Cingulate and hippocampal subregion abnormalities in combat-exposed veterans with PTSD.

BACKGROUND: The hippocampus and cingulate gyrus are strongly interconnected brain regions that have been implicated in the neurobiology of post-traumatic stress disorder (PTSD). These brain structures are comprised of functionally distinct subregions that may contribute to the expression of PTSD symptoms or associated cardio-metabolic markers, but have not been well investigated in prior studies. METHODS: Two divisions of the cingulate cortex (i.e., rostral and caudal) and 11 hippocampal subregions were investigated in 22 male combat-exposed veterans with PTSD and 22 male trauma-exposed veteran controls (TC). Cardio-metabolic measures included cholesterol, body mass index, and mean arterial pressure. RESULTS: Individuals with PTSD had less caudal cingulate area compared to TC even after controlling for caudal cingulate thickness. Total hippocampus volume was lower in PTSD compared to TC, accounted for by differences in CA1-CA4, granule cell layer of the dentate gyrus, molecular layer, and subiculum. Individuals with PTSD had higher mean arterial pressure compared to TC, which correlated with hippocampus volume only in the PTSD group. LIMITATIONS: Sample size, cross-sectional analysis, no control for medications and findings limited to males. CONCLUSIONS: These data demonstrate preferential involvement of caudal cingulate area (vs. thickness) and hippocampus subregions in PTSD. The inverse association between hippocampus volume and mean arterial pressure may contribute to accelerated aging known to be associated with PTSD.

Development of the interRAI Pressure Ulcer Risk Scale (PURS) for use in long-term care and home care settings.

BACKGROUND: In long-term care (LTC) homes in the province of Ontario, implementation of the Minimum Data Set (MDS) assessment and The Braden Scale for predicting pressure ulcer risk were occurring simultaneously. The purpose of this study was, using available data sources, to develop a bedside MDS-based scale to identify individuals under care at various levels of risk for developing pressure ulcers in order to facilitate targeting risk factors for prevention. METHODS: Data for developing the interRAI Pressure Ulcer Risk Scale (interRAI PURS) were available from 2 Ontario sources: three LTC homes with 257 residents assessed during the same time frame with the MDS and Braden Scale for Predicting Pressure Sore Risk, and eighty-nine Ontario LTC homes with 12,896 residents with baseline/reassessment MDS data (median time 91 days), between 2005-2007. All assessments were done by trained clinical staff, and baseline assessments were restricted to those with no recorded pressure ulcer. MDS baseline/reassessment samples used in further testing included 13,062 patients of Ontario Complex Continuing Care Hospitals (CCC) and 73,183 Ontario long-stay home care (HC) clients. RESULTS: A data-informed Braden Scale cross-walk scale using MDS items was devised from the 3-facility dataset, and tested in the larger longitudinal LTC homes data for its association with a future new pressure ulcer, giving a c-statistic of 0.676. Informed by this, LTC homes data along with evidence from the clinical literature was used to create an alternate-form 7-item additive scale, the interRAI PURS, with good distributional characteristics and c-statistic of 0.708. Testing of the scale in CCC and HC longitudinal data showed strong association with development of a new pressure ulcer. CONCLUSIONS: interRAI PURS differentiates risk of developing pressure ulcers among facility-based residents and home care recipients. As an output from an MDS assessment, it eliminates duplicated effort required for separate pressure ulcer risk scoring. Moreover, it can be done manually at the bedside during critical early days in an admission when the full MDS has yet to be completed. It can be calculated with established MDS instruments as well as with the newer interRAI suite instruments designed to follow persons across various care settings (interRAI Long-Term Care Facilities, interRAI Home Care, interRAI Palliative Care).

Benefits of a telepsychiatry consultation service for rural nursing home residents.

Psychiatric care for nursing home residents is difficult to obtain, especially in rural areas, and this deficiency may lead to significant morbidity or death. Providing this service by videoconference may be a helpful, cost-effective, and acceptable alternative to face-to-face treatment. We analyzed data for 278 telepsychiatry encounters for 106 nursing home residents to estimate potential cost and time savings associated with this modality compared to in-person care. A total of 843.5 hours (105.4 8-hour work days) of travel time was saved compared to in-person consultation for each of the 278 encounters if they had occurred separately. If four resident visits were possible for each trip, the time saved would decrease to 26.4 workdays. Travel distance saved was 43,000 miles; 10,750 miles if four visits per trip occurred. More than $3,700 would be spent on gasoline for 278 separate encounters; decreased to $925 for four visits per roundtrip. Personnel cost savings estimates ranged from $33,739 to $67,477. Physician costs associated with additional travel time ranged from $84,347 to $253,040 for 278 encounters, or from $21,087 to $63,260 for four encounters per visit. The telepsychiatry approach was enthusiastically accepted by virtually all residents, family members, and nursing home personnel, and led to successful patient management. Providing psychiatric care to rural nursing home residents by videoconference is cost effective and appears to be a medically acceptable alternative to face-to-face care. In addition, this approach will allow many nursing homes to provide essential care that would not otherwise be available.

Association between delirium resolution and functional recovery among newly admitted postacute facility patients.

BACKGROUND: Delirium is common among hospitalized elders and may persist for months. The adverse impact of delirium on independence may increasingly occur in the postacute care (PAC) setting. The purpose of this study is to examine the association between delirium resolution and functional recovery in skilled nursing facilities specializing in PAC. METHODS: Patients were screened for delirium on admission after an acute hospitalization at PAC facilities. Only patients with "Confusion Assessment Method"-defined delirium were enrolled. Delirium and activities of daily living were assessed prehospital, at PAC admission, and at four (2-week, and 1-, 3-, and 6-month) follow-up assessments to measure functional ability. Four distinct delirium resolution groups were created ranging from resolution within 2 weeks without recurrence to no resolution over 6 months. Repeated-measures analysis of covariance was used to determine if functional performance differed over time by delirium resolution status. RESULTS: Among the 393 PAC patients, functional recovery differed significantly (p <.0001) by delirium resolution status. Patients who resolved their delirium by 2 weeks without recurrence regained 100% of their prehospital functional level, whereas patients who never resolved their delirium retained less than 50% of their prehospital functional level. Patients with slower resolving delirium and recurrent delirium had intermediate functional outcomes. CONCLUSIONS: Resolution of delirium among PAC patients appears to be a prerequisite for functional recovery. Delirium resolution within 2 weeks without recurrence is associated with excellent functional recovery. Effective strategies to resolve delirium promptly and prevent its recurrence in the PAC setting will likely benefit patient rehabilitation and functional recovery.

A model for management of delirious postacute care patients.

Although delirium has been shown to be a common, morbid, and costly problem for hospitalized older people, evidence has mounted that it may persist for weeks or months. Therefore, concern about delirium can no longer be confined to acute care. After an acute hospitalization, many older people are discharged to postacute care (PAC) facilities--rehabilitation hospitals and skilled nursing facilities. Although several models designed to prevent delirium in the hospital setting have been described, there have been few such efforts in the PAC setting. This article describes the development of a multifactorial delirium abatement program (DAP), a new model of care for older patients admitted to the postacute skilled nursing facility with delirium. The DAP is a nurse-led, unit-based intervention. The program consists of four modules based on best practices as defined by the peer-reviewed literature: standardized screening for symptoms and signs of delirium upon admission to the PAC unit, assessment and treatment of possible causes of and contributors to delirium, prevention and management of common delirium complications, and restoration of patient cognitive and self-care function. This article also presents the process of facility introduction, staff education on DAP content, and multidisciplinary outreach. Key strategies for DAP implementation are reviewed. Program adoption challenges and corresponding model refinements to enhance adherence and overall care quality are highlighted. Last, clinical adaptation of this research-derived program is discussed.

Outcomes of older people admitted to postacute facilities with delirium.

OBJECTIVES: To compare outcomes of patients admitted to postacute skilled nursing facilities with delirium, subsyndromal delirium, and no delirium. DESIGN: Observational cohort study. SETTING: Seven skilled nursing facilities that specialize in postacute care within a single metropolitan region. PARTICIPANTS: Five hundred four subjects chosen from 1,248 consenting subjects aged 65 and older who underwent mental status testing within 5 days of admission to the participating facilities. Subjects who met full Confusion Assessment Method (CAM) criteria were classified as delirious, those with one or more CAM criteria were classified as having subsyndromal delirium, and those with no CAM features were classified as having no delirium. All subjects with delirium and with available medical records were included. A random subset of subjects with no delirium and subsyndromal delirium with available medical records was included. MEASUREMENTS: The medical records of all subjects underwent a structured review by trained research nurses who were masked to the subjects' initial delirium status. Records were reviewed for the development of new complications within the postacute setting and to determine whether the subjects were discharged within 30 days and, if so, the discharge destination. The National Death Index was used to assess 6-month mortality. RESULTS: Subjects with delirium were more likely to experience one or more complications than subjects with no delirium (73% vs 41%, P < .01). Within 30 days of postacute admission, subjects with delirium were more than twice as likely to be rehospitalized (30% vs 13%), and less than half as likely to be discharged to the community (30% vs 73%) than subjects without delirium (differences P < .01). Subjects with subsyndromal delirium had outcomes intermediate between those with and without delirium. Finally, subjects admitted to the postacute setting with delirium experienced a 6-month mortality rate of 25.0%, compared with 5.7% in subjects admitted without delirium. Subjects with subsyndromal delirium had a 6-month mortality rate of 18.3%. CONCLUSION: Patients admitted to postacute skilled nursing facilities with delirium are more likely to experience complications, rehospitalization, and death than patients without delirium. These findings support the need for improved case finding and management of delirium in postacute care.

Characteristics associated with delirium persistence among newly admitted post-acute facility patients.

BACKGROUND: Delirium is costly, common, and may persist for weeks or months. Therefore, the adverse impact of delirium on loss of independence may occur in the post-acute setting rather than in the hospital. The purpose of this study is to describe the rate of delirium persistence and identify baseline patient characteristics that are associated with delirium persistence at 1 month among newly admitted post-acute facility patients who were admitted with delirium. METHODS: Patients were recruited from 4 Boston area skilled nursing facilities specializing in post-acute care (PAC). Assessment instruments included the Confusion Assessment Method Diagnostic Algorithm, the modified Delirium Symptom Interview, the Memorial Delirium Assessment Scale (MDAS), and the Blessed Dementia Rating Scale (BDRS). Multiple logistic regression analyses were used to identify patient characteristics associated with delirium persistence (at 1 month). RESULTS: Nearly 51% of the 85 delirious patients enrolled in this study had delirium at their 1-month follow-up assessment. Four patient factors associated with delirium persistence were identified: older age (> or =85 years), severe delirium at PAC admission (MDAS score >15), prehospital cognitive impairment based on proxy report [BDRS], and the presence of all 8 modified Delirium Symptom Interview symptoms at PAC admission. Our model has very good predictive power (area under the receiver operating characteristic = 0.85). CONCLUSIONS: Delirium is persistent in the post-acute setting. If verified in further research, the risk factors found in this study could be used to identify patients who are likely to have delirium after 1 month, and may prove useful in developing and targeting interventions of care.

Delirium among newly admitted postacute facility patients: prevalence, symptoms, and severity.

BACKGROUND: Delirium may persist for weeks or months, and discharging elderly patients quickly from acute care facilities is not uncommon. Therefore, the adverse impact of delirium on loss of independence may occur in the postacute setting rather than in the hospital. The purpose of this study is to describe the prevalence of delirium, delirium symptoms, and severity assessed at admission to postacute facilities. METHODS: Subjects were recruited from seven Boston-area skilled nursing facilities specializing in postacute care. Assessment instruments included the Mini-Mental Status Exam, Delirium Symptom Interview, Memorial Delirium Assessment Scale, and Confusion Assessment Method (CAM) Diagnostic Algorithm. Delirium status was categorized into four groups: full, two or more symptoms, one symptom, and no delirium. Descriptive statistics were calculated and chi-square analyses and an analysis-of-variance were used to examine delirium characteristics by delirium group. RESULTS: Among 2158 subjects, approximately 16% had full CAM-defined delirium at admission to the postacute facility. In addition, nearly 13% of the subjects had two or more symptoms of delirium, approximately 40% had one delirium symptom, and 32% had no symptoms of delirium. In a comparison of the group with no symptoms of delirium with that with CAM-defined delirium, there was a significant trend toward (a) older age, (b) lower scores on the Mini-Mental Status Exam, (c) more Delirium Symptom Interview symptoms, and (d) higher Memorial Delirium Assessment Scale Scores. CONCLUSIONS: Results indicate that 16% of admissions to postacute facilities have CAM-defined delirium, and over two thirds had at least one delirium symptom. It is not known whether or not postacute staff have the training necessary to detect or manage delirium. Managing delirium may require different strategies and techniques in a postacute setting, thereby requiring further research.

Delirium symptoms in post-acute care: prevalent, persistent, and associated with poor functional recovery.

OBJECTIVES: To determine the prevalence of delirium symptoms at the time of admission to post-acute facilities, the persistence of delirium symptoms in this setting, and the association of delirium symptoms with functional recovery. DESIGN: Prospective cohort study. SETTING: Eighty-five post-acute care facilities: 55 rehabilitation hospitals and 30 skilled nursing facilities in 29 states. PARTICIPANTS: Five hundred fifty-one consenting patients aged 65 and older newly admitted to participating facilities from acute care hospitals. MEASUREMENTS: Data were collected as part of a field study effort related to the Minimum Data Set (MDS). Basic demographic data, medical comorbidity, delirium symptoms, and functional status--activities of daily living (ADLs) and instrumental activities of daily living (IADLs)--were obtained from MDS assessments performed within 4 days of admission and again 1 week later by the patient's primary nurse. Six delirium symptoms (easily distracted, periods of altered perception, disorganized speech, periods of restlessness, periods of lethargy, and mental function varies over the course of a day) were assessed after appropriate training. RESULTS: Of the 551 patients (mean age +/- standard deviation 78 +/- 7, 64% women), 126 had delirium symptoms on post-acute admission, for an overall prevalence of 23%. In patients with delirium symptoms on the admission assessment, 1 week later, 14% had completely resolved, 22% had fewer delirium symptoms, 52% had the same number of symptoms, and 12% had more symptoms. Of those with no delirium symptoms on admission, 4% had new symptoms 1 week later. Patients who had the same number of or more delirium symptoms at the second assessment had significantly worse ADL and IADL recovery than those with fewer or resolved delirium symptoms or those with no delirium symptoms at either assessment. Persistent delirium symptoms remained significantly associated with worse ADL and IADL recovery after adjusting for age, comorbidity, dementia, and baseline functional status. CONCLUSIONS: The data from this study provide strong preliminary evidence that, in patients newly admitted to post-acute care facilities from acute care hospitals, delirium symptoms are prevalent, persistent, and associated with poor functional recovery. Educational efforts are warranted to help post-acute facility staff recognize and manage this common and morbid condition.

Delirium: pathophysiology, recognition, prevention and treatment.

Delirium, a clinical syndrome characterized by the acute onset of confusion, indicates that there is a disruption in physiological equilibrium that may lead to death unless quick and appropriate action is taken. Despite its frequent appearance, delirium often goes unrecognized, undetected and untreated, leading to poorer outcomes including longer lengths of hospitalization, persistent deficits in cognitive function and the need for nursing home placement following acute treatment. Prevention and treatment strategies do not need to be complex or expensive, but require well co-ordinated interventions from multiple disciplines including nursing, psychiatry, neurology and primary care, as well as the co-operation and significant effort of family and friends who know the affected individual well.

Identification and evaluation of existing nursing homes quality indicators.

We summarize work done to identify and evaluate existing quality indicators (QIs) for long-term care (LTC) settings. Indicators operationally defined using routinely collected and computerized patient assessments were identified and then aggregated to characterize the performance of the nursing facility over a specific period of time. Of 143 indicators reviewed, only 22 were recommended for use in comparing performance across facilities. Conceptual and technical issues influence the appropriateness of QIs for different audiences.