ABSTRACT
BACKGROUND: Persons with dementia hospitalized for an acute illness have a high risk of poor outcomes and add to the burden on acute care systems. We developed a segregated Special Care Unit (SCU) in a somatic hospital for patients with challenging behavior resulting from dementia and/or delirium. This pilot study evaluates the feasibility and patient outcomes. METHODS: The SCU was established with environmental features that allow for safe and unrestricted ambulation within the unit and create a home-like atmosphere. Daytime activities structure the day and assure additional professional presence. The staff received intensive specialized training. Feasibility criteria were: acceptance by the staff, avoidance of transfers to geriatric psychiatry, lack of serious falls and mortality. Patient outcome criteria were ADL (Barthel index), mobility scores and behavior scores (Wilcoxon's, McNemar tests, pre-post design). RESULTS: 332 consecutively admitted patients were enrolled. The SCU has been well received by the staff. Length of hospital stay did not differ from other hospital patients (15.3 +/- 8.3 vs. 15.0 +/- 10.3 days, p = 0.54). Six patients were transferred to geriatric psychiatry. Two patients suffered a fall-related hip fracture. The median Barthel Index improved significantly (admission 30, discharge 45, p < 0.001), with only 8.5% of patients suffering functional loss. Wandering, aggression and agitation were significantly reduced (p < 0.001). CONCLUSIONS: The SCU has improved the care of patients with challenging behavior. Decline in ADL function and institutionalization occurred to a lesser degree than would be expected in this group of patients. Despite the selection of patients with behavioral problems, transfer to psychiatry was rare.
Subject(s)
Dementia/epidemiology , Patient Care/standards , Somatoform Disorders/epidemiology , Somatoform Disorders/rehabilitation , Acute Disease , Aged , Education , Feasibility Studies , Female , Health Personnel/education , Hospitalization , Humans , Male , Practice Patterns, Physicians' , Professional-Patient Relations , Referral and Consultation , Surveys and Questionnaires , Videotape RecordingABSTRACT
OBJECTIVES: To assess validity and interrater reliability of an operationalized German version of the Confusion Assessment Method (CAM) in geriatric patients with comorbid dementia and high delirium risk. DESIGN: Prospective cross-sectional cohort study with double CAM assessment by a medical and nonmedical rater. SETTING: Random sample of frail, cognitively impaired elderly with acute disease requiring hospital care. PARTICIPANTS: A total of 39 frail elderly, mean age 83 +/- 7 years, 72% (n = 28) female, with cognitive impairments, a high prevalence of dementia (86%, n = 33) and a significant risk of delirium. Of these, 13 revealed delirium, which was superimposed on dementia in 11. MEASUREMENTS: A translated and operationalized version of the CAM was validated against a neuropsychiatric and geriatric consensus reference standard based on DSM-IV. Additional measures included the Short Portable Mental Status Questionnaire, the Mini-Mental State Examination and the Delirium Index for cognitive impairment severity, the Informant Questionnaire on Cognitive Decline for dementia diagnosis and the Barthel Index, illness severity (Cumulative Illness Rating Scale) and medication. RESULTS: Delirium was correctly detected by CAM algorithm in 10 out of 13 delirious patients resulting in a high sensitivity of 0.77 and a specificity of 0.96-1.00 for both raters. Likelihood ratio revealed an almost 20-fold risk of delirium with positive CAM testing. Interrater reliability was excellent with a Cohen's k of 0.95 (CI 0.74-1.0) for the algorithm, single items' k values varied between 0.5 and 1. CONCLUSIONS: The German CAM is a reliable and valid measure of delirium, even in frail, acutely diseased elderly with concomitant dementia.
Subject(s)
Confusion/diagnosis , Delirium/diagnosis , Dementia/diagnosis , Frail Elderly/psychology , Personality Assessment/statistics & numerical data , Acute Disease , Aged , Aged, 80 and over , Algorithms , Comorbidity , Confusion/psychology , Delirium/psychology , Dementia/psychology , Diagnosis, Differential , Diagnostic and Statistical Manual of Mental Disorders , Female , Germany , Hospitalization , Humans , Male , Mental Status Schedule/statistics & numerical data , Neuropsychological Tests/statistics & numerical data , Psychometrics/statistics & numerical data , Reproducibility of Results , Risk FactorsABSTRACT
BACKGROUND: Delirium increases morbidity, mortality and healthcare costs especially in the elderly. Serum anticholinergic activity (SAA) is a suggested biomarker for anticholinergic burden and delirium risk, but the association with cerebral cholinergic function remains unclear. To clarify this relationship, we prospectively assessed the correlation of SAA with quantitative electroencephalography (qEEG) power, delirium occurrence, functional and cognitive measures in a cross-sectional sample of acutely hospitalized elderly (> 80 y) with high dementia and delirium prevalence. METHODS: 61 consecutively admitted patients over 80 years underwent an extensive clinical and neuropsychological evaluation. SAA was determined by using radio receptor assay as developed by Tune, and standard as well as quantitative EEGs were obtained. RESULTS: 15 patients had dementia with additional delirium (DD) according to expert consensus using DSM-IV criteria, 31 suffered from dementia without delirium (D), 15 were cognitively unimpaired (CU). SAA was clearly detectable in all patients but one (mean 10.9 +/- 7.1 pmol/ml), but was not associated with expert-panel approved delirium diagnosis or cognitive functions. Delirium-associated EEG abnormalities included occipital slowing, peak power and alpha decrease, delta and theta power increase and slow wave ratio increase during active delirious states. EEG measures correlated significantly with cognitive performance and delirium severity, but not with SAA levels. CONCLUSION: In elderly with acute disease, EEG parameters reliable indicate delirium, but SAA does not seem to reflect cerebral cholinergic function as measured by EEG and is not related to delirium diagnosis.
Subject(s)
Cholinergic Antagonists/blood , Delirium/diagnosis , Dementia/diagnosis , Aged, 80 and over , Biomarkers/blood , Cognition Disorders/blood , Cognition Disorders/diagnosis , Cognition Disorders/physiopathology , Delirium/blood , Delirium/physiopathology , Dementia/blood , Dementia/physiopathology , Diagnosis, Differential , Electroencephalography , Frail Elderly , Humans , Mental Status Schedule , Neurocognitive Disorders/blood , Neurocognitive Disorders/diagnosis , Neurocognitive Disorders/physiopathologyABSTRACT
This paper describes the development and management of a new model of care for hospitalized patients with challenging behaviour evoked by dementia and/or delirium. To ameliorate care for patients with dementia in a geriatric acute care hospital a segregated Special Care Unit for patients with challenging behaviour was created. Environmental features allow for safe and unrestricted ambulation within the unit and create a home-like atmosphere. Day-time activities structure the day and assure additional professional presence in the unit. An intensive training program for the staff was provided. The SCU has been well accepted by the staff and is considered to be an improvement in care. Psychological burden of the nurses did not increase over a time period of one year in caring for these difficult patients.
Subject(s)
Delirium/nursing , Dementia/nursing , Geriatrics , Hospitals, Special/organization & administration , Mental Disorders/nursing , Aged , Aged, 80 and over , Hospitals, University , Humans , Inservice Training/organization & administration , Patient Care Team/organization & administration , Psychomotor Agitation/therapy , Safety Management/organization & administration , Social Environment , WorkloadABSTRACT
Previous studies have suggested a possible link between cognitive impairment and anticholinergic burden as reflected by high serum anticholinergic activity (SAA). Thus, we hypothesized a close relationship between anticholinergic activity in cerebral spinal fluid (CSF) and blood. However, it has never been convincingly demonstrated that peripheral anticholinergic activity correlates with central anticholinergic levels in presurgical patients. Therefore, anticholinergic activity was measured in blood and CSF from 15 patients with admission scheduled for urological surgery to compare peripheral and central anticholinergic level. Blood and CSF probes were taken after routine premedication and before spinal anesthesia. Anticholinergic activity was determined by competitive radioreceptor binding assay for muscarinergic receptors. Correlation analysis was conducted for peripheral and central anticholinergic levels. The mean anticholinergic levels were 2.4+/-1.7 in the patients' blood and 5.9+/-2.1 pmol/mL of atropine equivalents in CSF. Interestingly, the anticholinergic activity in CSF was about 2.5-fold higher than in patients' blood. A significant linear correlation was detected between blood and CSF levels. Therefore we conclude that SAA levels adequately reflect central anticholinergic activity. When patients receiving or not receiving anticholinergic medication were compared, anticholinergic activity tended to increase in blood and CSF after receiving anticholinergic medication > or =4 weeks (p>0.05).
