Quality Improvement in Delirium Health Literacy in Older Adult Patients and Their Caregivers Attending a Geriatric Clinic.

Background: Delirium is a common medical condition that is highly prevalent in older adults who are at increased risk for its development with any illness, post-surgery or during hospitalization. The purpose of our study was to evaluate the health literacy of older adult patients and their caregivers about delirium, offer a brief educational intervention, and reevaluate their knowledge post intervention. Materials and Methods: We conducted a quality improvement project, focused on delirium health literacy in older adult patients ≥60 years and their caregivers. Delirium knowledge of participants was evaluated in a pre-education survey after which they were given a delirium education booklet to read. A post-education delirium survey was conducted within 2-3 weeks of the educational intervention. Chi-square test was used to analyze the knowledge base of older adults. Results: The study population consisted of a total of 70 older adults who participated in pre-education (n=35) and post-education (n=35) surveys. Older adult patients and their caregivers had significant knowledge gaps about the potential causes or etiologies, risk factors, symptomatology, and prevention of delirium in the pre-education survey. After the educational intervention, in the post-education survey, there were overall improvements in knowledge base of older adults in differentiating delirium with dementia (43% vs 94%, p<0.01) recognizing signs and symptoms (77% vs 94%, p<0.05), complications (76% vs 100%, p<0.01) and identifying the etiological factors associated with delirium. Conclusion: The quality improvement project demonstrated that older adults and caregivers have significant knowledge deficits about the common condition of delirium. This study also demonstrated that older adults were able to improve their health literacy regarding delirium after the intervention. Appropriate education on delirium for patients and caregivers might help in earlier identification, prevention, and better overall management of delirium.

The Modified and Extended Hospital Elder Life Program: A remote model of care to expand delirium prevention.

BACKGROUND: Delirium is a common complication of hospitalization and is associated with poor outcomes. Multicomponent delirium prevention strategies such as the Hospital Elder Life Program (HELP) have proven effective but rely on face-to-face intervention protocols and volunteer staff, which was not possible due to restrictions during the COVID-19 pandemic. We developed the Modified and Extended Hospital Elder Life Program (HELP-ME), an innovative adaptation of HELP for remote and/or physically distanced applications. METHODS: HELP-ME protocols were adapted from well-established multicomponent delirium prevention strategies and were implemented at four expert HELP sites. Each site contributed to the protocol modifications and compilation of a HELP-ME Operations Manual with standardized protocols and training instructions during three expert panel working groups. Implementation was overseen and monitored during seven learning sessions plus four coaching sessions from January 8, 2021, through September 24, 2021. Feasibility of implementing HELP-ME was measured by protocol adherence rates. Focus groups were conducted to evaluate the acceptability, provide feedback, and identify facilitators and barriers to implementation. RESULTS: A total of 106 patients were enrolled across four sites, and data were collected for 214 patient-days. Overall adherence was 82% (1473 completed protocols/1798 patient-days), achieving our feasibility target of >75% overall adherence. Individual adherence rates ranged from 55% to 96% across sites for the individual protocols. Protocols with high adherence rates included the nursing delirium protocol (96%), nursing medication review (96%), vision (89%), hearing (87%), and orientation (88%), whereas lower adherence occurred with fluid repletion (64%) and range-of-motion exercises (55%). Focus group feedback was generally positive for acceptability, with recommendations that an optimal approach would be hybrid, balancing in-person and remote interventions for potency and long-term sustainability. CONCLUSIONS: HELP-ME was fully implemented at four HELP sites, demonstrating feasibility and acceptability. Testing hybrid approaches and evaluating effectiveness is recommended for future work.

A case for continuing statin medications in the intensive care unit: Reducing the risk for delirium.

PURPOSE: The objective of this review is to detail the utility of statin medications in the prevention and treatment of intensive care unit (ICU) delirium. SUMMARY: Delirium is a syndrome characterized by altered mental status, inattention, and disorganized thinking. It is particularly concerning in the ICU where specific risk factors are much more prevalent. Nonpharmacological therapy is the mainstay of treatment, aimed at increasing patient awareness; pharmacological therapies have also been explored with varying success. The utility of statin medications in this scenario has been investigated because of the numerous pleiotropic effects of these drugs. Although the benefits in terms of treating delirium are uncertain, statins may be good candidates for prevention. The peak anti-inflammatory effect of statins is delayed, so initiating a statin on admission will likely have little protective benefit, whereas continuation of a home regimen seems more likely to exert an effect. CONCLUSION: Statin medications are very commonly used, and, while their role in treating delirium is unclear, continuation of these medications from a home regimen is reasonable to decrease the odds of delirium in the intensive care population.

Non-Pharmacological Nursing Interventions for Prevention and Treatment of Delirium in Hospitalized Adult Patients: Systematic Review of Randomized Controlled Trials.

Delirium is a common neurobehavioral complication in hospitalized patients that can occur in the acute phase and lead to poor long-term outcomes. The purpose of this study was to identify non-pharmacological nursing interventions for the prevention and treatment of delirium in hospitalized adult patients. We conducted a systematic review to synthesize the findings of published studies. We searched the PubMed, EMBASE, CINAHL, and Cochrane Library CENTRAL databases for randomized controlled trials in January 2021. We report this systematic review according to the PRISMA 2009 checklist. The study was registered on PROSPERO (CRD42021226538). Nine studies were systematically reviewed for non-pharmacological nursing interventions for the prevention and treatment of delirium. The types of non-pharmacological nursing interventions included multicomponent intervention, multidisciplinary care, multimedia education, music listening, mentoring of family caregivers concerning delirium management, bright light exposure, ear plugs, and interventions for simulated family presence using pre-recorded video messages. These results could help nurses select and utilize non-pharmacological nursing interventions for the prevention and treatment of delirium in clinical nursing practice.

Management of proximal femur fractures in the elderly: current concepts and treatment options.

As one of the leading causes of elderly patients' hospitalisation, proximal femur fractures (PFFs) will present an increasing socioeconomic problem in the near future. This is a result of the demographic change that is expressed by the increasing proportion of elderly people in society. Peri-operative management must be handled attentively to avoid complications and decrease mortality rates. To deal with the exceptional needs of the elderly, the development of orthogeriatric centres to support orthogeriatric co-management is mandatory. Adequate pain medication, balanced fluid management, delirium prevention and the operative treatment choice based on comorbidities, individual demands and biological rather than chronological age, all deserve particular attention to improve patients' outcomes. The operative management of intertrochanteric and subtrochanteric fractures favours intramedullary nailing. For femoral neck fractures, the Garden classification is used to differentiate between non-displaced and displaced fractures. Osteosynthesis is suitable for biologically young patients with non-dislocated fractures, whereas total hip arthroplasty and hemiarthroplasty are the main options for biologically old patients and displaced fractures. In bedridden patients, osteosynthesis might be an option to establish transferability from bed to chair and the restroom. Postoperatively, the patients benefit from early mobilisation and early geriatric care. During the COVID-19 pandemic, prolonged time until surgery and thus an increased rate of complications took a toll on frail patients with PFFs. This review aims to offer surgical guidelines for the treatment of PFFs in the elderly with a focus on pitfalls and challenges particularly relevant to frail patients.

The COVID-19 conundrum: Where both the virus and treatment contribute to delirium.

Whereas hospitalists and intensivists are treating the life-threatening respiratory conditions that often accompany COVID-19, delirium prevention, identification, and treatment may inadvertently be taking a backseat. However, delirium identification is important as it can serve as a key marker for hospital providers to identify COVID patients at risk for poor outcomes including ICU stay and death.2 COVID delirium has been difficult to manage because some COVID treatment methods are inherently deliriogenic and some medications traditionally used to manage delirium have been rendered ineffective among this population. Inpatient neurology and psychiatry practitioners are having to postulate new treatment techniques; one such medication algorithm can be found within this piece. It is important that delirium doesn't get lost in the chaos that is management of the COVID patient.

Low molecular weight heparin in COVID-19 patients prevents delirium and shortens hospitalization.

BACKGROUND: COVID-19 patients present with delirium during their hospitalization. AIMS: To assess the incidence of delirium in hospitalized COVID-19 patients and analyze the possible association with demographic, clinical, laboratory, and pharmacological factors. METHODS: COVID-19 patients were assessed for clinical signs of delirium and administered the assessment test for delirium and cognitive impairment (4AT) and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) scales. RESULTS: Out of the 56 patients of our cohort, 14 (25.0%) experienced delirium. The use of low molecular weight heparin (LMWH) (enoxaparin 1 mg/kg/daily) was less frequent in patients with delirium (p = 0.004) and was accompanied by lower C reactive protein (CRP) levels (p = 0.006). DISCUSSION: The use of LMWH was associated with absence of delirium, independently of comorbidities and age. CONCLUSIONS: The use of LMWH may help preventing the occurrence of delirium in COVID-19 patients, with possible reduction of length of stay in the hospital and sequelae.

Development and External Validation of a Delirium Prediction Model for Hospitalized Patients With Coronavirus Disease 2019.

Background: The coronavirus disease 2019 pandemic has placed unprecedented stress on health systems and has been associated with elevated risk for delirium. The convergence of pandemic resource limitation and clinical demand associated with delirium requires careful risk stratification for targeted prevention efforts. Objectives: To develop an incident delirium predictive model among coronavirus disease 2019 patients. Methods: We applied supervised machine learning to electronic health record data for inpatients with coronavirus disease 2019 at three hospitals to build an incident delirium diagnosis prediction model. We validated this model in three different hospitals. Both hospital cohorts included academic and community settings. Results: Among 2907 patients across 6 hospitals, 488 (16.8%) developed delirium. Applying the predictive model in the external validation cohort of 755 patients, the c-index was 0.75 (0.71-0.79) and the lift in the top quintile was 2.1. At a sensitivity of 80%, the specificity was 56%, negative predictive value 92%, and positive predictive value 30%. Equivalent model performance was observed in subsamples stratified by age, sex, race, need for critical care and care at community vs. academic hospitals. Conclusion: Machine learning applied to electronic health records available at the time of inpatient admission can be used to risk-stratify patients with coronavirus disease 2019 for incident delirium. Delirium is common among patients with coronavirus disease 2019, and resource constraints during a pandemic demand careful attention to the optimal application of predictive models.

Implementing Delirium Prevention in the Era of COVID-19.

Patients admitted with COVID-19 can develop delirium due to predisposing factors, isolation, and the illness itself. Standard delirium prevention methods focus on interaction and stimulation. It can be challenging to deliver these methods of care in COVID settings where it is necessary to increase patient isolation. This paper presents a typical clinical vignette of representative patients in a tertiary care hospital and how a medical team modified an evidence-based delirium prevention model to deliver high-quality care to COVID-19 patients. The implemented model focuses on four areas of delirium-prevention: Mobility, Sleep, Cognitive Stimulation, and Nutrition. Future studies will be needed to track quantitative outcome measures.

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).