Delirium in nursing homes: the continued case of B.M

This article considers current contemporaneous practical issues of delirium care in nursing homes with reference to a hypothetical case study B.M. I introduce the diagnosis and management of delirium-superimposed-on-dementia (DSD), being relatively common in patients in advanced phases of illness of many nursing home residents. General principles are discussed, although this article applies mainly to higher income countries. There is inevitably much palliative and end-of-life care in nursing homes, necessitating rigorous advance care planning. Nursing home residents are especially prone to acquiring infections. Urinary tract infections (UTIs) are traditionally the most commonly treated infection among nursing home residents and, indeed, the accurate diagnosis of a UTI poses significant and distinctive challenges in the nursing home setting. There is no denying, however, that recently the global coronavirus (SARS-CoV-2) pandemic has posed an existential threat to both staff and residents of nursing homes. Resident-focused factors are striking. Psychotropic drugs are the most frequently prescribed medications in European nursing homes, but medication errors in nursing homes in general are relatively prevalent. Contributing factors to a high burden from pain for residents include residents belief set that age-related pain is inevitable, as well as under-recognition of pain and inappropriate pain assessment by clinicians. Dehydration is associated with frailty, poor cognition, falls, delirium, disability, and mortality. Issues relating to the environment also matter. It is also impossible to ignore the organisational constraints on the provision of high quality care. Faced with widespread staffing shortages, and many economies in financial distress, one partial solution is to retain current staff longer in nursing homes. Research on nursing home staffing has expanded beyond just staffing levels to include multiple other staffing issues of concern.