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To provide efficient and effective inpatient mental health services, it is imperative to not only ascertain if service users are satisfied with the care received from nurses, but also the degree to which initial expectations are being met. Ten reports of primary research on service users' experiences, perceptions and expectations of inpatient mental health care were examined to understand what service users' expect of inpatient mental health care and the implications for nursing practice. The World Health Organization's description of responsiveness to service users' non-medical expectations of care was used as a framework for retrieving literature and organizing the research outcomes. Responsiveness includes seven categories of healthcare performance ranging from respect for the dignity of the person, to adequacy of amenities, and choice of provider. Service users expect to form interpersonal relationships with nurses; however, nonclinical responsibilities serve as barriers which consume considerable available nursing time that otherwise could be spent developing therapeutic relationships. In addition, inpatient programming ideas are identified for the provision of better services. Hospitals' expectations of mental health nurses will need to be reconsidered if these nurses are to provide the time and resources necessary to meet current service users' expectations. [ABSTRACT FROM AUTHOR]

Delirium is a disorder of acute onset with fluctuating symptoms and is characterized by inattention, disorganized thinking, and altered levels of consciousness. The risk for delirium is greatest in individuals with dementia, and the incidence of both is increasing worldwide because of the aging of our population. Although several clinical trials have tested interventions for delirium prevention in individuals without dementia, little is known about the mechanisms for the prevention of delirium in early-stage Alzheimer's disease (AD). The purpose of this article is to explore ways of preventing delirium and slowing the rate of cognitive decline in early-stage AD by enhancing cognitive reserve. An agenda for future research on interventions to prevent delirium in individuals with earlystage AD is also presented. [ABSTRACT FROM AUTHOR]

Delirium is a prevalent, costly, and global problem in older adults. This article is a systematic review of the literature on nurse recognition of delirium. Ten articles, reporting rates of nurse recognition ranging from 26% to 83%, were included in the review. The most compelling finding is that although related, the notions of nurse knowledge of delirium, nurse recognition of delirium, and nurses' assessment and documentation of delirium in older adults are different. Recommendations for practice are suggested at several levels, including education, guidelines, communication, health care system, and use of informatics. [ABSTRACT FROM AUTHOR]

The purpose of this study was to examine the prevalence of potentially inappropriate medication use (PIMs) among community-dwelling older adults and the association between PIMs and health care outcomes. Participants were 17,971 individuals age 65 years and older. PIM use was defined by the Beers criteria. Drug-related problems (DRPs) were defined using ICD-9 codes. Forty percent of the 17,971 individuals filled at least 1 PIM prescription, and 13% filled 2 or more PIM prescriptions. Overall DRP prevalence among those with at least 1 PIM prescription was 14.3% compared to 4.7% in the non-PIM group (p < .001). In conclusion, preventing PIM use may be important for decreasing medication-related problems, which are increasingly being recognized as requiring an integrated interdisciplinary approach. © 2007 Wiley Periodicals, Inc. Res Nurs Health 31:42-51, 2008 [ABSTRACT FROM AUTHOR]

Delirium is common in older adults who have dementia, but too often nurses confuse the symptoms of delirium with those of dementia and it goes unrecognized and untreated. Delirium can signal a serious underlying condition such as infection or dehydration and can increase the risk of falling and the length of hospitalization. This article presents an algorithm meant to guide nurses in the assessment and treatment of delirium superimposed on dementia. For a free online video demonstrating the use of this algorithm, go to http://links.lww.com/A211 [corrected]. [ABSTRACT FROM AUTHOR]

Background: Whether cognitive and functional recovery in skilled nursing facilities (SNF) following hospitalization differs by delirium and Alzheimer's disease related dementias (ADRD) has not been examined., Objective: To compare change in cognition and function among short-stay SNF patients with delirium, ADRD, or both., Design: Retrospective cohort study using claims data from 2011 to 2013., Setting: Centers for Medicare and Medicaid certified SNFs., Participants: A total of 740,838 older adults newly admitted to a short-stay SNF without prevalent ADRD who had at least two assessments of cognition and function., Measurements: Incident delirium was measured by the Minimum Data Set (MDS) Confusion Assessment Method and ICD-9 codes, and incident ADRD by ICD-9 codes and MDS diagnoses. Cognitive improvement was a better or maximum score on the MDS Brief Interview for Mental Status, and functional recovery was a better or maximum score on the MDS Activities of Daily Living Scale., Results: Within 30 days of SNF admission, the rate of cognitive improvement in patients with both delirium/ADRD was half that of patients with neither delirium/ADRD (HR = 0.45, 95% CI:0.43, 0.46). The ADRD-only and delirium-only groups also were 43% less likely to have improved cognition or function compared to those with neither delirium/ADRD (HR = 0.57, 95% CI:0.56, 0.58 and HR = 0.57, 95% CI:0.55, 0.60, respectively). Functional improvement was less likely in patients with both delirium/ADRD, as well (HR = 0.85, 95% CI:0.83, 0.87). The ADRD only and delirium only groups were also less likely to improve in function (HR = 0.93, 95% CI:0.92, 0.94 and HR = 0.92, 95% CI:0.90, 0.93, respectively) compared to those with neither delirium/ADRD., Conclusions: Among older adults without dementia admitted to SNF for post-acute care following hospitalization, a positive screen for delirium and a new diagnosis of ADRD, within 7 days of SNF admission, were both significantly associated with worse cognitive and functional recovery. Patients with both delirium and new ADRD had the worst cognitive and functional recovery., (© 2024 The Author(s). Journal of the American Geriatrics Society published by Wiley Periodicals LLC on behalf of The American Geriatrics Society.)

Background: Generative artificial intelligence (AI) and large language models, such as OpenAI's ChatGPT, have shown promising potential in supporting medical education and clinical decision-making, given their vast knowledge base and natural language processing capabilities. As a general purpose AI system, ChatGPT can complete a wide range of tasks, including differential diagnosis without additional training. However, the specific application of ChatGPT in learning and applying a series of specialized, context-specific tasks mimicking the workflow of a human assessor, such as administering a standardized assessment questionnaire, followed by inputting assessment results in a standardized form, and interpretating assessment results strictly following credible, published scoring criteria, have not been thoroughly studied., Objective: This exploratory study aims to evaluate and optimize ChatGPT's capabilities in administering and interpreting the Sour Seven Questionnaire, an informant-based delirium assessment tool. Specifically, the objectives were to train ChatGPT-3.5 and ChatGPT-4 to understand and correctly apply the Sour Seven Questionnaire to clinical vignettes using prompt engineering, assess the performance of these AI models in identifying and scoring delirium symptoms against scores from human experts, and refine and enhance the models' interpretation and reporting accuracy through iterative prompt optimization., Methods: We used prompt engineering to train ChatGPT-3.5 and ChatGPT-4 models on the Sour Seven Questionnaire, a tool for assessing delirium through caregiver input. Prompt engineering is a methodology used to enhance the AI's processing of inputs by meticulously structuring the prompts to improve accuracy and consistency in outputs. In this study, prompt engineering involved creating specific, structured commands that guided the AI models in understanding and applying the assessment tool's criteria accurately to clinical vignettes. This approach also included designing prompts to explicitly instruct the AI on how to format its responses, ensuring they were consistent with clinical documentation standards., Results: Both ChatGPT models demonstrated promising proficiency in applying the Sour Seven Questionnaire to the vignettes, despite initial inconsistencies and errors. Performance notably improved through iterative prompt engineering, enhancing the models' capacity to detect delirium symptoms and assign scores. Prompt optimizations included adjusting the scoring methodology to accept only definitive "Yes" or "No" responses, revising the evaluation prompt to mandate responses in a tabular format, and guiding the models to adhere to the 2 recommended actions specified in the Sour Seven Questionnaire., Conclusions: Our findings provide preliminary evidence supporting the potential utility of AI models such as ChatGPT in administering standardized clinical assessment tools. The results highlight the significance of context-specific training and prompt engineering in harnessing the full potential of these AI models for health care applications. Despite the encouraging results, broader generalizability and further validation in real-world settings warrant additional research., (©Yong K Choi, Shih-Yin Lin, Donna Marie Fick, Richard W Shulman, Sangil Lee, Priyanka Shrestha, Kate Santoso. Originally published in JMIR Formative Research (https://formative.jmir.org), 01.10.2024.)

Aims: To synthesise the evidence on and to compare the diagnostic accuracy of the Nu-DESC and CAM in detecting postoperative delirium among hospitalised patients., Design: Systematic review and diagnostic meta-analysis., Data Sources: The PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, ProQuest Dissertations and Theses A&I, and PsycINFO databases were systematically searched from their inception to February 10, 2023., Results: In total, 10 (n = 1950) and seven (n = 830) reports were included for the Nu-DESC and CAM, respectively. For Nu-DESC and CAM, the pooled sensitivities were 0.69 and 0.65, respectively, while the summary specificities were 0.99 for Nu-DESC and 0.92 for CAM. The pooled specificity differed significantly between the two tools (p < 0.001), despite comparable pooled sensitivities. The duration of stay in the intensive care unit significantly moderated the summary specificity of Nu-DESC (B = -0.0003, p = 0.009). Regarding CAM, the percentage of female participants showed a positive correlation with its pooled sensitivity (B = 0.005, p = 0.02). Furthermore, studies where clinical specialists served as assessors demonstrated a higher summary sensitivity than those assessed by nurses (0.87 vs. 0.25, p = 0.01)., Conclusion: The sensitivities of the Nu-DESC and CAM for detecting postoperative delirium did not achieve optimal levels. Therefore, developing more accurate tools to detect postoperative delirium by integrating features from related risk factors or incorporating technology-based algorithms to enhance the screening capability is warranted., Reporting Method: The study has adhered to PRISMA-DTA guideline., Patient or Public Contribution: No patient or public contribution., Trial Registration: The study protocol has been registered on PROSPERO (CRD42023398961)., (© 2024 John Wiley & Sons Ltd.)

Background: There has been a marked rise in the use of observation care for Medicare beneficiaries visiting the emergency department (ED) in recent years. Whether trends in observation use differ for people with Alzheimer's disease and Alzheimer's disease-related dementias (AD/ADRD) is unknown., Methods: Using a national 20% sample of Medicare beneficiaries ages 68+ from 2012 to 2018, we compared trends in ED visits and observation stays by AD/ADRD status for beneficiaries visiting the ED. We then examined the degree to which trends differed by nursing home (NH) residency status, assigning beneficiaries to four groups: AD/ADRD residing in NH (AD/ADRD+ NH+), AD/ADRD not residing in NH (AD/ADRD+ NH-), no AD/ADRD residing in NH (AD/ADRD- NH+), and no AD/ADRD not residing in NH (AD/ADRD- NH-)., Results: Of 7,489,780 unique beneficiaries, 18.6% had an AD/ADRD diagnosis. Beneficiaries with AD/ADRD had more than double the number of ED visits per 1000 in all years compared to those without AD/ADRD and saw a faster adjusted increase over time (+26.7 vs. +8.2 visits/year; p < 0.001 for interaction). The annual increase in the adjusted proportion of ED visits ending in observation was also greater among people with AD/ADRD (+0.78%/year, 95% CI 0.77-0.80%) compared to those without AD/ADRD (+0.63%/year, 95% CI 0.59-0.66%; p < 0.001 for interaction). Observation utilization was greatest for the AD/ADRD+ NH+ population and lowest for the AD/ADRD- NH- population, but the AD/ADRD+ NH- group saw the greatest increase in observation stays over time (+15.4 stays per 1000 people per year, 95% CI 15.0-15.7)., Conclusions: Medicare beneficiaries with AD/ADRD have seen a disproportionate increase in observation utilization in recent years, driven by both an increase in ED visits and an increase in the proportion of ED visits ending in observation., (© 2024 The American Geriatrics Society.)

Over half of older adults experience polypharmacy, including medications that may be inappropriate or unnecessary. Deprescribing, which is the process of discontinuing or reducing inappropriate and/or unnecessary medications, is an effective way to reduce polypharmacy. This review summarizes (1) the process of deprescribing and conceptual models and tools that have been developed to facilitate deprescribing, (2) barriers, enablers, and factors associated with deprescribing, and (3) characteristics of deprescribing interventions in completed trials, as well as (4) implementation considerations for deprescribing in routine practice. In conceptual models of deprescribing, multilevel factors of the patient, clinician, and health-care system are all related to the efficacy of deprescribing. Numerous tools have been developed for clinicians to facilitate deprescribing, yet most require substantial time and, thus, may be difficult to implement during routine health-care encounters. Multiple deprescribing interventions have been evaluated, which mostly include one or more of the following components: patient education, medication review, identification of deprescribing targets, and patient and/or provider communication about high-risk medications. Yet, there has been limited consideration of implementation factors in prior deprescribing interventions, especially with regard to the personnel and resources in existing health-care systems and the feasibility of incorporating components of deprescribing interventions into the routine care processes of clinicians. Future trials require a more balanced consideration of both effectiveness and implementation when designing deprescribing interventions., (© 2022 The Association for the Publication of the Journal of Internal Medicine.)

Competing Interests: Competing interests: None declared.

Background: Recently, the Ultra-Brief Confusion Assessment Method (UB-CAM), designed to help physicians and nurses to recognize delirium, showed high, but imperfect, accuracy compared with Research Reference Standard Delirium Assessments (RRSDAs). The aim of this study is to identify factors associated with disagreement between clinicians' app-based UB-CAM assessments and RRSDAs., Methods: This is a secondary analysis of a prospective diagnostic test study. The study was conducted at two hospitals and included 527 inpatients (≥70 years old) and 289 clinicians (53 physicians, 236 nurses). Trained research associates performed RRSDAs and determined delirium presence using the CAM. Clinicians administered the UB-CAM using an iPad app. Disagreement factors considered were clinician, patient, and delirium characteristics. We report odds ratios and 95% confidence intervals., Results: One thousand seven hundred and ninety-five clinician UB-CAM assessments paired with RRSDAs were administered. The prevalence of delirium was 17%. The rate of disagreement between clinician UB-CAM assessments and RRSDAs was 12%. Significant factors associated with disagreement between clinician UB-CAM assessments and RRSDAs (OR [95% CI]) included: presence of dementia (2.7 [1.8-4.1]), patient education high school or less (1.9 [1.3-2.9]), psychomotor retardation (2.5 [1.4-4.2]), and the presence of mild delirium or subsyndromal delirium (5.5 [3.5-8.7]). Significant risk factors for false negatives were patient age less than 80 (2.2 [1.1-4.3]) and mild delirium (3.5 [1.6-7.4]). Significant risk factors for false positives were presence of dementia (4.0 [2.3-7.0]), subsyndromal delirium (5.1 [2.9-9.1]), and patient education high school or less (2.0 [1.2-3.6]). Clinician characteristics were not significantly associated with disagreement., Conclusions: The strongest factors associated with disagreement between clinician UB-CAM screens and RRSDAs were the presence of dementia and subsyndromal delirium as risk factors for false positives, and mild delirium and younger age as a risk factor for false negatives. These disagreement factors contrast with previous studies of risk factors for incorrect clinician delirium screening, and better align screening results with patient outcomes., (© 2023 The American Geriatrics Society.)

Delirium is a significant geriatric condition associated with adverse clinical and economic outcomes. The cause of delirium is usually multifactorial, and person-centered multicomponent approaches for proper delirium management are required. In 2017, the John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI) launched a national initiative, Age-Friendly Health System (AFHS), promoting the use of a framework called 4Ms (what matters, medication, mentation, and mobility). The 4Ms framework's primary goal is to provide comprehensive and practical person-centered care for older adults and it aligns with the core concepts of optimal delirium management. In this special article, we demonstrate how a traditional delirium prevention and management model can be assessed from the perspective of AFHS. An example is the crosswalk with the Hospital Elder Life Program (HELP) Core Interventions and the 4MS, which demonstrates alignment in delirium management. We also introduce useful tools to create an AFHS environment in delirium management. Although much has been written about delirium management, there is a need to identify the critical steps in advancing the overall delirium care in the context of the AFHS. In this article, we suggest future directions, including the need for more prospective and comprehensive research to assess the impact of AFHS on delirium care, the need for more innovative and sustainable education platforms, fundamental changes in the healthcare payment system for proper adoption of AFHS in any healthcare setting, and application of AFHS in the community for continuity of care for older adults with delirium., (© 2023 The American Geriatrics Society.)

Competing Interests: Declaration of Competing Interest None.

Persons living with dementia (PLWD) are at increased risk for coronavirus disease 2019 (COVID-19) and poorer outcomes if they contract the disease. COVID-19 may also change and exacerbate usual stresses of family caregiving. The current qualitative descriptive study examined 14 family care partners' (FCPs) experiences and perspectives on how the COVID-19 pandemic impacted them, their care recipients, and their caregiving for their care recipients. Thematic analysis of interviews generated five themes: Cautious of COVID-19 Exposure , Challenges of Balancing COVID-19 Restrictions With Caregiv ing, Shared Loneliness , Functional Decline , and Communication Challenges With PLWD and Health Care Professionals (HCPs). FCPs are integral to the care of PLWD across care settings. The time is now to plan for changes in policy that will safely maintain FCPs' visitation with their care recipients with dementia and allow for partnering with HCPs to avoid the long-lasting negative effects on older adults' health and function. [ Journal of Gerontological Nursing, 49 (3), 27-33.].

Delirium in persons with dementia (DSD) is a common occurrence. Over the past three decades, several tools have been developed and validated to diagnose delirium, yet there is still a shortage of tools recommended in persons with dementia and there is a lack of sufficient research on the accuracy of performance of such tools in this growing population. The purpose of this article is to (1) conduct a clinical review of the detection of DSD across settings of care by formal health care professionals and informal family members and care partners; (2) identify barriers and facilitators to detection and highlight delirium tools that have been tested in person with dementia; and (3) make recommendations for future research, practice, and policy. Given this review, an "ideal" tool for DSD would point to tools being brief, easy to integrate into the EMR, and accurate with at least 90% accuracy given the poor outcomes associated with delirium and DSD. Knowing the baseline and communication between family members and healthcare professionals should be a top priority for education, research, and health systems policy. More work is needed in better understanding DSD and optimizing and standardizing feature assessment, especially the acute change feature at the bedside for DSD.

Objective: To assess how age-friendly deprescribing trials are regarding intervention design and outcome assessment. Reduced use of potentially inappropriate medications (PIMs) can be addressed by deprescribing-a systematic process of discontinuing and/or reducing the use of PIMs. The 4Ms-"Medication", "Mentation", "Mobility", and "What Matters Most" to the person-can be used to guide assessment of age-friendliness of deprescribing trials., Data Source: Published literature., Study Design: Scoping review., Data Extraction Methods: The literature was identified using keywords related to deprescribing and polypharmacy in PubMed, EMBASE, Web of Science, ProQuest, CINAHL, and Cochrane and snowballing. Study characteristics were extracted and evaluated for consideration of 4Ms., Principal Findings: Thirty-seven of the 564 trials identified met the review eligibility criteria. Intervention design: "Medication" was considered in the intervention design of all trials; "Mentation" was considered in eight trials; "Mobility" (n = 2) and "What Matters Most" (n = 6) were less often considered in the design of intervention. Most trials targeted providers without specifying how matters important to older adults and their families were aligned with deprescribing decisions., Outcome Assessment: "Medication" was the most commonly assessed outcome (n = 33), followed by "Mobility" (n = 13) and "Mentation" (n = 10) outcomes, with no study examining "What Matters Most" outcomes., Conclusions: "Mentation" and "Mobility", and "What Matters Most" have been considered to varying degrees in deprescribing trials, limiting the potential of deprescribing evidence to contribute to improved clinical practice in building an age-friendly health care system., (© 2022 Health Research and Educational Trust.)

Acute and chronic disease management continues to shift toward a health care in the home model, yet literature discussing continuity of home-based care services during public health emergencies, such as infectious disease pandemics, is scant. In the current study, we used semi-structured telephone interviews with 27 home-based care providers (HBCPs) from Medicare-certified home health care agencies located in eight U.S. counties to explore older adults' decision making around home-based care service continuation during the coronavirus disease 2019 (COVID-19) pandemic. Four themes emerged, including two related to older adults' decision making around refusal of in-home care and two related to HBCPs' responses to care refusals. Fear of COVID-19 infection motivated older adults to make care-related decisions that were incongruent with their health needs, including refusal of care in the home, despite receiving education from HBCPs. These data highlight a need for tools to help HBCPs better support patients through decision-making processes about care continuation during COVID-19 and future infectious disease pandemics. [ Journal of Gerontological Nursing, 49 (1), 35-41.].

Delirium superimposed on dementia (DSD) is common in older adults being discharged to post-acute care settings (PAC). Nurse documentation remains poorly understood. Aims were to describe nurse documentation and to determine associations in a secondary data analysis of a large, single-blinded randomized controlled trial (Recreational Stimulation For Elders As A Vehicle To Resolve DSD (Reserve For DSD). Just under 75% of the sample had at least one symptom of delirium documented by the nursing staff, while 25.9% had none despite being CAM positive by expert adjudication. Only 32% had an intervention documented. Number of documented interventions were significantly associated with number of documented symptoms. There is a need for research and innovation related to nurse documentation and communication of DSD symptoms and interventions in an efficient and accurate manner to impact care for vulnerable older adults in these settings., (Copyright © 2022 Elsevier Inc. All rights reserved.)

The Centers for Medicare and Medicaid Services mandate the provision of person-centered care (PCC), but there is limited evidence on how PCC impacts nursing home (NH) residents' care experiences. This study examined the relationship between n = 163 NH residents' ratings of satisfaction with care related to their preferences and their satisfaction with overall care. Residents with higher preference satisfaction ratings reported significantly higher levels of satisfaction with overall care. Using preference satisfaction ratings has the potential to improve PCC planning and delivery in nursing homes.

Background: Systematic screening can improve delirium identification among hospitalized older adults. Prior studies have shown clinicians and health system leaders may believe they do not have the time and resources for assessment. We conducted a comparative salary-related cost analysis of an adaptive delirium identification protocol directed by an iPad app., Methods: We recruited 527 older adult medicine patients from an urban academic medical center (n = 269) and a rural community hospital (n = 258). Physicians and nurses completed the two-step Ultra-brief Confusion Assessment Method (UB-CAM) protocol (with or without a skip pattern), while certified nursing assistants completed only the UB-2 ultra-brief screen. The sample included 527 patients (average age 80, 57% women, 35% with dementia). Time required to administer the protocol was collected automatically by the iPad app. Salary-related costs of screening were determined by multiplying the time required by the hourly wage for the three disciplines, as obtained from national and regional published healthcare salary cost data. Cost estimates for entire hospital implementation were also calculated., Results: Participants were screened on 924 hospital days by 399 clinicians (53 physicians, 236 nurses, 110 CNAs). For the UB-2, CNAs cost per screen was lower than the other clinician types ($0.37 per screen vs. $0.73 for nurses and $2.39 for hospitalists). For the UB-CAM with skip (UB-CAM), costs per protocol were $1.10 for nurses vs. $3.61 for physicians. The annual salary-related costs of hospital-wide implementation of a nurse-based UB-CAM protocol in a medium-sized (300-bed) hospital was $63,015 plus $4356 for initial and annual training., Conclusions: CNAs and nurses had the lowest salary-associated costs for app-directed CAM-based delirium screening and identification, respectively. Salary-related annual hospital costs for the most efficient protocols in a medium-sized hospital were less than the annual cost of hiring 1 FTE of the discipline performing the protocols., (© 2022 The American Geriatrics Society.)

Background: A positive delirium screen at skilled-nursing facility (SNF) admission can trigger a simultaneous diagnosis of Alzheimer's Disease or related dementia (AD/ADRD) and lead to psychoactive medication treatment despite a lack of evidence supporting use., Methods: This was a nationwide historical cohort study of 849,086 Medicare enrollees from 2011-2013 who were admitted to the SNF from a hospital without a history of dementia. Delirium was determined through positive Confusion Assessment Method screen and incident AD/ADRD through active diagnosis or claims. Cox proportional hazard models predicted the risk of receiving one of three psychoactive medications (i.e., antipsychotics, benzodiazepines, antiepileptics) within 7 days of SNF admission and within the entire SNF stay., Results: Of 849,086 newly-admitted SNF patients (62.6% female, mean age 78), 6.1% had delirium (of which 35.4% received an incident diagnosis of AD/ADRD); 12.6% received antipsychotics, 30.4% benzodiazepines, and 5.8% antiepileptics. Within 7 days of admission, patients with delirium and incident dementia were more likely to receive an antipsychotic (relative risk [RR] 3.09; 95% confidence interval [CI] 2.99 to 3.20), or a benzodiazepine (RR 1.23; 95% CI 1.19 to 1.27) than patients without either condition. By the end of the SNF stay, patients with both delirium and incident dementia were more likely to receive an antipsychotic (RR 3.04; 95% CI 2.95 to 3.14) and benzodiazepine (RR 1.32; 95% CI 1.29 to 1.36) than patients without either condition., Conclusion: In this historical cohort, a positive delirium screen was associated with a higher risk of receiving psychoactive medication within 7 days of SNF admission, particularly in patients with an incident AD/ADRD diagnosis. Future research should examine strategies to reduce inappropriate psychoactive medication prescribing in older adults admitted with delirium to SNFs., (© 2022 The American Geriatrics Society.)

Background: The ability to rate delirium severity is key to providing optimal care for persons with Alzheimer's Disease and Related Dementias (ADRD). Such ratings would allow clinicians to assess response to treatment, recovery time and prognosis, nursing burden and staffing needs, and to provide nuanced, appropriate patient-centered care. Given the lack of existing tools, we defined content domains for a new delirium severity instrument for use in individuals with mild to moderate ADRD, the DEL-S-AD., Methods: We built upon our previous study in which we created a content domain framework to inform development of a general delirium severity instrument, the DEL-S. We engaged a new expert panel to discuss issues of measurement in delirium and dementia and to determine which content domains from the prior framework were useful in characterizing delirium severity in ADRD. We also asked panelists to identify new domains. Our panel included eight interdisciplinary members with expertise in delirium and dementia. Panelists participated in two rounds of review followed by two surveys over 2 months., Results: Panelists endorsed the same content domains as for general delirium severity, including Cognitive, Level of Consciousness, Inattention, Psychiatric-Behavioral, Emotional Dysregulation, Psychomotor Features, and Functional; however, they excluded six of the original subdomains which they considered unhelpful in the context of ADRD: cognitive impairment; anxiety; fear/sense of unease; depression; gait/walking; and incontinence. Debated measurement challenges included assessment at one point in time versus over time, accounting for differences in clinical settings, and accurate assessment of symptoms related to delirium versus dementia., Conclusions: By capturing a range of characteristics of delirium severity potentially present in patients with ADRD, a population that may already have attention, functional, and emotional changes at baseline, the DEL-S-AD provides a novel rating tool that will be useful for clinical and research purposes to improve patient care., (© 2021 The American Geriatrics Society.)

Background: Systematic screening improves delirium identification among hospitalized older adults. Little data exist on how to implement such screening., Objective: To test implementation of a brief app-directed protocol for delirium identification by physicians, nurses, and certified nursing assistants (CNAs) in real-world practice relative to a research reference standard delirium assessment (RSDA)., Design: Prospective cohort study., Setting: Large urban academic medical center and small rural community hospital., Participants: 527 general medicine inpatients (mean age, 80 years; 35% with preexisting dementia) and 399 clinicians (53 hospitalists, 236 nurses, and 110 CNAs)., Measurements: On 2 study days, enrolled patients had an RSDA. Subsequently, CNAs performed an ultra-brief 2-item screen (UB-2) for delirium, whereas physicians and nurses performed a 2-step protocol consisting of the UB-2 followed in those with a positive screen result by the 3-Minute Diagnostic Assessment for the Confusion Assessment Method., Results: Delirium was diagnosed in 154 of 924 RSDAs (17%) and in 114 of 527 patients (22%). The completion rate for clinician protocols exceeded 97%. The CNAs administered the UB-2 in a mean of 62 seconds (SD, 51). The 2-step protocols were administered in means of 104 seconds (SD, 99) by nurses and 106 seconds (SD, 105) by physicians. The UB-2 had sensitivities of 88% (95% CI, 72% to 96%), 87% (CI, 73% to 95%), and 82% (CI, 65% to 91%) when administered by CNAs, nurses, and physicians, respectively, with specificities of 64% to 70%. The 2-step protocol had overall accuracy of 89% (CI, 83% to 93%) and 87% (CI, 81% to 91%), with sensitivities of 65% (CI, 48% to 79%) and 63% (CI, 46% to 77%) and specificities of 93% (CI, 88% to 96%) and 91% (CI, 86% to 95%), for nurses and physicians, respectively. Two-step protocol sensitivity for moderate to severe delirium was 78% (CI, 54% to 91%)., Limitation: Two sites; limited diversity., Conclusion: An app-directed protocol for delirium identification was feasible, brief, and accurate, and CNAs and nurses performed as well as hospitalists., Primary Funding Source: National Institute on Aging.