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Tools to Detect Delirium Superimposed on Dementia: A Systematic Review
Alessandro Morandi, MD, MPH • Jessica McCurly, MS • Eduard E. Vasilevskis, MD • Donna M. Fick, PhD • Giuseppe Bellelli, MD • Patricia Lee, MLS • James C. Jackson, PsyD • Susan D. Shenkin, MRCP, MSc • Marco Trabucchi, MD John Schnelle, PhD • Sharon K. Inouye, MD, MPH • Wesley E. Ely, MD, MPH • Alasdair MacLullich, MRCP, PhD
OBJECTIVES: To identify valid tools to diagnose delirium superimposed on dementia.
DESIGN: Systematic review of studies of delirium tools that explicitly included individuals with dementia.
PARTICIPANTS:Studies were included if delirium assessment tools were validated against standard criteria, and the presence of dementia was assessed according to standard criteria that used validated instruments.
MEASUREMENTS: PubMed, Embase, and Web of Science databases were searched for articles in English published between January 1960 and January 2012.
RESULTS: Nine studies fulfilled the selection criteria. Of 1,569 participants, 401 had dementia, and 50 had delirium superimposed on dementia. Six delirium tools were evaluated. One study using the Confusion Assessment Method (CAM) with 85% of participants with dementia had high specificity (96–100%) and moderate sensitivity (77%). Two intensive care unit studies that used the CAM for the Intensive Care Unit (CAM-ICU) reported 100% sensitivity and specificity for delirium in 23 individuals with dementia. One study using electroencephalography reported sensitivity of 67% and specificity of 91% in a population with a 100% prevalence of dementia. No studies examined potential effects of dementia severity or subtype on diagnostic accuracy.
CONCLUSION: The evidence base on tools for detection of delirium superimposed on dementia is limited, although some existing tools show promise. Further studies of existing or refined tools with larger samples and more detailed characterization of dementia are required to address the identification of delirium superimposed on dementia. J Am Geriatr Soc. 2012;60(11):2005-2013.
Influence of Hospice on Nursing Home Residents With Advanced Dementia Who Received Medicare-Skilled Nursing Facility Care Near the End of Life
Susan C. Miller, PhD • Julie C. Lima, PhD • Susan L. Mitchell, MD
OBJECTIVES: To examine differences in outcomes according to hospice status of skilled nursing facility (SNF) care recipients.
DESIGN: Retrospective cohort.
SETTING: Three thousand three hundred fifty-three U.S. nursing homes (NHs).
PARTICIPANTS: Four thousand three hundred forty-four persons with advanced dementia who died in NHs in 2006 and received SNF care within 90 days of death were studied, 1,086 of these also received hospice before death: 705 after SNF care, and 381 concurrent with SNF care.
MEASUREMENTS: Treatments, persistent pain and dyspnea, and hospital death.
RESULTS: Decedents with any hospice received fewer medications, injections, feeding tubes, intravenous fluids, and therapy services and more hypnotics than those without hospice (all P<.001). Decedents with hospice after SNF care received fewer antipsychotics and those with hospice concurrent with SNF care received more antipsychotics than those without (all P<.001). Multivariate logistic regressions showed that decedents with hospice after SNF had lower likelihood of persistent dyspnea (adjusted odds ratio [AOR]=.63, 95% confidence interval [CI]=.45–0.87) and hospital death (AOR=.02; 95% CI= .01, .07) than those without hospice. Decedents with hospice concurrent with SNF care had a higher likelihood of persistent pain (AOR=1.65, 95% CI=1.23, 2.19) and a lower likelihood of hospital death (AOR=.13, 95% CI=.07, .26) than those without hospice.
CONCLUSION: Residents dying with advanced dementia who received SNF care in the last 90 days of life had fewer aggressive treatments and lower odds of hospital death if they also received hospice care at any point during that time. Associations between hospice and persistent pain or dyspnea differed according to whether hospice care was received concurrent with or after SNF care. J Am Geriatr Soc. 2012;60(11):2035-2041.