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  • Jun 09 / 2021
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Current Affairs, David McMahon

Delirium or dementia and does it matter?

Delirium and dementia are both conditions which result in a persons altered conscious. Delirium is a short term and sudden onset (hours or days) disturbance in cognition, with usually treatable causes. It is often linked to infections such as chest infections, urine infections or dehydration. This contrasts with dementia which has a slow and insidious onset (several months to years) and sadly to date has no proven cure.

So why would it be important for both researchers and health professionals to not be confused themselves about why a patient is confused?

The truth is by being clear ourselves about what an aetiology or process is, we are creating a research environment with the correct nomenclature, discourse, and standards to meaningfully make contributions to research, and communicate with fellow researchers in the field. The ultimate aim being to push our knowledge of the processes and pathophysiology forward. This is a real and present need in both delirium research and dementia research[1] [2].

As part of my MD, I looked at how delirium and dementia are clinically assessed in real healthcare settings by reviewing the current international clinical practice guidelines (CPGs) on this.  To do this we performed a systematic review of the literature and had pre-defined criteria for data extraction which yielded our CPGs to analysis. The current field had a relatively small number of CPGs addressing these important topics, and many drew on expert opinion rather than higher standards of evidence for their recommendations to clinicians.

Apart from the intrinsic value that research itself has, and the duty of clinicians to improve upon, and offer the best care, there are also compelling demographic and socio-economic reasons which I’ll discuss below.

Person/patient benefits:

While it is true that there are no current cures available for dementia, it is nonetheless still worth identifying. Diagnosing the disease or risk of disease early is still valuable, as it means that the individual and their carers have time to make choices and plan for the future, and allows access to treatments that can help manage symptoms such as the pharmacological intervention for depression, or agents designed to retard the dementias progression  [7]. It can also enable vital support for their carers.

Specifically, the detection of delirium (an acute disturbance in cognition) on its own, or superimposed with the others, allows a treatable condition (i.e., infection), or iatrogenic effect to be addressed.  This is critical, as for every 48 hours of delirium that pass, there is an 11% increase in mortality. This also enhances the likelihood a person returning to their prior functioning [8].

Demographically:

There is a rising ageing population (i.e., those adults aged 65 years old and above) in Scotland, the rest of UK, and internationally [3]. This rise is fuelling escalating rates of dementia globally, in a linear fashion in high income countries and exponentially in low and middle income countries [4]. Equally, although delirium can affect anyone it primarily affects older patients [2].

Socio-health economics:

The costs to society, and not just to the person with dementia, is stark. The total estimated worldwide costs of dementia were US$604 billion in 2010. Roughly 70% of the costs occurred in western Europe and North America. Within high-income regions, costs of informal care and the direct costs of social care contribute similar proportions of total costs with direct medical costs accounting for a much smaller share. On the other hand, in low- and middle-income countries, informal care accounts for the majority of total costs with direct social care costs being negligible [5]. What these economic costs do not factor in is the huge human costs of caring for a relative or friend with dementia.

The same review went on to say that “Despite first being described more than 2500 years ago, delirium remains frequently unrecognised and poorly understood”. In 2011 delirium “affect[ed as many] as 50% of elderly people (i.e., those aged 65 years or older) in hospital, and cost more than US$164 billion per year in the USA and more than $182 billion per year in 18 European countries combined.”.  Again, the metrics are glaring – delirium presents a huge financial challenge to healthcare systems.

Methods and Results:

Given its importance in these conditions, clinicians look to guidelines to inform the care they offer which should be drawn from evidence-based medicine​ (i.e., research). Below details the methods we use to search the relevant literature and the quality score the results before combining those results into a synthesis:

The stacked polar chart shows which CPGs scored on which domains of the AGREE quality tool (generally Scottish & UK guidelines scored well, whereas the Royal College of Physicians CPG did not):

Results-AGREE scored CPGs:  

Below is  a table of all the guidelines – what they recommend to do, broken up by how to use the recommendations into 3 categories and the grade of the evidence used to make that recommendation i.e green high, yellow moderate and red poor quality CPG. This is presented for delirium in table 1 and for dementia in table 2.

Table 1: CPG synthesis for delirium

Key:

Table 2: CPG synthesis for dementia

Conclusion:
– Answers to key clinical questions vague or not addressed
– Quality of evidence for recommendation predominantly expert opinion
– Discord between number dementia CPGs v importance of disease/prevalence & healthcare burden
– Limited geographic spread of dementia CPGs V delirium CPGs

Looking at the conclusions of our work, there are not many CPGs around how to assess cognition in dementia compared to delirium despite this huge global health burden; policy makers and public involvement in research priorities needed. There is a lack of primary research to base most recommendations on, and CPGs are not standard operating procedures for doctors to follow.    

References:

1.  The search for a cure for dementia is not going well but behavioural changes can reduce the risk of developing it: The Economist; 2020 [cited 2021 18/05/2021]; Aug 29th 2020 edition:[Available from: https://www.economist.com/special-report/2020/08/27/the-search-for-a-cure-for-dementia-is-not-going-well

2.  Delirium is prevalent in older hospital inpatients and associated with adverse outcomes: results of a prospective multi-centre study on World Delirium Awareness Day. BMC medicine. 2019;17:1-11.

3.  Economic UNDo, Affairs S. World Population Prospects: The 2010 Revision, Volume II-Demographic Profiles. UN; 2013.

4.  Nichols E, Szoeke CE, Vollset SE, et al. Global, regional, and national burden of Alzheimer’s disease and other dementias, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet Neurology. 2019;18(1):88-106.

5.  Wimo A, Jönsson L, Bond J, et al. The worldwide economic impact of dementia 2010. Alzheimers Dement. 2013 Jan;9(1):1-11.e3.

6. Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet. 2014 Mar 8;383(9920):911-22.

7. Rasmussen J, Langerman H. Alzheimer’s Disease – Why We Need Early Diagnosis. Degenerative neurological and neuromuscular disease. 2019;9:123-130.

8.  González M, Martínez G, Calderón J, et al. Impact of delirium on short-term mortality in elderly inpatients: a prospective cohort study. Psychosomatics. 2009 May-Jun;50(3):234-8.

  • Apr 06 / 2021
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Current Affairs, Sophie Westrop

The health inequalities experienced by women with intellectual disabilities: A need for more research.

I was asked to contribute to the IHAWKES special on “Women” as my PhD relates to gender differences in the physical activity and sedentary behaviour of adults with intellectual disabilities. However, I want to take this special as an opportunity to raise awareness of the health inequalities experienced by women with intellectual disabilities and express a need for more researchers to address this issue.

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  • Mar 31 / 2021
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Cara Richardson, Current Affairs

Understanding Suicide Risk in Men

Suicides in men outnumber women in almost every country in the world (Naghavi, 2019), with the exception of the 15-19 year age group. In Scotland males accounted for almost 75% of all suicide deaths in 2019 (ScotPHO, 2020). Each life lost to suicide is a preventable tragedy and more needs to be done to understand the risk factors in individuals who take their own life.

A well-known theory in this field is the Gender Paradox of Suicide (Canetto & Sakinofsky, 1998) where women are more likely to attempt suicide, but men are more likely to die by suicide. Due to this increased risk in men we need to understand which risk factors are particularly relevant in this group. Recent reviews (Franklin et al., 2017; O’Connor & Nock, 2014; Turecki & Brent, 2016; Turecki et al., 2019) have highlighted advances in our understanding of risk factors for suicide in men and women, yet our ability to predict suicide remains no better than chance.

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  • Mar 03 / 2021
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Current Affairs, Emily Tweed

NEW SUSTAINABLE TRAVEL GUIDANCE LAUNCHED: REFLECTIONS FROM A STEERING GROUP MEMBER

Almost exactly a year ago, I sat in Stirling train station on a brief break between meetings in Dundee and Glasgow, perched on a freezing metal bench and balancing my laptop, a headset, my mobile phone, and a cup of soup as I attempted to join a meeting of the Sustainable Business Travel working group. The topic? How we could encourage University of Glasgow colleagues to use Zoom as an alternative to in-person meetings.

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  • Jul 28 / 2020
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Current Affairs, Patrice Reid

BLM. By Patrice Reid

baby resting head on man's cheek. father and son.

The embrace – Two generations of black men
Photo by: Trudy Dawson, Edited by: Patrice Reid
Copyright © 2020 Trudy Dawson.

The Black Lives Matter (BLM) movement evokes many feelings and thoughts. The fact that I have to write ‘black lives matter’ or the fact that this string of words has to be said is unreal. My mind is still coming to grips with the slogan. I am coming to grips with the fact that today the BLM chant echoes centuries-old outcries for equality against chattels and injustices. Chattels and injustices imposed by one set of humans onto another who are phenotypically different, and that remain due to notions of otherness.

It is unfair. It is wrong. It is heart-breaking. It hurts.

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  • Feb 05 / 2018
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Current Affairs, David Blane

Adult weight management – Time for action not words

Photo by Hush Naidoo. © 2017 Unsplash. Used with permission under the license of Creative Commons. Via Unsplash Photos.

By David Blane

 

We hear repeatedly that obesity is one of the biggest public health problems in the UK today.  Yet there is a stark mis-match between the newspaper column inches devoted to the nation’s waistline and the resources spent on NHS adult weight management services.  

ON the 26th October 2017, the Minister for Public Health and Sport, Aileen Campbell, launched the Scottish Government’s Consultation on a Diet and Obesity Strategy for Scotland. There is much to commend in the Strategy – prevention is better than cure, and targeting resources on more ‘upstream’ determinants of obesity (changing the so-called obesogenic environment) is rightly the focus of the new Strategy (and of Obesity Action Scotland’s advocacy).

However, for a country with one of the highest obesity rates in the world (where 1 in every 4 adults lives with obesity), there is a need for action at multiple levels.  As a recent Lancet commentary argued, the distinction between population-level and individual-level approaches is a false dichotomy. Yes, we should be restricting advertising and price promotions of junk food, but we also need high quality, accessible, multi-disciplinary treatment services for those with severe and complex obesity – and not just people with type 2 diabetes (the target of the Strategy). Continue Reading

  • May 30 / 2017
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Current Affairs, Katerina Kavalidou

On 13 Reasons Why: Acknowledging those working in suicide prevention

Photo by Elisa Riva. © 2017 Pixabay. Used with permission under the license of Creative Commons. Via Startup Stock Photos.

By Katerina Kavalidou 

No matter what you are going through, there is help out there; suicide is not the solution”

The above is an important message from Professor Rory O’Connor, an expert on suicide research and prevention, regarding the recent airing of 13 Reasons Why, a TV series about a teenage girl’s suicide. Reading this, I started thinking about one particular group of people working on suicide prevention: those who pick up the calls at suicide helplines. Continue Reading

  • Oct 05 / 2016
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Current Affairs, Tiago Zortea

Suicide prevention at the individual level: The role of empathy in saving lives

Photo by Korney Violin. © Dec 2015. Used with permission under the license of Creative Commons. Via Unsplash.

Photo by Korney Violin. © Dec 2015. Used with permission under the license of Creative Commons. Via Unsplash.

By Tiago Zortea

 

Every year, the 10th of September marks world suicide prevention day, with thousands of people across the globe calling for action to reduce deaths by suicide and save lives [1]. Suicide prevention strategies can be implemented at several different levels with interventions including: (i) restricting individuals’ access to the means of suicide, (ii) promoting responsible media coverage of suicide, (iii) improving mental health care systems and training health professionals, and finally (iv) ensuring societal support for the implementation of these interventions. Continue Reading

  • Jul 05 / 2016
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Current Affairs

The Social Distribution of Physical Activity: Can Bourdieu Help?

Photo by Josiah Mackenzie © April 5, 2009. Used with permission under the license of Creative Commons.

Photo by Josiah Mackenzie © April 5, 2009. Used with permission under the license of Creative Commons.

By Dr Chris Bunn and Dr Victoria Palmer 

Chris and Victoria are at the University of Bristol this week, speaking at the annual conference of the British Sociological Association’s Bourdieu Study Group. In this blog post they reflect on the value that Bourdieu’s work on the social distribution of culture and taste could have for those working in applied health contexts, such physical activity promotion.

We are all familiar with the public health campaigns that tell us to eat at least 5 portions of fruit and veg a day, to stop smoking and limit alcohol intake, watch our weight and do regular physical activity. These messages are the most visible manifestations of the public health agenda. They operate, through campaigns such as ‘Change 4 Life’, as a form of counter-ideology that attempts to contest the many incitements to consume health-damaging foods, drinks and sedentary activities that circulate in our media-saturated societies. However, these campaigns – sometimes dubbed ‘social marketing’ – tend to take a ‘one size fits all’ approach to their audiences. Continue Reading

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