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.

A Systematic Review of Chronic Pain Management Interventions Among Veterans of Recent Wars and Armed Conflicts.

OBJECTIVES: To identify chronic pain management strategies aimed to reduce pain intensity and enhance functional outcomes in veterans of wars and armed conflict. DESIGN: Systematic review without meta-analysis. DATA SOURCES: Key words "chronic pain," "veterans," and "injuries" were used to search for articles in the MEDLINE, CINAHL, APA PsycInfo, and Embase databases. Articles published in English between 2000 and 2023 were included. REVIEW/ANALYSIS METHODS: A systematic literature search was conducted in June 2020, updated in April 2023, and managed using Covidence review software. Inclusion criteria focused on combat-injured veterans with chronic pain, excluding nonveterans and civilians treated for acute or chronic pain. Data from included studies were extracted, summarized, and critically appraised using the 2018 Mixed Methods Appraisal Tool. This review is registered with PROSPERO (CRD42020207435). RESULTS: Fourteen studies met the inclusion criteria, with 10 of them supporting nonpharmacological approaches for managing chronic pain among veterans of armed conflicts and wars. Interventions included psychological/behavioral therapies, peer support, biofeedback training via telephone-based therapy, manual therapy, yoga, cognitive processing therapy, cognitive-behavioral therapy, and social and community integration to reduce pain intensity and enhance functional outcomes. CONCLUSION: Nonpharmacological treatments for chronic pain have increased in recent years, a shift from earlier reliance on pharmacological treatments. More evidence from randomized controlled trials on the benefits of combined pain interventions could improve pain management of veterans with complex care needs.

Associations of postoperative delirium with activities of daily living in older people after major surgery: A prospective cohort study.

AIMS: To assess the association of postoperative delirium developed in the post-anaesthetic care unit (PACU) with older patients' ability to perform activities of daily living (ADL) during the first five postoperative days. BACKGROUND: Previous studies have focused on the association between postoperative delirium and long-term function decline, however the association between postoperative delirium and the ability to perform ADL, particularly in the immediate postoperative period, needs further investigation. DESIGN: A prospective cohort study. METHODS: A total of 271 older patients who underwent elective or emergency surgery at a tertiary care hospital in Victoria, Australia, participated in the study. Data were collected between July 2021 and December 2021. Delirium was assessed using the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). The Katz Index of Independence in Activities of Daily Living (KATZ ADL) scale was used to measure ADL. ADL was assessed preoperatively and daily during the first five postoperative days. The STROBE checklist was used to report this study. RESULTS: Results showed that 44 (16.2%) patients developed new episode of delirium. Postoperative delirium was independently associated with decline in ADL (RR = 2.83, 95% CI = 2.71-2.97; p < 0.001). CONCLUSIONS: Postoperative delirium was associated with a decline in ADL among older people during the first five postoperative days. Screening for delirium in the PACU is essential to identify delirium during the early stages of postoperative period and implement a timely comprehensive plan. RELEVANCE TO CLINICAL PRACTICE: Delirium assessment of older patients in the PACU, and for at least the first five postoperative days, is strongly recommended. We also recommend engagement of patients in a focused physical and cognitive daily activity plan, particularly for older patients undergoing major surgery. PATIENT OR PUBLIC CONTRIBUTION: Patients and nurses helped in data collection at a tertiary care hospital.

Validation of Two Screening Tools for Detecting Delirium in Older Patients in the Post-Anaesthetic Care Unit: A Diagnostic Test Accuracy Study.

(1) Background: Delirium is a common complication among surgical patients after major surgery, but it is often underdiagnosed in the post-anaesthetic care unit (PACU). Valid and reliable tools are required for improving diagnoses of delirium. The objective of this study was to evaluate the diagnostic test accuracy of the Three-Minute Diagnostic Interview for Confusion Assessment Method (3D-CAM) and the 4A's Test (4AT) as screening tools for detection of delirium in older people in the PACU. (2) Methods: A prospective diagnostic test accuracy study was conducted in the PACU and surgical wards of a university-affiliated tertiary care hospital in Victoria, Australia. A consecutive prospective cohort of elective and emergency patients (aged 65 years or older) admitted to the PACU were recruited between July 2021 and December 2021 following a surgical procedure performed under general anaesthesia and expected to stay in the hospital for at least 24 h following surgery. The outcome measures were sensitivity, specificity positive predictive value and negative predictive value for 3D-CAM and 4AT. (3) Results: A total of 271 patients were recruited: 16.2% (44/271) had definite delirium. For a diagnosis of definite delirium, the 3D-CAM (area under curve (AUC) = 0.96) had a sensitivity of 100% (95% CI 92.0 to 100.0) in the PACU and during the first 5 days post-operatively. Specificity ranged from 93% (95% CI 87.8 to 95.2) to 91% (95% CI 85.9 to 95.2) in the PACU and during the first 5 days post-operatively. The 4AT (AUC = 0.92) had a sensitivity of 93% (95% CI 81.7 to 98.6) in the PACU and during the first 5 days post-operatively, and specificity ranged from 89% (95% CI 84.6 to 93.1) to 87% (95%CI 80.9 to 91.8) in the PACU and during the first 5 days post-operatively. (4) Conclusions: The 3D-CAM and the 4AT are sensitive and specific screening tools that can be used to detect delirium in older people in the PACU. Screening with either tool could have an important clinical impact by improving the accuracy of delirium detection in the PACU and hence preventing adverse outcomes associated with delirium.

Development of Screening Tools to Predict Medication-Related Problems Across the Continuum of Emergency Department Care: A Prospective, Multicenter Study.

Background: Medication-related problems (MRPs) occur across the continuum of emergency department (ED) care: they may contribute to ED presentation, occur in the ED/short-stay unit (SSU), at hospital admission, or shortly after discharge to the community. This project aimed to determine predictors for MRPs across the continuum of ED care and incorporate these into screening tools (one for use at ED presentation and one at ED/SSU discharge), to identify patients at greatest risk, who could be targeted by ED pharmacists. Methods: A prospective, observational, multicenter study was undertaken in nine EDs, between July 2016 and August 2017. Blocks of ten consecutive adult patients presenting at pre-specified times were identified. Within 1 week of ED discharge, a pharmacist interviewed patients and undertook a medical record review to determine a medication history, patient understanding of treatment, risk factors for MRPs and to manage the MRPs. Logistic regression was undertaken to determine predictor variables. Multivariable regression beta coefficients were used to develop a scoring system for the two screening tools. Results: Of 1,238 patients meeting all inclusion criteria, 904 were recruited. Characteristics predicting MRPs related to ED presentation were: patient self-administers regular medications (OR = 7.95, 95%CI = 3.79-16.65), carer assists with medication administration (OR = 15.46, 95%CI = 6.52-36.67), or health-professional administers (OR = 5.01, 95%CI = 1.77-14.19); medication-related ED presentation (OR = 9.95, 95%CI = 4.92-20.10); age ≥80 years (OR = 3.63, 95%CI = 1.96-6.71), or age 65-79 years (OR = 2.01, 95%CI = 1.17-3.46); potential medication adherence issue (OR = 2.27, 95%CI = 1.38-3.73); medical specialist seen in past 6-months (OR = 2.02, 95%CI = 1.42-2.85); pharmaceutical benefit/pension/concession cardholder (OR = 1.89, 95%CI = 1.28-2.78); inpatient in previous 4-weeks (OR = 1.60, 95%CI = 1.02-2.52); being male (OR = 1.48, 95%CI = 1.05-2.10); and difficulties reading labels (OR = 0.63, 95%CI = 0.40-0.99). Characteristics predicting MRPs related to ED discharge were: potential medication adherence issue (OR = 6.80, 95%CI = 3.97-11.64); stay in ED > 8 h (OR = 3.23, 95%CI = 1.47-7.78); difficulties reading labels (OR = 2.33, 95%CI = 1.30-4.16); and medication regimen changed in ED (OR = 3.91, 95%CI = 2.43-6.30). For ED presentation, the model had a C-statistic of 0.84 (95% CI 0.81-0.86) (sensitivity = 80%, specificity = 70%). For ED discharge, the model had a C-statistic of 0.78 (95% CI 0.73-0.83) (sensitivity = 82%, specificity = 57%). Conclusion: Predictors of MRPs are readily available at the bedside and may be used to screen for patients at greatest risk upon ED presentation and upon ED/SSU discharge to the community. These screening tools now require external validation and implementation studies to evaluate the impact of using such tools on patient care outcomes.

Delirium screening tools in the post-anaesthetic care unit: a systematic review and meta-analysis.

BACKGROUND: Delirium is a serious neurocognitive disorder among surgical patients in the post-anaesthetic care unit (PACU). Despite the development of screening tools to identify delirium, it is not clear which tool is the most accurate and reliable in assessing delirium in the PACU. AIM: To examine the diagnostic accuracy of delirium screening tools used in the PACU. METHODS: A systematic literature search of CINAHL, MEDLINE, Embase, PsycINFO and Scopus was conducted, using MeSH terms and relevant keywords, from databases establishment to 23 April 2021. Studies were assessed for methodological quality using the Standards for Reporting of Diagnostic Accuracy Studies (STARD) tool. RESULTS: A total of 1503 studies were screened from the database search, four studies met the inclusion criteria for this review. Six delirium screening tools used in the PACU were identified in the selected studies. Three studies evaluated screening tools in adult surgical patients without cognitive impairment and dementia. Two studies evaluated screening tools among patients who were scheduled for elective surgery. Review results indicated that two tools, the 4A's test (4AT; sensitivity 96%; specificity 99%) and the 3 min diagnostic interview for the Confusion Assessment Method (3D-CAM; sensitivity 100%; specificity 88%), had greatest validity and reliability as a screening tool for detecting delirium in the PACU. CONCLUSION: Results indicate the 4AT and the 3D-CAM are most accurate screening tools to detect delirium in the PACU. Further research is required to validate those tools among a broader surgical population, including patients with cognitive impairment, dementia and those undergoing emergency surgical procedures.

Factors associated with the decision to prescribe and administer antipsychotics for older people with delirium: a qualitative descriptive study.

OBJECTIVES: To explore factors associated with decision-making of nurses and doctors in prescribing and administering as required antipsychotic medications to older people with delirium. DESIGN: Qualitative descriptive. SETTING: Two acute care hospital organisations in Melbourne, Australia. PARTICIPANTS: Nurses and doctors were invited to participate. Semi-structured focus groups and individual interviews were conducted between May 2019 and March 2020. Interviews were audio-recorded and transcribed verbatim. Data were analysed using thematic analysis. RESULTS: Participants were 42 health professionals; n=25 nurses and n=17 doctors. Themes relating to decisions to use antipsychotic medication were: safety; a last resort; nursing workload; a dilemma to medicate; and anticipating worsening behaviours. Nurses and doctors described experiencing pressures when trying to manage hyperactive behaviours. Safety was a major concern leading to the decision to use antipsychotics. Antipsychotics were often used as chemical restraints to 'sedate' a patient with delirium because nurses 'can't do their job'. Results also indicated that nurses had influence over doctors' decisions despite nurses being unaware of this influence. Health professionals' descriptions are illustrated in a decision-making flowchart that identifies how nurses and doctors navigated decisions regarding prescription and administration of antipsychotic medications. CONCLUSIONS: The decision to prescribe and administer antipsychotic medications for people with delirium is complex as nurses and doctors must navigate multiple factors before making the decision. Collaborative support and multidisciplinary teamwork are required by both nurses and doctors to optimally care for people with delirium. Decision-making support for nurses and doctors may also help to navigate the multiple factors that influence the decision to prescribe antipsychotics.

The Effects of Education About Urinary Incontinence on Nurses' and Nursing Assistants' Knowledge, Attitudes, Continence Care Practices, and Patient Outcomes: A Systematic Review.

The aims of this systematic review were to describe, critique, and summarize research about the effects of education about urinary incontinence on nurses' and nursing assistants' knowledge and attitudes toward urinary incontinence, their continence care practices, and patient outcomes. We searched key electronic databases (PsycINFO, MEDLINE, CINAHL, Web of Science, and Cochrane Library) for full-text primary research articles written in the English language and published between January 1990 and October 2018. Studies were included if they described a controlled or uncontrolled trial of an education program for nurses or nursing assistants about urinary incontinence and evaluated the effects of the program on either knowledge, attitudes, practice, or patient outcomes. Data were extracted about the aim, design, sample and setting, trial methods, intervention, outcomes of interest, and findings. Quality appraisal was conducted using a mixed-methods appraisal tool. Results are presented in tabular format and reported descriptively. Nineteen studies met inclusion criteria; most were set in the United States or the UK. All trials that evaluated the effects on knowledge reported improvements; however, the effects of education on attitudes were mixed as were the effects of education on continence care practices. Eleven of the 19 studies reported the statistical effect of education on patient outcomes. Uncontrolled trials reported improvements in nursing home residents' and community-dwelling patients' continence status, but this effect was not observed in a large controlled trial. Similarly, 2 studies set in inpatient rehabilitation found no significant differences in patient continence outcomes following an educational intervention targeted to nurses.

Comprehensive identification of medication-related problems occurring prior to, during and after emergency department presentation: An Australian multicentre, prospective, observational study.

OBJECTIVE: Patients present to EDs with various medication-related problems (MRPs). MRPs are also associated with ED care, occurring during ED presentation or shortly afterwards. The aim of the present study is to describe the prevalence and nature of MRPs that occur prior to, during or shortly after leaving ED. METHODS: We undertook a prospective, observational study in nine Australian EDs. Blocks of 10 consecutive adult patients who were not seen by a pharmacist in ED and who presented at pre-specified times were identified. Within 1 week of ED discharge, a pharmacist interviewed patients and undertook a medical record review to determine their medication history, patients' understanding of treatment, potential MRP risk factors and manage any identified MRPs. RESULTS: A total of 904 patients were recruited: 14.8% aged ≥80 years, 18.9% taking more than eight regular medications; 581 MRPs were identified; 287 (49.4%, 95% confidence interval [CI] 45.3-53.5%) of moderate-high significance. Most highly significant MRPs involved high-risk medications, particularly strong opioids, insulin and anti-coagulants. The most common types of MRPs were prescribing errors (46.8%), patient adherence/knowledge issues (31.2%) and adverse drug reactions (7.4%). Of all patients, 381 (42.1%, 95% CI 38.9-45.5%) had at least one MRP; 31.4% (95% CI 28.4-34.6%) had MRPs that could be identified or managed by screening at ED presentation and 12.4% (95% CI 10.4-14.8%) had MRPs that could be identified or managed by screening at ED discharge. CONCLUSIONS: Patients experienced a range of MRPs throughout the ED continuum of care. From these data, screening tools will be developed so that ED clinicians may identify patients at greatest risk of MRPs.

Co-development of "BRAIN-TRK": Qualitative examination of acceptability, usability and feasibility of an App to support nurses' care for patients with behavioural and psychological symptoms of neurocognitive disorders in hospital.

AIMS AND OBJECTIVES: (a) Describe the co-development of a point-of-care App to promote uptake of best practice recommendations and consolidate nurses' knowledge for managing symptoms of neurocognitive disorders. (b) Report acceptability, usability and feasibility of the App to nurses for patient care in hospital. BACKGROUND: Strategies used in hospitals to reduce symptoms, risk of harm, or complications of behavioural and psychological symptoms associated with neurocognitive disorders are frequently inconsistent with best practice recommendations. DESIGN: Three-stage, mixed-methods, process and outcome evaluation. METHODS: The App was co-developed with experts, nurse end-users and a consumer. Evaluation data were collected from a convenience sample of nurses observed during delivery of 80.5 hr of care to 38 patients; the App (n = 32 patients); and individual and focus group interviews with nurses (n = 25). Reporting adhered to an adapted STROBE checklist. RESULTS: The App included three components: cognition and risk assessment; tailored evidence-based strategies; and monitoring and evaluation of effectiveness. Observation data captured nurses using the App with 44.7% (n = 17) of eligible inpatients. Cognitive screening was completed at least once for each patient, with 146 risk assessments recorded. Interview data indicated the App's acceptability was enhanced by familiarity and perceived benefits, but hindered by perceived increases in workload, inconsistent use, pressure to use the App and resistance to change. Feasibility and usability were enhanced by easy navigation, and clear and useful content, but hindered by unclear expectations, unfamiliarity and device-related factors. CONCLUSIONS: The App provided an evidence-based tool that was, overall, considered feasible and acceptable to support best practice. Findings provide guidance to enhance usability for future implementation. RELEVANCE TO CLINICAL PRACTICE: Co-development using best evidence and key stakeholders enabled creation of a novel, feasible and acceptable technology. Real-time access to assessment tools and tailored knowledge supported nurses' clinical decision-making; workload and unfamiliarity were barriers to use.

TotShots: An Innovative Pediatric Free Clinic Providing High Patient Satisfaction to the Underserved.

BACKGROUND AND OBJECTIVES: The University of Arizona College of Medicine-Tucson TotShots clinic is a student-developed, student-directed free clinic that provides sports physicals and vaccines to uninsured pediatric patients in Tucson, Arizona. TotShots runs under the greater umbrella of the Commitment to Underserved People Program, which aims to teach medical students how socioeconomic and cultural factors impact health and access to health care. Our objective was to study cost savings and patient satisfaction of this clinic. METHODS: Value of care provided through sports physicals and vaccine administration was calculated using the Centers for Medicare and Medicaid Services Physician Fee Schedule and Centers for Disease Control Vaccines for Children Decisions Analysis Model. In addition, patient satisfaction was measured through the utilization of an optional three-question survey completed by patients in their preferred language at the resolution of their visit. Vaccines and sports physicals were administered from April 2017 to November 2017. RESULTS: TotShots administered 51 vaccines and completed 115 sports physicals resulting in a value of $415.65 of administration fees and $5,878.80 of sports physical examinations. Sixty-three of 66 total patients completed patient satisfaction surveys. Of those patients, 57 (90.5%) were highly satisfied with their provider's communication, 58 (92%) rated their perception of the quality of medical care they received as excellent, and 54 (85.7%) of patients were highly satisfied with their overall TotShots experience. CONCLUSIONS: TotShots fills a valuable role in increasing access to vaccines and sports physicals while maintaining high patient satisfaction and high value of cost savings.

"Dignity": A central construct in nursing home staff understandings of quality continence care.

AIMS AND OBJECTIVES: To explore nursing home staff members' beliefs and expectations about what constitutes "quality continence care" for people living in nursing homes. BACKGROUND: Most nursing home residents require assistance to maintain continence or manage incontinence. Best practice guidelines promote active investigation of incontinence, treatment of underlying potentially reversible causes, and initial conservative interventions to prevent, minimise and/or treat incontinence. Despite research showing the positive benefits of implementing active interventions, translating the findings of research into practice in nursing homes has been modest. Understanding the perspectives of individuals who provide continence care may help bridge the gap between evidence and practice. DESIGN: A qualitative exploratory descriptive design. METHODS: Qualitative interviews were conducted with 19 nursing home staff: eight registered nurses, four enrolled nurses and seven personal care workers working in a nursing home in Australia between 2014-2015. Data were analysed inductively to identify themes and subthemes that described and explained staff beliefs about quality continence care in nursing homes. FINDINGS: Participants' understanding and expectations about quality continence care were linked to beliefs about incontinence being an intractable and undignified condition in nursing homes. The key theme to emerge was "protecting residents' dignity" which was supported by the following six subthemes: (i) using pads, ii) providing privacy, (iii) knowing how to "manage" incontinence, (iv) providing timely continence care, (v) considering residents' continence care preferences and (vi) communicating sensitively. CONCLUSION: The findings provide new insight into the basis for continence care practices in nursing homes. Education about continence care should challenge beliefs that limit continence care practice to cleaning, containing and concealing incontinence. There is a need for a multidimensional framework that is informed by social, psychological and biomedical research about incontinence, research about the fundamental elements of care, care-dependent individuals' expectations about care, and values about dignity and care. RELEVANCE TO CLINICAL PRACTICE: The in-depth exploration led to an understanding of the basis for continence care practices that centre on cleaning, containing and concealing residents' incontinence in some nursing homes. There is a need to review the quality of education for the aged care workforce about incontinence to ensure it equips them with a broad understanding of the fundamentals of care and how to enact dignity in continence care through a resident-centred approach.

Risk factors for incident delirium in an acute general medical setting: a retrospective case-control study.

AIMS AND OBJECTIVES: To determine predisposing and precipitating risk factors for incident delirium in medical patients during an acute hospital admission. BACKGROUND: Incident delirium is the most common complication of hospital admission for older patients. Up to 30% of hospitalised medical patients experience incident delirium. Determining risk factors for delirium is important for identifying patients who are most susceptible to incident delirium. DESIGN: Retrospective case-control study with two controls per case. METHODS: An audit tool was used to review medical records of patients admitted to acute medical units for data regarding potential risk factors for delirium. Data were collected between August 2013 and March 2014 at three hospital sites of a healthcare organisation in Melbourne, Australia. Cases were 161 patients admitted to an acute medical ward and diagnosed with incident delirium between 1 January 2012 and 31 December 2013. Controls were 321 patients sampled from the acute medical population admitted within the same time range, stratified for admission location and who did not develop incident delirium during hospitalisation. RESULTS: Identified using logistic regression modelling, predisposing risk factors for incident delirium were dementia, cognitive impairment, functional impairment, previous delirium and fracture on admission. Precipitating risk factors for incident delirium were use of an indwelling catheter, adding more than three medications during admission and having an abnormal sodium level during admission. CONCLUSIONS: Multiple risk factors for incident delirium exist; patients with a history of delirium, dementia and cognitive impairment are at greatest risk of developing delirium during hospitalisation. RELEVANCE TO CLINICAL PRACTICE: Nurses and other healthcare professionals should be aware of patients who have one or more risk factors for incident delirium. Knowledge of risk factors for delirium has the potential to increase the recognition and understanding of patients who are vulnerable to delirium. Early recognition and prevention of delirium can contribute to improved patients safety and reduction in harm.

DELIRIUM.

What is delirium? Delirium is a common but serious complication of hospitalisation. Delirium can occur in patients of all ages, but the highest incidence is in older patients (>65 years) (MacLullich et al. 2008).

Euthanasia and physician-assisted suicide in dementia: A qualitative study of the views of former dementia carers.

BACKGROUND: Despite media and academic interest on assisted dying in dementia, little is known of the views of those directly affected. AIM: This study explored the views of former carers on assisted dying in dementia. DESIGN: This was a qualitative study using thematic analysis. SETTING/PARTICIPANTS: A total of 16 former carers of people with dementia were recruited through national dementia charities and participated in semi-structured interviews. RESULTS: While many supported the individual's right to die, the complexity of assisted dying in dementia was emphasized. Existential, physical, psychological and psychosocial aspects of suffering were identified as potential reasons to desire an assisted death. Most believed it would help to talk with a trained health professional if contemplating an assisted death. CONCLUSION: Health workers should be mindful of the holistic experience of dementia at the end of life. The psychological and existential aspects of suffering should be addressed, as well as relief of physical pain. Further research is required.

Assisted dying in dementia: a systematic review of the international literature on the attitudes of health professionals, patients, carers and the public, and the factors associated with these.

BACKGROUND: Assisted death and dementia is a controversial topic that, in recent years, has been subject to considerable clinical, ethical and political debate. OBJECTIVE: This paper reviews the international literature on attitudes towards assisted dying in dementia and considers the factors associated with these. DESIGN: A systematic literature search was conducted in Cumulative Index to Nursing and Allied Health Literature, Excerpta Medica Database, PsychINFO and Web of Science between 1992 and August 2013. Electronic and hand searches identified 118 potential relevant studies. Eighteen studies met the full inclusion criteria and were screened using a quality assessment tool. RESULTS: Health professionals hold more restrictive views towards assisted dying, which appear less affected by their cultural background, than the public, patients and carers. However, opinions within each population vary according to dementia severity and issues of capacity, as well as differing according to factors such as age, ethnicity, gender and religion of those surveyed. There also appears to be a trend towards more accepting attitudes over time. CONCLUSIONS: Sociodemographic factors can influence attitudes towards assisted dying. The impact of these, however, may also differ according to the population surveyed. The findings from this review can contribute to current debates and inform clinical practice and future research in this area.