IPA Bulletin
Recent Advances

William Burke ● United States
Wendy Moyle ● Australia
Mark Rapoport ● Canada

Delirium and Its Impact on the Elderly: Recent Findings

Several intriguing articles recently highlighted and confirmed the serious nature of delirium, which preferentially affects the elderly.

Witlox J., Eurelings, L.S., de Jonghe, J.F., Kalisvaart, K.J., Eikelenboom, P., van Gool, W.A. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. JAMA. 2010 Jul 28;304(4):443–51. PubMed PMID: 20664045.  

Delirium occurs in half of older patients postoperatively and is even more common in elderly patients admitted to intensive care units.  Witlox et al. provide the first systematic summary of the risk of poor outcomes in elderly patients who experience delirium.  They conducted a meta-analysis that focused specifically on elderly patients with delirium with regard to three specific outcomes:  mortality, institutionalization, and dementia.  After controlling for age, sex, comorbid illness or illness severity, and baseline dementia, they found that delirium was associated with an increased adjusted hazard ratio for all three outcomes:  risk of death (delirium vs. controls, 38% versus 27.5%), risk of hospitalization (33.4% vs. 10.7%) and dementia (62.5% vs. 8.1%).  The authors suggest that older patients who experience delirium should be considered an especially vulnerable population.  They also noted that of the 51 high-quality articles they retrieved, there was very little data on the risk of dementia following delirium.  They were able to identify only 2 relevant studies, which makes the following article by Ehlenbach et al. even more noteworthy.

Ehlenbach, W.J., Hough, C.L., Crane, P.K., Haneuse, S.J., Carson, S.S., Curtis, J.R., Larson, E.B. Association between acute care and critical illness hospitalization and cognitive function in older adults. JAMA. 2010 Feb 24;303(8):763­–70.  PubMed Central PMCID: PMC2943865. 

Acknowledging the growing body of evidence that suggests an association between critical illness and long-term cognitive impairment, these authors provide the only study to date in which a cohort of patients who had premorbid cognitive testing was examined after an acute care hospitalization.  The study features a prospective cohort of patients followed from 1994 through 2007, comprising 2,929 individuals 65 years and older, without dementia at baseline, who were residing in the community.  They combined serial cognitive testing on these patients with administrative data from hospitalizations to measure the association between hospitalizations for acute illness or critical illness and cognitive decline and dementia in older individuals.  The authors report that those who experienced acute care hospitalization and critical illness hospitalization had a greater likelihood of cognitive decline compared with those who had no hospitalization.  Acute care hospitalization was also significantly associated with the development of dementia. Critical illness hospitalization was actually associated with a higher risk for dementia than acute care hospitalization, but the small number of subjects in this group did not result in a significant association.  This is the first study to find an association between critical illness and cognitive decline after adjusting for premorbid cognitive screening scores as well as comorbid illness.  Limits of the study include a reliance on administrative data for the determination of critical illness data and the fact that time interval between study visits was substantial.

Fong, T.G., Jones, R.N., Shi, P., Marcantonio, E.R., Yap, L., Rudolph, J.L., Yang, F.M., Kiely, D.K., Inouye, S.K. Delirium accelerates cognitive decline in Alzheimer disease. Neurology. 2009 May 5;72(18):1570–5. PubMed PMID: 19414723; PubMed Central PMCID: PMC2677515

Finally, given the striking finding just described that even hospitalizations that did not involve critically ill patients were associated with an increased risk of bad cognitive outcomes, what happens to our patients who already have dementia who develop delirium?  Fong et al. provide one answer from a study examining data collected from a large prospective cohort of AD patients whose cognitive performance was measured over time.  They compared patients with carefully diagnosed AD who developed or did not develop delirium during the course of their illnesses.  Cognitive performance was measured by changes in score on the Information-Memory-Concentration (IMC) subtest of the Blessed Dementia Rating Scale.  Delirium was identified using a validated chart review method. 

The authors found a significant acceleration in the slope of cognitive decline following an episode of delirium with a rate of change in the IMC score that was three times faster in those who experienced delirium.  The authors note that from a clinical standpoint, this translates into the scenario that, over 12 months, patients with AD who became delirious experienced the equivalent of an 18-month decline compared to those who did not experience delirium. 

These articles attest to the extraordinary importance of delirium and the challenges to try to prevent and better manage delirium in the medical setting.

Nursing Research:  • Medication use • depression • resilience in older adults 

This report explores the critical issues of medication use in older people and the implications of depression and resilience in care of older people.

·   Medication Use

Baker, J.A., Keady, J., Hardman, P., Kay, J., Jones, .L, & Jolley, D. (2010). Psychotropic PRN use among older people's inpatient mental health services. Journal of Psychiatric & Mental Health Nursing, 17: 463–8.

 A medication audit was undertaken to understand:  (1) the use of PRN psychotropic medications in older people's inpatient mental health services; and (2) the quality of prescriptions and nursing documentation associated with this use.  A retrospective audit was undertaken on 154 patients on 11 wards in three Mental Health Trusts in the North West of England.  The audit found 87 patients were prescribed combinations of 14 psychotropic drugs in 145 different prescriptions as PRN medication.  A total of 76 doses of PRN psychotropic drugs were administered to 26 patients (range 1­–17 doses).  The most commonly administered drug was lorazepam (n=28, 36.8%).  Psychotropic drugs were most frequently administered during the night (n=33, 43.4%).

Of major concern was the finding that the majority of PRN administrations were not documented (n=45, 59.2%).  The authors concluded that PRN medications were used differently in this audit (smaller doses and less frequently) compared to their previous research in people aged less than 65 years.  In order to reduce psychotropic use in this population, the authors recommend the need for further work to focus on developing alternative non-pharmacological interventions.

Banning, M. (2009). A review of interventions used to improve adherence to medication in older people. International Journal of Nursing Studies, 46: 1505–1515.

This literature review aimed to examine interventions that have been used to assess and improve medication adherence in older people.  Twenty relevant research papers and one report were selected.  RCTs were analysed using the JADAD scoring system, systematic reviews and reviews of the literature were reviewed using the Critical Appraisal Skills Programme and subjected to narrative analysis.  Key findings indicate the lack of a clear definition of non-adherent medication behaviour and a limited understanding of the theoretical implications of the complexities of adherence with medication in older people.  The researcher indicates that patient choice is often neglected in relation to medication taking, pharmacist-driven interventions are considered to be resource intensive, and health care outcomes and clinical effect, and perceptions, beliefs and lifestyle implications are frequently ignored in medication intervention studies.  Conclusions indicate the need for quality medication intervention research.   

·   Depression

Chau, J.P-C., Thompson, D.R., Chang, A.M, Woo, J., Twinn, S., Cheung, S.K., & Kwok, T. (2010). Depression among Chinese stroke survivors six months after discharge from a rehabilitation hospital. Journal of Clinical Nursing, 19, 3042–3050.

This research, using a cross sectional design, aimed to examine the prevalence of post-stroke depression in Chinese stroke survivors in Hong Kong six months after discharge from rehabilitation.  The study also aimed to determine whether six-month post-stroke depression was associated with psychological, social, and physical outcomes and demographic variables.  Data were collected from 124 male and 86 female stroke survivors (mean age 71.7, SD 10.2 years).  Outcome measures included GDS, State Self-esteem Scale, London Handicap Scale, Social Support Questionnaire, and Modified Barthel Index.  Findings indicated that 42 participants (20.5%) reported mild and 33 (16.1%) reported severe depression.  The presence of depression was associated with low levels of state self-esteem, social support satisfaction, and functional ability.  These variables were statistically significant in predicting the probability of having depression (p < 0.05).  The findings support previous research indicating that depression has a positive association with physical disability, living arrangements, and social support, and no significant association with the different types of brain lesion.  The authors highlight the importance of assessing stroke survivors for depression in order to enhance psychological and social well-being.

·   Resilience

Resnick, B.A., & Inguito, P.I. (2010). The Resilience Scale: Psychometric properties and clinical applicability in older adults.  Archives of Psychiatric Nursing, (Early on-line in press view), doi:10.1016/j.apnu.2010.05.001.

Resilience in older adults is important in helping this population retain or regain a level of physical or emotional health after illness or loss.  This descriptive study used two different samples of older adults:  163 older adults living in a retirement setting, and 101 older women post hip-fracture who had participated in a previous exercise program.  Participants in both studies completed the following outcome measures:  Resilience Scale, Self-efficacy Expectations for Exercise, MMSE, Yale Physical Activity Survey.  Participants in the retirement setting completed the Outcome Expectations for Exercise Scale-2, and the hip-fracture women completed the OEE.  Validity testing for the Resilience Scale in both samples was based on test-criterion relationships.  It was hypothesised that those who were more resilient would be more likely to exercise, an activity that is associated with successful aging and recovery.  Psychometric testing found some support for the reliability and validity of the Resilience Scale, although there was poor fit on 5 items in the 22-item scale.  Item matching indicated that additional items are needed to distinguish those who are particularly resilient.  Although revisions of the scale are indicated, the authors conclude the scale is particularly useful in identifying those older adults low in resilience, and that interventions targeted to improving resilience in this population may help to facilitate successful aging.

Imaging and Apathy

Brodaty, H., Altendorf, A., Withall, A., Sachdev, P. Do people become more apathetic as they grow older? A longitudinal study in healthy individuals. International Psychogeriatrics.  May;22(3):426–36.

Two recent reports provide interesting information about apathy in late life.  First, Brodaty et al. examined a cohort of 76 healthy adults in Australia ranging in age from 58–85 years, who were followed prospectively over five years.  The authors used informant ratings of cognitive decline and apathy, and neuropsychological and MRI  assessments of white matter hyperintensities and atrophy.  Age itself was not a predictor of apathy.  However, over the five years, apathy scores significantly increased in this healthy group, especially in men.  Higher premorbid informant-rated cognitive decline was associated with apathy, but the researchers did not find an association between any of the neuropsychological or neuroimaging measures.  There was a relationship between apathy and depression, as measured by the Geriatric Depression Scale, but when apathy-related items on the GDS were removed, that relationship was somewhat attenuated. 

Jonsson, M., Edman, A., Lind, K., Rolstad, S., Sjogren, M., Wallin, A. Apathy is a prominent neuropsychiatric feature of radiological white-matter changes in patients with dementia. International Journal of Geriatric Psychiatry.  Jun;25(6):588–95.

A group from Sweden conducted a cross-sectional examination of a group of 176 patients with dementia of the Alzheimer type, vascular dementia, mixed dementia, or mild cognitive impairment, with a mean MMSE of 19 (SD 6) They assessed apathy using an observational clinician-rated instrument with input from a relative and member of the clinical staff.  Of the group, 59% had white matter changes of various severities, noted on MRI or CT.  The group with white matter changes were more likely to be rated as disinhibited, apathetic, to have focal neurological symptoms, or mental slowness.  After adjustment in a multiple logistic regression, the only clinical features associated with white matter changes were apathy, mental slowness, and age. 

New Thoughts on Driving and Cognition?

Iverson, D.J., Gronseth, G.S., Reger, M.A., Classen, S., Dubinsky, R.M., Rizzo, M. Practice parameter update: evaluation and management of driving risk in dementia: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology.  Apr 20;74(16):1316–24.

In April, the American Academy of Neurology published an update of their practice parameter on evaluating and managing the risk of driving in dementia.  The authors systematically reviewed evidence pertaining to the role of global dementia severity, self- and caregiver-report, driving history, neuropsychological data, and interventions to reduce driving risk.  The only Level A evidence was that the risk of driving problems increases according to the severity of dementia.  Other evidence at lower levels suggested the potential role of caregiver ratings of marginal or unsafe driving, traffic citations, history of crashes, reduced driving mileage, self-reported situational avoidance, MMSE < 25, and aggressive or impulsive personality characteristics.  The authors proposed an algorithm in which patients with CDR of 0.5 (very mild dementia) or 1 (mild dementia) who have increasing numbers of these risk factors should consider voluntary cessation or a professional driving evaluation.  The review focused mostly on the results of on-road driving tests, and highlights the problem of wide confidence intervals in interpreting the results.  The authors emphasize that there is as yet “insufficient evidence to support or refute the benefit of neuropsychological testing” in assessing the risk.

Carr, D.B., Ott, B.R. The older adult driver with cognitive impairment: "It's a very frustrating life". JAMA.  Apr 28;303(16):1632–41.

In the same month, a case-based review of the literature was published in JAMA.  The review covers similar ground, but presents more detail about approaches for communicating risks with patients and families, about variability in mandatory reporting laws, and about the role of the on-road driving test in situations in which patients have mild dementia.  The authors discuss the variability of the on-road test and a lack of uniform standards for this objective testing.  In their review, the authors pooled data from two longitudinal studies of on-road tests in dementia and reported that 88% of patients with dementia at a severity of CDR 0.5 and 69% with CDR 1 were still able to pass a formal road test, although they emphasized that time to cessation was 2 years for CDR 0.5 and 1 year for CDR 1.  They also review the predictive value of neurocognitive tests and conclude that many patients may be misclassified using these as sole determinants. 

Lincoln, N.B., Taylor, J.L., Vella, K., Bouman, W.P., Radford, K.A. A prospective study of cognitive tests to predict performance on a standardised road test in people with dementia. International Journal of Geriatric Psychiatry.  May;25(5):489–96.

Another study has examined the potential role of detailed cognitive testing in predicting driving safety.   Lincoln et al conducted a cross-sectional study in which 65 drivers with dementia underwent a battery of 8 neuropsychological tests and an on-road driving assessment.  The authors found that using this battery, and applying a complex mathematical formula to assign probability of passing or failing the road test, they were able to correctly classify approximately 76% of patients.  The positive predictive value was 88.8% and the negative predictive value was 44.4%.  In their discussion, they emphasize the potential impact of misclassification, and they also acknowledged the uncertainty of the driving characteristics of subjects who refused the testing. 

Reprinted from IPA Bulletin, Volume 27, Number 3