Implementation of outcome measurement (HoNOS) in an outpatient psychiatric clinic in Sligo/Leitrim mental health service.

BACKGROUND: Routine clinical outcome monitoring (RCOM) is the standardised gathering of measures of clinical outcomes in everyday practice. HoNOS (Health of the Nation Outcome Scales) is a tool used in RCOM. AIMS: To examine (a) agreement between HoNOS and Global Assessment of Functioning (GAF), (b) HoNOS changes over time/attendance and (c) clinical parameters affecting HoNOS scores. METHODS: Data from outpatient clinics were collected at each contact over 2 years until June 2016 including: gender, age, diagnosis (ICD-10) and HoNOS scores. In a subsample, the GAF also were completed by community psychiatric nurses blind to HoNOS scores. RESULTS: A number of 470 outpatients have undergone 1125 HoNOS assessments during the study period. Mean age of the attendants was 43.12; SD 14.6. Male = 220 (46.8%). Longitudinal analysis demonstrated that lower HoNOS scores are independently significantly associated to number of assessments and diagnosis in ICD-10 categories of F20-F29 (Schizophrenia, schizotypal and delusional disorders) F30-F39 (mood disorders) F40-F48 (neurotic, stress-related and somatoform disorders) and F50-F59 (behavioural disorders associated with physiological disturbances). Gender and age were not significantly associated with decline of HoNOS scores. Neither were other diagnostic categories. Agreement between HoNOS and GAF was excellent (N = 261, rho = - 0.919, p < 0.001). CONCLUSIONS: This study shows that HoNOS is a feasible instrument which can be potentially used in ROCM in mental health services in Ireland and supports further the need for implementation of routine measurements in Mental Health Services. It adds longitudinal data which is lacking in similar previous studies.

Mother and Baby Units matter: improved outcomes for both.

BACKGROUND: Mother and Baby Units (MBUs) are usually preferred by patients and clinicians. Current provision is limited, although expansion is in progress. To ensure successful investment in services, outcome measurement is vital. AIMS: To describe maternal outcomes, mother-infant outcomes and their relationship in one MBU. METHOD: Paired maternal Brief Psychiatric Rating Scale (BPRS) scores, Health of the Nation Outcome Scales (HoNOS) scores and Crittenden CARE-Index (CCI) mother-infant interaction data were collected at admission and discharge. RESULTS: There were significant improvements in BPRS (n = 152), HoNOS (n = 141) and CCI (n = 62) scores across diagnostic groups. Maternal BPRS scores and mother-infant interaction scores were unrelated. Improvement in maternal HoNOS scores was associated with improved maternal sensitivity and reduction in maternal unresponsiveness and infant passiveness. CONCLUSIONS: Positive outcomes were achieved for mothers and babies across all diagnostic groups. Reduction in maternal symptoms, as measured by BPRS, does not necessarily confer improvement in mother-infant interaction. MBU treatment should focus on both maternal symptoms and mother-infant interaction. DECLARATION OF INTEREST: None.

Improving the quality of mental health services using patient outcome data: making the most of HoNOS.

Efforts to assess and improve the quality of mental health services are often hampered by a lack of information on patient outcomes. Most mental health services in England have been routinely collecting Health of the Nation Outcome Scales (HoNOS) data for some time. In this article we illustrate how clinical teams have used HoNOS data to identify areas where performance could be improved. HoNOS data have the potential to give clinical teams the information they need to assess the quality of care they deliver, as well as develop and test initiatives aimed at improving the services they provide.

Routine mental health outcome measurement in the UK.

This paper offers a short history of routine clinical outcomes measurement (RCOM) in UK mental health services. RCOM developments in primary and secondary care are described, with reference to measures currently in widespread use or likely to be implemented. Assessment procedure and completion rates are discussed. Some of the forces operating in this field are enumerated. Comparison is made with UK attempts at routine outcomes measurement in public education. This field is thus reviewed for lessons for RCOM, and opportunities and challenges considered.

Phenomenological and biological correlates of improved cognitive function in hospitalized elderly medical inpatients.

Deterioration of cognitive ability is a recognized outcome following acute illness in older patients. Levels of circulating cytokines and APOE genotype have both been linked with acute illness-related cognitive decline. In this observational longitudinal study, consecutive admissions to an elderly medical unit of patients aged ≥70 years were assessed within 3 days and re-assessed twice weekly with a range of scales assessing cognitive function, functional status and illness severity. Cytokines and APOE genotype were measured in a subsample. Improvement was defined as either a 20% or three points increase in mini mental state examination (MMSE). From the 142 participants 55 (39%) experienced cognitive improvement, of which 30 (54.5%) had delirium while 25 had non-delirious acute cognitive disorder. Using bivariate statistics, subjects with more severe acute illness, lower insulin-like growth factor-I (IGF-I) levels and more severe delirium were more likely to experience a ≥20% improvement in MMSE scores. When the criterion of cognitive improvement was a 3 point improvement in MMSE, those with more severe delirium, females and older were more likely to be improved. Longitudinal analysis using any criterion of improvement indicated that improvement was significantly (p<.05) predicted by higher levels of IGF-I, lower levels of IL-1 (alpha and beta), lack of APOE epsilon 4 allele, and female gender. In conclusion, cognitive recovery during admission is not exclusively linked to delirium status, but reflects a range of factors. The character and relevance of non-delirious acute cognitive disorder warrants further study.

Reliability of delirium rating scale (DRS) and delirium rating scale-revised-98 (DRS-R98) using variance-based multivariate modelling.

Delirium's characteristic fluctuation in symptom severity complicates the assessment of test-retest reliability of scales using classical analyses, but application of modelling to longitudinal data offers a new approach. We evaluated test-retest reliability of the delirium rating scale (DRS) and delirium rating scale-revised-98 (DRS-R98), two widely used instruments with high validity and inter-rater reliability. Two existing longitudinal datasets for each scale included DSM-IV criteria for delirium diagnosis and repeated measurements using the DRS or DRS-R98. To estimate the reliability coefficients RT and RΛ for each scale we used a macros provided by Dr. Laenen at http://www.ibiostat.be/software/measurement.asp. For each dataset a linear mixed-effects model was fitted to estimate the variance-covariance parameters. A total of 531 cases with between 4 and 9 measurement points across studies including both delirious and non-delirious patients. Comorbid dementia in the datasets varied from 27% to 55%. Overall RT for the DRS were 0.71 and 0.50 and for DRS-R98 0.75 and 0.84. RΛ values for DRS were 0.99 and 0.98 and for DRS-R98 were 0.92 and 0.96. Individual RT measures for DRS-R98 and DRS across visits within studies showed more range than overall values. Our models found high overall reliability for both scales. Multiple factors impact a scale's reliability values including sample size, repeated measurements, patient population, etc in addition to rater variability.

Validation of the Greek version of the Health of the Nation Outcome Scales for Elderly People (HoNOS65+, version 3).

OBJECTIVES: There is a growing need for evaluation of the results of mental health services and clinical treatment in older people, but evidence for effectiveness is limited in Greece. The Health of the Nations Outcome Scales for Elderly People (HoNOS65+) are promising instruments for the assessment of mental, physical and social health in older persons. They have been translated into the Greek language but have not been validated. The aim was to assess the inter-rater reliability, intraclass correlation, concurrent validity, internal consistency and sensitivity to change of HoNOS65+ in a Greek sample of older people with mental health problems. METHOD: Two samples, one of inpatients in a psychiatric hospital and the other of older people living in the community were used. In order to test the extent to which the HoNOS65+ were sensitive to change the first sample was reassessed after two months and the second after three months. For each participant HoNOS65+ were completed by two independent raters, and the clinician rated blindly each participant on the Stockton Geriatric Rating Scale and a scale which measured behavioural, physical, cognitive and emotional status. RESULTS: In both groups (inpatients n = 50, community n = 65), the inter-rater reliability, intraclass correlation and concurrent validity were high while internal consistency of the scales taken together was low. At reassessment in 98 participants, HoNOS65+ showed changes comparable to clinician ratings. CONCLUSION: The Greek version of HoNOS65+ can achieve high levels of reliability, validity and sensitivity to change for measuring outcomes in older people with mental health problems.

Combining routine outcomes measurement and 'Payment by Results': will it work and is it worth it?

The Department of Health in England has long encouraged the routine measurement of clinical outcomes in mental health services but has now decided to use outcome measures as part of a new payments system - Payment by Results. We examine how these two policies should or might interact.

Delirium and the functional recovery of older medical inpatients after acute illness: the significance of biological factors.

Previous studies have not clarified the relationship of delirium to functional capacity during acute illness. We have investigated this relationship, incorporating the potential roles of APOE genotype and circulating cytokines in a longitudinal study of acutely admitted patients aged 70+ years. In all participants was measured the: Barthel Index (BI), mini-mental state examination (MMSE), confusion assessment method (CAM), delirium rating scale (DRS), APACHE II, APOE genotype. In a sub-sample: serum interferon-γ (IFN-γ), interleukin-1 (Levels of IL-1α, IL-1ß and IL-1 receptor antagonist activity IL-1RA), interleukin-6 (IL-6), leukemia inhibitory factor (LIF), tumor necrosis factor-α (TNF-α) and insulin-like growth factor-I (IGF-I). Of 164 participants, mean age 84.6 ± 6.57 years (± S.D.), 67.1% were women. On first assessment, mean BI was 14.13 ± 4.46 and delirium prevalence was 25.6%. At discharge, the mean BI of survivors (n=150) was 15.61 ± 4.22. By discharge, survivors who had recovered from prevalent delirium had significant improvement in BI (n=38, p=0.005), but non-recovers did not (n=14, p=0.512). On, multivariate analysis, BI was significantly affected by MMSE, APOE, IL-1α, IL-6, LIF and TNF-α levels (p<0.05) but not by delirium. Delirium in acutely admitted patients is associated with functional decline only in those who do not recover. Biological factors, rather that delirium itself, may be responsible for this.

Objections to routine clinical outcomes measurement in mental health services: any evidence so far?

BACKGROUND: Routine clinical outcomes measurement (RCOM) is gaining importance in mental health services. AIMS: To examine whether criticisms published in advance of the development of RCOM have been borne out by data now available from such a programme. METHOD: This was an observational study of routine ratings using HoNOS65+ at inception/admission and again at discharge in an old age psychiatry service from 1997 to 2008. Testable hypotheses were generated from each criticism amenable to empirical examination. Inter-rater reliability estimates were applied to observed differences between scores between community and ward patients using resampling. RESULTS: Five thousand one hundred eighty community inceptions and 862 admissions had HoNOS65+ ratings at referral/admission and discharge. We could find no evidence of gaming (artificially worse scores at inception and better at discharge), selection, attrition or detection bias, and ratings were consistent with diagnosis and level of service. Anticipated low levels of inter-rater reliability did not vitiate differences between levels of service. CONCLUSIONS: Although only hypotheses testable from within RCOM data were examined, and only 46% of eligible episodes had complete outcomes data, no evidence of the alleged biases were found. RCOM seems valid and practical in mental health services.

Delirium scales: A review of current evidence.

OBJECTIVES: Delirium is a common neuropsychiatric condition with many adverse outcomes in elderly populations including death. Despite this, it is often misdiagnosed and mistreated. A number of scales can be used to detect delirium. We review scales that have been used in delirium studies and report their psychometric properties. METHOD: An extensive MEDLINE database search and subsequent examination of reference lists was conducted to identify the various delirium scales that have been designed, primarily for use in the elderly. RESULTS: Twenty-four scales were identified. Delirium instruments differed according to the classification system they were based on, length of time to administer, the rater and whether they were screening scales or measured symptom severity. The psychometric properties of each scale is reported. CONCLUSION: A large number of scales exist, but not all are properly evaluated in terms of psychometric properties, and there is not unanimity about which scale is the best. However, a small number of scales may be considered already to be robust and useable: the CAM, the DRS, the MDAS and the NEECHAM.

The association of the dopamine transporter gene and the dopamine receptor 2 gene with delirium, a meta-analysis.

Delirium is the most common neuropsychiatric syndrome in elderly ill patients. Previously, associations between delirium and the dopamine transporter gene (solute carrier family 6, member 3 (SLC6A3)) and dopamine receptor 2 gene (DRD2) were found. The aim of this study was to validate whether markers of the SLC6A3 and DRD2 genes are were associated with delirium in independent populations. Six European populations collected DNA of older delirious patients. Associations were determined per population and results were combined in a meta-analysis. In total 820 medical inpatients, 185 cardiac surgery patients, 134 non-cardiac surgery patients and 502 population-based elderly subjects were included. Mean age was 82 years (SD 7.5 years), 598 (36%) were male, 665 (41%) had pre-existing cognitive impairment, and 558 (34%) experienced delirium. The SLC6A3 rs393795 homozygous AA genotype was more frequent in patients without delirium in all populations. The meta-analysis showed an Odds Ratio (OR) for delirium of 0.4 (95% confidence interval (C.I.) 0.2-0.6, P = 0.0003) for subjects with AA genotype compared to the AG and GG genotypes. SLC6A3 marker rs1042098 showed no association with delirium. In meta-analysis the DRD2 rs6276 homozygous GG genotype showed an OR of 0.8 for delirium (95% C.I. 0.6-1.1, P = 0.24). When subjects were stratified for cognitive status the rs6276 GG genotype showed ORs of 0.6 (95% C.I. 0.4-1.0, P = 0.06) and 0.8 (95% C.I. 0.5-1.5, P = 0.51) for delirium in patients with and without cognitive impairment, respectively. In independent cohorts, a variation in the SLC6A3 gene and possibly the DRD2 gene were found to protect for delirium.

Ethical research in delirium: arguments for including decisionally incapacitated subjects.

Here we describe how more important findings were obtained in a delirium study by using an informal assessment of mental capacity, and, in those who lacked capacity, obtaining consent later when or if capacity returned or a proxy was found. From a total of 233 patients 23 patients lacked capacity as judged by our informal capacity judgment and 210 did not. Of those who lacked capacity, 13 agreed to enter in the study. Six of them regained capacity later. When these 13 participants were excluded from analysis, significant findings were no longer evident. These results show that by the inclusion of subjects who lacked capacity the results of analyses of the condition from whish they suffer are altered. We suggest that this approach to the study of delirium is more ethical than the usual system of strict exclusion of people who lack capacity to give consent and for whom assent is not available.

Cytokines and IGF-I in delirious and non-delirious acutely ill older medical inpatients.

BACKGROUND: therapeutic use of cytokines can induce delirium, and delirium often occurs during infections associated with elevated levels of cytokines. This study examined the association of demographic, clinical and biological factors (IL-1alpha, IL-1beta, IL-1RA, IL-6, TNF-alpha, IFN-gamma, LIF, IGF-I, APOE genotype) with the presence and severity of delirium. METHODS: in an observational prospective longitudinal study, patients aged 70+ were recruited from an elderly medical unit and assessed every 3-4 days (maximum assessments 4). At each time, the scales MMSE, DRS, CAM, APACHEII were administered and blood was withdrawn to estimate the above biological factors. Mixed effects (PQL) and GEE were used to analyse the repeated measurements and investigate the associations at the individual and population average levels. RESULTS: a total of 205 observations on 67 individuals were analysed. Lower levels of IGF-I, and lower levels of circulating IL-1RA, are significantly (P < 0.05) associated with delirium, while the remaining of cytokines, severity of illness and possession of epsilon 4 allele had a non-significant effect. This has been shown by both statistical methods. Similarly lower levels of IGF-I, and high levels of IFN-gamma, are statistically significantly (P < 0.05) associated with higher DRS scores (more severe delirium). CONCLUSIONS: this study finds that (i) low levels of both neuroprotective factors (IGF-I, IL-1RA) are associated with delirium, (ii) high IFN-gamma and low IGF-I have significant effects on delirium severity and (iii) otherwise the pro-inflammatory cytokines studied, APOE genotype and severity of illness do not appear to be associated, in older medically ill patients, with either delirium or severity of it.

The genetics of deliria.

Delirium not induced by alcohol or other psychoactive substance and alcohol withdrawal delirium (or delirium tremens) are both cerebral syndromes with similar presentations and are associated with various adverse outcomes. Recently, interest in identifying genetic predisposing factors that influence the occurrence or the outcome of delirium has become a prominent point of delirium research. We systematically searched published articles concerning genetic associations and the occurrence and outcome of delirium. Of 33 identified articles, six investigated non-alcohol withdrawal delirium, and from those six, five evaluated an association with apolipoprotein E (APOE). One association of APOE genotype with the emergence of delirium and two associations of APOE genotype with the duration of delirium were reported. The remaining 27 identified articles investigated genetic associations with alcohol withdrawal delirium and were mainly related to dopamine. Two studies reported a significant association of alcohol withdrawal delirium with the dopamine transporter gene (SLC6A3) and the dopamine receptor 3 (DRD3). Results are inconclusive, and no hard evidence exists due primarily to insufficiently powered studies and other methodological issues. Prospective studies incorporating systematic and rigorous diagnostic criteria and involving long term follow up are needed to advance understanding of this field.

Associations of delirium with in-hospital and in 6-months mortality in elderly medical inpatients.

BACKGROUND: Studies on the association between mortality and delirium in older hospital inpatients have produced conflicting results. This insconsistency might be explained by case-mix differences in terms of clinical or underlying patho-physiological processes. For example, both albumin and C-reactive protein (CRP) have been reported as predictors of in-hospital mortality and interleukin-6 of longer-term mortality. METHODS: We used data from a longitudinal study of delirium to investigate the delirium-mortality relationship. A cohort of 164 patients, 70+ years were assessed within 3 days of acute hospital admission and hence twice weekly until hospital discharge, for the presence and severity of delirium and a range of clinical and laboratory measures, including initial albumin (n = 149), CRP (n = 76) and cytokine (n = 60) levels. In-hospital and 6-months mortality were determined from clinical records and telephone contact. RESULTS: During hospitalisation 14 (8.5%) patients died, 6 with delirium: mortality was not associated with delirium. At 6 months, 119 of 150 (77.3%) discharged patients were still alive, 21 (14.0%) dead, and 13 (8.7%) uncontactable. In bivariate analysis, 6-months mortality was associated with older age (P = 0.013), lower albumin (P = 0.001), higher CRP (P = 0.014) and higher interleukin-6 levels (P = 0.007), but not with presence or severity of in-hospital delirium. After controlling for other variables significant predictors (P < 0.05) for six-month mortality were initial MMSE, albumin, interferon-lambda and interleukin-6. CONCLUSIONS: The lack of demonstrable association between delirium and mortality may reflect inadequate statistical power in this study due to low numbers. These findings, however, highlight specific patho-physiological factors which may be important in the prognosis after delirium.

APOE and cytokines as biological markers for recovery of prevalent delirium in elderly medical inpatients.

BACKGROUND: Delirium frequently occurs in the context of infection and other inflammatory conditions associated with elevated levels of cytokines. Cytokines used therapeutically can induce symptoms of delirium as an adverse effect. We hypothesized that a causal relationship might exist between delirium and cytokine production during illness. Further, we speculated that the APOE genotype of patients might influence their rate of recovery from delirium given that APOE is associated with amyloid deposition, increased susceptibility to exogenous neurotoxins, and can affect the immune response. METHODS: A cohort of 164 acutely ill patients, 70 years or older, admitted to an elderly medical unit were studied within 3 days of hospital admission and re-assessed twice weekly until their discharge, to identify and follow the clinical course of delirium. The APOE genotype and the level of circulating cytokines were determined for 116 and 60 patients respectively. RESULTS: Prevalent delirium was significantly (p < 0.05) associated with a previous history of dementia, age, illness severity, disability and low levels of circulating IGF-I. Recovery was significantly associated (p < 0.05) with lack of APOE 4 allele and higher initial IFN-gamma. A model incorporating gender, APOE epsilon 4 status and IGF-I levels predicted recovery or not from delirium in 76.5% of cases, with a sensitivity 0.77 and specificity 0.75. CONCLUSIONS: A relationship between delirium with APOE genotype, IFN-gamma, and IGF-I, but not with IL-6, IL-1, TNF-alpha, and LIF was found. A predictive model of recovery was derived from gender, APOE status, and IGF-I levels. This model needs replication with further studies.

A brief review of the history of delirium as a mental disorder.

We review the most important concepts about delirium, from ancient times until the twentieth century. We also focus on the question of how these concepts have dealt with the particular problems posed by prognosis and outcome. Althought different terms have been used, a robust description of delirium has existed since antiquity--at some times as a symptom and at others as a syndrome. It is clear that, throughout the millennia, delirium has been--and still is--a highly lethal syndrome; a poor mental outcome for survivors was often noted. Not until the twentieth century was it thought that delirium was marked by a full recovery among survivors, and this was probably due to the desire for a clear distinction from dementia.

Recovery and outcome of delirium in elderly medical inpatients.

This study investigates the relationships between delirium, cognitive impairment and acute illness severity with adverse clinical outcomes; in-hospital mortality, hospital length of stay, or new entry to a care home. It is a prospective observational study of medical inpatients 70 years or older, with repeated measurements of cognition, delirium status, delirium severity, and severity of physical illness every 3 days until the 18th day and then the 28th day of hospitalization. Of 94 participants, 33 had delirium and 14 recovered during their hospitalization. Predictor variables for recovery were initial Mini Mental State Examination (MMSE) (p=0.003) and severity of delirium at second assessment (p=0.02), for mortality initial MMSE (p=0.002) and for discharge to care home were initial delirium status (p=0.008) and age (p=0.004). Delirious people newly discharged to care homes stayed longer in hospital than those discharged to their previous address (p=0.016). We conclude that delirium is not a transient disorder. The presence of delirium was not related to measures of the severity of physical illness or disability. High mortality was associated with delirium but was specifically associated with cognitive impairment. Prolonged length of stay of delirious people may depend on discharge destination.

The performance of the Clock Drawing Test in elderly medical inpatients: does it have utility in the identification of delirium?

The Clock Drawing Test is an often-used test for the detection of cognitive impairment, but the few studies that have evaluated its utility in delirium have produced rather inconsistent results. In a longitudinal study of delirium in elderly medical inpatients, we have investigated the relationships between the Clock Drawing Test, the presence and severity of delirium, and cognitive impairment. Using mixed linear model analysis we found that cognitive impairment was the major factor associated with low Clock Drawing Test scores (P < .0001): neither the presence nor the severity of delirium had additional significant effect on the Clock Drawing Test. Thus, we conclude that although the Clock Drawing Test is a good detector of cognitive impairment, it is not a suitable tool for detection of delirium in elderly medical inpatients.