Delirium Screening in Skilled Nursing Facilities

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Journal of the American Geriatrics Society Research Summary

Delirium and Alzheimer’s disease and related dementias (ADRD) can play a role in the mental decline of older adults who enter skilled nursing facilities (SNFs) for rehabilitation after being hospitalized. Healthcare practitioners may mistake these conditions for each other or even overlook them, even though they are distinct conditions and require different treatments.

Delirium is a term that means “sudden confusion. ” It is an abrupt, rapid change in mental function that goes well beyond the typical forgetfulness of aging. Delirium is a result of abnormal functioning of the brain and requires the attention of a healthcare professional.

On the other hand, ADRD is a progressive and chronic decline in your cognitive abilities. You can have delirium and ADRD at the same time. In fact, new research reveals that delirium is a strong predictor of new ADRD cases. About 15 percent of older adults admitted to SNFs after being hospitalized have delirium, and patients with delirium have a nearly 13 percent increased risk of receiving a new diagnosis of ADRD over the next four years.

Delirium and ADRD can be difficult for healthcare practitioners to tell apart, and older adults can have both conditions at the same time. However, the two conditions have not been studied together in older adults admitted to skilled nursing facilities.

In order to learn more about the relationship between delirium detection and a potentially premature or inappropriate diagnosis of ADRD, researchers conducted a study. They based their findings on their examination of Medicare data from 2011-2013 for new nursing home admissions. The study was published in the Journal of the American Geriatrics Society.

Detecting delirium in the nursing home setting makes it easier for healthcare practitioners to address its underlying causes (which may include medications), and to develop a care plan to prevent complications and promote recovery. Screening for delirium also helps distinguish delirium from ADRD and is required by the Medicare program for all skilled nursing care admissions as part of a patient’s initial evaluation. If delirium is detected, current guidelines recommend that healthcare practitioners hold off from diagnosing ADRD until the delirium has resolved.

Delirium can last for months, although most cases resolve within 30 days of a patient’s admission to the SNF. Diagnosing ADRD while delirium symptoms are still present may result in misdiagnosis. In fact, misdiagnosis rates of ADRD are common and range from 18 to 85 percent.

In this study, the researchers assessed delirium by noting positive test results for delirium using the proven Confusion Assessment Method (CAM), a test that health care professionals use to identify and recognize delirium quickly and accurately.  A positive test for delirium requires acute onset or quickly changing symptoms along with inattention and either disorganized thinking or an altered level of consciousness.

The researchers found that a positive test for delirium is significantly linked to a dementia (ADRD) diagnosis in the skilled nursing home setting. The risk of an ADRD diagnosis following a positive delirium screen is highest for patients in the first days of their nursing home stay.

They concluded that among older adults without evidence of dementia, a positive test for delirium upon their admittance to a skilled nursing facility is strongly linked to the risk for a new ADRD diagnosis. This risk of receiving an ADRD diagnosis was highest immediately after a positive test for delirium, and among patients with the least cognitive impairment. Study findings suggest there is the potential for premature or inappropriate diagnosis of ADRD among older adults admitted to skilled nursing facilities with delirium.

This summary is from “Association of Positive Delirium Screening with Incident Dementia in Skilled Nursing Facilities.” It appears online ahead of print in the Journal of the American Geriatrics Society. The study authors are Becky A. Briesacher, PhD; Benjamin Koethe; Brianne Olivieri-Mui, PhD; Jane S. Saczynski, PhD; Donna Marie Fick, PhD, GCNS-BC; John W. Devlin, PharmD; and Edward R. Marcantonio, MD, SM.

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