The diagnosis, prevalence and prognosis of delirium in an older hospital population

Delirium is a syndrome which is characterised by a change in cognition, attentional difficulties and alterations to the sleep-wake cycle. In most cases it is caused by the onset of a physical illness. Delirium is more commonly found in older people aged 65 years or older, with prevalence in hospital being as high as 42%. Delirium is associated with negative outcomes such as increased length of hospital admissions, institutionalisation and mortality. There are tools which can identify and measure delirium and its associated symptoms. The Delirium Rating Scale-Revised-98 is claimed to be a valid tool, but its use in older patients in general hospital has not been fully investigated and there is limited research to support its validity in such a population. A cohort study of older people with mental health problems admitted to general hospital was used to establish whether the DRS–R–98 was able to distinguish delirium from other mental health problems, to examine the association between DRS-R-98 scores, demographic variables and health problems and to study outcomes associated with delirium. 250 patients over 70 years admitted to hospital as an emergency and likely to have a mental health problem on the basis of screening were recruited and 249 completed a battery of questionnaires including the DRS-R-98 at baseline. 180 days later 121 participants completed a follow-up questionnaire. 128 participants were lost to follow-up due to refusal of the outcomes questionnaire, ill-health, withdrawal, mortality or being un-contactable after the baseline questionnaire. Delirium was common in the study population (43%).The odds of having delirium increased with the presence of dementia (odds ratio=6.7) and functional disability (odds ratio=4.5). It was not significantly associated with mortality or length of stay in hospital. It was associated with recoverable cognitive impairment. The DRS-R-98 has reasonable content, concurrent and predictive validity but compared with clinician diagnosis the sensitivity and specificity of the DRS-R-98 were modest (about 0.75). The validity of the DRS-R-98 was not as strongly supported as in other research, which reported sensitivity and specificity as high as 0.98 and 0.77 respectively. This could be due to the differences in participant populations, as the participants of this study were all older patients with mental health problems on general hospital wards. In view of its ability to discriminate groups the DRS-R-98 is sufficiently valid for use in epidemiological research, but its moderate sensitivity and specificity make it unsuitable for use alone in clinical practice on individual patients, especially in populations where co-morbid dementia is prevalent

The diagnosis, prevalence and prognosis of delirium in an older hospital population

Delirium is a syndrome which is characterised by a change in cognition, attentional difficulties and alterations to the sleep-wake cycle. In most cases it is caused by the onset of a physical illness. Delirium is more commonly found in older people aged 65 years or older, with prevalence in hospital being as high as 42%. Delirium is associated with negative outcomes such as increased length of hospital admissions, institutionalisation and mortality. There are tools which can identify and measure delirium and its associated symptoms. The Delirium Rating Scale-Revised-98 is claimed to be a valid tool, but its use in older patients in general hospital has not been fully investigated and there is limited research to support its validity in such a population. A cohort study of older people with mental health problems admitted to general hospital was used to establish whether the DRS–R–98 was able to distinguish delirium from other mental health problems, to examine the association between DRS-R-98 scores, demographic variables and health problems and to study outcomes associated with delirium. 250 patients over 70 years admitted to hospital as an emergency and likely to have a mental health problem on the basis of screening were recruited and 249 completed a battery of questionnaires including the DRS-R-98 at baseline. 180 days later 121 participants completed a follow-up questionnaire. 128 participants were lost to follow-up due to refusal of the outcomes questionnaire, ill-health, withdrawal, mortality or being un-contactable after the baseline questionnaire. Delirium was common in the study population (43%).The odds of having delirium increased with the presence of dementia (odds ratio=6.7) and functional disability (odds ratio=4.5). It was not significantly associated with mortality or length of stay in hospital. It was associated with recoverable cognitive impairment. The DRS-R-98 has reasonable content, concurrent and predictive validity but compared with clinician diagnosis the sensitivity and specificity of the DRS-R-98 were modest (about 0.75). The validity of the DRS-R-98 was not as strongly supported as in other research, which reported sensitivity and specificity as high as 0.98 and 0.77 respectively. This could be due to the differences in participant populations, as the participants of this study were all older patients with mental health problems on general hospital wards. In view of its ability to discriminate groups the DRS-R-98 is sufficiently valid for use in epidemiological research, but its moderate sensitivity and specificity make it unsuitable for use alone in clinical practice on individual patients, especially in populations where co-morbid dementia is prevalent

Caring for cognitively impaired older patients in the general hospital: A qualitative analysis of similarities and differences between a specialist Medical and Mental Health Unit and standard care wards

Background: Around half of people aged over 70 admitted as an emergency to general hospital have dementia, delirium or both. Dissatisfaction is often expressed about the quality of hospital care. A medical and mental health unit was developed to provide best practice care to cognitively impaired older patients. The Unit was evaluated by randomised controlled trial compared to standard care wards. Part of this evaluation involved structured non-participant observations of a random sub-sample of participants and the recording of field notes. Objectives: The aim of this paper is to compare and contrast the behaviours of staff and patients on the Medical and Mental Health Unit and standard care wards and to provide a narrative account that helps to explain the link between structure, process and reported outcomes. Design: Field notes were analysed using the constant comparison method. Setting: A large hospital within the East Midlands region of the United Kingdom. Participants: Patient participants were aged over 65, and identified by Admissions Unit physicians as being ‘confused’. Most patients had delirium or dementia. Results: Sixty observations (360 hours) were made between March and December 2011. Cognitively impaired older patients had high physical and psychological needs, and were cared for in environments which were crowded, noisy and lacked privacy. Staff mostly prioritised physical over psychological needs. Person-centred care on the Medical and Mental Health Unit was mostly delivered during activity sessions or meal times by activities coordinators. Patients on this unit were able to walk around more freely than on other wards. Mental health needs were addressed more often on the Medical and Mental Health Unit than on standard care wards but most staff time was still taken up delivering physical care. More patients called out repetitively on the Unit and staff were not always able to meet the high needs of these patients. Conclusion: Care provided on the Medical and Mental Health Unit was distinctly different from standard care wards. Improvements were worthwhile, but care remained challenging and consistent good practice was difficult to maintain. Disruptive vocalisation may have been provoked by concentrating cognitively impaired patients on one ward

Factors associated with family caregiver dissatisfaction with acute hospital care of older cognitively impaired relatives

Objectives To identify patient and caregiver characteristics associated with caregiver dissatisfaction with hospital care of cognitively impaired elderly adults. Design Secondary analysis of data from a randomized controlled trial. Setting An 1,800-bed general hospital in England providing the only emergency medical services in its area. Participants Cognitively impaired individuals aged 65 and older randomly assigned to a specialist unit or standard geriatric or internal medical wards (N = 600) and related caregivers (N = 488). Measurements Patient and caregiver health status was measured at baseline, including delirium, cognitive impairment, behavioral and psychological symptoms, activities of daily living, and caregiver strain. Caregiver satisfaction with quality of care was ascertained after hospital discharge or death. Results Four hundred sixty-two caregivers completed satisfaction questionnaires. Regardless of assignment, 54% of caregivers were dissatisfied with some aspects of care, but overall 87% were satisfied with care. The main areas of dissatisfaction were communication, discharge planning, and medical management. Dissatisfaction was associated with high levels of patient behavioral and psychological symptoms on admission, caregiver strain and poor psychological well-being at admission, a diagnosis of delirium, and the relationship between the caregiver and the patient. There was less dissatisfaction from caregivers of patients managed on the specialist Medical and Mental Health Unit than those on standard wards, after controlling for multiple factors. Conclusion Dissatisfaction was associated with patient behavioral and psychological symptoms and caregiver strain but was not immutable to efforts to improve care

Cognitive behaviour therapy for non-cardiac pain in the chest (COPIC): a multicentre randomized controlled trial with economic evaluation

Background Most patients with chest pain have nothing wrong with their cardiac function. Psychological forms of treatment for this condition are more likely to be successful than others. Methods/design A two-arm parallel controlled randomized trial of standard care versus a modified form of cognitive behaviour therapy for chest pain (CBT-CP) in patients who have attended emergency hospital services. Inclusion criteria include (i) emergency attendance more than once in the previous year with chest pain when no physical pathology has been found, (ii) aged between 16 and 75, (iii) signed consent to take part in the study. Exclusion criteria are (i) under current psychiatric care, (ii) those who have had new psychotropic drugs prescribed within the last two months, (iii) are receiving or about to receive a formal psychological treatment. Those satisfying these criteria will be randomized to 4–10 sessions of CBT-CP or to continue with standard care. Participants are randomized using a remote web-based system using permuted stacked blocks stratified by study centre. Assessment is carried out at baseline by researchers subsequently masked to allocation and at 6 months and 1 year after randomization. The primary outcome is the Health Anxiety Inventory score at 6 months, and secondary outcomes are generalised anxiety and depressive symptoms, the Lucock Health Anxiety Questionnaire adapted for chest pain, visual analogue scales for chest pain and discomfort (Inskip Scale), the Schedule for Evaluating Persistent Symptoms (SEPS), health related quality of life, social functioning and medical resource usage. Intention to treat analyses will be carried out with clinical and functioning data, and a cost-utility analysis will compare differences in total costs and differences in quality of life using QALYs derived from the EQ-5D. The data will also be linked to another parallel study in New Zealand where 126 patients with the same inclusion criteria have been treated in a similar trial; the form of analysis of the combined data has yet to be determined. Discussion The morbidity and costs of non-cardiac chest pain are substantial and if a simple psychological treatment given by health professionals working in medical departments is beneficial it should prove to be of great value. Combining data with a similar study in New Zealand is an additional asset. Trial registration ISRCTN14711101 (registered 05/03/2015