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Background Delirium is a significant cause of morbidity and mortality among older people admitted to both acute and long-term care facilities (LTCFs). Multicomponent interventions have been shown to reduce delirium incidence in the acute care setting (30–73%) by acting on modifiable risk factors. Little work, however, has focused on using this approach to reduce delirium incidence in LTCFs. Methods The objective is to assess the effectiveness of the multicomponent PREPARED Trial intervention in reducing the following primary outcomes: incidence, severity, duration, and frequency of delirium episodes in cognitively impaired residents. This 4-year, parallel-design, cluster randomized study will involve nursing staff and residents in 45–50 LTCFs in Montreal, Canada. Participating public and private LTCFs (clusters) that provide 24-h nursing care will be assigned to either the PREPARED Trial intervention or the control (usual care) arm of the study using a covariate constrained randomization procedure. Approximately 400–600 LTC residents aged 65 and older with dementia and/or cognitive impairment will be enrolled in the study and followed for 18 weeks. Residents must be at risk of delirium, delirium-free at baseline and have resided at the facility for at least 2 weeks. Residents who are unable to communicate verbally, have a history of specific psychiatric conditions, or are receiving end-of-life care will be excluded. The PREPARED Trial intervention consists of four main components: a decision tree, an instruction manual, a training package, and a toolkit. Primary study outcomes will be assessed weekly. Functional autonomy and cognitive levels will be assessed at the beginning and end of follow-up, while information pertaining to modifiable delirium risk factors, medical consultations, and facility transfers will be collected retrospectively for the duration of the follow-up period. Primary outcomes will be reported at the level of intervention assignment. All researchers analyzing the data will be blinded to group allocation. Discussion This large-scale intervention study will contribute significantly to the development of evidence-based clinical guidelines for delirium prevention in this frail elderly population, as it will be the first to evaluate the efficacy of a multicomponent delirium prevention program translated into LTC clinical practice on a large scale. Trial registration NCT03718156, ClinicalTrials.gov.

To assess whether CC is more effective at reducing suicidal ideation in people with depression compared with usual care, and whether study and patient factors moderate treatment effects. We searched Medline, Embase, PubMed, PsycINFO, CINAHL, CENTRAL from inception to March 2020 for Randomised Controlled Trials (RCTs) that compared the effectiveness of CC with usual care in depressed adults, and reported changes in suicidal ideation at 4 to 6 months post-randomisation. Mixed-effects models accounted for clustering of participants within trials and heterogeneity across trials. This study is registered with PROSPERO, CRD42020201747. We extracted data from 28 RCTs (11,165 patients) of 83 eligible studies. We observed a small significant clinical improvement of CC on suicidal ideation, compared with usual care (SMD, -0.11 [95%CI, -0.15 to -0.08]; I , 0·47% [95%CI 0.04% to 4.90%]). CC interventions with a recognised psychological treatment were associated with small reductions in suicidal ideation (SMD, -0.15 [95%CI -0.19 to -0.11]). CC was more effective for reducing suicidal ideation among patients aged over 65 years (SMD, - 0.18 [95%CI -0.25 to -0.11]). Primary care based CC with an embedded psychological intervention is the most effective CC framework for reducing suicidal ideation and older patients may benefit the most. [Abstract copyright: Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.]

Objectives To describe unmet needs of caregivers of hospitalized older adults during the transition from hospital back home, and identify subgroups with different needs. Methods Patients and family caregivers were recruited from an acute care hospital in Montreal, Canada. Measures included Instrumental Activities of Daily Living (IADL), Hospital Anxiety and Depression Scale (HADS), Zarit burden scale, and Family Inventory of Needs. Dimensions of unmet needs were explored with principal component analysis; regression tree models were used to identify subgroups with different unmet needs. Results A total of 146 patient-caregiver dyads were recruited. Three categories of caregiver unmet needs were identified: patient medical information; role clarity and support; and reassurance. Caregiver subgroups with highest unmet needs were those with high burden of care plus depressive symptoms ( n = 46) and those caring for patients with low IADL scores ( n = 10). Discussion Caregivers with high burden and depression are those with the greatest unmet needs during the care transition.

Background:A few studies examine the time evolution of delirium in long-term care (LTC) settings. In this work, we analyze the multivariate Delirium Index (DI) time evolution in LTC settings.Methods:The multivariate DI was measured weekly for six months in seven LTC facilities, located in Montreal and Quebec City. Data were analyzed using a hidden Markov chain/latent class model (HMC/LC).Results:The analysis sample included 276 LTC residents. Four ordered latent classes were identified:fairly healthy(low “disorientation” and “memory impairment,” negligible other DI symptoms),moderately ill(low “inattention” and “disorientation,” medium “memory impairment”),clearly sick(low “disorganized thinking” and “altered level of consciousness,” medium “inattention,” “disorientation,” “memory impairment” and “hypoactivity”), andvery sick(low “hypoactivity,” medium “altered level of consciousness,” high “inattention,” “disorganized thinking,” “disorientation” and “memory impairment”). Four course types were also identified:stable,improvement,worsening, andnon-monotone. Class order was associated with increasing cognitive impairment, frequency of both prevalent/incident delirium and dementia, mortality rate, and decreasing performance in ADL.Conclusion:Four ordered latent classes and four course types were found in LTC residents. These results are similar to those reported previously in acute care (AC); however, the proportion of very sick residents at enrolment was larger in LTC residents than in AC patients. In clinical settings, these findings could help identify participants with a chronic clinical disorder. Our HMC/LC approach may help understand coexistent disorders, e.g. delirium and dementia.

Background:The delirium index (DI) is a valid measure of delirium severity. We proposed to describe longitudinal patterns of severity scores in older long-term care (LTC) residents.Methods:A prospective cohort study of 280 residents in seven LTC facilities in Montreal and Quebec City, Canada, was conducted. DI, Barthel Index, Mini-Mental State Examination, Charlson Comorbidity Index, Cornell Scale for Depression in Dementia, dementia assessment by an MD, and prevalent or incident probable delirium defined according to the Confusion Assessment Method were completed at baseline. The DI was also assessed weekly for 6 months. Demographic characteristics were abstracted from resident charts. Cluster analysis for longitudinal data was used to describe longitudinal patterns of DI scores.Results:During the 24 weeks following enrolment, 28 (10.0%) of 280 residents who had prevalent delirium and 76 (27.1%) who had incident delirium were included in our analysis. Average observation period was 18.3 weeks. Four basic types of time evolution patterns were discovered: Improvement, Worsening, Fluctuating, and Steady, including 22%, 18%, 25%, and 35%, of the residents, respectively. With the exception of the Worsening pattern, the average trajectory was stabilized at the 4th week or earlier. Poor baseline cognitive and physical function and greater severity of delirium predicted worse trajectories over 24 weeks.Conclusions:The longitudinal patterns of DI scores found in LTC residents resemble those found in an earlier study of delirium in acute care (AC) settings. However, compared to AC patients, LTC residents have a smaller DI variability over time, a less frequent Improvement pattern, and more frequent Worsening and Fluctuating patterns.

Objective: Among primary care patients with chronic physical conditions and comorbid depressive symptoms, to assess (1) the effect of lay telephone coaching on adherence to a psycho-educational intervention for depression, (2) demographic characteristics that predict adherence and (3) the association between adherence and 6-month outcomes. Design: Single blind randomised pragmatic trial of a lay telephone-supported depression self-care intervention compared to an unsupported intervention. Methods: All patients received a multimedia toolkit of paper and audiovisual materials on depression that provided education on depression and on self-care for depression. Core tools included a cognitive-behavioural therapy (CBT)-based workbook and a mood monitoring notebook, with opportunities for written exercises and notes, and a video. Intervention group patients were additionally offered telephone coaching. Self-reported use of the materials was assessed at 3 and 6 months post-randomisation; 6-month outcomes were patient satisfaction and change from baseline in depression severity. Results: In all, 223 patients were randomised; 165 (74.0%) completed follow-up. Coached versus uncoached patients reported significantly greater use of the workbook, but not of other tools. Men used more audiovisual tools; women used more paper tools. Self-reported completion of written exercises and a greater number of coach contacts were associated with greater satisfaction, but not with improvement in depression. Conclusion: Telephone coaching can increase adherence to CBT-based tools for depression self-care; however, use of these tools may not improve depression outcomes. Many patients are capable of self-directed use of self-care educational materials. Sex differences in patterns of tool use may be helpful in the targeting of tools.

Objective: To explore the effects of baseline psychological and antidepressant medication treatment in a trial of lay telephone coaching in a low-intensity, supported depression self-care intervention. Method: A single blind, individually randomised, pragmatic trial was conducted among primary care adults with chronic physical conditions and comorbid depressive symptoms. Eligible subjects were randomised to receive a depression self-care toolkit with (intervention group) or without (control group) telephone coaching provided by trained lay coaches. For this brief communication, a secondary analysis of the trial data focused on the effects of baseline psychological and antidepressant treatments on mental health outcomes (Patient Health Questionnaire 9 [PHQ-9], SF-12 Mental Component Summary [MCS], Generalized Anxiety Disorder 7 [GAD-7]) and satisfaction with the intervention. Results: In total, 223 patients were randomised, and 165 (74.0%) completed both 3- and 6-month follow-ups. There were 2 significant interactions of baseline treatment and study group for 6-month mental health outcomes. A significant benefit of coaching on 6-month PHQ-9 was seen only among participants who were not receiving baseline psychological treatment. A smaller interaction was found for baseline antidepressant medications and 6-month mental health. There was a significant main effect for baseline psychological treatment and lower 6-month satisfaction. Conclusions: Depressed patients receiving baseline psychological treatment may not benefit from lay coaching offered as part of a low-intensity depression self-care intervention.

OBJECTIVE The objective of this study is to explore whether the use of medications that antagonize mediators of inflammatory responses reduces the risk of delirium in older adults. METHODS A nested case-control study was conducted using data from a prospective study of delirium in older long-term care residents from 7 long-term care facilities in Montreal and Quebec City, Canada. The Confusion Assessment Method was used to diagnose incident delirium. The use of medications that antagonize mediators of inflammatory responses was determined by examining facility pharmacy databases and coding medications received daily by each resident. Risk sets were built using incidence density sampling: each risk set consisted of a case with incident delirium and all controls without incident delirium at the same date and facility. Conditional logistic regression was used to assess the association of exposure to inflammation antagonist medications with the incidence of delirium. RESULTS Of 254 residents, 95 developed incident delirium during 24 weeks (cases); each case was matched with up to 35 controls. Unadjusted and adjusted odds ratios (95% CI) of delirium for residents exposed to at least one inflammation antagonist medication were 0.53 (0.34, 0.81) and 0.60 (0.38, 0.92), respectively. Estimates of the risk of incident delirium associated with specific medications and medication classes were mostly protective but not statistically significant. CONCLUSION The use of medications that antagonize mediators of inflammatory responses may reduce the risk of delirium in older adults. Despite study limitations, the findings merit further investigation using larger patient samples, more precise measures of exposure and better control of potential confounding variables. Copyright © 2016 John Wiley & Sons, Ltd.

Objectif: Evaluation (faisabilite, acceptabilite, pertinence et bienfaits potentiels) d'une intervention de transition pour proches aidants. Methode: L'intervention visait a fournir du soutien emotionnel, de l'information sur les ressources communautaires et du soutien au developpement des capacites d'adaptation pour les proches aidants de patients de 65 ans et plus qui avaient recu leur conge suite a une hospitalisation de courte duree. L'approche methodologique a implique un seul groupe, qui a ete evalue lors d'un pre-test et d'un post-test effectue trois mois apres le debut de l'intervention. Resultats: Quatre-vingt-onze dyades patients-proches ont ete recrutees. Soixante-trois (69 %) proches aidants ont recu les cinq seances d'intervention (tel que prevu) et 60 (66 %) proches aidants ont complete le test final. Une diminution significative de l'anxiete et de la depression des proches aidants et un taux de satisfaction eleve ont ete notes apres l'intervention. Discussion: Cette intervention de transition pour les patients plus âges et leurs proches aidants devrait faire l'objet d'une evaluation plus poussee, de preference avec un groupe de controle, en tant qu'intervention autonome ou comme une composante d'une intervention de transition complete. Objective: To conduct a formative evaluation of a transitional intervention for family caregivers, with assessment of feasibility, acceptability, appropriateness, and potential benefits. Methods: The intervention aimed to provide emotional support, information on community resources, and information and support for development of coping skills for the caregivers of patients aged 65 and older who were to be discharged home from an acute medical hospital admission. We used a one-group, pre- and three-month post-test study design. Results: Ninety-one patient-caregiver dyads were recruited. Of these, 63 caregivers (69%) received all five planned intervention sessions, while 60 (66%) completed the post-test. There were significant reductions in caregiver anxiety and depression following the intervention, and high rates of satisfaction. Discussion: This transitional intervention should be further evaluated, preferably with a control group, either as a stand-alone intervention or as one component of a comprehensive transitional intervention for older patients and their caregivers.

Objectives To determine the frequencies of full, partial and no recovery from subsyndromal delirium (SSD) in older hospital inpatients. A secondary objective was to compare the recovery status of patients with SSD or delirium. Methods SSD was defined as acute onset of one or more Confusion Assessment Method core symptoms of delirium (fluctuation, inattention, disorganized thinking and altered level of consciousness) not meeting criteria for delirium and not progressing to delirium. The recovery status of medical or surgical inpatients aged 65 and older with SSD was assessed approximately 1 and 3 months after enrolment. Primary outcome categories were full recovery (no core symptoms of delirium), partial recovery (presence of one or more core symptoms but fewer symptoms than at enrolment), no recovery (same number of core symptoms as at enrolment) or death. Nominal logistic regression was used to compare the recovery status of patients with SSD or delirium. Results Twenty-eight patients with SSD were enrolled. At the first follow-up, the frequencies of full, partial and no recovery and death were 40%, 12%, 32% and 16%, respectively; at the second follow-up, the frequencies were 54%, 8%, 21% and 17%, respectively. The frequency of full recovery was much higher in patients with SSD than delirium. Conclusion Small study sample size notwithstanding, the majority (54%) of patients with SSD recovered fully, but a substantial proportion (29%) had a protracted course. It may be important to monitor the longer-term course of SSD and develop strategies to ensure full recovery in all patients. Copyright © 2015 John Wiley & Sons, Ltd.

Objectives To determine the frequency and baseline risk factors for partial and no recovery from delirium in older hospitalized adults. Design Cohort study with assessment of recovery status approximately 1 and 3 months after enrollment. Setting University-affiliated, primary, acute-care hospital. Participants Medical or surgical inpatients aged 65 and older with delirium (N = 278). Measurements The Mini-Mental State Examination (MMSE), Confusion Assessment Method (CAM), Delirium Index (DI), and activities of daily living (ADLs) were completed at enrollment and each follow-up. Primary outcome categories were full recovery (absence of CAM core symptoms of delirium), partial recovery (presence of ≥1 CAM core symptoms but not meeting criteria for delirium), no recovery (met CAM criteria for delirium), or death. Secondary outcomes were changes in MMSE, DI, and ADL scores between the baseline and last assessment. Potential risk factors included many clinical and laboratory variables. Results In participants with dementia, frequencies of full, partial, and no recovery and death at first follow-up were 6.3%, 11.3%, 74.6%, and 7.7%, respectively; in participants without dementia, frequencies were 14.3%, 17%, 50.9%, and 17.9%, respectively. In participants with dementia, frequencies at the second follow-up were 7.9%, 15.1%, 57.6%, and 19.4%, respectively; in participants without dementia, frequencies were 19.2%, 20.2%, 31.7%, and 28.8%, respectively. Frequencies were similar in participants with prevalent and incident delirium and in medical and surgical participants. The DI, MMSE, and ADL scores of many participants with partial and no recovery improved. Independent baseline risk factors for delirium persistence were chart diagnosis of dementia (odds ratio (OR) = 2.51, 95% confidence interval (CI) =1.38, 4.56), presence of any malignancy (OR = 5.79, 95% CI = 1.51, 22.19), and greater severity of delirium (OR =9.39, 95% CI = 3.95, 22.35). Conclusion Delirium in many older hospitalized adults appears to be much more protracted than previously thought, especially in those with dementia, although delirium symptoms, cognition, and function improved in many participants with partial and no recovery. It may be important to monitor the longer-term course of delirium in older hospitalized adults and develop strategies to ensure full recovery.

Background:Depression is a common problem in long-term care (LTC) settings. We sought to characterize depression symptom trajectories over six months among older residents, and to identify resident characteristics at baseline that predict symptom trajectory.Methods:This study was a secondary analysis of data from a six-month prospective, observational, and multi-site study. Severity of depressive symptoms was assessed with the 15-item Geriatric Depression Scale (GDS) at baseline and with up to six monthly follow-up assessments. Participants were 130 residents with a Mini-Mental State Examination score of 15 or more at baseline and of at least two of the six monthly follow-up assessments. Individual resident GDS trajectories were grouped using hierarchical clustering. The baseline predictors of a more severe trajectory were identified using the Proportional Odds Model.Results:Three clusters of depression symptom trajectory were found that described “lower,” “intermediate,” and “higher” levels of depressive symptoms over time (mean GDS scores for three clusters at baseline were 2.2, 4.9, and 9.0 respectively). The GDS scores in all groups were generally stable over time. Baseline predictors of a more severe trajectory were as follows: Initial GDS score of 7 or more, female sex, LTC residence for less than 12 months, and corrected visual impairment.Conclusions:The six-month course of depressive symptoms in LTC is generally stable. Most residents who experience a more severe symptom trajectory can be identified at baseline.

Objectives: To describe the 6-month outcomes of co-occurring delirium (full syndrome and subsyndromal symptoms), depression, and dementia in a long-term care (LTC) population. Design: Observational, prospective cohort study with 6-month follow-up conducted from 2005 to 2009. Setting: Seven LTC facilities in the province of Quebec, Canada. Participants: Newly admitted and long-term residents recruited consecutively from lists of residents aged 65 and older admitted for LTC, with stratification into groups with and without severe cognitive impairment. The study sample comprised 274 residents with complete data at baseline on delirium, dementia, and depression. Measurements: Outcomes were 6-month mortality, functional decline (10-point decline from baseline on 100-point Barthel scale), and cognitive decline (3-point decline on 30-point Mini-Mental State Examination). Predictors included delirium (full syndrome or subsyndromal symptoms, using the Confusion Assessment Method), depression (Cornell Scale for Depression in Dementia), and dementia (chart diagnosis). Results: The baseline prevalences of delirium, subsyndromal symptoms of delirium (SSD), depression, and dementia were 11%, 44%, 19%, and 66%, respectively. By 6 months, 10% of 274 had died, 19% of 233 had experienced functional decline, and 17% of 246 had experienced cognitive decline. An analysis using multivariable generalized linear models found the following significant interaction effects (P < .15): between depression and dementia for mortality, between delirium and depression for functional decline, and between SSD and dementia for cognitive decline. Conclusion: Co-occurrence of delirium, SSD, depression, and dementia in LTC residents appears to affect some 6-month outcomes. Because of limited statistical power, it was not possible to draw conclusions about the effects of the co-occurrence of some syndromes on poorer outcomes.

In this study on nursing documentation in long-term care facilities, a set of 9 delirium symptoms was used to evaluate the agreement between symptoms reported by nurses during monthly interviews and those documented in the nursing notes for the same 7-day observation period. Residents aged 65 and above ( N = 280) were assessed monthly over a 6-month period for the presence of delirium and its symptoms using the Confusion Assessment Method. The proportion of symptoms documented in the nursing notes ranged from 1.9% to 53.5%. A trend toward a lower proportion of documented symptoms for higher resident−nurse ratios was observed, although the difference was not statistically significant. Efforts should be made to improve the situation by revisiting the content of academic and clinical training given to nurses in addition to exploring innovative ways to make nursing documentation more efficient and less time-consuming within the current context of nurses’ work overload.

ObjectiveTo determine the frequency, risk factors, course and outcomes of subsyndromal delirium (SSD) in older people by systematically reviewing evidence on these topics.MethodsSubsyndromal delirium was defined as the presence of one or more symptoms of delirium, not meeting criteria for delirium and not progressing to delirium. MEDLINE, EMBASE, PsycINFO and the Web of Science were searched for potentially relevant articles published from 1996 to June 2011. The bibliographies of relevant articles were searched for additional references. Twelve studies met the inclusion criteria. The validity of included studies was assessed according to Evidence-Based Medicine criteria. Information about the study population and methods, age, gender, proportion with dementia, diagnostic criteria, period and frequency of observation, and the topics above was systematically abstracted, tabulated and synthesized using standard meta-analysis techniques.ResultsThe combined prevalence of SSD was 23% (95% CI, 9–42%); the combin...

Background The implications of partial and no recovery from delirium after hospital discharge are not clear. We sought to explore whether partial and no recovery from delirium among recently discharged patients predicted increased adverse events (emergency room visits, hospitalisations, death) during the subsequent 3 months. Method Prospective study of recovery from delirium in older hospital inpatients. The Confusion Assessment Method was used to diagnose delirium in hospital and determine recovery status after discharge (T0). Adverse events were determined during the 3 months T0. Survival analysis to the first adverse event and counting process modelling for one or more adverse events were used to examine associations between recovery status (ordinal variable, 0, 1 or 2 for full, partial or no recovery, respectively) and adverse events. Results Of 278 hospital inpatients with delirium, 172 were discharged before the assessment of recovery status (T0). Delirium recovery status at T0 was determined for 152: 25 had full recovery, 32 had partial recovery and 95 had no recovery. Forty-four patients had at least one adverse event during the subsequent 3 months. In multivariable analysis of one or more adverse events, poorer recovery status predicted increased adverse events; the hazard ratio (HR) (95% confidence interval, CI) was 1.72 (1.09, 2.71). The association of recovery status with adverse events was stronger among patients without dementia. Conclusion Partial and no recovery from delirium after hospital discharge appear to predict increased adverse events during the subsequent 3 months These findings have potentially important implications for in-hospital and post-discharge management and policy.

Delirium is defined as a neurocognitive disorder characterized by sudden onset, fluctuating course, and disturbances in level of consciousness, attention, orientation, memory, thought, perception, and behavior (American Psychiatric Association, 2013). It occurs in hyperactive, hypoactive, or mixed forms in up to 50% of older hospital patients (Inouye et al., 2014) and 70% of older long-term care residents (McCusker et al., 2011), many with pre-existing dementia (Fick et al., 2002).

Objectives. In a sample of primary care participants with chronic physical conditions and comorbid depressive symptoms: to describe the cross-sectional and longitudinal associations of activation and self-efficacy with demographic, physical and mental health status, health behaviors, depression self-care, health care utilization, and use of self-care tools; and to examine the effects of a depression self-care coaching intervention on these two outcomes. Design/Study Setting. A secondary analysis of activation and self-efficacy data collected as part of a randomized trial to compare the effects of a telephone-based coached depression self-care intervention with a noncoached intervention. Activation (Patient Activation Measure) was measured at baseline and 6 months. Depression self-care self-efficacy was assessed at baseline, at 3 months, and at 6 months. Principal Findings. In multivariable cross-sectional analyses ( n = 215), activation and/or self-efficacy were associated with language, birthplace, better physical and mental health, individual exercise, specialist visits, and antidepressant nonuse. In longitudinal analyses ( n = 158), an increase in activation was associated with increased medication adherence; an increase in self-efficacy was associated with use of cognitive self-care strategies and increases in social and solitary activities. There were significant improvements from baseline to 6 months in activation and self-efficacy scores both among coached and noncoached groups. The self-care coaching intervention did not affect 6-month activation or self-efficacy but was associated with quicker improvement in self-efficacy. Conclusions. Overall, the results for activation and self-efficacy were similar, although self-efficacy correlated more consistently than activation with depression-specific behaviors and was responsive to a depression self-care coaching intervention.

Objective: To describe Confusion Assessment Method (CAM) core symptoms of delirium occurring before and after incident episodes of delirium in older long-term care (LTC) residents. A secondary objective was to describe the mean number of symptoms before and after episodes by dementia status. Design: Secondary analysis of data collected for a prospective cohort study of delirium, with repeated weekly assessments for up to 6 months. Setting: Seven LTC facilities in Montreal and Quebec City, Canada. Participants: Forty-one older LTC residents who had at least one CAM-defined incident episode of delirium. Measurements: The Mini-Mental State Examination (MMSE), CAM, Delirium Index (DI), Hierarchic Dementia Scale, Barthel Index, and Cornell Scale for Depression were completed at baseline. The MMSE, CAM, and DI were repeated weekly for 6 months. The frequency, mean number, type, and duration of CAM core symptoms of delirium occurring before and after incident episodes were examined using descriptive statistics, frequency analysis, and survival analysis. Results: CAM core symptoms of delirium preceded 38 (92.7%) episodes of delirium for many weeks; core symptoms followed 37 (90.2%) episodes for many weeks. Symptoms of inattention and disorganized thinking occurred most commonly. The mean number of symptoms was higher in residents with dementia but not significantly so. Conclusion: CAM core symptoms of delirium were frequent and protracted before and after most incident episodes of delirium in LTC residents with and without dementia. If replicated, these findings have potentially important implications for clinical practice and research in LTC settings.

Objective: To determine the frequency, risk factors, course and outcomes of subsyndromal delirium (SSD) in older people by systematically reviewing evidence on these topics. Methods: Subsyndromal delirium was defined as the presence of one or more symptoms of delirium, not meeting criteria for delirium and not progressing to delirium. MEDLINE, EMBASE, PsycINFO and the Web of Science were searched for potentially relevant articles published from 1996 to June 2011. The bibliographies of relevant articles were searched for additional references. Twelve studies met the inclusion criteria. The validity of included studies was assessed according to Evidence-Based Medicine criteria. Information about the study population and methods, age, gender, proportion with dementia, diagnostic criteria, period and frequency of observation, and the topics above was systematically abstracted, tabulated and synthesized using standard meta-analysis techniques. Results: The combined prevalence of SSD was 23% (95% CI, 9–42%); the combined incidence was 13% (95% CI, 6– 23%). Risk factors were similar to those for delirium. Episodes lasted up to 133 days and were often recurrent. Outcomes were poor and often intermediate between those of older people with or without delirium. Of note, there was significant unexplained heterogeneity in the results of studies of prevalence, incidence and some risk factors. Conclusions: SSD in older people may be a frequent and clinically important condition that falls on a continuum between no symptoms and full delirium. Because of significant unexplained heterogeneity in the results of studies of SSD, however, the results of this review must be interpreted cautiously. Further research is necessary. Copyright © 2012 John Wiley & Sons, Ltd.

Inappropriate and widespread prescribing of antipsychotics in LTCF is of concern. This study aimed to explore the association of resident and room characteristics with antipsychotic use in this setting. This is cross-sectional secondary analysis of the baseline data of 280 residents ≥ 65 years old, from a prospective, observational, LTCF multi-site (n=7) cohort study on delirium. Demographic data included age, sex and length of stay. Resident characteristics assessed were presence of dementia, disruptive behavior, delirium and use of restraints. Room characteristics assessed were single room, clock/calendar, and telephone. Separate logistic regression models were used to explore the association of resident and room characteristics with antipsychotic use, adjusting for demographic variables. Mean age was 84.9 ± 7.0 years (± S.D.) with 56% female. The mean prevalence of antipsychotics use was 31.1% (range: 25.6-50.0%). The regression model of resident characteristics revealed a significant association between disruptive behavior (OR=1.18, 95% CI=1.12-1.25) and antipsychotic use. The model of room characteristics revealed a significant association between absence of a clock or calendar (OR=1.93, 95% CI=1.04-3.56) and absence of a telephone (OR=2.79, 95% CI=1.48-5.25). Our results suggest that behavior problems are associated with a higher likelihood of antipsychotic use. Absence of a clock/calendar and of a telephone was related to antipsychotic use. Further research is needed to confirm these findings.

Background: Delirium among long-term care (LTC) residents is frequent and is associated with increased morbidity and mortality. Identification of clinical changes during the prodromal phase of delirium could lead to prevention of a full-blown episode and perhaps limit the deleterious consequences of this syndrome. The aim of the present study was to identify clinical changes observable in the 2-week period prior to the onset of full-blown delirium.Methods: Long-term care (LTC) residents aged 65 years and over, with or without dementia were eligible for this nested case-control study. Delirium was assessed weekly over a 6-month period using the Confusion Assessment Method. Cases with incident delirium were matched by time since enrolment to one or more controls without delirium.Results: When compared to the controls, LTC residents who developed delirium (cases = 85) were more likely to have new-onset perceptual disturbances (OR = 4.75; 95% CI 1.65–13.66) and disorganized thinking (OR = 3.09; 95% CI 1.33–7.19) and a worsening of the Mini-Mental State Examination (MMSE) item measuring registration (OR = 2.59; 95% CI 1.24–5.41) during the preceding 2 weeks. However, the frequency of these changes was low. Residents with at least 3 clinical changes were more likely to develop delirium than those without any clinical change (OR = 2.52; 95% CI 1.08–5.87).Conclusions: This study provides evidence of clinical changes during the prodromal phase of delirium among LTC residents. More studies are needed to further explore the role and relevance of these clinical changes as warning signs of imminent delirium.

Major depression in older medical inpatients is frequent, persistent, and disabling (Cole and Bellavance, 1997). The incidence is 20.5%–30.2% during the 12 months following admission to hospital (Fenton et al., 1997; Cole et al., 2008). Up to 73% of patients have a protracted course (Koenig et al., 1992; Cole et al., 2006; Koenig, 2006). Moreover, major depression in older medical inpatients appears to be associated with decreased function (Covinsky et al., 1997), increased use of health care services (Koenig et al., 1989; Büla et al., 2001), increased caregiver burden (McCusker et al., 2007), and possibly increased mortality (Cole, 2007).

Objective To investigate the ability of nurses to recognize delirium and its symptoms and to investigate the factors associated with undetected delirium. Design A prospective, observational study with repeated measurements over a 6-month period. Setting Seven long term care settings in Montreal and Quebec City, Canada. Participants Residents aged 65 and older, with or without dementia, admitted to long term care (not respite care) and able to communicate in English or French. Measurements Delirium and its symptoms were assessed using the Confusion Assessment Method. Ratings of delirium by nurses based on their observations during routine care were compared with delirium ratings by trained research assistants based on a one-time formal structured evaluation (Confusion Assessment Method and Mini Mental State Examination). This procedure was repeated for 10 delirium symptoms. Sensitivity, specificity, and positive and negative predictive values were calculated. The method of generalized estimating equations was used to identify factors associated with undetected delirium. Results Research assistants identified delirium in 43 (21.3%) of the 202 residents. Nurses identified delirium in 51% of the cases identified by the research assistants. However, for cases without delirium according to the research assistants, nurses identified 90% of them correctly. Detection rates for delirium symptoms ranged from 25% to 66.7%. Undetected delirium was associated with lower number of depressive symptoms manifested by the resident. Conclusion Detection of delirium is a major issue for nurses. Strategies to improve nurse recognition of delirium could well reduce adverse outcomes for this vulnerable population.

Objective The aim of this study is to develop a delirium risk screening tool for use in long-term care (LTC) facilities. Methods The sample comprised residents aged 65 years and over of seven LTC facilities in Montreal and Quebec City, Canada, admitted for LTC. Primary analyses were conducted among residents without delirium at baseline. Incident delirium was diagnosed using multiple data sources during the 6-month follow-up. Risk factors, all measured at or prior to baseline, included the following six groups: sociodemographic, medical, cognitive status, physical function, agitated behavior, and symptoms of depression. Variables were analyzed individually and by group using Cox regression models. Clinical judgment was used to select the most feasible among similarly performing factors. Results The cohort comprised 206 residents without delirium at baseline; 69 cases of incident delirium were observed (rate 7.6 per 100 person weeks). The best-performing screening tool comprised five items, with an overall area under the curve of 0.82 (95% CI 0.76, 0.88). These items included brief measures of cognitive status, physical function, behavioral, and emotional problems. Using cut-points of 2 (or 3) over 5, the scale has a sensitivity of 90% (63%), specificity of 59% (85%), and positive predictive value of 52% (66%). Conclusions This brief screening tool allows nurses to identify LTC residents at increased risk for delirium. These residents can be targeted for closer monitoring and preventive interventions. Copyright © 2012 John Wiley & Sons, Ltd.

AimTo assess plasma zinc and copper concentration in individuals with autism and correlate these levels with symptom severity.Subjects and MethodsPlasma from 102 autistic individuals, and 18 neurotypical controls, were tested for plasma zinc and copper using inductively-coupled plasma-mass spectrometry. Copper and zinc levels and Cu/Zn were analyzed for possible correlation with severity of 19 symptoms.ResultsAutistic individuals had elevated plasma levels of copper and Cu/Zn and lower, but not significantly lower, plasma Zn compared to neurotypical controls. There was a correlation between Cu/Zn and expressive language, receptive language, focus attention, hyperactivity, fine motor skills, gross motor skills and Tip Toeing. There was a negative correlation between plasma zinc concentration and hyperactivity, and fine motor skills severity.DiscussionThese results suggest an association between plasma Cu/Zn and severity of symptoms associated with autism.

Background: one explanation for the poor prognosis of delirium among older hospital patients may be that many of these patients do not recover from delirium. We sought to determine the frequency and prognosis of persistent delirium (PerD) in older hospital patients by systematically reviewing original research on this topic. Methods: MEDLINE, EMBASE, PsycINFO and the Cochrane Database of Systematic Reviews were searched for potentially relevant articles. The bibliographies of relevant articles were searched for additional references. Eighteen reports (involving 1,322 patients with delirium) met the following seven inclusion criteria: original research published in English or French, prospective study design, study population of at least 20 hospital patients, patients aged 50 years or more, follow-up of at least 1 week, acceptable definition of delirium at enrolment and included at least one assessment for PerD at discharge or later. The methods of each study were assessed according to the six criteria for prognostic studies described by the Evidence-Based Medicine Working Group. Information about the sample origin and size, age, proportion with dementia, criteria for delirium, timing of follow-up assessments, criteria for PerD, proportion with PerD and prognosis of PerD was systematically abstracted from each report, tabulated and combined using standard meta-analysis techniques. Results: the combined proportions with PerD at discharge, 1, 3 and 6 months were 44.7% (95% CI 26.8%, 63.7%), 32.8% (95% CI 18.4%, 47.2%), 25.6% (95% CI 7.9%, 43.4%) and 21% (95% CI 1.4%, 40.6%), respectively. The outcomes (mortality, nursing home placement, function, cognition) of patients with PerD were consistently worse than the outcomes of patients who had recovered from delirium. Conclusion: PerD in older hospital patients is frequent, appears to be associated with adverse outcomes and may account for the poor prognosis of delirium in this population. These findings have potentially important implications for clinical practice and research.

OBJECTIVES: To compare the 6- and 12-month outcomes of patients who recovered from subsyndromal delirium (SSD) by 8 weeks with the outcomes of patients who did not recover or did not have an index episode. DESIGN: Secondary analysis of data collected for a cohort study of the prognosis of delirium. SETTING: University-affiliated primary acute care hospital. PARTICIPANTS: Older medical inpatients with prevalent, incident, or no SSD were classified into three mutually exclusive groups at 8 weeks (SSD-recovered, SSD-not recovered, no SSD) and followed up at 6 and 12 months. MEASUREMENTS: The primary hierarchical composite outcome was death, institutionalization, or cognitive or functional decline at 6 and 12 months. In secondary analyses, components of the primary outcome were examined separately. RESULTS: Of the 129 patients assessed at 8 weeks, 51, 47, and 31 met criteria for SSD-recovered, SSD-not recovered and no SSD, respectively. At 6 and 12 months, the primary and secondary outcomes of the SSD-recovered group were better than the outcomes of the SSD-not recovered group and, for the most part, intermediate between the outcomes of the SSD-not recovered and no SSD groups. CONCLUSION: Recovery from SSD appears to predict better longer-term outcomes than no recovery. Efforts to identify and treat SSD in older medical inpatients may improve outcomes.

Objectives: To determine the relation between level of depression and psychoactive medication use and nonadherence in Canadian seniors, given that late-life depression is a common, serious mental health problem in Canada. Methods: Canadian Community Health Survey-Mental Health and Weil-Being respondents aged 65 years and older (n = 7736) comprised the study sample. Using the Composite International Diagnostic Interview to assess depressive symptoms, we created 4 depression levels to capture a spectrum of depressive disorders and (or) symptoms: major depression, comorbid major depression, depressive symptoms, and no depressive symptoms. Psychoactive medications assessed included sleep aids, anxiolytics, and mood stabilizers and (or) antidepressants (AD). Nonadherence was defined as either not taking medication as recommended or taking medication at a lower dosage than prescribed. Results: In total, 22.5% of respondents took psychoactive medication for a mental health problem in the previous 12 months. Psychoactive medication use was 46.8% for major depression, 43.1% for comorbid major depression, 34.0% for depressive symptoms, and 17.6% for no depressive symptoms. Rates of psychoactive medication use ranged from 46.5% of those with major depression, to 17.6% of those with no depressive symptoms. Overall, the rate of nonadherence to psychoactive medication was 31%; rates were highest among those with depressive symptoms (37.4%) and lowest among those with no depressive symptoms (27.4%). All 3 depressive categories were associated with greater odds of use and nonadherence. Conclusion: All 3 depression categories were associated with increased use of and nonadherence to psychoactive medication; however, rates of AD and (or) mood stabilizer use for clinically significant depression were low. Can J Psychiatry 2008;53(9):609-620 Clinical Implications * Inquiring about depression during routine visits may help physicians to assess psychoactive medication use and adherence. * Suboptimal treatment was more common in respondents who had not visited a family physician or psychiatrist. * Nonadherence to psychoactive medication in elderly individuals with depressive symptoms may be an appropriate response. Limitations * The cross-sectional study design precludes determining the direction of associations between variables. * Results may not apply to seniors living in institutions and those with more than mild cognitive impairment. * Our definition of nonadherence might have included persons with very different patterns of nonadherence. Key Words: Canada, Canadian Community Health Survey, depression, elderly, psychoactive medication Abbreviations used in this article AD antidepressant CCHS 1.2 Canadian Community Health Survey-Mental Health and Weil-Being CIDI Composite International Diagnostic Interview DSM Diagnostic and Statistical Manual of Mental Disorders In Canada, late-life depression is a serious public health problem. A recent Canadian survey shows that 6.7% and 1 9% of the general elderly population has major depression or depressive symptoms, respectively.1 Because depressive disorders in elderly individuals are associated with elevated risks for impaired physical and emotional health,2,3 pain,4 loss of productivity,2 nursing home admission,5 and mortality from medical conditions6,7 and suicide,2 delivery of effective treatment is essential to improving both quality and length of life. Canadian guidelines were developed to assist practitioners with diagnosis and treatment of depression. According to these guidelines, ADs are the recommended pharmacotherapies for major depression,8 and lithium, divalproex, and some atypical antipsychotics are the recommended pharmacotherapies for bipolar disorder.9 According to the Canadian Study of Health and Aging, use of ADs is similar across Canadian provinces (ranging from 10% to 16%), although benzodiazepine use is significantly higher in Quebec, compared with the Atlantic and Prairie provinces (36% and 1 8%, respectively; P = 0. …

IMPORTANCE: Collaborative care is an intensive care model involving several health care professionals working together, typically a physician, a case manager, and a mental health professional. Meta-analyses of aggregate data have shown that collaborative care is particularly effective in people with depression and comorbid chronic physical conditions. However, only participant-level analyses can rigorously test whether the treatment effect is influenced by participant characteristics, such as chronic physical conditions.OBJECTIVE: To assess whether the effectiveness of collaborative care for depression is moderated by the presence, type, and number of chronic physical conditions.DATA SOURCES: Data were obtained from MEDLINE, EMBASE, PubMed, PsycINFO, CINAHL Complete, and Cochrane Central Register of Controlled Trials, and references from relevant systematic reviews. The search and collection of eligible studies was ongoing until May 22, 2015.STUDY SELECTION: This was an update to a previous meta-analysis. Two independent reviewers were involved in the study selection process. Randomized clinical trials that compared the effectiveness of collaborative care with usual care in adults with depression and reported measured changes in depression severity symptoms at 4 to 6 months after randomization were included in the analysis. Key search terms included depression, dysthymia, anxiety, panic, phobia, obsession, compulsion, posttraumatic, care management, case management, collaborative care, enhanced care, and managed care.DATA EXTRACTION AND SYNTHESIS: Individual participant data on baseline demographics and chronic physical conditions as well as baseline and follow-up depression severity symptoms were requested from authors of the eligible studies. One-step meta-analysis of individual participant data using appropriate mixed-effects models was performed.MAIN OUTCOMES AND MEASURES: Continuous outcomes of depression severity symptoms measured using self-reported or observer-rated measures.RESULTS: Data sets from 31 randomized clinical trials including 36 independent comparisons (N = 10 962 participants) were analyzed. Individual participant data analyses found no significant interaction effects, indicating that the presence (interaction coefficient, 0.02 [95% CI, -0.10 to 0.13]), numbers (interaction coefficient, 0.01 [95% CI, -0.01 to 0.02]), and types of chronic physical conditions do not influence the treatment effect.CONCLUSIONS AND RELEVANCE: There is evidence that collaborative care is effective for people with depression alone and also for people with depression and chronic physical conditions. Existing guidance that recommends limiting collaborative care to people with depression and physical comorbidities is not supported by this individual participant data meta-analysis.

This study examines the differences between older patients with major depression who significantly improved or remitted and those who did not, in terms of baseline depression severity, social network, and social support. Participants (n = 66), aged 60 or over, were evaluated at a 2-month follow-up on depression symptomatology, diagnosis, and social network and support. Patients were less likely to improve if, at the onset of the study, depressive symptoms, in particular somatic ones, were more severe and if they viewed their social support as inadequate. This research underlines the importance of depression severity, and emotional and instrumental social support, for depression outcome with depressed older adults.

Aim. The goal of this study was to determine whether the factors associated with delirium varied according to the severity of the delirium experienced by the older patients. Background. Delirium among older patients is prevalent and leads to numerous detrimental effects. The negative consequences of delirium are worse among older adults with severe delirium compared with patients with mild delirium. There has been no study identifying those factors associated with delirium severity among long-term care older patients newly admitted to an acute care hospital. Design. This is a descriptive study. Methods. This is a secondary analysis study of institutionalized older patients newly admitted to an acute care hospital (n = 104). Upon admission, patients were screened for delirium with the Confusion Assessment Method and severity of delirium symptoms were determined by using the Delirium Index. Results. Of the 71 delirious older patients, 32 (45·1%) had moderate-severe delirium while 39 (54·9%) presented mild delirium. In univariate analyses, a significant positive relationship was observed between the level of prior cognitive impairment and the severity of delirium (p = 0·0058). Low mini-mental state examination (MMSE) scores (p

Background Studies of recognition of depression in older (aged 65 or more) medical inpatients show low rates of recognition of depression by attending physicians. However, few studies have compared different measures of recognition of depression. Objectives (1) To compare the validity of four indicators of recognition of depression and a global measure of recognition against a diagnosis of depression and (2) to explore the effect of patient characteristics on recognition of depression. Methods In a cohort of 264 medical inpatients 65 years and older (115 with major or minor depression, 78 with no depression), sensitivities, specificities, and diagnostic odds ratios (DOR) of 4 indicators of recognition (symptoms, diagnosis, treatment, and referral) and a global measure of recognition (any of the 4 indicators) were calculated. The associations between patient characteristics (age, sex, history of depression, antidepressant use before admission, severity of depression, comorbidity, duration of hospitalization, disability, and hospital of admission) and recognition were explored using multiple logistic regression. Results Less than half of the depressed patients were recognized. The indicator with the highest sensitivity was treatment (27.8%, 95% confidence interval [CI] 20.0–37.0), whereas the indicator with the best specificity was diagnosis (96.6%, 95% CI 91.9–98.7). The unadjusted DOR of global recognition was 2.6 (95% CI 1.5, 4.4). Less comorbidity, more severe depression symptoms, a history of depression, longer hospital stay, and antidepressant use before admission were significantly associated with better global recognition. Conclusion Recognition of depression in elderly medical inpatients depends upon the indicator of recognition used.

BACKGROUND: The potential for family physicians (FPs) to be self-care coaches for patients with depression was explored within a feasibility study examining lay coach support for self-care of depressive symptoms in adults with chronic physical illness. METHODS: FPs were approached from a list of 400 randomly generated urban FPs to assist recruitment of adults with chronic illness and depressive symptoms. Patients received, independent of usual FP care, six months of lay coaching for self-care of depression. Nested within this intervention FPs completed questionnaires at study entry and termination exploring how they normally used self-care, the degree to which they promoted it, and their hypothetical interest in coaching self-care. Two-sided paired T-tests and McNemar's tests were performed respectively for continuous and binary outcomes to assess significance of change from study onset to completion. RESULTS: 110 / 400 FPs were contactable and eligible. 63 consented to participate, and 4 withdrew at onset. Of the 59 FP participants 86% (51/59) completed entry questionnaires and 63% (37/59) terminal ones. For physical illness versus depression significantly more FPs were familiar with self-care (p=0.002) and felt it more effective (p=0.013). Of 7 targeted illnesses for which self-care might be recommended depression was ranked 5th by them. Attitudes and practice did not change as a result of study participation. CONCLUSIONS: At present it is unlikely that FPs will act as depression self-care coaches, except perhaps on an individual basis. Changes in FP training, practice styles, practice support, and remuneration may be required to improve this. Language: en

Background Major and minor depression is frequent in older medical inpatients, but the prognosis of these two disorders is not clear. The current study proposed to determine the prognosis of major and minor depression in this population. Method This prospective, observational cohort study, conducted in Montreal, Quebec, Canada, involved assessment of 380 elderly medical inpatients with major, minor, or no depression at three, six, and 12 months after enrollment using the Diagnostic Interview Schedule and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria. Information on suicide attempts, completed suicides, and potential prognostic factors was also collected. Analysis of outcomes and potential prognostic factors involved descriptive statistics and multiple logistic regression. Results Among patients with major depression at enrollment, 13% were recovered, 14% were partially recovered, and 73% remained depressed with a protracted stable or protracted fluctuating course. Among patients with minor depression, 28% were recovered and 72% had a protracted course. Patients diagnosed with major depression at enrollment often had minor depression at follow up and vice versa. Conclusion The prognosis of both major and minor depression in older medical inpatients is poor and worse than previously thought.

Background. Previous studies of the effect of depression on mortality among older medical inpatients have yielded inconsistent results. We examined the effects on mortality of both a diagnosis of depression at hospital admission and a history of previous depression, taking into account potential sources of bias (sample selection and confounding). Methods. Medical inpatients aged 65þ with at most mild cognitive impairment were recruited at two Montreal hospitals and were screened for depression. All those with a diagnosis of major or minor depression (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [DSM-IV] criteria) and a random sample of nondepressed patients were invited to participate. Baseline data included: history of previous depression, severity of physical illness, comorbidity, and health services utilization. Cox proportional hazards methods were used to analyze survival during the 16- to 52-month follow-up period. Results. Five hundred patients were enrolled; 116 (23.2%) had a history of previous depression. After adjustment for demographic factors, physical illness, cognitive impairment, and prior service utilization, the only depression group with significantly different mortality was patients with both current major depression and a history of depression, who had lower mortality than all other patient groups (hazard ratio 0.42; 95% confidence interval: 0.25, 0.70). Conclusions. Among patients with no history of depression, a diagnosis of depression was not associated with mortality after adjustment for confounding by physical illness and other factors. Coincident major depression and history of depression was associated with decreased mortality.

Delirium is a frequent syndrome among patients who are elderly. People who are older with cognitive impairment who are institutionalized are at increased risk of developing delirium when hospitalized. In addition, their prior cognitive impairment makes detecting their delirium a challenge. This study goal was to describe the effect of severity of prior cognitive impairment on delirium prevalence and symptom presentation among patients who were older and were newly admitted to an acute care hospital. A total of 104 were included in this descriptive study and screened for delirium. The results showed that the prevalence of delirium increased according to the severity of the patients’ prior cognitive impairment. Except for disorganized thinking, all symptoms of delirium were similar among patients with mild, moderate, and severe prior cognitive impairment. The study concluded that training nurses to recognize subtle changes in mental status among those patients who were older with prior cognitive impairment may prevent the underdetection of delirium.

Background: Delirium is common and often goes undetected in older patients admitted to medical services. It is associated with poor outcomes. We conducted a randomized clinical trial to determine whether systematic detection and multidisciplinary care of delirium in older patients admitted to a general medical service could reduce time to improvement in cognitive status. Methods: Consecutive patients aged 65 or more who were newly admitted to 5 general medical units between Mar. 15, 1996, and Jan. 31, 1999, were screened with the Confusion Assessment Method within 24 hours after admission to detect prevalent delirium and rescreened within a week to detect incident cases. Patients with delirium were randomly allocated to receive the intervention or usual care. Subjects in the intervention group were seen by a geriatric specialist consultant and followed in hospital for up to 8 weeks by an intervention nurse who liaised with the consultant, attending physicians, family and the primary care nurses. Subjects in the usual care group received standard hospital services but could consult geriatric specialists as needed. A research assistant, blinded as to treatment allocation, administered within 24 hours after enrolment the MiniMental Status Exam (MMSE), Delirium Index (measuring the severity of the delirium) and Barthel Index (measuring independence of personal care). Improvement was defined as an increase in the MMSE score of 2 or more points, with no decrease below baseline plus 2 points, or no decrease below a baseline MMSE score of 27. A short form of the Informant Questionnaire on Cognitive Decline in the Elderly was completed to identify patients with possible dementia. Subjects were assessed 3 times during the first week and weekly thereafter for up to 8 weeks in hospital or until discharge. Data on clinical severity of illness, length of stay and living arrangements after discharge were also collected. The primary outcome measure was time to improvement in MMSE score. Results: Of the 1925 patients who met the inclusion criteria and were screened, 227 had prevalent or incident delirium and consented to participate (113 in intervention group and 114 in usual care group). There were no clinically significant differences between the intervention and usual care groups except for sex (female 58.4% v. 50.0%) and marital status (married 34.8% v. 41.2%). Overall, 48% of the patients in the intervention group and 45% of those in the usual care group met the predetermined criteria for improvement. The Cox proportional hazards ratio (HR) for a shorter time to improvement with the intervention versus usual care, adjusted for age, sex and marital status, was 1.10 (95% confidence interval [CI] 0.74–1.63). There were no significant differences within 8 weeks after enrolment between the 2 groups in time to and rate of improvement of the Delirium Index, the Barthel Index, length of stay, rate of dis

Objectives: To describe the prevalence of and characteristics associated with major and minor depression in older medical inpatients and to compare associated characteristics by sex and history of depression. Design: Cross-sectional study of two patient samples, with and without a screening diagnosis of major or minor depression. Setting: The medical services of two acute care hospitals. Participants: Medical admissions of people aged 65 and older with at most mild cognitive impairment (N=380). Measurements: Diagnoses of major and minor depression (Diagnostic Interview Schedule), cognitive impairment (Mini-Mental State Examination), premorbid disability, sociodemographic variables (including social networks and support), comorbidity, severity of illness, history of depression. Results: The prevalence of major depression differed by hospital, ranging from 14.2% (95% confidence interval (CI)=11.7–17.1) in Hospital A to 44.5% (95% CI=33.1–56.4) in Hospital B. The prevalence of minor depression was similar in the two hospitals, ranging from 9.4% (95% CI=7.4–11.9) in Hospital A to 7.9% (95% CI=2.9–16.3) in Hospital B. After adjustment for hospital, the same characteristics (history of depression, premorbid disability, cognitive impairment, perceived adequacy of support, and visits from friends) were associated with major and minor depression, although most of these associations tended to be weaker for minor depression. Most of these factors were also associated with depression in multivariate analyses. The most important characteristics in women were premorbid disability, history of depression, and adequacy of emotional support; in men they were history of depression, cognitive impairment, and adequacy of emotional support. A cerebrovascular or other cardiovascular diagnosis did not explain the association between depression and cognitive impairment. Conclusion: Major and minor depression occur frequently in older medical inpatients and are associated with similar patient characteristics. A history of depression and the patient's sex should be considered in the identification and interpretation of these associated factors.

Delirium is a mental disorder characterized by disturbances in consciousness, orientation, memory, thought, perception, and behavior, of acute onset and fluctuating course. It occurs in hyperactive, hypoactive, or mixed forms, in up to 50% of elderly hospital inpatients, many with pre-existing dementia, and appears to be independently associated with significant increases in functional disability, length of hospital stay, rates of admission to long-term care institutions, rates of death, and healthcare costs. Despite its clinical importance, delirium is often not detected or it is misdiagnosed as dementia or other psychiatric illness even though there are potential strategies (e.g., screening by nurses, risk-factor assessment) and instruments that can improve detection and diagnosis. Although there has been limited progress in understanding the etiology, pathogenesis, assessment, and specific treatment of delirium, systematic detection and treatment programs appear to be beneficial for elderly surgical patients, as are preventive programs for elderly medical and surgical patients. Even now, there is probably enough evidence to recommend implementation of these two types of programs in acute-care hospitals.

Summary Objectives The aims of this study were to describe the characteristics of institutionalized older patients with delirium and to explore whether the factors associated with delirium differed according to the severity of the prior cognitive impairment of newly admitted older patients. Methods This is a secondary analysis study (cross-sectional) of institutionalized older patients newly admitted to an acute care hospital (n = 104). We screened patients for delirium upon their admission, using the Confusion Assessment Method. Results Of the 104 cognitively impaired older patients included in the study, 68% had delirium. We identified the following as characteristic of older patients with delirium: male sex ( p = 0.0259), being admitted from a nursing home ( p = 0.0269), lower MMSE score at admission ( p = 0.0001), severe illness ( p = 0.0001), lower functional autonomy (BI: p = 0.0001; IADL: p = 0.0089), bladder ( p = 0.0018) and bowel ( p = 0.0276) incontinence, and physical restraints ( p = 0.0003). Apart from hearing impairment, we found that remaining factors were similarly distributed among older patients with mild, moderate and severe prior cognitive impairment. Conclusion(s) The severity of prior cognitive impairment does not appear to influence the distribution of the factors associated with delirium. Hence patients with severe prior cognitive impairment at admission to an acute-care hospital would not require preventive nursing interventions different from those for older patients with mild or moderate impairment.

Objectives: To assess the reliability, validity, and responsiveness of an instrument for measuring the severity of delirium, the Delirium Index (DI). Design: Prospective cohort study, with repeated patient assessments at multiple points in the hospital, at 8 weeks after discharge, and at 6 and 12 months after admission. Setting: The medical services of a primary acute-care hospital. Participants: Medical admissions aged 65 and older: 165 with delirium and dementia, 57 with delirium only, 55 with dementia only, and 41 with neither. Measurements: Severity of delirium symptoms was measured using the DI. Delirium was diagnosed using the Confusion Assessment Method. Other measures included the Mini-Mental State Examination, Informant Questionnaire on Cognitive Decline in the Elderly, Barthel Index (BI), premorbid instrumental activities of daily living, Charlson Comorbidity Index, Clinical Severity of Illness scale (CSI), and the Acute Physiology Score (APS). Results: The intraclass correlation coefficient of interrater reliability was 0.98. Two measures of fluctuation were significantly higher in patients with delirium than in those without delirium. At baseline, the DI was correlated with the BI, APS, and CSI in delirious patients with (correlation coefficient (r)=−0.43, 0.17, and 0.36, respectively) or without (r=−0.44, 0.39, 0.22, respectively) dementia. At 8 weeks, in delirious patients with and without dementia, internal responsiveness as measured by effect sizes was −0.60 and −0.74, respectively, and the standardized response mean for both groups was −0.64. Low to good levels of external responsiveness were found. Conclusion: The DI appears to be a reliable, valid, and responsive measure of the severity of delirium, in patients with delirium, with or without dementia.

Objectives: To determine the effects of prevalent and incident delirium on length of hospital stay. Design: Prospective cohort study, comparing (1) length of stay after admission in cases of prevalent delirium versus controls without prevalent delirium with (2) length of stay after diagnosis in cases of incident delirium versus controls matched by day of diagnosis. Setting: The medical services of a primary, acute care hospital. Participants: Medical admissions of patients aged 65 and older from the emergency department with delirium diagnosed during the first week in hospital. Patients admitted to intensive care or oncology and those with a primary diagnosis of stroke were excluded. A sample of those without delirium was also enrolled. Measurements: Delirium was diagnosed using the Confusion Assessment Method. Data on length of stay and diagnosis-related groups (DRGs) were abstracted from administrative data. Measures of covariates included the Informant Questionnaire on Cognitive Decline in the Elderly, the Delirium Index, the instrumental activities of daily living questionnaire from the Older American Resources and Services project, the Charlson Comorbidity Index, the Clinical Severity Scale, and the Acute Physiology Score. Results: The study sample comprised 359 patients: 204 with prevalent delirium, 37 with incident delirium, and 118 without delirium. After controlling for covariates, prevalent delirium was not associated with a significantly longer hospital stay, but incident delirium was associated with an excess stay after diagnosis of 7.78 days (95% confidence interval=3.07, 12.48). Similar results were obtained using log-transformed or DRG-adjusted estimates of length of stay. Conclusion: In older medical inpatients, incident but not prevalent delirium is an important predictor of longer hospital stay. Interventions to prevent incident delirium may reduce length of stay.

OBJECTIVES: To determine the prognostic significance of subsyndromal delirium (SSD) presentations. DESIGN: Cohort study. SETTING: University-affiliated primary acute care hospital. PARTICIPANTS: One hundred sixty-four elderly medical inpatients who did not meet Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) criteria for delirium during the first week after admission were classified into three mutually exclusive groups. The first group, prevalent SSD, included those who had two or more of four core symptoms of delirium (clouding of consciousness, inattention, disorientation, perceptual disturbances) at admission. The second group, incident SSD, included those who did not meet criteria for prevalent SSD but displayed one or more new core symptoms during the week after admission. The third group had no prevalent or incident SSD. The three groups were followed up at 2, 6, and 12 months. MEASUREMENTS: Outcomes (length of stay, symptoms of delirium (Delirium index), cognitive (Mini-Mental State Examination) and functional status (instrumental activities of daily living), and mortality) were compared using univariate techniques and multivariate regression models that adjusted for age, sex, marital status, living arrangements before admission, comorbidity, clinical and physiological severity of illness, and dementia status and severity. RESULTS: Patients with prevalent SSD had longer acute care hospital stay, increased postdischarge mortality, more symptoms of delirium, and a lower cognitive and functional level at follow-up than patients with no SSD. Most of the findings for incident SSD were similar but not statistically significant. Patients with prevalent or incident SSD had risk factors for DSM-defined delirium. CONCLUSION: SSD in elderly medical inpatients appears to be a clinically important syndrome that falls on a continuum between no symptoms and DSM-defined delirium.

We assessed adherence to and predictors of two components of a telephone-supported self-care intervention for depression among primary care adults aged 40 and above with chronic physical illnesses and comorbid depressive symptoms. Participants received a “toolkit” containing six self-care tools. Trained lay self-care “coaches” negotiated a contact schedule of up to weekly contacts. Study outcomes were levels of completion of the self-care tool and the coach contacts at the 2-month follow-up. Coaches reported the number of completed contacts. In all, 57 of 63 participants completed the 2-month follow-up. Of these, 67% completed at least 1 tool; the mean number of coach contacts was 5.7 ( SD = 2.4) of a possible 9 contacts (63% adherence). Higher disease comorbidity and lower initial depression severity independently predicted better tool adherence. Findings suggest that people with chronic physical illnesses can achieve acceptable levels of adherence to a depression self-care intervention similar to those reported for other populations.

Objective The aim of this study was to compare outcomes of use of a depression self-care toolkit with and without lay telephone coaching among primary care patients 40 years and older with depressive symptoms and comorbid chronic physical conditions. Method A single blind, individually randomized, pragmatic trial of a depression self-care toolkit (Toolkit) with or without lay telephone coaching was conducted among primary care adults with depressive symptoms and comorbid chronic physical conditions. Eligible patients were randomized to receive the Toolkit with (intervention) or without (control) telephone coaching provided by trained lay coaches. The primary outcome was depression severity [Patient Health Questionnaire (PHQ-9)] at 6 months. Secondary outcomes were self-efficacy, satisfaction, and use of health services at 6 months. Results A total of 223 patients were randomized, and 172 (77.1%) completed 6-month follow-ups. PHQ-9 scores improved significantly in both groups over the 6-month follow-up; the differences in PHQ-9 scores between intervention and control groups were statistically significant at 3 months [effect size = 0.44; 95% confidence interval (CI) = 0.16–0.72] but not at 6 months (effect size = 0.24; 95% CI = − 0.01 to 0.60). Patients with moderate depression severity (PHQ-9 10–19) and high self-efficacy at baseline were most likely to benefit from the intervention. There was no significant effect of the intervention on the secondary outcomes. Conclusions The incremental value of lay telephone coaching of a Toolkit appears short-lived. Targeting of coaching to those with moderate depression severity may be indicated.

OBJECTIVES: To evaluate the relationship of environmental risk factors in hospitals to changes over time in delirium symptom severity scores. DESIGN: Observational prospective clinical study with repeated measurements, several times during the first week of hospitalization and then weekly during hospitalization. SETTING: University-affiliated general community hospital. PARTICIPANTS: Four hundred forty-four patients age 65 and older admitted to the medical wards: 326 with delirium and 118 without delirium. Patients with prior cognitive impairment were oversampled. MEASUREMENTS: The severity of delirium symptoms was measured with the Delirium Index, a scale developed and validated by our group, based on the Confusion Assessment Method. Potential environmental risk factors assessed included isolation, hospital unit, room changes, levels of sensory stimulation, aids to orientation, and presence of medical (e.g., intravenous) or physical restraints. RESULTS: Controlling for initial severity of delirium and patient characteristics, variables significantly related to an increase in delirium severity scores included hospital unit (intensive care or long-term care unit), number of room changes, absence of a clock or watch, absence of reading glasses, presence of a family member, and presence of medical or physical restraints. CONCLUSION: The associations of intensive care and medical and physical restraints with severity of delirium symptoms may be due to uncontrolled confounding by indication. However, the other factors identified suggest potentially modifiable risk factors for symptoms of delirium in hospitalized older people. J Am Geriatr Soc 49:1327–1334, 2001.

Delirium in hospitalized elderly patients is a phenomenon requiring a lot of nursing attention. It is also a disorder contributing to poor health outcomes in this population. Because of their 24-hour work schedule, nurses are frequently the first to observe acute changes in patients' mental health status and to initiate early interventions. However, delirium is not always easily identified. Therefore, the goal of this article is to increase nurses' knowledge and awareness of early signs of delirium using the Confusion Assessment Method (CAM) routinely and systematically.

Background/literature review: The prevalence of agitated behaviors in different populations with dementia is between 24% and 98%. Although agitated behaviors are potentially disruptive, little research attention has been focused on the effects of these behaviors upon nursing staff. The objectives of this study of demented patients in long-term-care beds at an acute care community hospital were to determine the frequency and disruptiveness of agitated behaviors; to investigate the associations of patient characteristics and interventions with the level of agitation; and to explore the burden of these agitated behaviors on nursing staff. Method: The study sample comprised 56 demented patients in the long-term-care unit during the study period. Twenty-seven staff who cared for these patients during three shifts over a 2-week period were interviewed to rate the frequency and disruptiveness of agitated behaviors using the Cohen-Mansfield Agitation Inventory, and the burden of care using a modified version of the Zarit Burden Interview. Data on patient characteristics and interventions extracted from the hospital chart included scores on the Barthel Index and Mini-Mental State Examination, the use of psychotropic medication, and the use of physical restraints. Results: Ninety-five percent of the patients with dementia were reported to have at least one agitated behavior; 75% had at least one moderately disruptive behavior. A small group of six patients (11%) had 17 or more disruptive behaviors. The frequency of most behaviors did not vary significantly by shift. Length of stay on long-term care, Barthel Index score, and the use of psychotropic medications were significantly associated with the number of agitated behaviors. The number of behaviors, their mean frequency, and their mean disruptiveness were all significantly correlated with staff burden. Discussion: The prevalence of agitated behaviors in patients with dementia in long-term-care beds at an acute care hospital is similar to that reported in long-term-care facilities. These behaviors are associated with staff burden.

To determine the feasibility and effectiveness of treatments for depressed elderly medical inpatients, MEDLINE was searched for potentially relevant articles published from January 1987 to August 1997, using the keywords “depression or depressive disorder” (exploded) and “aged.” The bibliographies of relevant articles were searched for additional references. Fifteen reports met the following inclusion criteria: (a) published in English or French; (b) minimum age criterion of 55 and over or mean age 65 and over; (c) subjects admitted to the medical service of an acute care hospital; (d) used accepted criteria for depression; (e) examined treatment(s) for depression; and (f) reported outcomes as a depression diagnosis and/or symptom level. Information was abstracted independently from each article by two reviewers, tabulated, and compared. The limited evidence suggests contraindications to treatment in 38% to 87% of subjects who received a heterocyclic antidepressant compared to 4% of subjects who received the selective serotonin reuptake inhibitor (SSRI) fluoxetine; rates of discontinuation and study completion were similar for heterocyclics, the SSRIs, and psychostimulants. All of the treatments (including social support/psychotherapy) appeared to be at least modestly effective in the short term.