Hospitalized Elders with Dementia

I have recently taken a position as one of the nurse educators in psychiatry at a Boston hospital. I'm glad to be back in the thick of it and notice once again what a therapeutic milieu is for people with dementia. Research shows that it isn't really the ratio of staff to patients but the number of contacts the patient has with staff on any given day. This cements the practice of frequent connection with a confused and frightened elder reduces the likelihood of agitation and/or aggression. We've seen that aggression is most often the result of not understanding what is going on around them or misperceiving the intent of the caregiver. Smiling, connecting by calling him or her by their name, asking, "how are you today?'(the only open ended questions that is OK),making a positive comment about the person all go towards creating a therapeutic milieu (environment). Therapeutic communication is the practice of being clear, keeping eye contact, speaking slowly, simply and concretely. One patient who recently returned to the hospital after an outburst at the assisted living residence he had been discharged to,recognized staff's faces and voices but thought he had been on a cruise last time he was hospitalized. Sometimes delusions can be helpful I guess. Happily with the right dose of medication he was able to be returned to his new home at the residence.

Deliuium in hospitalization of dementia patients

AN INTERVENTION INTEGRATED INTO DAILY CLINICAL PRACTICE REDUCES THE INCIDENCE OF DELIRIUM DURING HOSPITALIZATION IN ELDERLY PATIENTS, VIDAN M, SANCHEZ E, ET AL. JOURNAL OF THE AMERICAN GERIATRICS SOCIETY, 2009: 57 (NOVEMBER): 2029-2036

OBJECTIVES: To analyze the effectiveness of a multicomponent intervention integrated into daily practice for the prevention of in-hospital delirium in elderly patients.
DESIGN: Controlled study comparing an intervention in a geriatric unit (GI) with usual care in two internalmedicine services (UC).
SETTING: University Hospital in Madrid, Spain.
PARTICIPANTS: Five hundred forty-two consecutive patients (170 GI, 372 UC), aged 70 and older, with any of the risk criteria for delirium (cognitive impairment, visual impairment, acute disease severity, dehydration).
INTERVENTION: Educational measures and specific actions in seven risk areas (orientation, sensory impairment, sleep, mobilization, hydration, nutrition, drug use). Daily monitoring of adherence.
MEASUREMENTS: Baseline characteristics, risk factors for delirium, and quality care indicators were analyzed. The primary endpoint was incidence of delirium assessed daily. The secondary endpoint was functional decline, defined as loss of independence in any of the activities of daily living. The intervention effect was evaluated using logistic regression analysis.
RESULTS: Delirium affected 11.7% of the GI group and 18.5% of the UC group (P=.04). After adjustment for confounders, the intervention was associated with lower incidence of delirium (odds ratio=0.4, 95% confidence interval=0.24–0.77; P=.005). In the patients who experienced delirium, severity, length, and recurrence of episodes were similar in both groups. Adherence to the intervention protocols was 75.7%. The intervention reduced the rate of functional decline (45.5% in GI vs 56.3% in UC, P=.03) and improved other quality indicators (e.g., mobilization and physical restraints reduction).
CONCLUSION: A multicomponent, nonpharmacological intervention integrated into routine practice reduces delirium during hospitalization in older patients, improves quality of care, and can be implemented without additional resources in a public healthcare system.
KEVIN’S COMMENTS: Delirium is a common and serious geriatric problem that affects a high percentage of older adults admitted to hospitals. Delirium may persist for weeks and is very common in persons transferred from hospitals to nursing homes and assisted living communities. It is associated with considerable morbidity and mortality. Recognition is important in order to look for reversible causes such as drugs, electrolyte disturbances, infections, etc. This study demonstrates that delirium is a preventable problem and does not require additional resources. Several interventions aimed at reducing well-recognized risk factors for delirium (such as sensory deprivation, sleep disturbance, dehydration, and inappropriate drug use) markedly reduced the incidence of delirium in the study group. By Dr. Kevin O'Neil