Evaluation and Management of Delirium

Delirium, sometimes referred to as encephalopathy, is an acute confusional state that is both common in hospitalized patients and associated with poor outcomes. For patients, families, and caregivers, delirium can be a traumatic experience. While delirium is one of the most common diagnoses encountered by the consulting neurologist, the majority of the time it will have been previously unrecognized as such by the care team. Neurologic syndromes such as dementia or aphasia can either be misdiagnosed as delirium or may coexist with it, necessitating careful neurologic assessment. Once the diagnosis of delirium has been established, a careful evaluation for predisposing and precipitating factors can help uncover modifiable contributors, which should be addressed as part of a multicomponent, primarily nonpharmacologic intervention. Importantly, delirium management, which begins with comprehensive prevention, should emphasize the humanity of the delirious patient and the challenges of caring for this vulnerable population. When considered, delirium represents an important opportunity for the neurologist to substantially enhance patient care.

A longitudinal evaluation of family caregivers’ willingness to pay for an in-home nonpharmacologic intervention for people living with dementia: results from a randomized trial

Objective: To determine the willingness-to-pay (WTP) of family caregivers to learn care strategies for persons living with dementia (PLwD). Design: Randomized clinical trial. Setting: Community-dwelling PLwD and their caregivers (dyads) in Maryland and Washington, DC. Participants: 250 dyads. Intervention: Tailored Activity Program (TAP) compared to attention control. TAP provides activities tailored to the PLwD and instructs caregivers in their use. Measurement: At baseline, 3 and 6 months, caregivers were asked their WTP per session for an 8-session 3-month in-home nonpharmacologic intervention to address behavioral symptoms and functional dependence. Results: At baseline, 3 and 6 months, caregivers assigned to TAP were willing to pay $26.10/session (95%CI:$20.42, $33.00), $28.70 (95%CI:$19.73, $39.30), and $22.79 (95%CI: $16.64, $30.09), respectively; attention control caregivers were willing to pay $37.90/session (95%CI: $27.10, $52.02), $30.92 (95%CI: $23.44, $40.94), $27.44 (95%CI: $20.82, $35.34), respectively. The difference in baseline to 3 and 6 months change in WTP between TAP and the attention control was $9.58 (95%CI: −$5.00, $25.47) and $7.15 (95%CI: −$5.72, $21.81). The difference between TAP and attention control in change in the proportion of caregivers willing to pay something from baseline to 3 and 6 months was −12% (95%CI: −28%, −5%) and −7% (95%CI:−25%, −11%), respectively. The difference in change in WTP, among caregivers willing to pay something, between TAP and attention control from baseline to 3 and 6 months was $17.93 (95%CI: $0.22, $38.30) and $11.81 (95%CI: −$2.57, $28.17). Conclusions: Family caregivers are willing to pay more for an intervention immediately following participation in a program similar to which they were asked to value.

A Systematic Review of Assessments and Interventions for Chronic Pain in Young Children With or at High Risk for Cerebral Palsy

Background: Pain is common in children with cerebral palsy. The purpose of this systematic review was to evaluate the evidence regarding assessments and interventions for chronic pain in children aged ≤2 years with or at high risk for cerebral palsy. Methods: A comprehensive literature search was performed. Included articles were screened using PRISMA guidelines and quality of evidence was reviewed using best-evidence tools by independent reviewers. Using social media channels, an online survey was conducted to elicit parent preferences. Results: Six articles met criteria. Parent perception was an assessment option. Three pharmacologic interventions (gabapentin, medical cannabis, botulinum toxin type A) and 1 nonpharmacologic intervention were identified. Parent survey report parent-comfort and other nonpharmacologic interventions ranked as most preferable. Conclusion: A conditional GRADE recommendation was in favor of parent report for pain assessment. Clinical trials are sorely needed because of the lack of evidence for safety and efficacy of pharmacologic interventions.

CHANGE IN DEMENTIA FAMILY CAREGIVERS’ WILLINGNESS TO PAY FOR A NONPHARMACOLOGIC INTERVENTION

Family caregivers provide a majority of care for persons with dementia (PwD); however, little is known about caregiver’s willingness to pay (WTP) for an intervention to help them manage dementia symptoms. To fill this gap, caregiver/PwD dyads (n=223) were recruited to participate in a randomized trial evaluating tailored activities to minimize behavioral symptoms and functional decline. At baseline and 6-months caregivers were asked their WTP per session for the 8-session 3-month program compared to caregiver education/support only. At baseline, treatment caregivers were WTP $26.20, which was $11.50 (95%CI:-$12.70, -$10.3) less per session compared to control group caregivers WTP $37.30. At 6-months, treatment caregivers were WTP $22.90 and control caregivers $27.30. From baseline to 6-months, a change in WTP was $7.00 (95%CI:$5.80, $8.30) greater than the change in WTP for control group caregivers. Caregivers WTP slightly decreases over time in both groups but decrease is less for TAP following program participation.

Nationally Representative Estimates of Serum Testosterone Concentration in Never-Smoking, Lean Men Without Aging-Associated Comorbidities

Context Testosterone deficiency prevalence increases with age, comorbidities, and obesity. Objective To inform clinical guidelines for testosterone deficiency management and development of targets for nonpharmacologic intervention trials for these men, we determined serum testosterone in never-smoking, lean men without select comorbidities in nationally representative surveys. Design, Setting, Participants We used cross-sectional data for never-smoking, lean men ≥20 years without diabetes, myocardial infarction, congestive heart failure, stroke, or cancer, without use of hormone-influencing medications, and participated in morning sessions of National Health and Nutrition Examination Survey (NHANES) III (phase I 1988–1991) or continuous NHANES (1999–2004). By age, we determined median total testosterone (ng/mL) measured previously by a Food and Drug Administration-approved immunoassay and median estimated free testosterone concentration. Results In NHANES III, in never-smoking, lean men without comorbidities, median (25th, 75th percentile) testosterone was 4% to 9% higher than all men—20 to 39 years: 6.24 (5.16, 7.51), 40 to 59: 5.37 (3.83, 6.49), and ≥60: 4.61 (4.01, 5.18). In continuous NHANES, in never-smoking, lean men without comorbidities, levels were 13% to 24% higher than all men—20 to 39 years: 6.26 (5.32, 7.27), 40 to 59: 5.86 (4.91, 6.55), and ≥60: 4.22 (3.74, 5.73). In never-smoking, lean men without comorbidities, median estimated free testosterone was similar to (NHANES III) or slightly higher than (continuous NHANES) in all men. Conclusions These nationally representative data document testosterone levels (immunoassay) in never-smoking, lean men without select comorbidities 30 and 15 to 20 years ago. This information can be incorporated into guidelines for testosterone deficiency management and used to develop targets for nonpharmacologic intervention trials for testosterone deficiency.

Pearls and pitfalls of bathing in atopic dermatitis

The latest guidelines of the American Academy of Dermatology suggest bathing as an advantageous nonpharmacologic intervention for regular skin care of patients with atopic dermatitis. Regular bathing with water can hydrate the skin, remove scale, crust, irritants, and allergens, enhance penetration of topical agents, and potentially reduce bacterial colonization. However, it is still unclear whether the addition of oils, emollients, and other additives to bath water may produce further benefits for the management of atopic dermatitis. This article will review current pearls and pitfalls of adding salts and nonirritating, nonsensitizing substances to water baths for the long-term maintenance treatment of atopic dermatitis in children.