UNIVERSITY PARK, Pa. — Delirium, a sudden and usually reversible confusion, is common in hospitalized older adults and can have devasting outcomes for individuals and their care partners. It often leads to physical and cognitive decline, nursing home placement and even death — yet more than half of all cases go undetected in routine care, according to Penn State researchers.
With a $3.8 million grant from the National Institutes of Health’s National Institute on Aging, an interdisciplinary team of researchers and community partners led by Penn State and Beth Israel Deaconess Medical Center (BIDMC) in Boston will build on its previous efforts to improve screening accuracy, increase the number of healthy days an older adult spends at home and decrease complications from delirium.
Adequate screening is a critical first step in identifying and managing the impacts of delirium; with highly effective and easy-to-use tools, recovering from delirium becomes more likely, according to the research team. Diagnostic challenges can be attributed to a variety of factors, including confounding comorbidities such as dementia. Clinicians also frequently cite a lack of time and lack of confidence in delirium screening tools.
This new initiative extends a delirium screening investigation completed by the team during READI: Researching Efficient Approaches to Delirium Identification. In that study, Multiple Principal Investigator (MPI) Edward R. Marcantonio from BIDMC teamed up with Penn State Ross and Carol Nese College of Nursing professors Donna M. Fick (MPI), Marie Boltz and Erica Husser; Doug Leslie, chair of Penn State’s Department of Public Health Sciences; and others to develop, validate and conduct a cost analysis of an ultra-brief delirium screening tool to better understand how to improve time efficiency, accuracy and, ultimately, delirium identification.
Specifically, the READI team developed and 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). Further, to eliminate barriers and build confidence in screening tools, the researchers along with Long Ngo from BIDMC and John Hannan, associate professor of computer science and engineering at Penn State, developed and launched an app based on the UB-CAM and UB-2 that can be found for free on Apple or the Android store.
While READI substantially advanced clinicians’ ability to quickly detect delirium, according to the researchers, it did not test full-scale implementation of screening among hospitalized older adults.
Now, the research team — again led by Fick, the Elouise Ross Eberly Endowed Professor of Nursing and director of the Tressa Nese and Helen Diskevich Center of Geriatric Nursing Excellence (CGNE), and Marcantonio — will take this next step in READI-SET-GO (READI — Sustaining Effective Translation to create Gero-Friendly Organizations).
“Delirium is common and deadly for older adults and more common in persons with dementia and in hospitalized older adults,” Fick said. “Our study has several innovations including testing our sensitive — almost 90% accuracy with real-world clinicians — and quick — less than a minute in most older adults — screening tool in over 20,000 older adults, integrating it into practice and engaging the perspectives of caregivers and persons living with dementia to design the study and important outcomes. If successful, this will be highly impactful by providing clinicians and health systems with the best tools for managing a common and serious condition.”
The study will integrate daily delirium screening using the UB-CAM into routine care for every older adult admitted to six acute medical/surgical units at three hospitals in two states.
“We are also grateful to partner with the nursing staff and leadership at Mount Nittany Medical Center and Penn State Health in Pennsylvania and Beth Israel Deaconess Medical Center in Boston,” Fick said.
The five-year award is one of the largest restricted grants from a federal sponsor in the College of Nursing’s history.
“The Nese College of Nursing has been actively involved in gerontology research for over 25 years, contributing significantly to the field and advancing our understanding of aging and older adults’ needs,” said Judith E. Hupcey, associate dean for research and innovation and professor of Nursing and Medicine. “This new research inquiry by Dr. Fick and her team is poised to build upon the college’s past successes and expertise in gerontology and is expected to yield valuable findings that will not only benefit hospitalized older adults but also inform policy, interventions and practice.”
Researchers will launch UB-CAM screening at a new unit every six months during the 42-month study across a cohort of 20,000 older adults, including a subset with Alzheimer’s Disease and Alzheimer’s Disease-Related Dementias (AD/ADRD). Specific aims include:
- testing the fidelity, accuracy and sustainability of integrating daily nurse screening for delirium using the UB-CAM into routine care for all hospitalized older adults.
- evaluating the impact of UB-CAM delirium screening on patient and care partner-centered outcomes and perceptions of care assessed at one month follow-up interviews.
- evaluating the impact of UB-CAM screening on rates of delirium complications such as falls, pressure injury or aspiration, and adverse delirium management such as psychoactive medication or restraint use.
“We anticipate that our findings from READI-SET-GO will directly impact clinical care by advancing best practices for delirium screening, especially for vulnerable older individuals with AD/ADRD,” Marcantonio said. “Integrating rapid, accurate screening of delirium into routine care has the potential to make the hospital a safer and more ‘gero-friendly’ place and reduce distress for both hospitalized older adults and their care partners.”