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Delirium is a major health care problem with potentially serious consequences. Sub-optimal management is an unfortunate but pervasive hallmark of the disorder. We argue that lapses in the care of delirious patients are related to the peculiarities of delirium as a disorder that affects the “self” of the sufferer. Therefore, corruption of self renders behaviour outside the control of the delirious individual and places the person at risk of mechanistic dehumanisation. A proposed solution is to foster an expanded view of the self, taken from recent philosophy and cognitive science, which would allow the clinician to understand pathological behaviour as indicative of disruption to thought. An ethics of care approach that reframes the patient/carer relationship is proposed. These unique propositions could, together, facilitate the development of a framework of more caring and effective practices and relationships for delirium treatment.
This work builds on a survey first done in 1999 to understand how old age psychiatry teaching is embedded in undergraduate medical schools in the UK and Ireland and the influence of academic old age psychiatrists on teaching processes. We invited deans of 31 medical schools in the UK and Ireland in 2015 to complete an online survey to reassess the situation 16 years later.
Response rate was 74%. As found in the original survey, there was variation across medical schools in how old age psychiatry is taught. Half of schools stated there was not enough space in the curriculum dedicated to old age psychiatry, and not all medical school curricula offered a clinical attachment. Medical schools that involved academic old age psychiatrists in teaching (59%) showed a greater diversity of teaching methods.
There is a need to recognise the importance of old age psychiatry teaching, with the consensus of opinion continuing to be that more curriculum space needs to be given to old age psychiatry. To achieve this we advocate increasing the number of old age psychiatrists with teaching roles, as relying on academics to teach and lead on curriculum development is challenging given their greater research pressures.
The co-occurrence of physical and mental ill health means there is considerable overlap between the patients that geriatric medicine and old age psychiatry serve. In this editorial we detail similarities between the specialisms, highlight the common challenges facing them and argue that closer alignment holds the potential to improve patient care.
Despite awareness of the negative health and financial outcomes of delirium, systems to routinely assess and manage the condition are absent in clinical practice. We report the development and pilot evaluation of a Delirium Early Monitoring System (DEMS), designed to be completed by non-medical staff to influence clinical processes within inpatient settings. Two versions of the DEMS are described based on a modified Confusion Assessment Method (DEMS-CAM) and Delirium Observation Screening Scale (DEMS-DOSS).
Both versions of DEMS were piloted on a 20-bedded Psychogeriatric ward over 6 weeks. Training was administered to ward staff on the use of each version of the DEMS and data were collected via electronic medical records and completed assessment sheets. The primary outcome was patterns of DEMS use and the secondary outcome was the initiation of delirium management protocols. Data regarding the use of the DEMS DOSS and DEMS CAMS were analyzed using χ2 tests.
Completion rates for the DEMS CAM and DEMS DOSS were 79% and 68%, respectively. Non-medical staff were significantly more likely to use the DEMS-CAM as part of daily practice as opposed to the DEMS-DOSS (p<0.001). However, there was no difference between the use of the DEMS-CAM and DEMS-DOSS in triggering related actions such as documentation of assessment scores in patients’ medical records and implementation of delirium management protocols.
This real world evaluation revealed that non-medical staff were able to incorporate delirium monitoring into their practice, on the majority of occasions, as part of their daily working routine. Further research is necessary to determine if the routine use of the DEMS can lead to improved understandings and practice of non-medical staff regarding delirium detection.
Despite advances in delirium knowledge and the publication of best practice guidelines, uncertainties exist regarding assessment of Delirium Superimposed on Dementia (DSD). An international survey of delirium specialists was undertaken to evaluate current practice.
Invitations to participate in an online survey were distributed by email among members of four international delirium associations with additional publication on their websites. The survey covered the assessment and diagnosis of DSD in clinical practice and research studies. Questions were structured around current practice and attitudes.
The 205 responders were mostly confident that they could detect DSD with 60% rating their confidence at 7 or above on a likert scale of 0 (none) to 10 (excellent). Seventy-six percent felt that Dementia with Lewy Bodies (DLB) was the most challenging dementia subtype in which to diagnose DSD. Several scales were used to assess for the presence of DSD including the Confusion Assessment Method (CAM) (54%), DSM-5 criteria (25%) and CAM-ICU (15%). Responders stated that attention (71%), fluctuation in cognitive status (65%), and arousability (41%) were the most clinically useful features to assess when diagnosing DSD. Motor fluctuations were also deemed important but 61% had no specific test to monitor these.
The largest survey of DSD practice to date demonstrates that despite good levels of confidence in recognizing DSD, there exists a lack of consensus concerning assessment and diagnosis globally. These findings suggest the need for the development of more research leading to precise diagnostic criteria and comprehensive guidelines regarding the assessment and diagnosis of DSD.
This editorial discusses current challenges faced by educators in
undergraduate psychiatry in a community setting. It explores day-to-day
difficulties faced by clinical educators and also considers the changing
landscape of community services and how this might have an impact on
learning opportunities. We call for efforts to improve undergraduate
teaching in community psychiatry.
Background: Effectiveness of educational interventions targeted at improving delirium care is limited by implementation barriers. Studying factors which shape learning needs can overcome these knowledge transfer barriers. This in-depth qualitative study explores learning needs of hospital staff relating to care needs of the confused older patients.
Methods: Fifteen research participants from across the healthcare spectrum working within an acute care setting were interviewed. Five focus groups were undertaken with patients, carers, and mental health specialists. A Grounded Theory methodology was adopted and data were analyzed thematically in parallel to collection until theoretical saturation was reached.
Results: Eight categories of practice gap emerged: ownership of the confused patient, negative attitudes, lack of understanding of how frightened the patient is in hospital, carer partnerships, person-centered care, communication, recognition of cognitive impairment and specific clinical needs (e.g. capacity assessments). Conceptually, the learning needs were found to be hierarchically related. Moreover, a vicious circle relating to the core learning needs of ownership, attitudes and patient's fear emerged. A patient with delirium may be frightened in an alien environment and then negatively labeled by staff who subsequently wish for their removal, thereby worsening the patient's fear.
Discussion: These findings reconceptualize delirium education approaches suggesting a need to focus interventions on core level practice gaps. This fresh perspective on education, away from disease-based delirium knowledge toward work-based patient, team and practice knowledge, could lead to more effective educational strategies to improve delirium care.
Brain white matter changes (WMC) and depressive symptoms are linked, but the directionality of this association remains unclear.
To investigate the relationship between baseline and incident depression and progression of white matter changes.
In a longitudinal multicentre pan-European study (Leukoaraiosis and Disability in the elderly, LADIS), participants aged over 64 underwent baseline magnetic resonance imaging (MRI) and clinical assessments. Repeat scans were obtained at 3 years. Depressive outcomes were assessed in terms of depressive episodes and the Geriatric Depression Scale (GDS). Progression of WMC was measured using the modified Rotterdam Progression scale.
Progression of WMC was significantly associated with incident depression during year 3 of the study (P = 0.002) and remained significant after controlling for transition to disability, baseline WMC and baseline history of depression. There was no significant association between progression of WMC and GDS score, and no significant relationship between progression of WMC and history of depression at baseline.
Our results support the vascular depression hypothesis and implicate WMC as causal in the pathogenesis of late-life depression.
Background: Deficiencies in the knowledge, skills and attitudes of all healthcare professionals working within the general hospital contribute towards the suboptimal care of older hospitalized patients with confusion. In the U.K., policy dictates that Liaison Old Age Psychiatry teams deliver effective education to general hospital clinical staff. The purpose of this paper is to review the literature concerning the learning needs of healthcare professionals in relation to managing confusion in the older patient in order to inform effective educational approaches for Liaison Old Age Psychiatry teams.
Methods: A broad range of medical and educational databases were searched. Identified English language studies were selected for further analysis if they had a specific educational focus in the hospital setting and then further subdivided into intervention and naturalistic studies. The impact of intervention studies was evaluated by Kirkpatrick's system. Learning needs, as determined from the naturalistic studies, were mapped to identify themes.
Results: 13 intervention studies were identified. Despite a high level of effectiveness for educational interventions, it was unclear what the active components were. A further 23 naturalistic studies were identified; their findings focused on knowledge gaps, diagnostic behaviors and experiences, attitudes and training issues. Few studies specifically researched learning needs or the educational role of liaison teams. Conspicuous by its absence was reference to relevant educational theories.
Conclusions: The findings of this review can be incorporated in the planning of local curricula by Liaison Teams in order to design educational strategies. There is a need for further research, especially studies exploring the learning needs of all healthcare professionals.
Evidence from cross-sectional studies suggests a link between cerebral age-related white matter changes and depressive symptoms in older people, although the temporal association remains unclear.
To investigate age-related white matter changes on magnetic resonance imaging (MRI) as an independent predictor of depressive symptoms at 1 year after controlling for known confounders.
In a pan-European multicentre study of 639 older adults without significant disability, MRI white matter changes and demographic and clinical variables, including cognitive scores, quality of life, disability and depressive symptoms, were assessed at baseline. Clinical assessments were repeated at 1 year.
Using logistic regression analysis, severity of white matter changes was shown to independently and significantly predict depressive symptoms at 1 year after controlling for baseline depressive symptoms, quality of life and worsening disability (P<0.01).
White matter changes pre-date and are associated with the development of depressive symptoms. This has implications for treatment and prevention of depression in later life.