Clinical characteristics associated with the onset of delirium among long-term nursing home residents

Evelyn Ning Man Cheung, Sophia Benjamin, George HeckmanJoanne Man-Wai HoLinda LeeSamir K. Sinha and Andrew P. Costa

Abstract

Background

Nursing home residents are frail, have multiple medical comorbidities, and are at high risk for delirium. Most of the existing evidence base on delirium is derived from studies in the acute in-patient population. We examine the association between clinical characteristics and medication use with the incidence of delirium during the nursing home stay.

Methods

This is a retrospective cohort study of 1571 residents from 12 nursing homes operated by a single care provider in Ontario, Canada. Residents were over the age of 55 and admitted between February 2010 and December 2015 with no baseline delirium and a minimum stay of 180 days. Residents with moderate or worse cognitive impairment at baseline were excluded. The baseline and follow-up characteristics of residents were collected from the Resident Assessment Instrument-Minimal Data Set 2.0 completed at admission and repeated quarterly until death or discharge. Multivariate logistic regression was used to identify characteristics and medication use associated with the onset of delirium.

Results

The incidence of delirium was 40.4% over the nursing home stay (mean LOS: 32 months). A diagnosis of dementia (OR: 2.54, p < .001), the presence of pain (OR: 1.64, p < .001), and the use of antipsychotics (OR: 1.87, p < .001) were significantly associated with the onset of delirium. Compared to residents who did not develop delirium, residents who developed a delirium had a greater increase in the use of antipsychotics and antidepressants over the nursing home stay.

Conclusions

Dementia, the presence of pain, and the use of antipsychotics were associated with the onset of delirium. Pain monitoring and treatment may be important to decrease delirium in nursing homes. Future studies are necessary to examine the prescribing patterns in nursing homes and their association with delirium.

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Identificación del anciano frágil en ucias

Identification of older adults with frailty in the Emergency Department using a frailty index: results from a multinational study.

Brousseau et al Age and Aging (pub ahead of print)

Este trabajo sitúa la fragilidad como signo vital pronóstico en el anciano atendido en el servicio de Urgencias.

La identificación de la fragilidad se realiza a través de 24 ítems incluidos en un proceso de valoración geriátrica integral y se basa en la teoría de acúmulo de déficits de Rockwood .

Esta valoración estandarizada se realiza con el instrumento de valoración de contacto interRAI Contact Assessment de Urgencias. Una valoración geriátrica administrada en unos 15 minutos, mayoritariamente por enfermería, contemplando los diferentes dominios geriátricos y habiendo demostrado su valor predictivo.

El presente trabajo estudia la relación de este índice de fragilidad con resultados adversos (muerte a 28 día, estancia media hospitalaria, institucionalización) y demuestra la factibilidad de aplicar el índice de fragilidad en los servicios de urgencias y su asociación con resultados asistenciales.

Los autores demuestran en este estudio la validez del índice de Fragilidad en Urgencias en una cohorte internacional procedente de 7 países. La identificación de los ancianos más vulnerables en urgencias brinda la oportunidad de considerar la fragilidad en la orientación diagnostica, en la intervención y en la planificación de cuidados. Permitiendo así disponer de una herramienta que nos ayude a asignar y ajustar mejor los recursos sociosanitarios.

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Validation of a Falls Risk Screening Tool Derived From InterRAI Acute Care Assessment.

Journal of Patient Safety, 2018 Jan 22

Peel NM, Jones LV, Berg K, Gray LC.

OBJECTIVES:

This study aimed to develop and validate a falls risk screening tool derived from interRAI Acute Care (AC) Assessment.

METHODS:

For derivation and validation, two prospective cohorts were recruited from AC hospitals in Australia. The derivation cohort comprised 1418 patients from 11 hospitals. In the validation cohort, 393 patients were recruited from four hospitals. The interRAI AC tool was used to collect comprehensive geriatric assessment data at admission. In-hospital falls were documented from medical records. A falls risk score was calculated using logistic regression. Predictive ability was compared with St. Thomas Risk Assessment Tool In Falling elderlY (STRATIFY), using area under curve (AUC). The validation cohort provided external validity.

RESULTS:

Complete data in the derivation cohort were available for 1288 patients (91%), with 75 (5.8%) having an in-hospital fall. The derived interRAI AC falls risk score (range = 0-6) had significantly better predictive ability (AUC = 0.70, 95% confidence interval [CI] = 0.63-0.76) compared with St. Thomas Risk Assessment Tool In Falling elderlY (AUC = 0.64, 95% CI = 0.58-0.70) (P = 0.033). At a cut point of three, 54 of 75 falls were correctly predicted by the falls risk score derived from interRAI AC (sensitivity = 0.72 [95% CI = 0.60-0.82] and specificity = 0.60 [95% CI = 0.57-0.62]). The falls risk score performed similarly in the validation cohort.

CONCLUSIONS:

The falls risk tool developed from interRAI AC is a valid measure to screen for in-hospital falls. Reduction in assessment burden without loss of fidelity can be achieved through integrating the risk screener within the interRAI hospital system, which automatically triggers protocols for falls prevention based on identified risk.

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Un nuevo instrumento de Calidad de Vida autopercibida (interRAI SQOL) para el medio residencial. Morris et al, JAMDA 2017

Este instrumento el SQOL-LTCF pertenece a la familia de herramientas de valoración interRAI usadas en dispositivos de atención domiciliaria, salud mental y residencias de válidos. Como ocurre con los instrumentos interRAI utiliza un core de variables comunes y otras específicas, en este caso con el dispositivo de cuidados de larga duración (Long Term Care Facilities, LTCF).

Los resultados presentados en el artículo pertenecen a un grupo de  8 “early adopters countries” con una muestra de 16.017 residentes, procedentes de 355 unidades de cuidados de larga duración. La herramienta identificó 5 escalas: vida social, Control personal, Alimentación, Staff cuidador y Respuesta del Staff.

Las escalas incorporadas en la herramienta relacionan significativamente la percepción, en las residencias, de un entorno hogareño “como en casa” (home like). Esta herramienta podrá  ayudar en la monitorización y benchmarking de la mejora de la calidad de vida en el sector residencial

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Indice de Fragilidad de…Morris’s interRAI Home Care Frailty Scale

La aportación de John Morris al concepto de fragilidad

Morris JN, Howard EP, Steel KR. Development of the interRAI home care frailty scale. BMC geriatrics. 2016;16(1):188.

Conocidos los dos paradigmas de Fried vs Rockwood y el consabido recelo de muchos investigadores en penetrar en la caverna platoniana de la fragilidad. John Morris se adentra por fin en este difícil terreno y nos aporta una valiente e interesante visión. Esta contrasta con la recomendación de muchos, de realizar una valoración geriatrica integral cuando se detecta fragilidad; anteponiendo por lo tanto la valoración sistemática al diagnostico específico.

La escala de fragilidad surge de la VGI realizada a través del instrumento de valoración interRAI de Atención Domiciliaria. El abordaje que propone Morris también pivota en la teoría del acumulo de déficits y en la valoración multidimensional incorporando componentes físicos, cognitivos, clínicos y psiocoosiclaes.

La escala de fragilidad estudió 70 variables procedentes de 967,865 valoraciones basales y 464,788 valoraciones de seguimiento semestral. La escala final consiste en 29 ítems que se correlacionan con una selección de medidas de deterioro y complicaciones clínicas. Estos ítems contemplan función, movimiento, cognición y comunicación, vida social, nutrición y síntomas clínicos. La escala resultante es consistente con estudios previos que demuestran la fragilidad como un estado relativo de debilidad con expectativa de perdida progresiva.

Esta escala puede servir en la planificación y toma de decisiones sobre los pacientes y sus cuidadores (formales e informales) de atención domiciliaria  a nivel mundial.

 

 

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FORUM MUNDIAL SOBRE EXCELENCIA EN ATENCIÓN SANITARIA DE AGUDOS

brisbanecaptura-de-pantalla-2016-11-11-a-las-20-09-16

Para más información sobre la conferencia clickar aquí

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Mixed methods for telehealth research.

“La alternativa”

Evaluation in “real world settings”…the success of complex health interventions like telehealth is dependent on human behaviour, program adoption, level of participant activation or engagement, and other contextual factor present where intervention is implemented. Randomized controlled trials are the gold standard method for conducting rigorous evaluation. However, this is not always the rule in telehealth evaluation; introducing again the debate on the positivist versus naturalist approach. Mixed methods, an emerging and evolving research methodology  combining quantitative plus qualitative approaches could be the answer as pointed out by Martin-Khan and cols. in her paper  “Mixed methods for telehealth research”. J Telemed Telecare. 2016.

telehealth-heart-graphic-update

 

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What’s going on in A&E? The key questions answered

We analyse the latest data and address some of the key questions at the heart of the debate around the pressures in A&E. Accident and emergency (A&E) waiting times are a key NHS performance metric, and so they generate significant national interest.

Sourced through Scoop.it from: www.kingsfund.org.uk

El informe de The King’s Fund del UK muestra un incremento del numero total de visits a  ucias respecto al año anterior (3%), incremento en el numero de ingresos procedentes de urgencias (10% más que hace 5 años), trolley waits (espera de ingreso una vez asignado superior a 4 horas) era de un 9% del total de ingresos. Aumento en espera de alta (transfer a otro nivel asistencial) y dificultades de mantener staff medico en sucias. De nuevo” la tormenta perfecta”

See on Scoop.itComprehensive Geriatric Assessment

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Predicting Functional Decline and Recovery for Residents in Veterans Affairs Nursing Homes

In this study partial recovery from ADL loss was common; however, the mean number of days to recover from a single impairment was 119 days (SD = 41). Thus, a lack of benefit from traditional rehabilitative interventions may simply result from measuring outcomes before improvement can be reasonably expected

Sourced through Scoop.it from: gerontologist.oxfordjournals.org

Este artículo ofrece un nuevo abordaje sobre el modelo secuencial de perdida funcional de via única de Sidney Katz.

De gran interés y relevancia es el hecho de observar patrones de mejora funcional para un único deterioro mas allá de los tres meses (media de 119 días).

See on Scoop.itComprehensive Geriatric Assessment

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The Effect of Adult Day Program Attendance on Emergency Room Registrations, Hospital Admissions, and Days in Hospital: A Propensity-Matching Study.

Gerontologist. 2015 Dec 6. pii: gnv145. [Epub ahead of print]

Abstract

PURPOSE OF THE STUDY: 

This study is an investigation of the effect of adult day program attendance by home care clients 65 years of age and older on numbers and rates of emergency room registrations, hospital admissions, and days in hospital.

DESIGN AND METHODS: 

Each adult day program attendee was matched to a single unique nonattendee (n = 812) on the basis of similar propensity scores which had been estimated from 19 demographic, psychosocial, clinical, and functional covariates. Evaluation of the propensity-matching procedure indicated that balance had been achieved on the covariates.

RESULTS: 

Subsequent analyses revealed significantly lower mean 100-day rates of emergency room registrations, hospital admissions, and days in hospitals for attendees, compared to matched nonattendees. Although lower rates were largely attributable to longer stays in the home care program for attendees, attendees’ mean number of days in hospital was still significantly lower compared to nonattendees.

IMPLICATIONS: 

Findings replicate and extend results from previous research that reported a decreased reliance on costly health care services by seniors who attend adult day programs.

 

 

Sourced through Scoop.it from: www.ncbi.nlm.nih.gov

See on Scoop.itMedical education

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