Early detection of delirium in older medical inpatients: prodrome, predictors and motor subtyping

Background Delirium is highly prevalent, especially in older patients. It independently leads to adverse outcomes, but remains under-detected, particularly hypoactive forms. Although early identification and intervention is important, delirium prevention is key to improving outcomes. The delirium prodrome concept has been mooted for decades, but remains poorly characterised. Greater understanding of this prodrome would promote prompt identification of delirium-prone patients, and facilitate improved strategies for delirium prevention and management. Methods Medical inpatients of ≥70 years were screened for prevalent delirium using the Revised Delirium Rating Scale (DRS--‐R98). Those without prevalent delirium were assessed daily for delirium development, prodromal features and motor subtype. Survival analysis models identified which prodromal features predicted the emergence of incident delirium in the cohort in the first week of admission. The Delirium Motor Subtype Scale-4 was used to ascertain motor subtype. Results Of 555 patients approached, 191 patients were included in the prospective study. The median age was 80 (IQR 10) and 101 (52.9%) were male. Sixty-one patients developed incident delirium within a week of admission. Several prodromal features predicted delirium emergence in the cohort. Firstly, using a novel Prodromal Checklist based on the existing literature, and controlling for confounders, seven predictive behavioural features were identified in the prodromal period (for example, increasing confusion; and being easily distractible). Additionally, using serial cognitive tests and the DRS-R98 daily, multiple cognitive and other core delirium features were detected in the prodrome (for example inattention; and sleep-wake cycle disturbance). Examining longitudinal motor subtypes in delirium cases, subtypes were found to be predominantly stable over time, the most prevalent being hypoactive subtype (62.3%). Discussion This thesis explored multiple aspects of delirium in older medical inpatients, with particular focus on the characterisation of the delirium prodrome. These findings should help to inform future delirium educational programmes, and detection and prevention strategies.

Women's help seeking behaviour and the associated influencing factors on self discovery of a breast symptom

To investigate women’s help seeking behavior (HSB) following self discovery of a breast symptom and determine the associated influencing factors. A descriptive correlation design was used to ascertain the help seeking behavior (HSB) and the associated influencing factors of a sample of women (n = 449) with self discovered breast symptoms. The study was guided by the ‘Help Seeking Behaviour and Influencing Factors” conceptual framework (Facione et al., 2002; Meechan et al., 2003, 2002; Leventhal, Brissette and Leventhal, 2003 and O’Mahony and Hegarty, 2009b). Data was collected using a researcher developed multi-scale questionnaire package to ascertain women’s help seeking behavior on self discovery of a breast symptom and determine the factors most associated with HSB. Factors examined include: socio-demographics, knowledge and beliefs (regarding breast symptom; breast changes associated with breast cancer; use of alternative help seeking behaviours and presence or absence of a family history of breast cancer),emotional responses, social factors, health seeking habits and health service system utilization and help seeking behavior. A convenience sample (n = 449 was obtained by the researcher from amongst women attending the breast clinics of two large urban hospitals within the Republic of Ireland. All participants had self-discovered breast symptoms and no previous history of breast cancer. The study identified that while the majority of women (69.9%; n=314) sought help within one month, 30.1% (n=135) delayed help seeking for more than one month following self discovery of their breast symptom. The factors most significantly associated with HSB were the presenting symptom of ‘nipple indrawn/changes’ (p = 0.005), ‘ignoring the symptom and hoping it would go away’ (p < 0.001), the emotional response of being ‘afraid@ on symptom discovery (p = 0.005) and the perception/belief in longer symptom duration (p = 0.023). It was found that women who presented with an indrawn/changed nipple were more likely to delay (OR = 4.81) as were women who ‘ignored the symptoms and hoped it would go away’ (OR = 10.717). Additionally, the longer women perceived that their symptom would last, they more likely they were to delay (OR = 1.18). Conversely, being afraid following symptom discovery was associated with less delay (OR = 0.37; p=0.005). This study provides further insight into the HSB of women who self discovered breast symptoms. It highlights the complexity of the help seeking process, indicating that is not a linear event but is influenced by multiple factors which can have a significant impact on the outcomes in terms of whether women delay or seek help promptly. The study further demonstrates that delayed HSB persists amongst women with self discovered breast symptoms. This has important implications for continued emphasis on the promotion of breast awareness, prompt help seeking for self discovered breast symptoms and early detection and treatment of breast cancer, amongst women of all ages.