Detection of delirium in older patients-A point prevalence study in surgical and non-surgical hospital wards.

AIMS AND OBJECTIVES: To (i) determine the prevalence of delirium and identify delirium subtypes in surgical and non-surgical patients aged ≥65 years, (ii) determine whether certain precipitating factors affect the prevalence of delirium and (iii) review patients' medical records for description of delirium symptoms and the presence of International Classification of Diseases (ICD-10) coding for delirium in discharge summaries. METHODOLOGICAL DESIGN AND JUSTIFICATIONS: Despite being a robust predictor of morbidity and mortality in older adults, delirium might be inadequately recognised and under-reported in patients' medical records and discharge summaries. A point prevalence study (24-h) of patients ≥65 years from surgical and non-surgical wards was therefore conducted in a tertiary university hospital. ETHICAL ISSUES AND APPROVAL: The study was approved by the Data Protection Officer at the university hospital (2018/3454). RESEARCH METHODS, INSTRUMENTS AND/OR INTERVENTIONS: Patients were assessed for delirium with 4AT and delirium subtypes with the Delirium Motor Subtype Scale. Information about room transfers, need and use of sensory aids and medical equipment was collected onsite. Patients' medical records were reviewed for description of delirium symptoms and of ICD-10 codes. RESULTS: Overall, 123 patients were screened (52% female). Delirium was identified in 27% of them. Prevalence was associated with advanced age (≥85 years). The uncharacterised delirium subtype was most common (36%), followed by hypoactive (30%), hyperactive (24%) and mixed (9%). There were significant associations between positive screening tests and the need and use of sensory aids. Delirium symptoms were described in 58% of the patients who tested positive for delirium and the ICD-10 code for delirium was registered in 12% of these patients' discharge summaries. CONCLUSIONS: The high prevalence of delirium and limited use of discharge codes highlight the need to improve the identification of delirium in hospital settings and at discharge. Increased awareness and detection of delirium in hospital settings are vital to improve patient care.

How Do Persons Who Inject Drugs Experience Care From Nurses in Hospital Settings? A Qualitative Study.

People who inject drugs (PWID) are at increased risk of acute and chronic health outcomes and in need of in-hospital healthcare services. This study aims to give insight into how PWID experience care from nurses in hospital settings. We used a qualitative descriptive design and applied reflexive thematic analysis to 11 individual semi-structured interviews with PWID. Our analysis generated the following main themes: (1) diminishment and distance-always just a drug addict, (2) gratitude-equal care not taken for granted, and (3) vulnerability-already carrying a heavy burden. Our findings reveal a complex, nuanced narrative regarding participants' experiences of nursing care and highlight the importance of enhancing knowledge, understanding, empathy, and communication skills when nurses encounter PWID. Our research suggests that patients' vulnerability resulting from previous experiences defined their perception of quality of care. Insight from this study provides valuable knowledge about how to enhance nursing care for PWID.

Anxiety and depression in patients aged 80 years and older following aortic valve therapy. A six-month follow-up study.

BACKGROUND: Little is known about mental health following advanced cardiac procedures in the oldest patients. AIMS: To study changes in anxiety and depression from baseline to one- and six-month follow-up in older patients following transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR). METHODS: Prospective cohort study of patients ≥ 80 years undergoing elective TAVI or SAVR in a tertiary university hospital. Anxiety and depression were assessed with the Hospital Anxiety and Depression Scale. Differences between TAVI/SAVR were analyzed using Welch's t test or chi-squared. Changes over time and group differences were established with longitudinal models using generalized least squares. RESULTS: In 143 patients (83.5 ± 2.7 years), 46% (n = 65) received TAVI. Anxiety was identified in 11% of TAVI patients at baseline. One- and six-months later, percentages were 8% and 9%. In SAVR patients, 18% had baseline scores indicating anxiety. One and six-months later, percentages were 11% and 9%. Depression was identified in 15% of TAVI patients. One- and six-months later, percentages were 11% and 17%. At baseline, 11% of SAVR patients had scores indicating depression. One- and six-months after SAVR, percentages were 15% and 12%. Longitudinal analyses showed reductions (P < 0.001) in anxiety from baseline to one-month, and stable scores between one- and six-months for both treatment groups. There was no change over time for depression among treatment groups (P = 0.21). DISCUSSION AND CONCLUSIONS: SAVR or TAVI in patients ≥ 80 years was associated with anxiety reduction between baseline and follow-up. For depression, there was no evidence of change over time in either treatment group.

Consequences of the Covid-19 virus on individuals receiving homecare services in Norway. A qualitative study of nursing students' reflective notes.

BACKGROUND: Reflective notes in nursing education can facilitate students' understanding of how individuals in need of home healthcare services experience unfamiliar situations, such as a pandemic. The aim of this study is to describe the consequences of the COVID-19 virus for individuals receiving homecare services through the eyes of nursing students. METHODS: This is a qualitative descriptive study using content analysis to examine reflection notes from 17 nursing students in their last year of academic studies while undertaking home healthcare service training. RESULTS: Our study shows students' reflections on the consequences of the COVID-19 virus on individuals needing home healthcare services and their families. The analysis reveals three categories that described the effect of the virus according to students' reflections: i) how social life became restricted and only includes the closest family members and home healthcare staff (declining social circle), ii) how family members take on more responsibility to care for the individual and the pronounced impact of this on the day-to-day lives of the individual's next of kin (expanding responsibility of care), and iii) actions and reactions related to preventing the spread of the virus (dealing with the invisible threat). CONCLUSIONS: Students' reflection notes show that COVID-19 had major consequences, not only on the individuals receiving home healthcare services, but also on their relatives and on home healthcare staff.

Frailty Status and Patient-Reported Outcomes in Octogenarians Following Transcatheter or Surgical Aortic Valve Replacement.

BACKGROUND: Frailty status and patient-reported outcomes are especially pertinent in octogenarians following transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) to guide treatment decisions and promote patient-centred care. AIM: We aimed to determine if frailty changed 6 months after aortic valve replacement (AVR) in octogenarians, and to describe changes in self-rated health according to frailty status in patients who underwent TAVI or SAVR. METHOD: In a prospective cohort study, frailty and self-rated health were measured one day prior to and 6 months after AVR. Frailty status was measured with the Study of Osteoporotic Fracture index. Self-rated health was measured comprehensively with the disease-specific Minnesota Living with Heart Failure Questionnaire, the generic Medical Outcomes Study Short Form-12 questionnaire (SF-12), and two global questions from The World Health Organization Quality of Life Instrument Abbreviated. RESULTS: Data were available for 143 consecutive patients (mean age 83±2.7 years, 57% women; 45% underwent TAVI). At baseline, 34% were robust, 27% prefrail, and 39% frail. Overall, there was no change in the distribution of frailty status 6 months after baseline (p=0.13). However, on an individual level 65 patients changed frailty status after AVR (40 patients improved and 25 declined). Improvement in frailty status was common in prefrail (33%; n=13) and frail patients (48%; n=27). Patients had improved self-rated health after AVR, with significant differences between frailty states both at baseline (SF-12 physical: 37.4 [robust], 33.1 [prefrail], 31.6 [frail], p=0.03); SF-12 mental: 51.9 [robust], 50.8 [prefrail], 44.5 [frail], p<0.001); and at the 6-month follow-up (SF-12 physical: 45.4 [robust], 38.3 [prefrail], 32.1 [frail], p<0.001); SF-12 mental: 54.9 [robust], 49.6 [prefrail], 46.8 [frail], p=0.002). CONCLUSIONS: Advanced treatment performed in a high-risk population allowed people to improve their self-rated health. Although frailty is associated with poor self-rated health, frailty status does not equal negative outcomes. The frail patients were those who improved most in self-rated physical and mental health. They had the lowest baseline self-rated health scores and had therefore the most to gain.

"Eight Days of Nightmares " - Octogenarian Patients' Experiences of Postoperative Delirium after Transcatheter or Surgical Aortic Valve Replacement.

BACKGROUND: Surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) are increasingly performed in octogenarian patients with severe aortic stenosis (AS), including those with high surgical risk. Postoperative delirium (PD) is a common and serious complication in older patients, characterised by reduced awareness, change in consciousness, disturbance in logical thinking and hallucinations. METHODS: To explore how octogenarian patients experienced PD, a qualitative study was conducted including five women and five men between 81 and 88 years. The incidence of PD was assessed for five days using the Confusion Assessment Method. Cognitive function was assessed preoperatively and at a 6-month follow-up using the Mini-Mental State Examination. In-depth interviews were conducted 6-12 months post-discharge, transcribed, and analysed using Giorgi's phenomenological method. RESULTS: Postoperative delirium experiences were grouped into six themes: "Like dreaming while awake", "Disturbed experiences of time", "Existing in a twilight zone", "Trapped in medical tubes", "Moving between different surroundings" and "Meeting with death and the deceased". CONCLUSIONS: For the first time, we show that octogenarian patients who undergo SAVR or TAVI have strong and distressing memories of their delirious state that can persist for up to 12 months later. These findings provide valuable new information that will likely improve delivery of health services and enhance professional and empathic care of octogenarians after SAVR and TAVI.

Readmissions and mortality in delirious versus non-delirious octogenarian patients after aortic valve therapy: a prospective cohort study.

OBJECTIVES: To determine whether postoperative delirium predicts first-time readmissions and mortality in octogenarian patients within 180 days after aortic valve therapy with surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI), and to determine the most common diagnoses at readmission. DESIGN: Prospective cohort study of patients undergoing elective SAVR or TAVI. SETTING: Tertiary university hospital that performs all SAVRs and TAVIs in Western Norway. PARTICIPANTS: Patients 80+ years scheduled for SAVR or TAVI and willing to participate in the study were eligible. Those unable to speak Norwegian were excluded. Overall, 143 patients were included, and data from 136 are presented. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was a composite variable of time from discharge to first all-cause readmission or death. Secondary outcomes were all-cause first readmission alone and mortality within 180 days after discharge, and the primary diagnosis at discharge from first-time readmission. Delirium was assessed with the confusion assessment method. First-time readmissions, diagnoses and mortality were identified in hospital information registries. RESULTS: Delirium was identified in 56% of patients. The effect of delirium on readmissions and mortality was greatest during the first 2 months after discharge (adjusted HR 2.9 (95% CI 1.5 to 5.7)). Of 30 first-time readmissions occurring within 30 days, 24 (80%) were patients who experienced delirium. 1 patient (non-delirium group) died within 30 days after therapy. Delirious patients comprised 35 (64%) of 55 first-time readmissions occurring within 180 days. Circulatory system diseases and injuries were common causes of first-time readmissions within 180 days in delirious patients. 8 patients died 180 days after the procedure; 6 (75%) of them experienced delirium. CONCLUSIONS: Delirium in octogenarians after aortic valve therapy might be a serious risk factor for postoperative morbidity and mortality. Cardiovascular disorders and injuries were associated with first-time readmissions in these patients.

Delirium as a Predictor of Physical and Cognitive Function in Individuals Aged 80 and Older After Transcatheter Aortic Valve Implantation or Surgical Aortic Valve Replacement.

OBJECTIVES: To determine how development of delirium after surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI) could predict activity of daily living (ADL) and instrumental ADLs (IADL) disability, cognitive function, and self-reported health in individuals aged 80 and older. DESIGN: Prospective cohort study. SETTING: Tertiary university hospital. PARTICIPANTS: Individuals aged 80 and older undergoing elective SAVR or TAVI (N = 136). MEASUREMENTS: Delirium was assessed for 5 days using the Confusion Assessment Method. The Barthel Index, Nottingham Extended ADL Scale, and SF-12 were used to determine ADL and IADL ability and self-reported health at baseline and 1- and 6-month follow-up. Cognition was assessed using the Mini-Mental State Examination at baseline and 6-month follow-up. RESULTS: Participants had lower IADL scores 1 month after SAVR than at baseline (baseline 58, 1 month: delirium 42, no delirium 50, P ≤ .02), but scores had returned to baseline levels at 6 months. The Medical Outcomes Study 12-item Short-Form Health Survey (SF-12) Physical Component Summary (PCS) score was higher at 6-month follow-up (48) than at baseline (39), especially in participants who did not develop delirium (P < .001). No differences in other outcomes were found. Regression models suggest that delirium may help predict IADL disability 1 month after baseline (P ≤ .07) but does not predict large differences in ADL disability, cognitive function, or SF-12-scores. Individuals who underwent TAVI and developed delirium had lower ADL (baseline 19, 1-month 16, P < .001) and IADL (baseline 49, 1-month 40, P = .003) scores at 1-month follow-up. SF-12 PCS score (baseline 30) increased from baseline to 1- (35, P = .04) and 6- (35, P = .02) month follow-up in individuals who underwent TAVI and did not develop delirium. Delirium after TAVI predicted greater ADL and IADL disability at 1-month but not at 6-month follow-up. CONCLUSION: Individuals who develop delirium after SAVR and TAVI have poorer short-term IADL function but do not seem to have long-term reductions in physical, mental, or self-reported health.

Comparison of frequency, risk factors, and time course of postoperative delirium in octogenarians after transcatheter aortic valve implantation versus surgical aortic valve replacement.

Postoperative delirium (PD) after transcatheter aortic valve implantation (TAVI) remains to be explored. We sought to (1) determine the incidence of PD in octogenarians who underwent TAVI or surgical aortic valve replacement (SAVR), (2) identify its risk factors, and (3) describe possible differences in the onset and course of PD between treatment groups. A prospective cohort study of consecutive patients aged ≥80 years with severe aortic stenosis who underwent elective TAVI or SAVR (N = 143) was conducted. The incidence of PD was assessed for 5 days using the Confusion Assessment Method (CAM). Risk factors for PD were studied with logistic regression. Patients treated with TAVI were older (p ≤0.001), had lower cognitive scores (p = 0.007), and more co-morbidities (p = 0.003). Despite this, significantly fewer (p = 0.013) patients treated with TAVI (44%) experienced PD compared to patients treated with SAVR (66%). Undergoing SAVR (p = 0.02) and having lower cognitive function (p = 0.03) emerged as risk factors for PD, whereas gender, activities of daily living, frailty, atrial fibrillation, and postoperative use of opioids and anxiolytics did not. Patients treated with TAVI and without PD during the first 2 postoperative days were unlikely to experience PD on subsequent days. The onset of PD after SAVR could occur at any time during the postoperative evaluation. In conclusion, SAVR in octogenarian patients with aortic stenosis might be considered as a predisposing factor for PD. Our data also suggest that the onset of PD was more unpredictable after SAVR.