Donna M. Fick, PhD, GCNS-BC, Associate Professor of Nursing, School of Nursing, Pennsylvania State University, University Park, PA, USA.
Ann Kolanowski, PhD, RN, FAAN, Elouise Ross Eberly Professor of Nursing, School of Nursing, Pennsylvania State University, University Park, PA, USA.

Delirium superimposed on dementia (DSD) is common, is associated with poor clinical and economic outcomes, and occurs across all settings of care. In this article, we briefly review outcomes of DSD, propose the idea of cognitive reserve as a possible mechanism for interventions that prevent and manage DSD, and present the evidence for delirium interventions. We conclude with implications for practice and suggest web-based resources for supporting best practices in the care of persons with DSD.
Key words: delirium, dementia, prevention, interventions, cognitive reserve.

Tarek Rajji, MD, Geriatric Mental Health Program, Centre for Addiction and Mental Health; Department of Psychiatry, University of Toronto, Toronto, ON.
Benoit H. Mulsant, MD, MSc, FRCPC, Western Psychiatric Institute and Clinic and Department of Psychiatry, University of Pittsburgh, Pittsburgh, USA; Geriatric Mental Health Program, Centre for Addiction and Mental Health; Department of Psychiatry, University of Toronto, Toronto, ON.
Hiroyuki Uchida, MD, PhD, PET Centre, Centre for Addiction and Mental Health, Toronto, ON.
David Mamo, MD, MSc, FRCPC, PET Centre and Geriatric Mental Health Program, Centre for Addiction and Mental Health; Department of Psychiatry, University of Toronto; Centre for Addiction and Mental Health, Toronto, ON.

Antipsychotics are increasingly being prescribed to older patients for the management of a variety of neuropsychiatric conditions. Available evidence supports the use of second-generation antipsychotics (SGAs) when treating these conditions. However, given their modest clinical effect for certain conditions (e.g., behavioural and psychological symptoms of dementia), their adverse effects, and their safety profile, a careful analysis of their risks and benefits is needed before initiating treatment with an SGA for an older patient. Among SGAs, choice of medication should be guided by their respective clinical indications and adverse effect profile, with use of lower initial and target doses (compared to younger adults) and periodic reviews of whether or not their continued use is warranted.
Key words: antipsychotics, older adults, dementia, delirium, schizophrenia.

Sudeep S. Gill, MD, MSc, FRCPC, Assistant Professor, Division of Geriatric Medicine, Queen’s University, Kingston, ON.

Delirium is common among hospitalized older adults and is associated with significant morbidity and excess mortality. Despite its prevalence and consequences, delirium is often underrecognized and undertreated. Antipsychotic drugs are commonly used to manage symptoms of delirium, but few controlled trials exist to support their efficacy and safety in this setting. Several recent studies have focussed on preventing delirium in high-risk populations. Clinical trials have demonstrated benefits with multifaceted nonpharmacological interventions, but widespread implementation of these interventions has not yet occurred. Two recent drug trials evaluated an antipsychotic and a cholinesterase inhibitor to prevent delirium, but neither trial demonstrated a reduction in incident delirium. At present, the most promising approach involves targeted, multifactorial interventions that focus on preventing delirium in high-risk patient groups. More work is needed to facilitate the implementation of these evidence-based strategies.
Key words: delirium, prevention, treatment, antipsychotic drugs, cholinesterase inhibitors.

Lynn McNicoll, MD, FRCPC, Department of Internal Medicine, Brown University School of Medicine, Providence, RI.

Delirium in older hospitalized persons in non-critical care settings is associated with higher morbidity, mortality, and worse long-term outcomes. Delirium in critically ill persons is a growing field of research. This article presents recent research indicating a high frequency of delirium in critical care. Several studies have shown that delirium in critical care is associated with poor short-term as well as long-term outcomes, including increased length of stay, persistent cognitive deficits, and hospital and one-year mortality. Further research on strategies to prevent delirium in critical care may improve short- and long-term outcomes.

Key words: delirium, critical care, aging, outcomes, older adults.

Anna T. Monias, MD, Erickson Retirement Communities, Oak Crest Village, Parkville, MD.

Kenneth S. Boockvar, MD, MS, Assistant Professor, Brookdale Department of Geriatrics and Adult Development, Mount Sinai School of Medicine; Investigator, Program of Research on Serious Physical and Mental Illness, Bronx Veterans Affairs Medical Center, Geriatric Research, Education, and Clinical Center, New York, NY.

Acute illness often presents atypically in long-term care patients. Atypical presentation refers to the lack of one or more symptoms or signs that usually indicate acute illness. Due to underlying medical illness, nursing home patients with acute infection, metabolic disorders, and even surgical emergencies frequently present with delirium, malaise, or weakness. Nursing assistants are often the first to recognize these non-specific indicators. It is imperative that researchers include assessments by nursing assistants when developing and validating tools to recognize early but atypical indicators of disease.

Key words: long-term care facility, atypical presentation, delirium, nursing assistants, non-specific symptoms.

Rola Moghabghab, RN, MN,¹ Lori Adler, RN, MHSc,² Carol Banez, RN, MAN,¹ Faith Boutcher RN, MSc,³ Athina Perivolaris, RN, MN,³ Donna-Michelle Rancoeur, RN, MSc(A),³ Donna Spevakow, RN, MSN,³ Sandra Tully, RN, MAEd,¹ Susan Wallace, RN, MSc³ and Kevin Woo, RN, MSc.<sup>4

1</sup>Advanced Practice Nurse, University Health Network; ²Administrative Director, Regional Geriatric Program, Toronto Rehabilitation Institute; ³Advanced Practice Nurse, Toronto Rehabilitation Institute; ⁴Advanced Practice Nurse, Mount Sinai Hospital; Toronto, ON.

Confusion related to dementia, delirium and/or depression is a common concern in the older adult. The Registered Nurses Association of Ontario Best Practice Guideline (BPG),"Screening for Delirium, Dementia and Depression in the Older Adult", was implemented as a pilot project by Advanced Practice Nurses on eight different units at Toronto Rehabilitation Institute, University Health Network and Mount Sinai Hospital. This article describes the development of the BPG and its implementation, including the design of an education program and a screening process to assist nurses. Discussion focuses on the facilitators and barriers to BPG implementation and effecting sustainable change in practice.

Yoanna Skrobik, MD, FRCP(C), Director, Adult Critical Care Training Program, Université de Montreal; Associate Professor, Faculty of Medicine, Université de Montreal, Montreal, QC.

Delirium is a morbid and common complication in the critically ill patient. Its recognition is made more difficult by the inability to interview the intubated patient, and by the presence of drugs and confounding comorbidities. Delirium screening (described with the ICDSC and the CAM-ICU) with tools specifically designed for the acute care setting can help the nurse or clinician identify its presence. Risk factors for delirium in the critical care setting differ from those described in other populations. Treatment is currently empiric.
Key words: delirium, critical care, outcomes, intensive care, screening.

Jane McCusker, MD, DrPH, Professor, Epidemiology and Biostatistics, McGill University; Head, Clinical Epidemiology and Community Studies, St. Mary's Hospital, Montreal, QC.

Nine published studies of the outcomes of delirium with at least six months of follow-up were reviewed. The results indicate that: 1) the symptoms of delirium are more persistent than previously thought; up to 15% of those without dementia and 49% of those with dementia continued to have core symptoms of delirium 12 months after the initial diagnosis; 2) a diagnosis of delirium is an independent predictor of increased mortality for up to three years after diagnosis and; 3) a diagnosis of delirium predicts continued poorer cognitive and physical functioning for up to 12 months after diagnosis.
Key words: delirium, prognosis, dementia, functioning, cognitive status.

James L. Rudolph, MD, SM, Division of Aging, Brigham and Women's Hospital and the Boston VA Geriatric Research, Education, and Clinical Center, Boston, MA.

Edward R. Marcantonio, MD, SM, Hebrew Rehabilitation Center for Aged and Beth Israel Deaconess Medical Center, Boston, MA.

Delirium is a common syndrome in hospitalized older patients that is frequently undiagnosed by health care professionals. This is particularly troubling because delirium is associated with poor outcomes such as increased nursing home placement, nosocomial infections and increased mortality. Criteria for the diagnosis of delirium are validated, reliable and can readily be applied to patients by health care professionals. Solid evidence exists that delirium can be prevented with educated prescribing of medications, practical in-hospital interventions and geriatric consultation.
Key words: delirium, differential diagnosis, prevention, Confusion Assessment Method.

I am writing this editorial shortly after returning from the 2nd Canadian Colloquium on Dementia (CCD2), held from October 16-18 in Montreal. This was one of the finest meetings I have ever attended, and if you are interested in cognitive disorders you should reserve time to attend the next meeting, planned for 2005 in Ottawa.

Several of the topics in this issue of Geriatrics & Aging also were addressed at the Colloquium. The crucial issue of recognizing delirium (and dementia and depression) is addressed here by Rola Moghabghab and her colleagues, as they describe the process of implementing nursing best practice guidelines for the recognition of these disorders.

Although there are proven strategies for handling these concerns, recognition is crucial in order for these to be implemented. Several of the speakers at the CCD2 also commented on the issue of what happens after delirium. Dr. Jane McCusker addresses this topic more systematically in her article on the long-term prognosis of delirium.

The theme of under-recognition of delirium and its consequences is addressed more comprehensively by Drs. James L. Rudolph and Edward R. Marcantonio, followed by articles that examine delirium in more specific settings. Dr. Yoanna Skrobik discusses the recognition and management of delirium in the critical care setting, while Dr. Lars S. Rasmussen reviews the detection and prevention of postoperative cognitive dysfunction in older adults. Although the incidence of postoperative delirium is quite variable, it can reach as high as 50% in certain circumstances (older patients with hip fractures), and is a considerable concern whenever it does occur. In fact, I am writing this editorial immediately after seeing a patient in clinic who says, with confirmation from her daughter, that her memory has never returned to normal since her coronary artery bypass surgery six years ago.

We also have our usual varied collection of columns in this issue. Dr. Joseph H. Friedman reviews the incredibly common issue of drug-induced parkinsonism in older adults, while Dr. Osman O. Al-Radi discusses the pathophysiology of mitral regurgitation and its implications for surgical management. Our senior editor, Dr. Shabbir Alibhai, and his colleagues Drs. Foster and Oughton have reviewed the literature on the role of calcium and vitamin D3 supplementation for the primary prevention of fractures.

Enjoy this issue, and I hope to see you in Ottawa for the 3rd Canadian Colloquium on Dementia.