RESUMO
Delirium is a serious consequence of many acute or worsening chronic medical conditions, a side effect of medications, and a precipitant of worsening functional and cognitive status in older adults. It is a syndrome characterized by fluctuations in cognition and impaired attention that develops over a short period of time in response to an underlying medical condition, a substance (prescribed, over the counter, or recreational), or substance withdrawal and can be multi-factorial. We present a narrative review of the literature on nonpharmacologic and pharmacologic approaches to prevention and treatment of delirium with a focus on older adults as a vulnerable population. Older adult patients are most at risk due to decreasing physiologic reserves, with delirium rates of up to 80% in critical care settings. Presentation of delirium can be hyperactive, hypoactive, or mixed, making identification and study challenging as patients with hypoactive delirium are less likely to come to attention in an inpatient or long-term care setting. Studies of delirium focus on prevention and treatment with nonpharmacological or medication interventions, with the preponderance of evidence favoring multi-component nonpharmacological approaches to prevention as the most effective. Though use of antipsychotic medication in delirium is common, existing evidence does not support routine use, showing no clear benefit in clinically significant outcome measures and with evidence of harm in some studies. We therefore suggest that antipsychotics be used to treat agitation, psychosis, and distress associated with delirium at the lowest effective doses and shortest possible duration and not be considered a treatment of delirium itself. Future studies may clarify the use of other agents, such as melatonin and melatonin receptor agonists, alpha-2 receptor agonists, and anti-epileptics.
RESUMO
BACKGROUND: The Veterans Health Administration (VHA) established a patient-centered medical home model of care for veterans experiencing homelessness called a Homeless Patient Aligned Care Team (HPACT) to improve engagement with primary care and reduce utilization of hospital-based services. To evaluate the impact of the HPACT model, this study compares the number and type of health care visits in the 12 months before and after enrollment in HPACT at one VHA facility, and explores patient characteristics associated with increases and decreases in visits. METHODS: Chart reviews of VHA medical records were conducted for all patients enrolled in an HPACT in Pittsburgh, Pennsylvania, between May 2012 and December 2013 (N = 179). Multivariable mixed-effect logistic regressions estimated differences in having any visit in the 0-6 months and 7-12 months before and after HPACT enrollment, and multinomial logistic regressions predicted increases or decreases versus no change in number of visits over 12 months. RESULTS: Compared with 0-6 months prior to HPACT, patients were more likely to visit primary care in the 0-6 months (adjusted odds ratio [aOR] = 4.91, 95% confidence interval [CI] = 2.94-8.20) and 7-12 months (aOR = 2.30, 95% CI = 1.42-3.72) following HPACT. Patients were less likely to visit the emergency department (ED) or to be hospitalized in the 0-6 months (aOR = 0.57, 95% CI = 0.34-0.94; and aOR = 0.55, 95% CI = 0.25-0.76) and 7-12 months (aOR = 0.43, 95% CI = 0.33-0.91; and aOR = 0.45, 95% CI = 0.26-0.80) following HPACT. Patients were less likely to visit mental health (aOR = 0.35, 95% CI = 0.20-0.60) and addiction specialists (aOR = 0.39, 95% CI = 0.18-0.84) in the 7-12 months following HPACT. Overall, 59% of patients had increases in primary care visits following HPACT. Female patients and those with self-housing were less likely to have increases versus no change in primary care visits (adjusted relative risk ratio [aRRR] = 0.15, 95% CI = 0.03-0.74; and aRRR = 0.35, 95% CI = 0.14-0.90). CONCLUSIONS: An integrated HPACT model was successful in engaging homeless veterans in primary care for 1 year, potentially contributing to reductions in ED use. More tailored approaches may be needed for vulnerable populations experiencing homelessness, including homeless women.
