OBJECTIVE:To evaluate the interrater reliability of a structured delirium assessment method for nonclinician interviewers in elderly patients newly admitted for postacute care.DESIGN:Prospective assessment using dyads of nonclinician raters.SETTING:Postacute (Medicare) units at 6 skilled nursing facilities.PARTICIPANTS:Forty elderly patients newly admitted for postacute care from medical or surgical units at acute care hospitals.MEASUREMENTS:Subjects underwent dual delirium assessments within 5 days of admission. The standardized delirium assessment included the Mini-Mental Status Exam and Digit Span to assess overall cognitive function, the Delirium Symptom Interview to elicit specific delirium symptoms, the Memorial Delirium Assessment Scale to measure the severity of delirium, and the Confusion Assessment Method (CAM) to make the diagnosis of delirium. A coding protocol that linked observations to specific coding was used to improve reliability.RESULTS:The structured delirium assessment process produced very high interobserver agreement for all instruments. Kappa for agreement on delirium diagnosis was 0.95.CONCLUSIONS:Nonclinician interviewers using a structured delirium assessment achieved reliability that rivaled or exceeded that of trained clinical assessors in other studies. Nonclinicians may offer an effective alternative for the assessment of delirium among postacute patients in skilled nursing facilities.

BACKGROUND Delirium is common among hospitalized elders and may persist for months. The adverse impact of delirium on independence may increasingly occur in the postacute care (PAC) setting. The purpose of this study is to examine the association between delirium resolution and functional recovery in skilled nursing facilities specializing in PAC. METHODS Patients were screened for delirium on admission after an acute hospitalization at PAC facilities. Only patients with "Confusion Assessment Method"-defined delirium were enrolled. Delirium and activities of daily living were assessed prehospital, at PAC admission, and at four (2-week, and 1-, 3-, and 6-month) follow-up assessments to measure functional ability. Four distinct delirium resolution groups were created ranging from resolution within 2 weeks without recurrence to no resolution over 6 months. Repeated-measures analysis of covariance was used to determine if functional performance differed over time by delirium resolution status. RESULTS Among the 393 PAC patients, functional recovery differed significantly (p <.0001) by delirium resolution status. Patients who resolved their delirium by 2 weeks without recurrence regained 100% of their prehospital functional level, whereas patients who never resolved their delirium retained less than 50% of their prehospital functional level. Patients with slower resolving delirium and recurrent delirium had intermediate functional outcomes. CONCLUSIONS Resolution of delirium among PAC patients appears to be a prerequisite for functional recovery. Delirium resolution within 2 weeks without recurrence is associated with excellent functional recovery. Effective strategies to resolve delirium promptly and prevent its recurrence in the PAC setting will likely benefit patient rehabilitation and functional recovery.

Although delirium has been shown to be a common, morbid, and costly problem for hospitalized older people, evidence has mounted that it may persist for weeks or months. Therefore, concern about delirium can no longer be confined to acute care. After an acute hospitalization, many older people are discharged to postacute care (PAC) facilities-rehabilitation hospitals and skilled nursing facilities. Although several models designed to prevent delirium in the hospital setting have been described, there have been few such efforts in the PAC setting.This article describes the development of a multifactorial delirium abatement program (DAP), a new model of care for older patients admitted to the postacute skilled nursing facility with delirium. The DAP is a nurse-led, unit-based intervention. The program consists of four modules based on best practices as defined by the peer-reviewed literature: standardized screening for symptoms and signs of delirium upon admission to the PAC unit, assessment and treatment of possible causes of and contributors to delirium, prevention and management of common delirium complications, and restoration of patient cognitive and self-care function.This article also presents the process of facility introduction, staff education on DAP content, and multidisciplinary outreach. Key strategies for DAP implementation are reviewed. Program adoption challenges and corresponding model refinements to enhance adherence and overall care quality are highlighted. Last, clinical adaptation of this research-derived program is discussed.

BACKGROUND Delirium is costly, common, and may persist for weeks or months. Therefore, the adverse impact of delirium on loss of independence may occur in the post-acute setting rather than in the hospital. The purpose of this study is to describe the rate of delirium persistence and identify baseline patient characteristics that are associated with delirium persistence at 1 month among newly admitted post-acute facility patients who were admitted with delirium. METHODS Patients were recruited from 4 Boston area skilled nursing facilities specializing in post-acute care (PAC). Assessment instruments included the Confusion Assessment Method Diagnostic Algorithm, the modified Delirium Symptom Interview, the Memorial Delirium Assessment Scale (MDAS), and the Blessed Dementia Rating Scale (BDRS). Multiple logistic regression analyses were used to identify patient characteristics associated with delirium persistence (at 1 month). RESULTS Nearly 51% of the 85 delirious patients enrolled in this study had delirium at their 1-month follow-up assessment. Four patient factors associated with delirium persistence were identified: older age (> or =85 years), severe delirium at PAC admission (MDAS score >15), prehospital cognitive impairment based on proxy report [BDRS], and the presence of all 8 modified Delirium Symptom Interview symptoms at PAC admission. Our model has very good predictive power (area under the receiver operating characteristic = 0.85). CONCLUSIONS Delirium is persistent in the post-acute setting. If verified in further research, the risk factors found in this study could be used to identify patients who are likely to have delirium after 1 month, and may prove useful in developing and targeting interventions of care.

BACKGROUND:Delirium may persist for weeks or months, and discharging elderly patients quickly from acute care facilities is not uncommon. Therefore, the adverse impact of delirium on loss of independence may occur in the postacute setting rather than in the hospital. The purpose of this study is to describe the prevalence of delirium, delirium symptoms, and severity assessed at admission to postacute facilities.METHODS:Subjects were recruited from seven Boston-area skilled nursing facilities specializing in postacute care. Assessment instruments included the Mini-Mental Status Exam, Delirium Symptom Interview, Memorial Delirium Assessment Scale, and Confusion Assessment Method (CAM) Diagnostic Algorithm. Delirium status was categorized into four groups: full, two or more symptoms, one symptom, and no delirium. Descriptive statistics were calculated and chi-square analyses and an analysis-of-variance were used to examine delirium characteristics by delirium group.RESULTS:Among 2158 subjects, approximately 16% had full CAM-defined delirium at admission to the postacute facility. In addition, nearly 13% of the subjects had two or more symptoms of delirium, approximately 40% had one delirium symptom, and 32% had no symptoms of delirium. In a comparison of the group with no symptoms of delirium with that with CAM-defined delirium, there was a significant trend toward (a) older age, (b) lower scores on the Mini-Mental Status Exam, (c) more Delirium Symptom Interview symptoms, and (d) higher Memorial Delirium Assessment Scale Scores.CONCLUSIONS:Results indicate that 16% of admissions to postacute facilities have CAM-defined delirium, and over two thirds had at least one delirium symptom. It is not known whether or not postacute staff have the training necessary to detect or manage delirium. Managing delirium may require different strategies and techniques in a postacute setting, thereby requiring further research.

OBJECTIVES: To examine racial and state differences in the use of advance directives and surrogate decision-making in a nursing home population.DESIGN: A retrospective cohort study.SETTING: Nursing homes in the states of California (CA), Massachusetts (MA), New York (NY), and Ohio (OH).PARTICIPANTS: Nursing home residents: 130,308 in CA, 59,691 in MA, 112,080 in NY, and 98,954 in OH.MEASUREMENTS: Minimum Data Set information concerning resident race and whether or not residents have a living will (LW), a do not resuscitate (DNR) order, or a surrogate decision-maker (SDM).RESULTS: The proportion of LWs, DNR orders, and SDMs varied significantly (P < .0001) by racial categories in each state. In general, whites were distinctly different from other racial categories. Whites were significantly more likely to have a LW (odds ratio (OR) = 1.9 (CA), OR = 2.2 (NY), OR = 4.9 (OH)), a DNR order (OR = 2.4 (CA), OR = 2.4 (MA), OR = 3.3 (NY), OR = 3.2 (OH)), and a SDM (OR = 1.1 (CA), OR = 1.2 (NY), OR = 1.6 (OH)) than were nonwhites, after adjusting for potentially confounding factors. Significant state differences (P < .0001) were observed in LWs, DNR orders, and SDMs and were most pronounced in residents of Ohio, who were significantly more likely to have a LW than were residents in other states (OR = 9.3).CONCLUSIONS: Various resident characteristics explain some of the racial differences, although whites are still more likely to have a LW, a DNR order, or an SDM independent of various resident characteristics included in the adjusted analyses. This pattern is observed in all states, although the ORs varied by state. Some of these differences may be due to distinct cultural approaches to end-of-life care and lack of knowledge and understanding of advance directives. The distinctly higher rates of LWs among all racial groups in Ohio than in other states suggest that states can potentially increase the use of advance directives through intervention.