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Objective To investigate the ability of nurses to recognize delirium and its symptoms and to investigate the factors associated with undetected delirium. Design A prospective, observational study with repeated measurements over a 6-month period. Setting Seven long term care settings in Montreal and Quebec City, Canada. Participants Residents aged 65 and older, with or without dementia, admitted to long term care (not respite care) and able to communicate in English or French. Measurements Delirium and its symptoms were assessed using the Confusion Assessment Method. Ratings of delirium by nurses based on their observations during routine care were compared with delirium ratings by trained research assistants based on a one-time formal structured evaluation (Confusion Assessment Method and Mini Mental State Examination). This procedure was repeated for 10 delirium symptoms. Sensitivity, specificity, and positive and negative predictive values were calculated. The method of generalized estimating equations was used to identify factors associated with undetected delirium. Results Research assistants identified delirium in 43 (21.3%) of the 202 residents. Nurses identified delirium in 51% of the cases identified by the research assistants. However, for cases without delirium according to the research assistants, nurses identified 90% of them correctly. Detection rates for delirium symptoms ranged from 25% to 66.7%. Undetected delirium was associated with lower number of depressive symptoms manifested by the resident. Conclusion Detection of delirium is a major issue for nurses. Strategies to improve nurse recognition of delirium could well reduce adverse outcomes for this vulnerable population.

Objectives To evaluate the impact of using different diagnostic criteria on prevalence rates of delirium and subsyndromal delirium (SSD) among demented long-term care (LTC) residents. Design Descriptive study. Setting LTC settings in Quebec City, Canada. Participants Participants were 155 individuals aged 65 and older, with dementia. Measurements (1) Prevalence rates of delirium according to: (a) the Diagnostic and Statistical Manual of Mental Disorders (DSM-III, DSM-III-R, and DSM-IV) and (b) the Confusion Assessment Method (CAM) algorithms for definite and probable delirium; and (2) prevalence rates of SSD employing 2 definitions described in previous studies. Results Prevalence rates of delirium according to each set of criteria were 26.5% for DSM-III; 29% for DSM-IV-TR; 41.3% for DSM-III-R; 45.8% for CAM algorithm for definite delirium; and 70.3% for CAM algorithm for probable delirium. A total of 109 subjects (70.3%) were identified as delirious consistent with at least one classification and 37 (23.9%) met all the sets of criteria considered. Prevalence rates for SSD were 75 (48.4%) and 78 (50.3%) depending on the definition employed. Conclusion Prevalence rates for delirium are much affected by the diagnostic formulations used. The use of DSM-IV-TR among this population could result in fewer cases being identified as delirious and thus compromise proper care for those individuals. Considering that SSD was prevalent among this population, a systematic implementation of protocols targeting risk factors of delirium might be beneficial among demented LTC residents.

In this participatory action research study, researchers conducted a total of 3 implementation cycles to evaluate the feasibility and acceptability of a new delirium prevention program (DPP) for cognitively impaired residents in long term care (LTC) settings. Researchers interviewed 95 health care staff to obtain feedback on their use of the DPP and then modified the DPP and tested the changes in the next implementation cycle. Our results indicated that the DPP was feasible and that health care staff would accept it under certain conditions. We found there were 4 keys to successful implementation of the DPP: support for the program from both the administration and the users; effective clinician leadership to ensure proper delivery of the DPP (format, content and values) and its appropriate adaptation to the LTC facility's internal culture and policies; a sense of ownership among the DPP users; and, last, practical hands-on training as well as theoretical training for staff.

Background Seniors with severe dementia residing in nursing homes (NHs) frequently receive large numbers of medications. With disease progression, the medications' harm-benefit ratio changes and they need to be reviewed, adjusted, or discontinued. Evidence on successful interventions to optimize medication use among these residents is lacking. Objectives The objective of the study was to identify categories of appropriateness for medications as well as successful interventions or elements thereof to improve medication use in NH residents with severe dementia, suitable for use in Canada. Methods A scoping literature review was performed to identify criteria and categories of appropriateness of medications for these residents as well as elements of successful interventions to optimize medication use. A 15-member multidisciplinary Delphi panel was convened to evaluate the applicability of these findings for NHs in a Canadian province. Results The scoping review identified 1 study presenting categories of appropriateness specific to residents with severe dementia and 35 interventions aimed at reducing drug-drug interactions, inappropriate use of specific drug classes, inappropriate drug use overall, or polypharmacy. Regarding appropriateness, the Delphi panel agreed on the categorization of 63 medications or medication classes as “generally,” “sometimes,” or “rarely appropriate.” The main elements of interventions successful in improving appropriate medication use in NH residents with dementia also were approved by the Delphi panel (ie, medication reviews using criteria of appropriateness, educational and training sessions, and interdisciplinary case conferences). Conclusions These results may be used to develop an intervention to optimize medication use in NH residents with severe dementia.