RESERVE for Delirium Superimposed on Dementia (DSD)

描述(申请人提供)：精神错乱是一种常见的老年人综合症，其特征是认知功能的突然和波动下降。大多数精神错乱的病例发生在老年痴呆症患者的急性疾病期间。痴呆症叠加精神错乱(DSD)具有很高的发病率和死亡率，国家成本与糖尿病不相上下。DSD在医院后持续的时间比以前认识到的要长得多，并加速了认知能力下降的轨迹。这些老年人经历了更多的并发症，实现了较少的康复潜力，并面临过早住院的风险。目前，对DSD的循证治疗很少。我们从认知储备的文献中衍生出了一种基于理论的对DSD的干预，并基于我们之前的工作。精神错乱和痴呆症都是认知储备减少的情况，都有共同的危险因素：一生低参与复杂的精神活动，以及存在ApoE*E4等位基因。一些证据还表明，精神错乱和痴呆症有许多共同的临床、代谢和细胞表现，表明认知储备减少。因此，在一种情况下改善认知储备的干预措施在另一种情况下也可能有效，这是有道理的。认知刺激活动通过诱导支持认知储备的神经可塑性事件来改善认知功能。我们的临床观察和初步工作表明，使用这些活动也可能有助于解决DSD：个性化的认知活动可以促进受精神错乱影响的认知域的处理：注意力、定向、记忆、抽象思维和执行功能。认知处理有助于恢复认知功能。在精神错乱中，认知功能的改善伴随着身体功能的改善和精神错乱的解决。我们在这项随机对照试验中的主要目的是测试老年人娱乐刺激作为解决DSD(Reserve-DSD)的工具的有效性。我们将把256名新入院接受急性护理的受试者随机分为干预组(Reserve-DSD)和对照组(平时护理)。干预对象将接受30分钟的量身定做的认知刺激娱乐活动，最长可达30天。我们假设，与接受常规护理的DSD受试者相比，接受Reserve-DSD的受试者将会有：精神错乱的严重程度和持续时间减少；注意力、方向性、记忆力、抽象思维和执行功能获得更大的进步；以及身体功能得到更大的改善。我们还将评估干预效果的潜在调节因素(复杂精神活动的持续时间和载脂蛋白E状态)。我们的第二个目标是描述与Reserve-DSD相关的成本。这个项目建立在研究人员进行的十多年资助研究和临床实践的基础上，并以创新的方式将他们独特的和合作的努力结合在一起，以解决急性后护理中的DSD问题。 公共卫生相关性：这项研究解决了一个重大的公共卫生问题，即痴呆症患者在精神错乱(急性精神错乱)发作后精神和身体衰退加速。有证据表明，这一代价高昂的健康问题可以通过个性化的精神刺激活动来解决。

DESCRIPTION (provided by applicant): Delirium is a common syndrome in older adults, characterized by a sudden and fluctuating decline in cognitive functioning. Most cases of delirium occur in older adults with dementia during an acute illness. Delirium superimposed on dementia (DSD) carries a high rate of morbidity and mortality and a national cost rivaling that of diabetes. DSD persists much longer in the post-hospital period than formerly recognized and accelerates the trajectory of cognitive decline. These older adults experience more complications, realize less rehabilitation potential and are at risk for premature institutionalization. Currently there are few evidence-based treatments for DSD. We have developed a theory-based intervention for DSD that is derived from the literature on cognitive reserve and based on our prior work. Both delirium and dementia are conditions of reduced cognitive reserve and share common risk factors: a lifetime of low engagement in complex mental activities and presence of the ApoE *E4 allele. Several lines of evidence also indicate that delirium and dementia share many clinical, metabolic, and cellular manifestations that indicate reduced cognitive reserve. It is plausible, then, that interventions that improve cognitive reserve in one condition may also be effective in the other. Cognitively stimulating activities improve cognitive functioning by inducing neuroplastic events that support cognitive reserve. Our clinical observations and preliminary work indicate that use of these activities may also help resolve DSD: individually tailored cognitive activities can facilitate processing in the cognitive domains affected by delirium: attention, orientation, memory, abstract thinking, and executive functioning. Cognitive processing helps restore cognitive functioning. In delirium, improved cognitive function is accompanied by improvement in physical function and resolution of delirium. Our primary aim in this RCT is to test the efficacy of Recreational Stimulation for Elders as a Vehicle to resolve DSD (RESERVE- DSD). We will randomize 256 subjects, newly admitted to post acute care, to intervention (RESERVE-DSD) or control (usual care). Intervention subjects will receive 30-minute sessions of tailored cognitively stimulating recreational activities for up to 30 days. We hypothesize that subjects who receive RESERVE-DSD will have: decreased severity and duration of delirium; greater gains in attention, orientation, memory, abstract thinking, and executive functioning; and greater gains in physical function compared to subjects with DSD who receive usual care. We will also evaluate potential moderators of intervention efficacy (lifetime of complex mental activities and APOE status). Our secondary aim is to describe the costs associated with RESERVE-DSD. This project builds on over a decade of funded research and clinical practice conducted by the investigators, and brings their unique and collaborative efforts together in an innovative manner to address the problem of DSD in post-acute care. PUBLIC HEALTH RELEVANCE: This research addresses a significant public health concern, accelerated mental and physical decline in people with dementia following an episode of delirium (acute confusion). There is evidence to suggest that this costly health issue can be addressed using individualized mentally stimulating activities.