Development of a complex intervention to prevent delirium in older hospitalized patients by optimizing discharge and transfer processes and involving caregivers: A multi-method study.

BACKGROUND: Delirium is a common yet challenging condition in older hospitalized patients, associated with various adverse outcomes. Environmental factors, such as room changes, may contribute to the development or severity of delirium. Most previous research has focused on preventing and reducing this condition by addressing risk factors and facilitating reorientation during hospital stay. OBJECTIVE: We aimed to systematically develop a complex intervention to prevent delirium in older hospitalized patients by optimizing discharge and transfer processes and involving caregivers during and after these procedures. The intervention combines stakeholder and expert opinions, evidence, and theory. This article provides guidance and inspiration to research groups in developing complex interventions according to the recommendations in the Medical Research Council framework for complex interventions. DESIGN AND METHODS: A stepwise multi-method study was conducted. The preparation phase included analysis of the context and current practice via focus groups. Based on these results, an expert workshop was organized, followed by a Delphi survey. Finally, the intervention was modeled and a program theory was developed, including a logic model. RESULTS: A complex intervention was developed in an iterative process, involving healthcare professionals, delirium experts, researchers, as well as caregiver and patient representatives. The key intervention component is an 8-point-program, which provides caregivers with recommendations for preventing delirium during the transition phase and in the post-discharge period. Information materials (flyers, handbook, videos, posters, defined "Dos and Don'ts", discharge checklist), training for healthcare professionals, and status analyses are used as implementation strategies. In addition, roles were established for gatekeepers to act as leaders, and champions to serve as knowledge multipliers and trainers for the multi-professional team in the hospitals. CONCLUSIONS: This study serves as an example of how to develop a complex intervention. In an additional step, the intervention and implementation strategies will be investigated for feasibility and acceptability in a pilot study with an accompanying process evaluation. TWEETABLE ABSTRACT: Delirium prevention can benefit from optimizing discharge and transfer processes and involving caregivers of older patients in these procedures. STUDY REGISTRATION: DRKS00017828, German Register of Clinical Studies, date of registration 17.09.2019.

Validation of a telephone-based administration of the simplified nutritional appetite questionnaire.

BACKGROUND: Anorexia of aging is characterized by an age-associated reduction of appetite, whose aetiology in most cases is multifactorial and which often triggers malnutrition. The Simplified Nutritional Appetite Questionnaire (SNAQ) is an established screening tool. This study aimed to investigate reliability, validity, and feasibility of its telephone administration (T-SNAQ) in German community-dwelling older adults. METHODS: This cross-sectional single-centre study recruited participants from April 2021 to September 2021. First, the SNAQ was translated into German according to an established methodology. After translation, reliability, construct validity, and feasibility of the T-SNAQ were analysed. A convenience sample of community-dwelling older adults aged ≥70 years was recruited. The following measurements were applied to all participants: T-SNAQ, Mini Nutritional Assessment - Short Form (MNA-SF), six-item Katz index of independence in activities of daily living (ADL), eight-item Lawton instrumental activities of daily living (IADL), telephone Montreal Cognitive Assessment (T-MoCA); FRAIL scale, Geriatric Depression Scale (GDS-15) and Charlson co-morbidity index as well as daily caloric and protein intake. RESULTS: One hundred twenty participants (59.2% female) with a mean age of 78.0 ± 5.8 years were included in the present study. The percentage of participants identified with poor appetite based on T-SNAQ was 20.8% (n = 25). T-SNAQ showed a good internal reliability with a Cronbach's alpha coefficient of 0.64 and a good test-retest reliability [intraclass coefficient of 0.95 (P < 0.05)]. Regarding construct validity, T-SNAQ was significantly positively correlated with MNA-SF (r = 0.213), T-MoCA (r = 0.225), daily energy (r = 0.222) and protein intake (r = 0.252) (P < 0.05). It also demonstrated a significant negative association with GDS-15 (r = -0.361), FRAIL scale (r = -0.203) and Charlson co-morbidity index (r = -0.272). Regarding applicability, the mean time for T-SNAQ was 95 s and completion rate was 100%. CONCLUSIONS: The T-SNAQ is a feasible screening instrument for anorexia of aging in community-dwelling older adults via telephone interviews.

Selecting a Bedside Cognitive Vital Sign to Monitor Cognition in Hospital: Feasibility, Reliability, and Responsiveness of Logical Memory.

Although there is a high prevalence of delirium and cognitive impairment among hospitalised older adults, short, reliable cognitive measures are rarely used to monitor cognition and potentially alert healthcare professionals to early changes that might signal delirium. We evaluated the reliability, responsiveness, and feasibility of logical memory (LM), immediate verbal recall of a short story, compared to brief tests of attention as a bedside "cognitive vital sign" (CVS). Trained nursing staff performed twice-daily cognitive assessments on 84 clinically stable inpatients in two geriatric units over 3-5 consecutive days using LM and short tests of attention and orientation including months of the year backwards. Scores were compared to those of an expert rater. Inter-rater reliability was excellent with correlation coefficients for LM increasing from r = 0.87 on day 1 to r = 0.97 by day 4 (p < 0.0001). A diurnal fluctuation of two points from a total of 30 was deemed acceptable in clinically stable patients. LM scores were statistically similar (p = 0.98) with repeated testing (suggesting no learning effect). All nurses reported that LM was feasible to score routinely. LM is a reliable measure of cognition showing diurnal variation but minimal learning effects. Further study is required to define the properties of an ideal CVS test, though LM may satisfy these.

Assessing suitability for sacubitril-valsartan therapy in an Irish cohort: challenges and opportunities.

INTRODUCTION: Sacubitril-valsartan has been shown by the PARADIGM-HF trial to decrease hospital admissions and improve mortality in patients with heart failure with reduced ejection fraction. The PARADIGM trial had stringent exclusion criteria. It is not known how applicable these trial criteria are to real-life practice. In this study, we sought to determine the percentage of patients eligible for sacubitril-valsartan therapy in a level 3 hospital without a dedicated heart failure service. METHODS: All patients discharged from our service with a diagnosis of congestive cardiac using our hospital in-patient enquiry (HIPE) system underwent hierarchal analysis. In order to be deemed eligible for sacubitril-valsartan therapy, patients had to meet PARADIGM-HF inclusion criteria. RESULTS: Our 143 patients represented a more clinically unwell, elderly cohort than the PARADIGM trial study population. Only 24 patients (16.66%) had an ejection fraction of 40% or less. Our results indicate that only 4/143 patients in a real-world setting (2.79%) were eligible for sacubitril-valsartan therapy at the point of discharge as per the PARADIGM-HF study criteria. This is primarily due to the higher than expected percentage of patients in our cohort with an ejection fraction of over 40% (n = 120) and the low percentage of patients on therapeutic doses of ACEI/ARB (n = 15). CONCLUSIONS: Our study showed that a smaller than expected proportion of our patients in real-world practice are suitable for sacubitril-valsartan therapy at discharge. Most patients were in the HFPEF cohort which does not currently have evidence for treatment with sacubitril-valsartan. Low rates of prescribing of basic heart failure medicatons and the absence of dedicated heart failure services in a non-tertiary centre may explain the poor compliance observed. Improving guideline adherence and increasing awareness of evidence-based medication use at primary and secondary care levels would be of benefit to Irish heart failure patients.