Persistent pain in older adults is difficult to assess and therefore address consistently. The experience of pain is individual, and therefore a comprehensive way to assess pain is required. Roy’s ...adaptation model offers a systematic way of evaluating pain in the older adult. In this column, the author shares some statistics about persistent pain and a case study using Roy’s model as a system for assessment.
ABSTRACT
Behavioral and psychological symptoms of dementia (BPSD) include aggression, agitation, resistiveness to care, depression, anxiety, apathy, and hallucinations. BPSD are common in nursing ...home residents and can be ameliorated using person‐centered approaches. Despite regulatory requirements, less than 2% of nursing homes consistently implement person‐centered behavioral approaches. In a National Institute of Nursing Research‐funded research protocol, we are implementing a pragmatic cluster randomized clinical trial designed to enable staff in nursing homes to reduce BPSD using behavioral approaches while optimizing function, preventing adverse events, and improving quality of life of residents. The implementation is based on use of the Evidence Integration Triangle (EIT), a parsimonious, community‐engaged participatory framework that is well suited to the complexity and variability in the nursing home environment. A total of 50 nursing home communities will be randomized to EIT‐4‐BPSD or education only. Primary Aim 1 is to determine if communities exposed to EIT‐4‐BPSD demonstrate evidence of implementation evaluated by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE‐AIM) criteria. Primary Aim 2 is to evaluate the feasibility, utility, and cost of the EIT approach in EIT‐4‐BPSD communities.
BACKGROUND
Each hospital day of delirium incurs greater healthcare costs, higher levels of care, greater staff burden, and higher complication rates. Accordingly, administrators are incentivized to ...identify models of care that reduce delirium rates and associated costs.
PURPOSE
We present a systematic review and meta‐analysis of delirium prevention models of care.
DATA SOURCES
Ovid MEDLINE, CINAHL, Cochrane Database of Systematic Reviews, EMBASE, and PsycINFO.
STUDY SELECTION
Eligible models of care were defined as provider‐oriented interventions involving revision of professional roles, multidisciplinary teams, and service integration. Included studies implemented multidomain, multicomponent interventions, used a validated delirium instrument, and enrolled a control group to evaluate efficacy or effectiveness.
DATA EXTRACTION
We extracted data on study design; Population, model of care, outcomes, and results.
DATA SYNTHESIS
A total of 15 studies were included. All but two studies reported reduction in delirium or its duration, and 11 studies reported statistically significant improvements. Using random effects models, the pooled odds ratios of delirium incidence were 0.56 (95% CI: 0.37‐0.85) from three randomized controlled trials, 0.63 (95% CI 0.37‐1.07) from four pre–post intervention studies, and 0.79 (95% CI: 0.46‐1.37) from three additional nonrandomized studies.
CONCLUSIONS
Several models of care can prevent delirium. In general, higher quality studies were more likely to demonstrate statistical significance of an effect. The diverse models of care included here explored interventions adapted to specific care settings, especially by addressing setting‐specific delirium risk factors. These care models illustrate a range of promising strategies that deserve growing recognition, refinement, and implementation.
The purpose of this study was to test the reliability and validity of the Care Plan Checklist for Evidence of Person-Centered Approaches for Behavioral and Psychological Symptoms Associated with ...Dementia (BPSD).
This study used baseline data from the first cohort of a larger randomized clinical trial testing the implementation of the Evidence of Integration Triangle for BPSD. Fourteen settings volunteered to participate, 8 from Maryland and 6 from Pennsylvania, and a total of 137 residents were recruited. In addition to completing the Care Plan Checklist for Evidence of Person-Centered Approaches for BPSD, assessments of depressive symptoms (Cornell Scale for Depression in Dementia), resistiveness to care (Resistiveness to Care Scale), and agitation (Cohen-Mansfield Agitation Inventory) were also completed on each participant. Reliability was tested based on evidence of internal consistency and inter-rater reliability. Construct validity was tested using a Rasch measurement model to determine item fit and hypothesis testing using bivariate correlations. Item mapping was also performed.
The majority of the sample was female (69%), Caucasian (69%), non-Hispanic (98%), and not married (78%). The mean age of the sample was 82.01 years (standard deviation = 11.44). There was evidence of reliability based on internal consistency with a Cronbach alpha of 0.96 and inter-rater reliability with correlations between 2 evaluators of r = 0.93, P = .001. There was evidence of validity of the scale based on item fit as the infit statistics and outfit statistics were all within the acceptable range with the exception of the outfit statistic for the item focused on sexually inappropriate behaviors. Lastly, there was evidence of significant relationships between the Care Plan Checklist for Evidence of Person-Centered Approaches for BPSD and the Cornell Scale for Depression in Dementia (r = 0.38, P < .001) and the Cohen-Mansfield Agitation Inventory (r = 0.44, P < .001). There was not a significant relationship between resistiveness to care and scores on the Care Plan Checklist for Evidence of Person-Centered Approaches for BPSD (r = -0.02, P = .86). There were 78 care plans that were so low in evidence of using appropriate interventions that they could not be differentiated.
There was sufficient evidence for the reliability and validity of the Care Plan Checklist for Evidence of Person-Centered Approaches for BPSD. Additional items should be considered to better differentiate those low on the Checklist for Evidence of Person-Centered Approaches for BPSD.
Objectives
Delirium is a common, serious and potentially life‐threatening syndrome affecting older adults. This syndrome continues to be under‐recognised and under treated by healthcare professionals ...across all care settings. Older adults who develop delirium have poorer outcomes, higher mortality and higher care costs. The purposes of this study were to correlate the confusion assessment method–family assessment method and confusion assessment method in the detection of delirium in postacute care, to correlate the confusion assessment method–family assessment method and diagnostic and statistical manual of mental disorders text revision criteria in detection of delirium in postacute care, to determine the prevalence of delirium in postacute care elders and to describe the relationship of level of cognitive impairment and delirium in the postacute care setting. Implications for Practice Delirium is disturbing for patients and caregivers. Frequently . family members want to provide information about their loved one. The use of the CAM‐FAM and CAM can give a more definitive determination of baseline status. Frequent observations using both instruments may lead to better recognition of delirium and implementation of interventions to prevent lasting sequelae.
Methods
Descriptive studies determined the strengths of relationship between the confusion assessment method, confusion assessment method–family assessment method, Mini‐Cog and diagnostic and statistical manual of mental disorders text revision criteria in detection of delirium in the postacute care setting.
Results
Prevalence of delirium in this study was 35%. The confusion assessment method–family assessment method highly correlates with the confusion assessment method and diagnostic and statistical manual of mental disorders text revision criteria for detecting delirium in older adults in the postacute care setting. Persons with cognitive impairment are more likely to develop delirium. Family members recognise symptoms of delirium when asked.
Discussion
The confusion assessment method–family assessment method is a valid tool for detection of delirium.
Implications for Practice
Delirium is disturbing for patients and caregivers. Frequently. family members want to provide information about their loved one. The use of the CAM‐FAM and CAM can give a more definitive determination of baseline status. Frequent observations using both instruments may lead to better recognition of delirium and implementation of interventions to prevent lasting sequelae.
Background/rationale:
This study tested the psychometric properties of the Quality of Life in Late-Stage Dementia (QUALID) Scale using Rasch analysis. The QUALID includes 11 items with a 5-point ...response scale. Scores range from 11 to 55, and lower scores indicate higher quality of life (QoL).
Methods:
Baseline data from a randomized clinical trial including 137 residents from 14 nursing homes were used. Psychometric testing included item mapping, evaluation of response categories, item reliability, construct validity based on INFIT and OUTFIT statistics, and convergent validity based on correlations between QoL and pain, agitation, depression, and function.
Results:
The Cronbach α was .89. All the items except “appears physically uncomfortable” fit the model. There was a significant relationship between QoL and depressive symptoms (r = .71, P = .001), pain (r = .26, P = .01), physical function (r = −.19, P = .03), and agitation (r = .56, P = .001). The categories were appropriately used. Item mapping suggested a need for easier items.
Delirium represents a common, serious and potentially life-threatening problem for older adults. The American Psychiatric Association defines delirium as disturbance of consciousness with reduced ...ability to focus, sustain or shift attention, changes in cognition or development of a perceptual disturbance that is not better accounted for by a pre-existing, established or evolving dementia, disturbance that develops over a short period of time and tends to fluctuate during the course of a day, and evidence that the disturbance is directly caused by the effects of a medical condition. Here, Flanagan illustrates an acute delirium episode of an elderly woman admitted to post acute care following a laparoscopic choleycystectomy.
Driving is considered an instrumental activity of daily living and, for many older adults, is also associated with the ability to maintain independence. The diagnosis of dementia, distressing on its ...own, paired with the threat to driving independence, makes this a difficult issue for patients, families, and clinicians. The purpose of this article is to provide a brief overview of the current research regarding driving safety and dementia, guidelines that can be used to assess driving risk, and counseling tips for patients and families regarding driving safety.
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