INNOVATIVE METHODS TO ENGAGE LEARNERS IN GERIATRICS AND GERONTOLOGY
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In this symposium we share experiences developing, using, and evaluating innovative methods for engaging learners in geriatrics education across disciplines. In our first talk, Powers and colleagues present multiple technologic innovations to manage diverse learners, including a phone app, a web based learning tool, and a video-based system for teaching and evaluation. Kresevic and colleagues present data on 80+ learners on the use of simulation as part of a multi-modal delirium education intervention. Garner describes the use of the team as an educational tool including individual and team based assessment and activities in learning focusing on palliative care. Nathan and Schwartz provide two examples of engaging Harvard Medical School trainees in geriatrics through the arts and humanities, with results from 170 learners. Amir describes the implementation of a geriatrics curriculum at a Indian Health Services site using multi-modal techniques. In view of the geriatric workforce shortage, there will not be enough geriatric trained professionals to meet the healthcare needs of older adults. Therefore geriatric professionals will have increasing roles as educators to students, staff, patients, and families. This symposium provides an up to date overview and outcome evaluation of the wide ranging platforms and possibilities for engaging learners in geriatric education.The prognostic significance of delirium in hospitalized elderly has not yet been fully clarified.The present study was designed to evaluate the relationship between prevalent delirium (PrD), incident delirium (InD) and final outcome.A historical cohort of 261 patients was selected. delirium was diagnosed using the Confusion Assessment Method.The total frequency of delirium detected was 42.5%-31.4% PrD and 16.2% InD. Among patients with InD, the average length of hospital stay was 9.1 days longer than for patients without delirium (p=0.002), and the hospital mortality associated with InD was 48% versus 2.7% for those without delirium (p< 0.001). However, no difference was observed between patients with PrD and those without delirium.These results suggest that, when investigating delirium and prognosis amongst hospitalized elderly, it is fundamental to differentiate in terms of time of onset. Furthermore, the absence of delirium seems to be an important protective factor.O significado do prognóstico de delirium em idosos hospitalizados ainda não está completamente elucidado.O presente estudo foi designado para avaliar a relação entre delirium prevalente (DeP), delirium incidente (DeI) e o desfecho final.Uma coorte histórica de 261 pacientes foi selecionada. delirium foi diagnosticado pelo Confusion Assessment Method.A freqüência total de delirium foi de 42.5%, DeP 31.4%, e DeI 16.2%. Para pacientes com DeI, a média de duração de hospitalização foi 9.1 dias maior do que aqueles sem delirium (p=0.002), e a mortalidade hospitalar associada a DeI foi de 48.3% contra 2.7% dos livres de delirium (p< 0.001). Contudo, não houve diferença entre pacientes com DeP e sem delirium.Os resultados sugerem que, ao estudar delirium e prognóstico entre idosos hospitalizados, é fundamental diferenciar o problema quanto ao seu momento de início. Além disso, não apresentar delirium parece constituir-se num fator protetor importante.
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Delirium is a common problem and cause of distress among patients with palliative care needs. The focus to date has been on managing the patient with agitated, hyperactive delirium, as these patients are very noticeable within the palliative care setting. This study in two parts shows that palliative care patients with agitated delirium are a minority of the total proportion of those with delirium. Part I: 100 acute admissions to a specialist palliative care unit were assessed and while 29% were found to have delirium, 86% of these had the hypoactive subtype of delirium. We also demonstrated a positive correlation between high ratings on a depression screening tool and delirium severity ratings. Part II: 8 specialist palliative care units took part in a point prevalence study of delirium over a 48-hour period. One hundred and nine patients were assessed and while 29.4% of these inpatients had delirium, 78% of them had the hypoactive subtype. Patients with hypoactive delirium may be much less noticeable or may be misdiagnosed as having depression or fatigue and the results of this study would advocate the routine use of delirium screening tools in all palliative care settings.
Depression
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Studies of outcome have started to challenge the assumption that delirium is a truly reversible disorder with a good prognosis. Prospective outcome studies of delirium are required to describe its prognosis. The evidence is that delirium recovers slowly and often incompletely. Delirious patients stay longer in hospital than those without delirium. High mortality rates seen in delirium may be contributed to by the delirium itself. The prognosis of delirium is almost certainly not therefore, one of early full recovery. Rather, delirium is a condition with a slow recovery and one that often fails to resolve completely.
Excess mortality
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Background: Delirium in advanced cancer inpatient ranges between 13% and 85%. Reasons for this variability on the reported data could be related to the setting where they are admitted. Methods: This is an observational, comparative, prospective study on delirium diagnosis and delirium course of advanced cancer inpatients in two different palliative care settings. Hospice (C1) versus palliative care supportive team (C2). Differences between delirium precipitants, delirium treatment, and delirium survival were observed. Results: From 582 consecutive admissions, 494 from C1 and 88 from C2, finally 227 patients met inclusion criteria, were entered in the study. Total population delirium rate at admission, if we add both centers, was 57 patients (25%), 46 (26%) from C1 and 11 (22%) from C2; no statistically significant differences between delirium rate at admission between the two centers were found (χ2). When delirium course between delirious patients admitted in C1 and C2 was analyzed, a significantly higher rate of delirium reversibility was found in C2 [11/14 (78%)] versus [9/65 (14%)] in C1 (χ2p ≤ 0.001). Conclusion: The frequency of delirium at admission and during the hospitalization in advanced cancer patients does not seem to be related to the setting, what seems to be related is the delirium course.
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I read with interest the study by Cole and colleagues.1 This is an area of significant interest to many clinicians and researchers given the adverse outcomes associated with delirium. Longer duration and greater severity of delirium are well-recognized risk factors for adverse outcomes of delirium.2-4 The researchers note that, “the participants were reassessed at only two time points, it is possible that some recovered from the index episode of delirium but experienced a second episode at the time of follow-up.” This is an important point to emphasize and is a significant limitation of this study. Unless individuals are assessed daily for delirium, one could not assume that a delirium diagnosis made 1 or 3 months after a delirium diagnosis is protracted delirium. The Confusion Assessment Method (CAM) is a widely used delirium screening tool with high sensitivity and specificity.5 “Is there evidence of an acute change in mental status from the patient's baseline?” is the standardized question for one of the core symptoms of delirium in the CAM. The CAM training manual defines that symptom as “alteration in mental status (e.g., attention, orientation, cognition) that was new or worse for this patient, usually over hours to days.” If one follows the CAM strictly for a diagnosis of delirium, the delirium diagnosed at 1 and 3 months in this study population of older adults with multiple medical comorbidities would be considered a new delirium diagnosis. My point is that this is a thoughtful study of an important clinical observation, but it does not measure the outcomes proposed. Daily delirium assessments until delirium fully or partially resolves would be the best way to test the hypothesis put forth in this study. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that the author has no financial or any other kind of personal conflicts with this paper. The author is a Board Member for the Society of Liaison Psychiatry in New York. Author Contributions: The author was the sole author of this letter. Sponsor's Role: N/A.
Confusion
Organic mental disorders
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to determine the presentation, course and duration of delirium in hospitalized older people. observational cohort study. inpatient surgical and medical wards at a university hospital. 432 people over the age of 65. all participants were screened daily for confusion and, in those who were confused, delirium was ascertained using the Diagnostic and Statistical Manual of Mental Disorders (DSM) ITI-R criteria. Those who were found to be delirious were followed daily while in hospital for evidence of delirium. The Delirium Rating Scale (DRS) was used to describe the clinical characteristics of delirium. about 15% of subjects had delirium. Sixty-nine percent of delirious subjects had delirium on a single day. The DRS total was higher on the first day of delirium for those with delirium on multiple days than those with delirium on a single day (P = 0.03). Among those with delirium on multiple days, there were no patterns of change over time in specific DRS items. delirium in hospitalized older people is common and has a varied presentation and time course. Clinicians and researchers need to consider this great heterogeneity when caring for patients and when studying delirium.
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Delirium is the most common acute cognitive disorder seen in critically ill patients in the cardiovascular intensive care unit. It is defined as a disturbance of consciousness and cognition that develops suddenly and fluctuates over time. Delirious patients can become hyperactive, hypoactive, or both. The occurrence of delirium during hospitalization is associated with increased in-hospital and long-term morbidity and mortality. The cause of delirium is multifactorial and may include imbalances in neurotransmitters, inflammatory mediators, metabolic disturbances, impaired sleep, and the use of sedatives and analgesics. Patients with advanced age, dementia, chronic illness, extensive vascular disease, and low cardiac output are at particular risk of developing delirium. Specialized bedside assessment tools are now available to rapidly diagnose delirium, even in mechanically ventilated patients. Increased awareness of delirium risk factors, in addition to non-pharmacological and pharmacological treatments for delirium, can be effective in reducing the incidence of delirium in cardiac patients and in minimizing adverse outcomes, once delirium occurs.
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Бұл зерттеужұмысындaКaно моделітурaлы жәнеоғaн қaтыстытолықмәліметберілгенжәнеуниверситетстуденттерінебaғыттaлғaн қолдaнбaлы (кейстік)зерттеужүргізілген.АхметЯссaуи университетініңстуденттеріүшін Кaно моделіқолдaнылғaн, олaрдың жоғaры білімберусaпaсынa қоятынмaңыздытaлaптaры, яғнисaпaлық қaжеттіліктері,олaрдың мaңыздылығытурaлы жәнесaпaлық қaжеттіліктерінеқaтыстыөз университетінқaлaй бaғaлaйтындығытурaлы сұрaқтaр қойылғaн. Осы зерттеудіңмaқсaты АхметЯсaуи университетіндетуризмменеджментіжәнеқaржы бaкaлaвриaт бaғдaрлaмaлaрыныңсaпaсынa қaтыстыстуденттердіңқaжеттіліктерінaнықтaу, студенттердіңқaнaғaттaну, қaнaғaттaнбaу дәрежелерінбелгілеу,білімберусaпaсын aнықтaу мен жетілдіружолдaрын тaлдaу болыптaбылaды. Осы мaқсaтқaжетуүшін, ең aлдыменКaно сaуaлнaмaсы түзіліп,116 студенткеқолдaнылдыжәнебілімберугежәнеоның сaпaсынa қaтыстыстуденттердіңтaлaптaры мен қaжеттіліктерітоптықжұмыстaрaрқылыaнықтaлды. Екіншіден,бұл aнықтaлғaн тaлaптaр мен қaжеттіліктерКaно бaғaлaу кестесіменжіктелді.Осылaйшa, сaпa тaлaптaры төрт сaнaтқa бөлінді:болуытиіс, бір өлшемді,тaртымдыжәнебейтaрaп.Соңындa,қaнaғaттaну мен қaнaғaттaнбaудың мәндеріесептелдіжәнестуденттердіңқaнaғaттaну мен қaнaғaттaнбaу деңгейлерінжоғaрылaту мен төмендетудеосытaлaптaр мен қaжеттіліктердіңрөліaйқын aнықтaлды.Түйінсөздер:сaпa, сaпaлық қaжеттіліктер,білімберусaпaсы, Кaно моделі.
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Delirium is a troubling complication in hospitalized older patients with cancer. Although preventable and potentially reversible, delirium may be prolonged. Persistent delirium at the time of hospital discharge is common and associated with multiple adverse outcomes. We conducted a secondary data analysis to examine delirium resolution in 43 hospitalized older patients with cancer who had prevalent or incident delirium. We describe trajectories of delirium resolution and evaluate differences in patients with and without delirium resolution. Delirium was assessed using the NEECHAM confusion scale. Forty-one of the 43 patients had delirium during hospitalization before discharge; 2 had delirium only at the time of discharge. Although delirium resolved in 13 patients, a significant majority (70%) had delirium at discharge. Patients with delirium resolution were less functionally impaired before hospitalization and exhibited fewer etiologic risk patterns at admission. Mild delirium was more likely to resolve than severe delirium. All patients with chronic cognitive impairment had persistent delirium. Care for hospitalized older patients with cancer should incorporate delirium prevention and intervention strategies. Caregiver education, communication between providers, and follow-up are critical when delirium persists. Additional research focusing on the management and impact of persistent delirium in hospitalized older patients with cancer is needed.
Confusion
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