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Delirium is a serious medical complication associated with poor outcomes. Given the complexity of the syndrome, prevention and early detection are critical in mitigating its effects. We used Confusion Assessment Method (CAM) screening and Electronic Health Record (EHR) data for 64,038 inpatient visits to train and test a model predicting delirium arising in hospital. Incident delirium was defined as the first instance of a positive CAM occurring at least 48 h into a hospital stay. A Random Forest machine learning algorithm was used with demographic data, comorbidities, medications, procedures, and physiological measures. The data set was randomly partitioned 80% / 20% for training and validating the predictive model, respectively. Of the 51,240 patients in the training set, 2774 (5.4%) experienced delirium during their hospital stay; and of the 12,798 patients in the validation set, 701 (5.5%) experienced delirium. Under-sampling of the delirium negative population was used to address the class imbalance. The Random Forest predictive model yielded an area under the receiver operating characteristic curve (ROC AUC) of 0.909 (95% CI 0.898 to 0.921). Important variables in the model included previously identified predisposing and precipitating risk factors. This machine learning approach displayed a high degree of accuracy and has the potential to provide a clinically useful predictive model for earlier intervention in those patients at greatest risk of developing delirium.

The purpose of this article is to describe 2 quality improvement projects aimed at embedding 2 of the 4Ms into the electronic health record for system-wide spread of Age-Friendly care. The 2 projects described in this case study serve as exemplars for the future implementation and sustainability of 4Ms care. Rapid-cycle quality improvement projects, via the Plan, Do, Study Act model, focused on the 4Ms were conducted by interprofessional teams to integrate clinical decision support for clinicians within the electronic health record. Project Senior Care Review for Evaluating and Eliminating Non-essential and potentially inappropriate medications (SCREEN) embedded a geriatric medication screen into the ordering panels of the top medications identified as being prescribed to older patients potentially inappropriately. Project Predictive Real-time Evaluation of Delirium in Clinical Therapy (PREDICT) embedded a delirium prediction rule in the electronic health records to guide clinicians to implement delirium mitigation interventions on patients at risk of developing or experiencing delirium. Outcomes were evaluated descriptively utilizing data and reports generated by the electronic health record. Embedding non-interruptive and actionable clinical decision support in the electronic health record supported the rapid spread of Age-Friendly care across a 7-hospital system. The 4Ms can be embedded into existing workflows through novel implementation of best practices by leveraging the electronic health record. By embedding 2 of the 4Ms into existing workflows and creating non-disruptive, actionable clinical decision support within the electronic health record, clinicians have the tools to implement Age-Friendly care within the 4Ms framework. Additional projects aimed at embedding the other Ms are underway, and long-term outcomes are being evaluated.

A dynamic tension exists between preventing falls and optimally mobilizing hospitalized patients. The SAFER program aimed for patients, families, and staff to collaboratively design and simultaneously operationalize patient-specific fall reduction and mobilization strategies. This pilot project was implemented on six units of a large level one trauma center. Patients were engaged in goal setting to maximize their mobilization potential while avoiding a fall during hospitalization. A poster displaying each patient's fall risk factors, corresponding mitigation strategies, and patient responsibilities served as a visual aid to assist staff, patients, and families in following the individualized safe mobilization plan. Falls and mobilization trends were measured. This project achieved a 43% reduction in falls with a trend toward increased patient mobilization over a 6-month period. This project demonstrated a patient-centered approach to promoting safe mobilization within the context of the Age-Friendly Health Systems 4Ms Framework during hospitalization.

For patients and their loved ones, delirium can be a frightening experience. A fluctuating mental status is important to identify because it often signals a need for additional treatment. The Confusion Assessment Method (CAM) diagnostic algorithm enables nurses to assess for delirium by identifying the four features of the disorder that distinguish it from other forms of cognitive impairment. It can be completed in five minutes and is easily incorporated into ongoing assessments of hospitalized patients. (This screening tool is included in the series Try This: Best Practices in Nursing Care to Older Adults, from the Hartford Institute for Geriatric Nursing at New York University's College of Nursing.) For a free online video demonstrating the use of this tool, go to http://links.lww.com/A209.

Delirium occurs in up to 25% to 50% hospitalized patients and the risk is increased for older adults with dementia. Multi-sensory stimulation has been effective in community and nursing home settings to reduce delirium in persons with dementia. This paper presents qualitative findings from field notes, observations and participant/family interviews. A sample of 25 individuals with dementia and were recruited from 2 medical units and randomized to intervention with two sessions in the multi-sensory “Hub” on 2 hospital days or receive usual care. One investigator recorded field notes prior to and during the intervention (or control). An RN in the Hub documented participant engagement. Audio-taped interviews with participants and family were recorded immediately after Hub visits. All data was transcribed and analyzed by two other team members using NVivo 12.0. Both coders reached consensus after independently coding the first 12 transcripts using open coding and descriptive content analysis. Pre-intervention data revealed common symptoms of delirium in both groups and post-intervention fatigue as a prominent theme. Participants in both groups were able to engage with the researcher and respond to interviews. Hub participants demonstrated high levels of engagement with some surprising positive responses and improvement from pre-intervention behavior. Qualitative findings from this pilot study highlight the abundance of delirium risk factors encountered by hospitalized older adults with dementia and demonstrate positive, engaging MMSE experiences, despite these risks. Further study is needed to identify longer-term impact.

Purpose: A dynamic tension exists between preventing falls and optimally mobilizing hospitalized patients. The SAFER program aimed for patients, families, and staff to collaboratively design and simultaneously operationalize patient-specific fall reduction and mobilization strategies. Method: This pilot project was implemented on six units of a large level one trauma center. Patients were engaged in goal setting to maximize their mobilization potential while avoiding a fall during hospitalization. A poster displaying each patient's fall risk factors, corresponding mitigation strategies, and patient responsibilities served as a visual aid to assist staff, patients, and families in following the individualized safe mobilization plan. Falls and mobilization trends were measured. Results: This project achieved a 43% reduction in falls with a trend toward increased patient mobilization over a 6-month period. Conclusion: This project demonstrated a patient-centered approach to promoting safe mobilization within the context of the Age-Friendly Health Systems 4Ms Framework during hospitalization.

Delirium is a common and serious postoperative complication. Subanaesthetic ketamine is often administered intraoperatively for postoperative analgesia, and some evidence suggests that ketamine prevents delirium. The primary purpose of this trial was to assess the effectiveness of ketamine for prevention of postoperative delirium in older adults. The Prevention of Delirium and Complications Associated with Surgical Treatments [PODCAST] study is a multicentre, international randomised trial that enrolled adults older than 60 years undergoing major cardiac and non-cardiac surgery under general anaesthesia. Using a computer-generated randomisation sequence we randomly assigned patients to one of three groups in blocks of 15 to receive placebo (normal saline), low-dose ketamine (0·5 mg/kg), or high dose ketamine (1·0 mg/kg) after induction of anaesthesia, before surgical incision. Participants, clinicians, and investigators were blinded to group assignment. Delirium was assessed twice daily in the first 3 postoperative days using the Confusion Assessment Method. We did analyses by intention-to-treat and assessed adverse events. This trial is registered with clinicaltrials.gov, number NCT01690988. Between Feb 6, 2014, and June 26, 2016, 1360 patients were assessed, and 672 were randomly assigned, with 222 in the placebo group, 227 in the 0·5 mg/kg ketamine group, and 223 in the 1·0 mg/kg ketamine group. There was no difference in delirium incidence between patients in the combined ketamine groups and the placebo group (19·45% vs 19·82%, respectively; absolute difference 0·36%, 95% CI −6·07 to 7·38, p=0·92). There were more postoperative hallucinations (p=0·01) and nightmares (p=0·03) with increasing ketamine doses compared with placebo. Adverse events (cardiovascular, renal, infectious, gastrointestinal, and bleeding), whether viewed individually (p value for each >0·40) or collectively (36·9% in placebo, 39·6% in 0·5 mg/kg ketamine, and 40·8% in 1·0 mg/kg ketamine groups, p=0·69), did not differ significantly across groups. A single subanaesthetic dose of ketamine did not decrease delirium in older adults after major surgery, and might cause harm by inducing negative experiences. National Institutes of Health and Cancer Center Support.

Background Delirium is a common and serious problem among acutely unwell persons. Alhough linked to higher rates of mortality, institutionalisation and dementia, it remains underdiagnosed. Careful consideration of its phenomenology is warranted to improve detection and therefore mitigate some of its clinical impact. The publication of the fifth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-5) provides an opportunity to examine the constructs underlying delirium as a clinical entity. Discussion Altered consciousness has been regarded as a core feature of delirium; the fact that consciousness itself should be physiologically disrupted due to acute illness attests to its clinical urgency. DSM-5 now operationalises `consciousness ’ as `changes in attention ’ . It should be recognised that attention relates to content of consciousness, but arousal corresponds to level of consciousness. Reduced arousal is also associated with adverse outcomes. Attention and arousal are hierarchically related; level of arousal must be sufficient before attention can be reasonably tested. Summary Our conceptualisation of delirium must extend beyond what can be assessed through cognitive testing (attention) and accept that altered arousal is fundamental. Understanding the DSM-5 criteria explicitly in this way offers the most inclusive and clinically safe interpretation.

Delirium is frequently overlooked in hospitalized adult patients of all ages. Because nurses spend significant amounts of time with patients, the nursing assessment is vital to the identification of delirium. This pilot study investigated nurses' evaluation of the Confusion Assessment Method related to ease of use and helpfulness in identifying delirium in adult patients on two hospital units. Delirium rates are reported for patients across all shifts for 1 month. The majority of nurses found the Confusion Assessment Method to be an effective, user-friendly instrument for the assessment of patients' cognitive status over time.

Abstract Introduction: Delirium occurs in up to 50% of hospitalized patients and the risk is higher in persons with dementia. Multi-sensory stimulation environments (MSSE), including trademarked “Snoezelen” rooms, have been effective in achieving positive outcomes in persons with dementia, but there have been no studies in the acute-care setting. Purpose: This pilot study tested the effect of a therapeutic Multi-sensory Stimulation Environment known as “the Hub” in an acute-care hospital. Methods: A sample of 56 patients were randomized to receive usual care or the Therapeutic Hub intervention during hospital days 2-4. Hub activities were multi-sensory and tailored based on preferences and abilities. We will describe techniques to address methodological challenges in the study with acutely ill, cognitively vulnerable participants. We will also present qualitative data describing the experience of participants receiving the Hub intervention, and will present preliminary findings regarding between group-differences in function (Functional Independence Measure), mobility, falls, wellbeing (Warwick-Edinburgh Mental Wellbeing Scale)– and person-environment relationship conceptualized as situational at-homeness (S-EOH). Conclusion: The results of this study will inform future trials on the effects of unique therapeutic environments for hospitalized persons at highest risk for delirium.