Abstract
BackgroundNursing home residents are frail, have multiple medical comorbidities, and are at high risk for delirium. Most of the existing evidence base on delirium is derived from studies in the acute in-patient population. We examine the association between clinical characteristics and medication use with the incidence of delirium during the nursing home stay.MethodsThis is a retrospective cohort study of 1571 residents from 12 nursing homes operated by a single care provider in Ontario, Canada. Residents were over the age of 55 and admitted between February 2010 and December 2015 with no baseline delirium and a minimum stay of 180 days. Residents with moderate or worse cognitive impairment at baseline were excluded. The baseline and follow-up characteristics of residents were collected from the Resident Assessment Instrument-Minimal Data Set 2.0 completed at admission and repeated quarterly until death or discharge. Multivariate logistic regression was used to identify characteristics and medication use associated with the onset of delirium.ResultsThe incidence of delirium was 40.4% over the nursing home stay (mean LOS: 32 months). A diagnosis of dementia (OR: 2.54, p < .001), the presence of pain (OR: 1.64, p < .001), and the use of antipsychotics (OR: 1.87, p < .001) were significantly associated with the onset of delirium. Compared to residents who did not develop delirium, residents who developed a delirium had a greater increase in the use of antipsychotics and antidepressants over the nursing home stay.ConclusionsDementia, the presence of pain, and the use of antipsychotics were associated with the onset of delirium. Pain monitoring and treatment may be important to decrease delirium in nursing homes. Future studies are necessary to examine the prescribing patterns in nursing homes and their association with delirium.
Highlights
Nursing home residents are frail, have multiple medical comorbidities, and are at high risk for delirium
We excluded 762 (19.1%) residents who had a Confusion Assessment Method (CAM) defined delirium at baseline, 1486 residents (37.3%) with moderate to severe cognitive impairment based on the Cognitive Performance Scale (CPS), and 78 residents (2.0%) with moderate to severe communication difficulties
A diagnosis of dementia, Activities of Daily Living (ADL) impairment, reporting pain, bowel incontinence, and the use of analgesics and antidepressants were common at baseline
Summary
Nursing home residents are frail, have multiple medical comorbidities, and are at high risk for delirium. Older adults who live in nursing home facilities are frail with multiple medical comorbidities, including dementia, that put them at higher risk for delirium [6]. While studies suggest that some of the predisposing and precipitating factors for delirium in nursing homes (e.g. acute illness, depression, and dementia [7,8,9]) are similar to those found among hospitalized patients, there are notable differences in the course of delirium [2, 3] and patients’ exposure to stressors. The association between inadequate pain control and delirium has been studied repeatedly in the acute postoperative hip fracture population [11, 12], but there is little evidence from the nursing home setting. The use of acetaminophen for pain control has been shown to significantly reduce agitation among nursing home residents with moderate to severe dementia [13], but evidence suggests that analgesic use for long-term pain control has no impact on the rate of delirium [14]
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