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PubMed | University Utrecht, University of New South Wales, Ancelle Hospital, Johns Hopkins University and 13 more.
Type: Review | Journal: Journal of the American Medical Directors Association | Year: 2016

Delirium occurring in patients with dementia is referred to as delirium superimposed on dementia (DSD). People who are older with dementia and who are institutionalized are at increased risk of developing delirium when hospitalized. In addition, their prior cognitive impairment makes detecting their delirium a challenge. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision are considered the standard reference for the diagnosis of delirium and include criteria of impairments in cognitive processes such as attention, additional cognitive disturbances, or altered level of arousal. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision does not provide guidance regarding specific tests for assessment of the cognitive process impaired in delirium. Importantly, the assessment or inclusion of preexisting cognitive impairment is also not addressed by these standards. The challenge of DSD gets more complex as types of dementia, particularly dementia with Lewy bodies, which has features of both delirium and dementia, are considered. The objective of this article is to critically review key elements for the diagnosis of DSD, including the challenge of neuropsychological assessment in patients with dementia and the influence of particular tests used to diagnose DSD. To address the challenges of DSD diagnosis, we present a framework for guiding the focus of future research efforts to develop a reliable reference standard to diagnose DSD. A key feature of a reliable reference standard will improve the ability to clinically diagnose DSD in facility-based patients and research studies.


Morandi A.,Ancelle Hospital | Morandi A.,Geriatric Research Group | Han J.H.,Vanderbilt University | Meagher D.,University of Limerick | And 10 more authors.
Journal of the American Medical Directors Association | Year: 2016

Objectives Delirium disproportionately affects patients with dementia and is associated with adverse outcomes. The diagnosis of delirium superimposed on dementia (DSD), however, can be challenging due to several factors, including the absence of caregivers or the severity of preexisting cognitive impairment. Altered level of consciousness has been advocated as a possible useful indicator of delirium in this population. Here we evaluated the performance of the Richmond Agitation and Sedation Scale (RASS) and the modified-RASS (m-RASS), an ultra-brief measure of the level of consciousness, in the diagnosis of DSD. Design Multicenter prospective observational study. RASS and m-RASS results were analyzed together, labeled RASS/m-RASS. Setting Acute geriatric wards, in-hospital rehabilitation, emergency department. Participants Patients 65 years and older with dementia. Measurements Delirium was diagnosed with the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) or with the Delirium Rating Scale-Revised (DRS-R-98), or with the 4 A's Test (4AT). Dementia was detected with the Clinical Dementia Rating (CDR) Scale, the Short Form–Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) or via the clinical records. Results Of the 645 patients included, 376 (58%) had delirium. According to the instrument used to evaluate delirium, the prevalence was 66% with the 4AT, 23% with the DSM, and 100% with the DRS-R-98. Overall a RASS/m-RASS score other than 0 was 70.5% sensitive (95% confidence interval [CI] 65.9%–75.1%) and 84.8% (CI 80.5%–89.1%) specific for DSD. Using a RASS/m-RASS value greater than +1 or less than −1 as a cutoff, the sensitivity was 30.6% (CI 25.9%–35.2%) and the specificity was 95.5% (CI 93.1%–98.0%). The sensitivity and the specificity did not greatly vary according to the method of delirium diagnosis and the dementia ascertainment, although the specificity was slightly higher when the DSM and the IQCODE were used. Conclusion In older patients admitted to different clinical settings, the RASS and m-RASS analyzed as a single group had moderate sensitivity and very high specificity for the detection of DSD. Level of consciousness is therefore a valuable clinical indicator that should form part of delirium screening strategies, although for higher sensitivity other methods of assessment should be used. © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine


PubMed | Ancelle Hospital, University of Rome Tor Vergata, University of Milan Bicocca, Centro Hospitalar Universitario Of Coimbra and 4 more.
Type: Journal Article | Journal: Journal of the American Medical Directors Association | Year: 2016

Delirium disproportionately affects patients with dementia and is associated with adverse outcomes. The diagnosis of delirium superimposed on dementia (DSD), however, can be challenging due to several factors, including the absence of caregivers or the severity of preexisting cognitive impairment. Altered level of consciousness has been advocated as a possible useful indicator of delirium in this population. Here we evaluated the performance of the Richmond Agitation and Sedation Scale (RASS) and the modified-RASS (m-RASS), an ultra-brief measure of the level of consciousness, in the diagnosis of DSD.Multicenter prospective observational study. RASS and m-RASS results were analyzed together, labeled RASS/m-RASS.Acute geriatric wards, in-hospital rehabilitation, emergency department.Patients 65years and older with dementia.Delirium was diagnosed with the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) or with the Delirium Rating Scale-Revised (DRS-R-98), or with the 4 As Test (4AT). Dementia was detected with the Clinical Dementia Rating (CDR) Scale, the Short Form-Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) or via the clinical records.Of the 645 patients included, 376 (58%) had delirium. According to the instrument used to evaluate delirium, the prevalence was 66% with the 4AT, 23% with the DSM, and 100% with the DRS-R-98. Overall a RASS/m-RASS score other than 0 was 70.5% sensitive (95% confidence interval [CI] 65.9%-75.1%) and 84.8% (CI 80.5%-89.1%) specific for DSD. Using a RASS/m-RASS value greater than+1 or less than-1 as a cutoff, the sensitivity was 30.6% (CI 25.9%-35.2%) and the specificity was 95.5% (CI 93.1%-98.0%). The sensitivity and the specificity did not greatly vary according to the method of delirium diagnosis and the dementia ascertainment, although the specificity was slightly higher when the DSM and the IQCODE were used.In older patients admitted to different clinical settings, the RASS and m-RASS analyzed as a single group had moderate sensitivity and very high specificity for the detection of DSD. Level of consciousness is therefore a valuable clinical indicator that should form part of delirium screening strategies, although for higher sensitivity other methods of assessment should be used.


Bellelli G.,University of Milan Bicocca | Bellelli G.,Geriatric Unit S Gerardo Hospital | Bellelli G.,Geriatric Research Group | Mazzola P.,University of Milan Bicocca | And 12 more authors.
Journal of the American Geriatrics Society | Year: 2014

Objectives To evaluate the association between number of days with delirium and 6-month mortality in elderly adults after hip fracture surgery. Design Prospective cohort study with 6-month follow-up. Setting Orthogeriatric Unit (OGU). Participants Individuals (mean age = 84.3 ± 6.4) admitted to the OGU between October 2011 and April 2013 with hip fracture (N = 199). Measurements Postoperative delirium (POD) was assessed daily using the Confusion Assessment Method algorithm and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, criteria. Multivariable Cox regression models were used to evaluate the association between POD of and 6-month mortality after surgery, after adjustment for covariates including age, prefracture residence, Katz activity of daily living score, New Mobility score, diagnosis of prefracture dementia, American Society of Anesthesiologists score, albumin serum levels, Charlson Comorbidity Index, and length of OGU stay. Results Fifty-seven participants (28.6%) developed POD. In the 6-month period after surgery, 35 (17.6%) participants died: 16 of 57 (28.1%) with POD and 19/ of 142 (13.4%) with no POD. The average duration of POD was 2.0 ± 3.2 days for participants who died and 0.7 ± 1.8 days for those who survived (P <.001). After adjusting for covariates, each day of POD in the OGU increased the hazard of dying at 6 months by 17% (hazard ratio = 1.17, 95% confidence interval = 1.07-1.28). Conclusion In older adults undergoing hip fracture surgery, duration of POD is an important prognostic factor for 6-month mortality. Efforts to reduce duration of POD are therefore crucial for these individuals. © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.


Morandi A.,Ancelle Hospital | Morandi A.,Geriatric Research Group | Morandi A.,Center for Quality Aging | Barnett N.,Vanderbilt University | And 12 more authors.
Journal of Critical Care | Year: 2013

Purpose: The pathophysiology of delirium in critical illness is unclear. 25-OH vitamin D (25-OHD) has neuroprotective properties but a relationship between serum 25-OHD and delirium has not been examined. We tested the hypothesis that low serum 25-OHD is associated with delirium during critical illness. Materials and Methods: In a prospective cohort of 120 medical intensive care unit (ICU) patients, blood was collected within 24 hours of ICU admission for measurement of 25-OHD. Delirium was identified once daily using the Confusion Assessment Method for the ICU. Multivariable logistic regression was used to analyze the association between 25-OHD and delirium assessed the same day and the subsequent day after25-OHD measurement, with adjustments for age and severity of illness. Results: Median age was 52 years (interquartile range, 40-62), and Acute Physiology and Chronic Health Evaluation II was 23 (interquartile range, 17-30). Thirty-seven patients (41%) were delirious on the day of 25-OHD measurement. 25-OHD levels were not associated with delirium on the day of 25-OHD measurement (odds ratio, 1.01; 95% confidence interval, 0.98-1.02) or on the day after measurement (odds ratio, 1.01; 95% confidence interval, 0.99-1.03). Conclusions: This pilot study suggests that 25-OHD levels measured early during critical illness are not important determinants of delirium risk. Since 25-OHD levels can fluctuate during critical illness, a study of daily serial measurements of 25-OHD levels and their relationship to delirium during the duration of critical illness may yield different results. © 2013 Elsevier Inc.


Morandi A.,Ancelle Hospital | Morandi A.,Geriatric Research Group | Girard T.D.,Vanderbilt University | Girard T.D.,Geriatric Research | And 13 more authors.
Rejuvenation Research | Year: 2014

The effect of statins on functional status in older patients is unclear. Statins might carry a deleterious effect on muscle function leading to myopathy and therefore affecting functional recovery. We evaluated the relationship between statin exposure at in-hospital rehabilitation admission and functional outcome at discharge. This was a retrospective cohort study of older patients 70 years and older consecutively admitted to an in-hospital rehabilitation after an acute hospitalization. Statin exposure was measured at the time of rehabilitation admission. Functional status was defined with the Barthel Index (BI) score at the time of discharge. A multi-variable linear regression model was used to evaluate the association between statin exposure and functional status at discharge adjusting for potential confounders through a propensity score for statin exposure. A total of 2435 patients were included. The cohort had a mean age of 81.1 years. Of these 9% (n=220) were on statins at the time of admission. In the multi-variable analysis, the use of statins at the time of admission was independently associated with an improved functional status at discharge (point estimate 5.2; 95% confidence interval 1.5-8.9; p<0.01) after adjusting for relevant confounders. Patients who were receiving statins at the time of admission had a BI score 5 points higher compared to those who were not receiving statins. The use of statins was overall safe in a group of co-morbid older patients undergoing rehabilitation training after an acute hospitalization. Additionally, a possible benefit was found given the positive association between statin use and higher functional status at discharge. © 2014, Mary Ann Liebert, Inc.


PubMed | Ancelle Hospital
Type: Journal Article | Journal: Journal of critical care | Year: 2013

The pathophysiology of delirium in critical illness is unclear. 25-OH vitamin D (25-OHD) has neuroprotective properties but a relationship between serum 25-OHD and delirium has not been examined. We tested the hypothesis that low serum 25-OHD is associated with delirium during critical illness.In a prospective cohort of 120 medical intensive care unit (ICU) patients, blood was collected within 24 hours of ICU admission for measurement of 25-OHD. Delirium was identified once daily using the Confusion Assessment Method for the ICU. Multivariable logistic regression was used to analyze the association between 25-OHD and delirium assessed the same day and the subsequent day after 25-OHD measurement, with adjustments for age and severity of illness.Median age was 52 years (interquartile range, 40-62), and Acute Physiology and Chronic Health Evaluation II was 23 (interquartile range, 17-30). Thirty-seven patients (41%) were delirious on the day of 25-OHD measurement. 25-OHD levels were not associated with delirium on the day of 25-OHD measurement (odds ratio, 1.01; 95% confidence interval, 0.98-1.02) or on the day after measurement (odds ratio, 1.01; 95% confidence interval, 0.99-1.03).This pilot study suggests that 25-OHD levels measured early during critical illness are not important determinants of delirium risk. Since 25-OHD levels can fluctuate during critical illness, a study of daily serial measurements of 25-OHD levels and their relationship to delirium during the duration of critical illness may yield different results.


PubMed | Ancelle Hospital
Type: Journal Article | Journal: Rejuvenation research | Year: 2014

The effect of statins on functional status in older patients is unclear. Statins might carry a deleterious effect on muscle function leading to myopathy and therefore affecting functional recovery. We evaluated the relationship between statin exposure at in-hospital rehabilitation admission and functional outcome at discharge. This was a retrospective cohort study of older patients 70 years and older consecutively admitted to an in-hospital rehabilitation after an acute hospitalization. Statin exposure was measured at the time of rehabilitation admission. Functional status was defined with the Barthel Index (BI) score at the time of discharge. A multi-variable linear regression model was used to evaluate the association between statin exposure and functional status at discharge adjusting for potential confounders through a propensity score for statin exposure. A total of 2435 patients were included. The cohort had a mean age of 81.1 years. Of these 9% (n=220) were on statins at the time of admission. In the multi-variable analysis, the use of statins at the time of admission was independently associated with an improved functional status at discharge (point estimate 5.2; 95% confidence interval 1.5-8.9; p<0.01) after adjusting for relevant confounders. Patients who were receiving statins at the time of admission had a BI score 5 points higher compared to those who were not receiving statins. The use of statins was overall safe in a group of co-morbid older patients undergoing rehabilitation training after an acute hospitalization. Additionally, a possible benefit was found given the positive association between statin use and higher functional status at discharge.

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