Journal of Gerontological Nursing ( IF 1.1 ) Pub Date : 2022-10-01 , DOI: 10.3928/00989134-20220909-01 Donna M Fick 1 , Priyanka Shrestha 2
Introduction
I (D.M.F.) first met Juanita in the 1990s when practicing as a board certified geriatric clinical nurse specialist (GCNS). We were less than 2 weeks into a care management project, and I received a phone call telling me that Juanita, a 92-year-old female in the practice living independently (and whom I had not even met in person yet) had been admitted to a psychiatric unit. She was placed on a 72-hour hold after she had pulled the fire alarm in her lower income apartment building and was directing traffic in her nightgown. Thankfully, I was able to get to know Juanita over approximately 2 years, so the story did not end here.
Juanita, like many older adults who live to be in their 80s and 90s, had several chronic conditions, such as hearing loss, arthritis, and urinary incontinence, but she was also doing fairly well functionally living alone at home, ambulating without assistive devices, and socializing with friends. She was a former retail person and had worked as a telephone circuit board operator during World War II. What we came to know was that she had mild to moderate dementia that had never been assessed, and on that particular day, she became acutely confused with delirium on top of her dementia, also known as delirium superimposed on dementia (DSD).
The Importance of Mentation
The story of Juanita is one that illustrates the importance of assessing mentation regularly with an evidence-based tool and the John A. Hartford Foundation and Institute for Health-care Improvement (IHI) 4Ms framework (What Matters, Medication, Mentation, and Mobility) for age-friendly care (access https://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx). What mattered to Juanita was being able to go out to lunch with her friends once per week and stay independent in her home. She had been showing signs of impaired thinking and memory but had not been formally assessed. She was also taking oxybutynin for incontinence, which is on the American Geriatrics Society (AGS) Beers Criteria® of drugs to avoid in older adults (2019 AGS Beers Criteria® Update Expert Panel, 2019). Juanita was worried about incontinence occurring while she was out, so she doubled her dose and did not hydrate well on a warm day, which resulted in reversible and preventable DSD. Mobility, what matters, and medications were all critical in restoring and maintaining function for Juanita and allowing her to perform activities that were important to her. The evidence-base for physical activity and medications impact on mentation is strong and these 4Ms of age-friendly care are critical to consider as a set in the assessment and care of Juanita and others like her.
The IHI Age-Friendly Care Initiative has resources for assessing and acting on all 4Ms and these are similar by setting of care, except for mentation, which has some differences by setting of care (see IHI for most up to date resources and guidance, access https://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx). Mentation is generally not assessed in the presence of an acute illness so the focus in acute care is more on delirium detection; clinicians follow up after discharge with any concerns about pre-existing cognitive impairment. The frequency of delirium assessment occurs less often in nursing homes and primary care, but delirium is still important to consider if there is reason to suspect an acute change.
Detecting Delirium and Delirium Superimposed on Dementia
Dementia is one of the largest independent risk factors for having delirium and is associated with poor outcomes, including declines in function and death, yet decades after making progress with delirium, DSD continues to be challenging to detect and manage (Marcantonio, 2017). As with the story of Juanita, delirium is often not recognized or is misdiagnosed as an underlying dementia, sundowning, or other psychiatric issue. Depression is also common in older adults, can co-occur with dementia, and leads to poor outcomes if not recognized and treated (Birrer & Vemuri, 2004). Depression, age-related losses, and grief are common in older adults. Oxybutynin and other anticholinergic medications can lead to or worsen delirium and dementia. Delirium that is undetected in persons with dementia leads to increased distress for older adults and their care partners, increased staff care, and missed opportunities to intervene (Leslie et al., 2008; Morandi et al., 2015). Delirium that is hypo-active (i.e., without behavioral disturbances), superimposed on dementia, and in those aged >80 years is most likely to be missed (Fick, 2018).
Our research team has focused on the recognition and management of DSD since the 1990s and published the first systematic review of DSD more than 20 years ago with an agenda for research and practice that continues to be relevant today (Fick et al., 2002). To address the challenge of delirium identification in vulnerable populations, our group conducted READI: Researching Efficient Approaches to Delirium Identification (R01AG030618). We developed, validated, and field tested the Ultra-brief Confusion Assessment Method (UB-CAM), a two-step delirium identification protocol that combines an ultra-brief two-item screen (UB-2) with a validated diagnostic tool (3D-CAM) (Fick et al., 2015; Marcantonio et al., 2014). We prospectively enrolled 527 patients with a mean age of 80 years, of which 35% had Alzheimer's disease/Alzheimer's disease and related dementias, from two hospitals. We performed reference standard delirium assessments on 924 hospital days (153 were delirium positive), followed by blinded UB-CAM application (app)-directed assessments by physicians (n = 53), RNs (n = 236), and certified nursing assistants (CNAs) (n = 110) (Marcantonio et al., 2021). The UB-CAM was feasible, quick (taking on average 1 minute, 15 seconds), had overall accuracy of 89%, and performed equally well when administered by all disciplines, with the lowest accuracy-adjusted cost achieved by RNs (Leslie et al., 2022; Marcantonio et al., 2021). To our knowledge, this is the only delirium screen that has been tested on a large scale with CNAs completing the UB-2 step of the protocol.
A free iPhone® app for the UB-CAM can be downloaded from the Apple store ( https://apps.apple.com/us/app/ub-cam-delirium-screen/id1591656740). We are currently testing screens for prevention and management to go along with our app. The UB-CAM uses adaptive testing, so the user can skip questions that have already triggered a delirium feature, allowing it to be performed quickly (Figure A, available in the online version of this article). However, clinicians and health systems screening for delirium should use whatever evidence-based delirium tool that best fits their needs and local setting. More than 25 delirium tools can be accessed on the Network for Investigation of Delirium: Unifying Scientists (NIDUS) site (Fick et al., 2017). Another recent tool for DSD is the 4-DSD, which has a sensitivity of >80% and was evaluated in persons with moderate and severe dementia (Morandi et al., 2021).
Ultra-Brief Confusion Assessment Method (UB-CAM).
Reprinted from https://deliriumnetwork.org/measurement/ub-cam/; in the public domain, permission to reprint is not required.
Nurses should suspect delirium with any change in mental status, search for reversible causes, and use best practices for the management of expressions of behavior that occur in delirium, dementia, and depression (Kolanowski et al., 2020). Although it may be tempting to dismiss these changes as sundowning or worsening of dementia itself, DSD can be a medical emergency. When an older adult experiences symptoms of dementia or cognitive impairment, they may be referred for comprehensive cognitive assessment and support. However, in the initial assessment stages, delirium and depression are differential diagnoses that require consideration and need to be ruled out as they can mimic the presentation of dementia (Downing et al., 2013). Nurses and other clinicians should understand that delirium, dementia, and depression are distinct syndromes with different prognoses and management (Han & Suyama, 2018). Similarly, delirium and depression can be superimposed on a person who already has an existing diagnosis of dementia. Nurses have a significant role to play in the screening, identification, assessment, and management of persons with dementia, delirium, and depression (Table 1).
| Clinical Feature | Delirium | Dementia | Depression |
|---|---|---|---|
| Onset | Sudden/abrupt, can be minutes, hours, days | Insidious/slow, usually unrecognized | Variable |
| Course | Short with diurnal fluctuations in symptomatology | Chronic and progressive over months to years | Variable, symptoms typically worse in the early morning |
| Progression | Abrupt | Protracted | Variable |
| Consciousness | Altered | Clear except in severe cases or end of life | Clear |
| Attention | Impaired; fluctuates (hallmark of delirium) | Initially normal | Generally normal |
| Orientation | Generally impaired, severity varies | Generally normal | Selective disorientation |
| Memory | Recent and immediate impaired | Recent and remote impaired | Selective impairment |
| Thinking | Disorganized, incoherent | Difficulty with abstraction, thoughts impoverished | Intact with themes of hopelessness and helplessness |
| Perception | Misperceptions common with illusions, hallucinations, and delusions | Misperceptions usually absent | Intact |
| Psychomotor behavior | Variable: hypokinetic, hyperkinetic, and mixed | Generally normal | Variable |
| Assessment | Distracted from task; numerous errors | Struggles with assessment to find appropriate reply, may try and cover up | Generally lacks motivation, frequent “don't know” answers |
Note. Adapted from Milisen et al. (2004).
Recent articles in The American Journal of Geriatric Psychiatry and other publications raise the issue of the even greater challenge of recognizing delirium in persons with advanced dementia. Fong et al. (2022) present an adaptation of the CAM for questions to ask informants for the acute change feature of delirium. Acute change is the holy grail of delirium detection, so knowing the older adult and engaging the family and care partners in delirium, dementia, and depression detection and care is critical (Shrestha & Fick, 2020). In a recent commentary, I (D.M.F.) propose ways to know older adults in the context of delirium and dementia:
…With the advent of age-friendly care and the understanding of the poor outcomes of DSD, we have an opportunity to do better, to know our patients' baseline mentation and goals of care and to develop ways to communicate this to others including in the electronic medical record dashboard…. We must provide the leadership and toolkits at the bedside to make it easier for nurses to understand and intervene in the moment for behavior, provide adequate staffing, infrastructure, and best practices for communication to address delirium causes, prevention, discharge teaching and recovery.
(Fick, 2022, p. P1081)Additional Delirium Resources
Resources for the detection and management of delirium are growing with the collaboration of the American Delirium Society and global delirium societies ( idelirium.org) and the NIDUS network and Delirium Central. NIDUS is free to register and includes many resources, including a delirium bibliography, seminars, adult and pediatric delirium tools, access to studies on delirium, a delirium boot camp, pilot funding, and a delirium site for clinicians (access https://deliriumnetwork.org). The Hospital Elder Life Program (HELP) has best practices for the management and prevention of delirium and is the groundwork for most programs for prevention and management of delirium. The HELP includes resources for focusing on hydration, mobility, socialization, providing hearing and other sensory devices, orientation and validation, prevention and early treatment of infection, and avoidance of high-risk medications and can be accessed on the AGS website ( https://geriatricscareonline.org/ProductAbstract/Hospital-Elder-Life-Program/M0011). The How To Try This series also addresses DSD specifically and can be found online (access https://hign.org/consultgeri/try-this-series/assessing-and-managing-delirium-persons-dementia).
Conclusion
As a GCNS, I (D.M.F.) worked with Juanita and her caregivers and they were able to partner with the area Agency on Aging and a local home health agency. I visited Juanita after her hospitalization to perform a home and geriatric assessment. The team brought in an aide that came in three times per week and helped Juanita with activities of daily living and continued socialization. Juanita also reconnected with her son who she had been estranged from and she was able to live at home for another 1 year until her dementia progressed and she needed additional care. In summary, gerontological nurses are often leaders in age-friendly care and the care of older adults and persons with cognitive impairment, including delirium, depression, and dementia.
Donna M. Fick, PhD, GCNS-BC, FGSA, FAAN
Editor, Journal of Gerontological Nursing
Elouise Ross Eberly Endowed Professor
Ross and Carol Nese College of Nursing
Pennsylvania State University
Director, Tressa Nese and Helen Diskevich
Center of Geriatric Nursing Excellence
State College, Pennsylvania
Priyanka Shrestha, PhD, RN
Assistant Professor
George Washington University School of
Nursing
Washington, DC
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中文翻译：
痴呆症患者的谵妄：将老年友好型护理的 4 毫秒整合到老年人护理中
介绍
我 (DMF) 在 1990 年代第一次遇到 Juanita，当时他是一名董事会认证的老年临床护士专家 (GCNS)。我们进行了一个护理管理项目不到 2 周，我接到一个电话，告诉我 Juanita，一位 92 岁的独立生活的执业女性（我什至还没有亲自见过她）已被录取到精神病院。在她拉下低收入公寓楼的火警并穿着睡衣指挥交通后，她被关押了 72 小时。值得庆幸的是，我能够在大约 2 年的时间里认识胡安妮塔，所以故事并没有到此结束。
与许多 80 多岁和 90 多岁的老年人一样，胡安妮塔患有多种慢性病，例如听力丧失、关节炎和尿失禁，但她在独自在家中的功能上也做得很好，在没有辅助设备的情况下行走，并与朋友交往。她曾是一名零售业人员，在二战期间曾担任电话电路板操作员。我们了解到，她患有从未被评估过的轻度至中度痴呆症，并且在那一天，她严重混淆了痴呆症之上的谵妄，也称为痴呆叠加谵妄（DSD）。
提及的重要性
Juanita 的故事说明了使用基于证据的工具和约翰 A. 哈特福德基金会和医疗保健改进研究所 (IHI) 4Ms 框架（重要事项、药物治疗、心理治疗和流动性）定期评估心理状态的重要性关爱老人护理（访问 https://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx）。对胡安妮塔来说，重要的是每周能和她的朋友一起出去吃午饭，并在家里保持独立。她一直表现出思维和记忆力受损的迹象，但尚未接受正式评估。她还服用奥昔布宁治疗失禁，这是美国老年病学会 (AGS) 啤酒标准®老年人应避免使用的药物（2019 AGS Beers Criteria® Update Expert Panel，2019）。Juanita 担心外出时会出现尿失禁，因此她将剂量增加了一倍，并且在温暖的日子里没有很好地补充水分，这导致了可逆和可预防的 DSD。活动能力、重要事项和药物对于恢复和维持 Juanita 的功能以及让她进行对她来说很重要的活动都至关重要。身体活动和药物对心理的影响的证据基础很强，这些 4M 关爱老人的护理对于 Juanita 和其他像她一样的人的评估和护理至关重要。
IHI Age-Friendly Care Initiative 拥有评估和处理所有 4M 的资源，这些资源在护理设置方面是相似的，除了心理，在护理设置方面存在一些差异（有关最新资源和指南，请参阅 IHI，访问https://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx）。出现急性疾病时通常不会评估精神状态，因此急性护理的重点更多是检测谵妄；临床医生在出院后跟进是否存在对预先存在的认知障碍的任何担忧。谵妄评估的频率在疗养院和初级保健中发生的频率较低，但如果有理由怀疑是否有急性变化，谵妄仍然很重要。
检测谵妄和叠加在痴呆症上的谵妄
痴呆症是谵妄的最大独立风险因素之一，并且与不良结果相关，包括功能下降和死亡，但在谵妄取得进展几十年后，DSD 仍然难以检测和管理（Marcantonio，2017）。与胡安妮塔的故事一样，谵妄通常未被识别或被误诊为潜在的痴呆、日落或其他精神问题。抑郁症在老年人中也很常见，可能与痴呆症同时发生，如果不加以识别和治疗，则会导致不良后果（Birrer & Vemuri，2004 年）。抑郁、与年龄有关的损失和悲伤在老年人中很常见。奥昔布宁和其他抗胆碱能药物可导致或加重谵妄和痴呆。在痴呆症患者中未被发现的谵妄会导致老年人及其护理伙伴的痛苦增加、员工护理增加以及错失干预机会（Leslie 等人，2008 年；Morandi 等人，2015 年）。低活跃（即没有行为障碍）、叠加在痴呆症上以及年龄 >80 岁的谵妄最有可能被遗漏（Fick，2018 年）。
自 1990 年代以来，我们的研究团队一直专注于 DSD 的识别和管理，并在 20 多年前发表了对 DSD 的第一份系统评价，其中的研究和实践议程在今天仍然具有相关性（Fick 等，2002）。为了应对弱势群体谵妄识别的挑战，我们小组开展了 READI：研究谵妄识别的有效方法 (R01AG030618)。我们开发、验证和现场测试了超简要混淆评估方法 (UB-CAM)，这是一种两步谵妄识别协议，将超简要两项筛查 (UB-2) 与经过验证的诊断工具 (3D -CAM）（Fick 等人，2015 年；Marcantonio 等人，2014 年）。我们前瞻性地招募了 527 名平均年龄为 80 岁的患者，其中 35% 患有阿尔茨海默病/阿尔茨海默病 s 疾病和相关的痴呆症，来自两家医院。我们在 924 个住院日（153 个谵妄阳性）进行了参考标准谵妄评估，随后由医生进行了盲法 UB-CAM 应用程序（app）指导的评估（n = 53)、注册护士 ( n = 236) 和认证护理助理 (CNA) ( n = 110) (Marcantonio et al., 2021)。UB-CAM 可行、快速（平均耗时 1 分 15 秒），总体准确率为 89%，在所有学科管理时表现同样出色，RN 达到的准确度调整成本最低（Leslie 等人.，2022 年；Marcantonio 等人，2021 年）。据我们所知，这是唯一一个经过大规模测试的谵妄屏幕，CNA 完成了协议的 UB-2 步骤。
可以从 Apple 商店 (https://apps.apple.com/us/app/ub-cam-delirium-screen/id1591656740) 下载适用于 UB-CAM的免费 iPhone ®应用程序。我们目前正在测试与我们的应用程序一起使用的预防和管理屏幕。UB-CAM 使用自适应测试，因此用户可以跳过已经触发谵妄功能的问题，从而可以快速执行（图 A，可在本文的在线版本中找到）。然而，筛查谵妄的临床医生和卫生系统应使用最适合其需求和当地环境的任何基于证据的谵妄工具。在谵妄调查网络：统一科学家 (NIDUS) 网站上可以访问超过 25 个谵妄工具（Fick 等人，2017 年）。另一个最近用于 DSD 的工具是 4-DSD，其敏感性超过 80%，并在中度和重度痴呆患者中进行了评估（Morandi 等人，2021 年）。
超简要混淆评估方法（UB-CAM）。
转载自 https://deliriumnetwork.org/measurement/ub-cam/；在公共领域，不需要转载许可。
护士应怀疑精神状态发生任何变化的谵妄，寻找可逆的原因，并使用最佳实践来管理谵妄、痴呆和抑郁中发生的行为表现（Kolanowski 等人，2020 年）。尽管可能很容易将这些变化视为痴呆症本身的日落或恶化，但 DSD 可能是一种医疗紧急情况。当老年人出现痴呆或认知障碍症状时，他们可能会被转介进行全面的认知评估和支持。然而，在最初的评估阶段，谵妄和抑郁是需要考虑和排除的鉴别诊断，因为它们可以模仿痴呆的表现（Downing 等，2013）。护士和其他临床医生应该了解谵妄、痴呆、和抑郁症是具有不同预后和管理的不同综合征（Han & Suyama，2018）。同样，谵妄和抑郁症可以叠加在已经诊断为痴呆症的人身上。护士在痴呆、谵妄和抑郁症患者的筛查、识别、评估和管理中发挥着重要作用。表 1 )。
| 临床特征 | 谵妄 | 失智 | 沮丧 |
|---|---|---|---|
| 发作 | 突然/突然，可以是几分钟、几小时、几天 | 阴险/缓慢，通常无法识别 | 多变的 |
| 课程 | 症状的昼夜波动短 | 数月至数年的慢性和进展性 | 多变的，症状通常在清晨更严重 |
| 进步 | 突然 | 旷日持久 | 多变的 |
| 意识 | 改变 | 清除，除非在严重的情况下或生命终结 | 清除 |
| 注意力 | 受损；波动（谵妄的标志） | 初期正常 | 一般正常 |
| 方向 | 一般受损，严重程度不一 | 一般正常 | 选择性迷失方向 |
| 记忆 | 最近和立即受损 | 最近和远程受损 | 选择性损伤 |
| 思维 | 杂乱无章，不连贯 | 抽象困难，思想贫乏 | 完整的绝望和无助的主题 |
| 洞察力 | 错觉、幻觉和妄想中常见的误解 | 误解通常不存在 | 完好无损的 |
| 精神运动行为 | 变量：运动迟缓、运动过度和混合 | 一般正常 | 多变的 |
| 评估 | 从任务中分心；无数错误 | 努力评估以找到适当的答复，可能会尝试掩盖 | 一般缺乏动力，经常回答“不知道” |
笔记。改编自 Milisen 等人。（2004 年）。
美国老年精神病学杂志和其他出版物最近发表的文章提出了识别晚期痴呆患者谵妄的更大挑战。方等人。(2022) 提出了对 CAM 的改编，用于向知情人询问谵妄的急性变化特征。急性变化是谵妄检测的圣杯，因此了解老年人并让家人和护理伙伴参与谵妄、痴呆和抑郁症的检测和护理至关重要（Shrestha & Fick，2020 年）。在最近的评论中，我 (DMF) 提出了在谵妄和痴呆的背景下了解老年人的方法：
......随着老年友好型护理的出现和对 DSD 不良结果的理解，我们有机会做得更好，了解我们患者的基线心理和护理目标，并开发与其他人交流的方法，包括在电子病历仪表板…… 我们必须在床边提供领导和工具包，使护士更容易理解和干预行为，提供足够的人员配置、基础设施和最佳沟通实践，以解决谵妄的原因、预防、出院教学和康复。
（菲克，2022 年，第 P1081 页）额外的谵妄资源
在美国谵妄协会和全球谵妄协会 (idelirium.org) 以及 NIDUS 网络和谵妄中心的合作下，用于检测和管理谵妄的资源正在增加。NIDUS 可免费注册，并包含许多资源，包括谵妄参考书目、研讨会、成人和儿童谵妄工具、谵妄研究、谵妄训练营、试点资金和临床医生谵妄网站（访问 https://deliriumnetwork .org）。医院老年生活计划 (HELP) 具有管理和预防谵妄的最佳实践，是大多数谵妄预防和管理计划的基础。HELP 包括专注于水合作用、移动性、社交、提供听力和其他感官设备、定位和验证的资源，预防和早期治疗感染，避免使用高风险药物，可在 AGS 网站 (https://geriatricscareonline.org/ProductAbstract/Hospital-Elder-Life-Program/M0011) 上访问。如何尝试本系列还专门针对 DSD，可以在线找到（访问 https://hign.org/consultgeri/try-this-series/assessing-and-managing-delirium-persons-dementia）。
结论
作为 GCNS，我 (DMF) 与 Juanita 和她的护理人员一起工作，他们能够与地区老龄化机构和当地家庭健康机构合作。在她住院后，我拜访了胡安妮塔，进行了家庭和老年病评估。该团队带来了一名每周来 3 次的助手，帮助胡安妮塔进行日常生活和继续社交活动。胡安妮塔还与她疏远的儿子重新建立了联系，她能够在家里再住一年，直到她的痴呆症恶化，她需要额外的照顾。总而言之，老年科护士通常是老年护理和老年人和认知障碍患者（包括谵妄、抑郁和痴呆）的领导者。
Donna M. Fick，博士，GCNS-BC，FGSA，FAAN
编辑，老年护理杂志
Elouise罗斯埃伯利赋予教授
罗斯和卡罗尔·内塞护理学院
宾夕法尼亚州立大学
导演，Tressa Nese 和 Helen Diskevich
老年护理卓越中心
宾夕法尼亚州立大学
Priyanka Shrestha，博士，注册护士
助理教授
乔治华盛顿大学学院
护理
华盛顿特区
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