenging. Identifying those older patients at risk would be clinically important and would have research implications. METHODS: A computer search was performed to identify all cohort studies of risk factor(s) for psychotic symptoms or disorders with onset at 40 years or older. Experts were contacted and bibliographies were screened for additional references. Validity of located studies was assessed according to evidence-based medicine criteria for risk factors studies. Data were extracted and tabulated for qualitative and quantitative analyses. RESULTS: Twelve articles were retrieved, corresponding to 11 studies of 32 potential risk factors. In the qualitative analysis, only the history of psychotic symptoms, cognitive problems, poor health status, visual impairment, and negative life events appeared to be significant risk factors of late-onset psychosis. Older age, female gender, and hearing impairment were not associated with psychosis in older patients. Quantitative analysis was feasible with only one item, female gender, and confirmed the lack of associated risk with late-onset psychosis. CONCLUSIONS: Despite the methodological limitations of the studies included in this review, there is some evidence from cohort studies that history of psychotic symptoms, cognitive problems, poor physical health, visual impairment, and negative life events are risk factors for late-onset psychosis. More long-term follow-up studies are needed to confirm these findings.

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.

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.

Prevalence and incidence of delirium in long-term care.

OBJECTIVES: (1) To describe the prevalence and 6-month incidence of delirium in long-term care facility (LTCF) residents age 65 and over; (2) To describe differences in these measures by resident baseline characteristics. METHODS: A multisite, prospective observational study was conducted in seven LTCFs in the province of Quebec, Canada. Residents of age 65 and over were recruited into two cohorts: Cohort A with a Mini-Mental State Examination (MMSE) score of 10 or more and Cohort B with an MMSE score of less than 10. Baseline resident measurements were obtained from research resident assessments, nurse interviews, and chart review. Weekly resident assessments for up to 24 weeks included the Confusion Assessment Method (CAM). RESULTS: Two hundred seventy-nine residents were recruited and completed baseline delirium assessments: 204 in Cohort A and 75 in Cohort B. The prevalence of delirium at baseline was 3.4% in Cohort A and 33.3% in Cohort B. The incidence of delirium among those without delirium at baseline (per 100 person-weeks of follow-up) was 1.6 in Cohort A and 6.9 in Cohort B. In multivariate analyses, a diagnosis of dementia, moderate to severe cognitive impairment, and depressive symptoms at baseline were associated with a greater prevalence and incidence of delirium. CONCLUSION: Delirium is an important clinical problem in LTCF residents, particularly among those with moderate to severe cognitive impairment at baseline.

Use of nurse-observed symptoms of delirium in long-term care: effects on prevalence and outcomes of delirium.

BACKGROUND: Previous studies have reported that nurse detection of delirium has low sensitivity compared to a research diagnosis. As yet, no study has examined the use of nurse-observed delirium symptoms combined with research-observed delirium symptoms to diagnose delirium. Our specific aims were: (1) to describe the effect of using nurse-observed symptoms on the prevalence of delirium symptoms and diagnoses in long-term care (LTC) facilities, and (2) to compare the predictive validity of delirium diagnoses based on the use of research-observed symptoms alone with those based on research-observed and nurse-observed symptoms. METHODS: Residents aged 65 years and over of seven LTC facilities were recruited into a prospective study. Using the Confusion Assessment Method (CAM), research assistants (RAs) interviewed residents and nurses to assess delirium symptoms. Delirium symptoms were also abstracted independently from nursing notes. Outcomes measured at five month follow-up were: death, the Hierarchic Dementia Scale (HDS), the Barthel ADL scale, and a composite outcome measure (death, or a 10-point decline in either the HDS or the ADL score). RESULTS: The prevalence of delirium among 235 LTC residents increased from 14.0% (using research-observed symptoms only) to 24.7% (using research- and nurse-observed symptoms). The relative risks (and 95% confidence intervals) for prediction of the composite outcome, after adjustment for covariates, were: 1.43 (0.88, 1.96) for delirium using research-observed symptoms only; 1.77 (1.13, 2.28) for delirium using research- and nurse-observed symptoms, in comparison with no delirium. CONCLUSIONS: The inclusion of delirium symptoms observed by nurses not only increases the detection of delirium in LTC facilities but improves the prediction of outcomes.

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.