Why We Must Prevent and Appropriately Manage Delirium.

Delirium is common and increases in prevalence with age and medical complexity. A form of acute brain dysfunction, its presence is associated with significant morbidity, such as cognitive impairment, decreased mobility, depression, and institutionalization, as well as mortality. Many organizations have developed clinical protocols to prevent and treat delirium and what are called "cognitive-friendly" policies to care for elderly patients.

Fact Check: Assessing the Response of ChatGPT to Alzheimer's Disease Statements with Varying Degrees of Misinformation.

Background: There are many myths regarding Alzheimer's disease (AD) that have been circulated on the Internet, each exhibiting varying degrees of accuracy, inaccuracy, and misinformation. Large language models such as ChatGPT, may be a useful tool to help assess these myths for veracity and inaccuracy. However, they can induce misinformation as well. The objective of this study is to assess ChatGPT's ability to identify and address AD myths with reliable information. Methods: We conducted a cross-sectional study of clinicians' evaluation of ChatGPT (GPT 4.0)'s responses to 20 selected AD myths. We prompted ChatGPT to express its opinion on each myth and then requested it to rephrase its explanation using a simplified language that could be more readily understood by individuals with a middle school education. We implemented a survey using Redcap to determine the degree to which clinicians agreed with the accuracy of each ChatGPT's explanation and the degree to which the simplified rewriting was readable and retained the message of the original. We also collected their explanation on any disagreement with ChatGPT's responses. We used five Likert-type scale with a score ranging from -2 to 2 to quantify clinicians' agreement in each aspect of the evaluation. Results: The clinicians (n=11) were generally satisfied with ChatGPT's explanations, with a mean (SD) score of 1.0(±0.3) across the 20 myths. While ChatGPT correctly identified that all the 20 myths were inaccurate, some clinicians disagreed with its explanations on 7 of the myths.Overall, 9 of the 11 professionals either agreed or strongly agreed that ChatGPT has the potential to provide meaningful explanations of certain myths. Conclusions: The majority of surveyed healthcare professionals acknowledged the potential value of ChatGPT in mitigating AD misinformation. However, the need for more refined and detailed explanations of the disease's mechanisms and treatments was highlighted.

Geriatrics Fellows Learning Online And Together (Geri-a-FLOAT): A sustainable model of learning and support.

BACKGROUND: Geriatrics Fellows Learning Online And Together (Geri-a-FLOAT) is a virtual curriculum designed to convene fellows nationwide for learning and peer support. This paper presents the expansion and evaluation of the program from the "Wave 1" pilot to the "Wave 2" year-long curriculum. METHODS: Kern's six-step approach to curriculum development was used to develop the Wave 2 curriculum. Participation was collected via Zoom. Post-session web-based surveys evaluated participant satisfaction regarding speaker, content, and overall session quality; intent-to-change; and a free-response section. A one-year follow-up survey sent to participants with valid e-mail addresses assessed sustained knowledge, skills, and behavior change. RESULTS: Nineteen sessions were held with mean (SD) of 23 (13) participants per session, totaling 182 unique participants. Fifteen of 19 sessions were evaluated with 96 evaluations completed (mean [SD] 6 [4] evaluations per session). Mean (SD) ratings per session that were excellent or above average was 100% (0) for content, 99% (4) for speaker, and 99% (4) overall. Mean (SD) evaluations per session noting intent to change was 90% (14). Respondents reported helpful aspects as sharing resources and examples, perspectives and experiences of others, professional connections, and collaborative discussion. Of 127 participants with valid e-mail addresses, 40 (response rate = 31%) completed the one-year follow-up survey. Mean (SD) respondents reporting some or significant sustained impact was 89% (7) across all learning outcomes. CONCLUSIONS: This virtual, national curriculum for geriatrics fellows was well-received and associated with high rates of self-reported, sustained impact one-year post curriculum. Geri-a-FLOAT may be a model to standardize education and build collaboration and peer support across a discipline.

Caregivers' experience with Tele-Savvy Caregiver Program post-hospitalization.

Despite the frequent hospitalizations and readmissions of persons living with dementia (PLWD), no telehealth transitional care interventions focus on PLWDs' unpaid caregivers. Tele-Savvy Caregiver Program is a 43-day evidence-based online psychoeducational intervention for PLWDs' caregivers. The aim of this formative evaluation was to explore caregivers' acceptability of and experience with their participation in Tele-Savvy after their PLWDs' hospital discharge. Additionally, we gathered caregivers' feedback on the recommended features of a transitional care intervention, suitable for caregivers' schedule and needs post-discharge. Fifteen caregivers completed the interviews. Data were analyzed via conventional content analysis. Four categories were identified: (1) Tele-Savvy improved participants' understanding of dementia and caregiving; (2) hospitalization started a "new level of normal"; (3) PLWDs' health concerns; and (4) transitional care intervention development. Participation in Tele-Savvy was acceptable for most caregivers. Participants' feedback provides content and structural guidance for the development of a new transitional care intervention for PLWDs' caregivers.

Effect of physical and occupational therapy on delirium duration in older emergency department patients who are hospitalized.

Objective: Delirium in older emergency department (ED) adults is associated with poorer long-term physical function and cognition. We sought to evaluate if the time to and intensity of physical and/or occupational therapy (PT/OT) are associated with the duration of ED delirium into hospitalization (ED delirium duration). Methods: This is a secondary analysis of a prospective cohort study conducted from March 2012 to November 2014 at an urban, academic, tertiary care hospital. Patients aged ≥65 years presenting to the ED and who received PT/OT during their hospitalization were included. Days from enrollment to the first PT/OT session and PT/OT duration relative to hospital length of stay (PT/OT intensity) were abstracted from the medical record. ED delirium duration was defined as the duration of delirium detected in the ED using the Brief Confusion Assessment Method. Data were analyzed using a proportional odds logistic regression adjusted for multiple variables. Adjusted odds ratios (ORs) were calculated with 95% confidence intervals (95%CI). Results: The median log PT/OT intensity was 0.5% (interquartile range [IQR]: 0.3%, 0.9%) and was associated with shorter delirium duration (adjusted OR, 0.39; 95% CI, 0.21-0.73). The median time to the first PT/OT session was 2 days (IQR: 1, 3 days) and was not associated with delirium duration (adjusted OR, 1.02; 95% CI, 0.82-1.27). Conclusion: In older hospitalized adults, higher PT/OT intensity may be a useful intervention to shorten delirium duration. Time to first PT/OT session was not associated with delirium duration but was initiated a full 2 days after the ED presentation.

Improving the assessment and documentation of patient mobility using a quality improvement framework.

OBJECTIVE: To implement a system for assessing and documenting patient mobility in an inpatient geriatric unit using a quality improvement framework. METHODS: Whiteboards incorporating the Johns Hopkins Highest Level of Mobility scale were placed on each door of the unit. Staff were trained to assess and document patient mobility, and documentation compliance was measured. Nurses were surveyed to assess perceived burden of the system. Fall rates were calculated and analyzed for change from baseline. RESULTS: Median daily documentation rates reached 79% by the end of the project. Surveys indicated a low perceived burden of the system. Fall rates did not increase when compared to the previous year baseline (p = 0.80) and the analogous time frames during the previous two years (p = 0.84). CONCLUSION: A quality improvement framework may be used to improve mobility assessment and documentation in a geriatric unit without increasing patient falls or nursing burden.

Delirium Assessment in Critically Ill Older Adults: Considerations During the COVID-19 Pandemic.

Older adults are particularly vulnerable during the Coronavirus disease 2019 (COVID-19) pandemic, because higher age increases risk for both delirium and COVID-19-related death. Despite the health care system limitations and the clinical challenges of the pandemic, delirium screening and management remains an evidence-based cornerstone of critical care. This article discusses practical recommendations for delirium screening in the COVID-19 pandemic era, tips for training health care workers in delirium screening, validated tools for detecting delirium in critically ill older adults, and approaches to special populations of older adults (eg, sensory impairment, dementia, acute neurologic injury).

A randomized trial of a specialist palliative care intervention for patients undergoing surgery for cancer: rationale and design of the Surgery for Cancer with Option of Palliative Care Expert (SCOPE) Trial.

BACKGROUND: In medical oncology settings, early specialist palliative care interventions have demonstrated improvements in patient quality of life and survival compared with usual oncologic care. However, the effect of early specialist palliative care interventions in surgical oncology settings is not well studied. METHODS: The Surgery for Cancer with Option for Palliative Care Expert (SCOPE) Trial is a single-center, prospective, single-blind, randomized controlled trial of a specialist palliative care intervention for cancer patients undergoing non-palliative surgery. It will enroll 236 patients scheduled for major abdominal operations for malignancy, who will be randomized 1:1 at enrollment to receive usual care (control arm) or specialist palliative care consultation (intervention arm). Intervention arm patients will receive consultations from a palliative care specialist (physician or nurse practitioner) preoperatively and postoperatively. The primary outcome is physical and functional wellbeing at 90 days postoperatively. Secondary outcomes are quality of life at 90 days postoperatively, posttraumatic stress disorder symptoms at 180 days postoperatively, days alive at home without an emergency room visit in the first 90 postoperative days, and overall survival at 1 year postoperatively. Participants will be followed for 3 years after surgery for exploratory analyses of their ongoing quality of life, healthcare utilization, and mortality. DISCUSSION: SCOPE is an ongoing randomized controlled trial evaluating specialist palliative care interventions for cancer patients undergoing non-palliative oncologic surgery. Findings from the study will inform ways to identify and improve care of surgical patients who will likely benefit from specialist palliative care services. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03436290 First Registered: 16 February 2018 Enrollment Began: 1 March 2018 Last Update: 20 December 2018.

A Brief Informant Screening Instrument for Dementia in the ICU: The Diagnostic Accuracy of the AD8 in Critically Ill Adults Suspected of Having Pre-Existing Dementia.

BACKGROUND/AIM: The diagnostic accuracy of brief informant screening instruments to detect dementia in critically ill adults is unknown. We sought to determine the diagnostic accuracy of the 2- to 3-min Ascertain Dementia 8 (AD8) completed by surrogates in detecting dementia among critically ill adults suspected of having pre-existing dementia by comparing it to the Clinical Dementia Rating Scale (CDR). METHODS: This substudy of BRAIN-ICU included a subgroup of 75 critically ill medical/surgical patients determined to be at medium risk of having pre-existing dementia (Informant Questionnaire on Cognitive Decline in the Elderly [IQCODE] score ≥3.3). We calculated the sensitivity, specificity, positive and negative predictive values (PPV and NPV), and AUC for the standard AD8 cutoff of ≥2 versus the reference standard CDR score of ≥1 for mild dementia. RESULTS: By the CDR, 38 patients had very mild or no dementia and 37 had mild dementia or greater. For diagnosing mild dementia, the AD8 had a sensitivity of 97% (95% CI 86-100), a specificity of 16% (6-31), a PPV of 53% (40-65), an NPV of 86% (42-100), and an AUC of 0.738 (0.626-0.850). CONCLUSIONS: Among critically ill patients judged at risk for pre-existing dementia, the 2- to 3-min AD8 is highly sensitive and has a high NPV. These data indicate that the brief tool can serve to rule out dementia in a specific patient population.

Deficits in Self-Reported Initiation Are AssociatedWith Subsequent Disability in ICU Survivors.

OBJECTIVE: To determine whether deficits in a key aspect of executive functioning, namely, initiation, were associated with current and future functional disabilities in intensive care unit survivors. METHODS: A nested substudy within a 2-center prospective observational cohort. We used 3 tests of initiation at 3 and 12 months: the Ruff Total Unique Design, Controlled Oral Word Association, and Behavior Rating Inventory of Executive Function initiation. Disability in instrumental activities of daily living (IADL) was measured with the Functional Activities Questionnaire. We used a proportional odds logistic regression model to evaluate the association between initiation and disability. Covariates in the model included age, education, baseline Functional Activities Questionnaire, pre-existing cognitive impairment, comorbidities, admission severity of illness, episodes of hypoxia, and days of severe sepsis. RESULTS: In 195 patients, after adjusting for covariates, only the Behavior Rating Inventory of Executive Function initiation was associated with disability at any time point. Comparing the 25th vs the 75th percentile scores (95% confidence interval) of the Behavior Rating Inventory of Executive Function initiation at 3 months, patients with worse initiation scores had 5.062 times the odds (95% confidence interval: 2.539, 10.092) of disability according to the Functional Activities Questionnaire at 3 months, with similar odds at 12 months (odds ratio: 3.476, 95% confidence interval: 1.943, 6.216). Worse Behavior Rating Inventory of Executive Function initiation scores at 3 months were associated with future disability at 12 months odds ratio (95% confidence interval) 5.079 (2.579, 10.000). CONCLUSIONS: Executive function deficits acquired after a critical illness in the domain of initiation are common in intensive care unit survivors, and when they are identified via self-report tools, they are associated with current and future disability in instrumental activities of daily living.

Delirium and Catatonia in Critically Ill Patients: The Delirium and Catatonia Prospective Cohort Investigation.

OBJECTIVES: Catatonia, a condition characterized by motor, behavioral, and emotional changes, can occur during critical illness and appear as clinically similar to delirium, yet its management differs from delirium. Traditional criteria for medical catatonia preclude its diagnosis in delirium. Our objective in this investigation was to understand the overlap and relationship between delirium and catatonia in ICU patients and determine diagnostic thresholds for catatonia. DESIGN: Convenience cohort, nested within two ongoing randomized trials. SETTING: Single academic medical center in Nashville, TN. PATIENTS: We enrolled 136 critically ill patients on mechanical ventilation and/or vasopressors, randomized to two usual care sedation regimens. MEASUREMENTS AND MAIN RESULTS: Patients were assessed for delirium and catatonia by independent and masked personnel using Confusion Assessment Method for the ICU and the Bush Francis Catatonia Rating Scale mapped to Diagnostic Statistical Manual 5 criterion A for catatonia. Of 136 patients, 58 patients (43%) had only delirium, four (3%) had only catatonia, 42 (31%) had both, and 32 (24%) had neither. In a logistic regression model, more catatonia signs were associated with greater odds of having delirium. For example, patient assessments with greater than or equal to three Diagnostic Statistical Manual 5 symptoms (75th percentile) had, on average, 27.8 times the odds (interquartile range, 12.7-60.6) of having delirium compared with patient assessments with zero Diagnostic Statistical Manual 5 criteria (25th percentile) present (p < 0.001). A cut-off of greater than or equal to 4 Bush Francis Catatonia Screening Instrument items was both sensitive (91%; 95% CI, 82.9-95.3) and specific (91%; 95% CI, 87.6-92.9) for Diagnostic Statistical Manual 5 catatonia. CONCLUSIONS: Given that about one in three patients had both catatonia and delirium, these data prompt reconsideration of Diagnostic Statistical Manual 5 criteria for "Catatonic Disorder Due to Another Medical Condition" that preclude diagnosing catatonia in the presence of delirium.

The relationship between executive dysfunction, depression, and mental health-related quality of life in survivors of critical illness: Results from the BRAIN-ICU investigation.

PURPOSE: Although executive dysfunction and depression are common among intensive care unit (ICU) survivors, their relationship has not been evaluated in this population. We sought to determine (1) if executive dysfunction is independently associated with severity of depressive symptoms or worse mental health-related quality of life (HRQOL) in ICU survivors, and (2) if age modifies these associations. METHODS: In a prospective cohort (n=136), we measured executive dysfunction by the Behavior Rating Inventory of Executive Function-Adult, depression by the Beck Depression Inventory-II, and mental HRQOL by the Short-Form 36. We used multiple linear regression models, adjusting for potential confounders. We included age as an interaction term to test for effect modification. RESULTS: Executive dysfunction 3 months post-ICU was independently associated with more depressive symptoms and worse mental HRQOL 12 months post-ICU (25th vs 75th percentile of executive functioning scored 4.3 points worse on the depression scale [95% confidence interval, 1.3-7.4; P=.015] and 5 points worse on the Short-Form 36 [95% confidence interval, 1.7-8.3; P=.006]). Age did not modify these associations (depression: P=.12; mental HRQOL: P=.80). CONCLUSION: Regardless of age, executive dysfunction was independently associated with subsequent worse severity of depressive symptoms and worse mental HRQOL. Executive dysfunction may have a key role in the development of depression.