1
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Lai H, Kolanko M, Li LM, Parkinson ME, Bourke NJ, Graham NSN, David MCB, Mallas EJ, Su B, Daniels S, Wilson D, Golemme M, Norman C, Jensen K, Jackson R, Tran M, Freemont PS, Wingfield D, Wilkinson T, Gregg EW, Tzoulaki I, Sharp DJ, Soreq E. Population incidence and associated mortality of urinary tract infection in people living with dementia. J Infect 2024; 88:106167. [PMID: 38679203 DOI: 10.1016/j.jinf.2024.106167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 03/03/2024] [Accepted: 04/20/2024] [Indexed: 05/01/2024]
Abstract
OBJECTIVES Urinary tract infections (UTIs) frequently cause hospitalisation and death in people living with dementia (PLWD). We examine UTI incidence and associated mortality among PLWD relative to matched controls and people with diabetes and investigate whether delayed or withheld treatment further impacts mortality. METHODS Data were extracted for n = 2,449,814 people aged ≥ 50 in Wales from 2000-2021, with groups matched by age, sex, and multimorbidity. Poisson regression was used to estimate incidences of UTI and mortality. Cox regression was used to study the effects of treatment timing. RESULTS UTIs in dementia (HR=2.18, 95 %CI [1.88-2.53], p < .0) and diabetes (1.21[1.01-1.45], p = .035) were associated with high mortality, with the highest risk in individuals with diabetes and dementia (both) (2.83[2.40-3.34], p < .0) compared to matched individuals with neither dementia nor diabetes. 5.4 % of untreated PLWD died within 60 days of GP diagnosis-increasing to 5.9 % in PLWD with diabetes. CONCLUSIONS Incidences of UTI and associated mortality are high in PLWD, especially in those with diabetes and dementia. Delayed treatment for UTI is further associated with high mortality.
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Affiliation(s)
- Helen Lai
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Magdalena Kolanko
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Lucia M Li
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Megan E Parkinson
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Perioperative and Ageing Group, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
| | - Niall J Bourke
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK; Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London, 16 De Crespigny Park, London SE5 8AB, UK
| | - Neil S N Graham
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Michael C B David
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Emma-Jane Mallas
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Bowen Su
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
| | - Sarah Daniels
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Danielle Wilson
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Mara Golemme
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Claire Norman
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Brook Green Medical Centre, Hammersmith and Fulham GP Partnership, Bute Gardens, London W6 7EG, UK
| | - Kirsten Jensen
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Section of Structural and Synthetic Biology, Department of Infectious Disease, Imperial College London, School of Medicine, St Mary's Hospital, Praed Street, London W2 1NY, UK
| | - Raphaella Jackson
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Section of Structural and Synthetic Biology, Department of Infectious Disease, Imperial College London, School of Medicine, St Mary's Hospital, Praed Street, London W2 1NY, UK
| | - Martin Tran
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Section of Structural and Synthetic Biology, Department of Infectious Disease, Imperial College London, School of Medicine, St Mary's Hospital, Praed Street, London W2 1NY, UK
| | - Paul S Freemont
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Section of Structural and Synthetic Biology, Department of Infectious Disease, Imperial College London, School of Medicine, St Mary's Hospital, Praed Street, London W2 1NY, UK
| | - David Wingfield
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK; Brook Green Medical Centre, Hammersmith and Fulham GP Partnership, Bute Gardens, London W6 7EG, UK
| | - Tim Wilkinson
- Centre for Clinical Brain Sciences, University of Edinburgh, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Edward W Gregg
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, South Kensington Campus, London SW7 2AZ, UK; School of Population Health, Royal College of Surgeons of Ireland, University of Medicine and Health Sciences, 123 St Stephen's Green, Dublin 2, Ireland
| | - Ioanna Tzoulaki
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, South Kensington Campus, London SW7 2AZ, UK; Biomedical Research Foundation Academy of Athens, 4 Soranou Ephessiou Street, Athens 115 27, Greece
| | - David J Sharp
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Eyal Soreq
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK.
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2
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Selkoe DJ. The advent of Alzheimer treatments will change the trajectory of human aging. NATURE AGING 2024; 4:453-463. [PMID: 38641654 DOI: 10.1038/s43587-024-00611-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 03/08/2024] [Indexed: 04/21/2024]
Abstract
Slowing neurodegenerative disorders of late life has lagged behind progress on other chronic diseases. But advances in two areas, biochemical pathology and human genetics, have now identified early pathogenic events, enabling molecular hypotheses and disease-modifying treatments. A salient example is the discovery that antibodies to amyloid ß-protein, long debated as a causative factor in Alzheimer's disease (AD), clear amyloid plaques, decrease levels of abnormal tau proteins and slow cognitive decline. Approval of amyloid antibodies as the first disease-modifying treatments means a gradually rising fraction of the world's estimated 60 million people with symptomatic disease may decline less or even stabilize. Society is entering an era in which the unchecked devastation of AD is no longer inevitable. This Perspective considers the impact of slowing AD and other neurodegenerative disorders on the trajectory of aging, allowing people to survive into late life with less functional decline. The implications of this moment for medicine and society are profound.
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Affiliation(s)
- Dennis J Selkoe
- Ann Romney Center for Neurologic Diseases Brigham and Women's Hospital Harvard Medical School, Boston, MA, USA.
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3
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Matovelle P, Olivan-Blázquez B, Magallón-Botaya R, García-Sangenís A, Monfà R, Morros R, Navarro Sanmartín A, Mateos-Nozal J, Sáez Bejar C, Rodríguez Jiménez C, López Pérez E, Llor C. Antimicrobial Agent Use for Urinary Tract Infection in Long-Term Care Facilities in Spain: Results from a Retrospective Analytical Cohort Analysis. Antibiotics (Basel) 2024; 13:152. [PMID: 38391537 PMCID: PMC10885965 DOI: 10.3390/antibiotics13020152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 01/25/2024] [Accepted: 01/31/2024] [Indexed: 02/24/2024] Open
Abstract
Urinary tract infections (UTIs) are highly prevalent in long-term care facilities, constituting the most common infection in this setting. Our research focuses on analyzing clinical characteristics and antimicrobial prescriptions for UTIs in residents across nursing homes (NH) in Spain. This is a retrospective analytical cohort analysis using a multifaceted approach based on the normalization process theory to improve healthcare quality provided by nursing staff in 34 NHs in Spain. In this study, we present the results of the first audit including 719 UTI cases collected between February and April 2023, with an average age of 85.5 years and 74.5% being women. Cystitis and pyelonephritis presented distinct symptom patterns. Notably, 6% of asymptomatic bacteriuria cases were treated. The prevalence of dipstick usage was 83%, and that of urine culture was only 16%, raising concerns about overreliance, including in the 46 asymptomatic cases, leading to potential overdiagnosis and antibiotic overtreatment. Improved diagnostic criteria and personalized strategies are crucial for UTI management in NHs, emphasizing the need for personalized guidelines on the management of UTIs to mitigate indiscriminate antibiotic use in asymptomatic cases.
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Affiliation(s)
- Priscila Matovelle
- Geriatrics Department, Hospital San Juan de Dios, 50006 Zaragoza, Spain
- Geriatrics Department, Universidad de Zaragoza, 50009 Zaragoza, Spain
| | - Bárbara Olivan-Blázquez
- Group B21-23R, Health Research Institute of Aragon (IISA), 50009 Zaragoza, Spain
- Network for Research on Chronicity, Primary Care and Health Promotion (RICAPPS, RD21/0016/0005), 50015 Zaragoza, Spain
- Department of Psychology and Sociology, University of Zaragoza, 50009 Zaragoza, Spain
| | - Rosa Magallón-Botaya
- Group B21-23R, Health Research Institute of Aragon (IISA), 50009 Zaragoza, Spain
- Network for Research on Chronicity, Primary Care and Health Promotion (RICAPPS, RD21/0016/0005), 50015 Zaragoza, Spain
- Medicine Department, Universidad de Zaragoza, 50009 Zaragoza, Spain
| | - Ana García-Sangenís
- Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, 08007 Barcelona, Spain
- Pharmacology Department, Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), 08193 Bellaterra, Spain
- CIBER en Enfermedades Infecciosas Instituto Carlos III, 28029 Madrid, Spain
| | - Ramon Monfà
- Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, 08007 Barcelona, Spain
- Pharmacology Department, Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), 08193 Bellaterra, Spain
| | - Rosa Morros
- Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, 08007 Barcelona, Spain
- Pharmacology Department, Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), 08193 Bellaterra, Spain
- CIBER en Enfermedades Infecciosas Instituto Carlos III, 28029 Madrid, Spain
| | | | - Jesús Mateos-Nozal
- Geriatrics Department, Hospital Universitario Ramón y Cajal (IRYCIS), 28034 Madrid, Spain
| | - Carmen Sáez Bejar
- Internal Medicine Department, Hospital Universitario La Princesa, Instituto de Investigación Sanitaria (IIS-Princesa), 28006 Madrid, Spain
- Research Institute of Princesa (IIS Princesa), 28006 Madrid, Spain
| | - Consuelo Rodríguez Jiménez
- Pharmacology Department, Complejo Hospitalario Universitario de Canarias, 38320 Santa Cruz de Tenerife, Spain
| | | | - Carl Llor
- Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, 08007 Barcelona, Spain
- CIBER en Enfermedades Infecciosas Instituto Carlos III, 28029 Madrid, Spain
- Institut Català de la Salut, 08038 Barcelona, Spain
- Research Unit for General Practice, Department of Public Health, University of Southern Denmark, 5230 Odense, Denmark
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4
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Frost DW, Vaisman A. The Use of Urinalysis and Urine Culture in Diagnosis: The Role of Uncertainty Tolerance. Am J Med 2023; 136:729-731. [PMID: 37004955 DOI: 10.1016/j.amjmed.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 03/02/2023] [Indexed: 04/04/2023]
Affiliation(s)
- David W Frost
- Division of General Internal Medicine, University of Toronto, Ontario, Canada; University Health Network, Toronto, Ontario, Canada; Department of Medicine.
| | - Alon Vaisman
- University Health Network, Toronto, Ontario, Canada; Department of Medicine; Division of Infectious Diseases, University of Toronto, Ontario, Canada
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5
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Hojat LS, Saade EA, Hernandez AV, Donskey CJ, Deshpande A. Can Electronic Clinical Decision Support Systems Improve the Diagnosis of Urinary Tract Infections? A Systematic Review and Meta-Analysis. Open Forum Infect Dis 2022; 10:ofac691. [PMID: 36632418 PMCID: PMC9830539 DOI: 10.1093/ofid/ofac691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 12/23/2022] [Indexed: 12/29/2022] Open
Abstract
Background Urinary tract infection (UTI) is a commonly misdiagnosed infectious syndrome. Diagnostic stewardship interventions can reduce rates of asymptomatic bacteriuria treatment but are often labor intensive, and thus an automated means of reducing unnecessary urine testing is preferred. In this systematic review and meta-analysis, we sought to identify studies describing interventions utilizing clinical decision support (CDS) to optimize UTI diagnosis and to characterize the effectiveness of these interventions. Methods We conducted a comprehensive electronic search and manual reference list review for peer-reviewed articles published before July 2, 2021. Publications describing an intervention intending to enhance UTI diagnosis via CDS were included. The primary outcome was urine culture test rate. Results The electronic search identified 5013 studies for screening. After screening and full-text review, 9 studies met criteria for inclusion, and a manual reference list review identified 5 additional studies, yielding a total of 14 studies included in the systematic review. The most common CDS intervention was urinalysis with reflex to urine culture based on prespecified urinalysis parameters. All 9 studies that provided statistical comparisons reported a decreased urine culture rate postintervention, 8 of which were statistically significant. A meta-analysis including 4 studies identified a pooled urine culture incidence rate ratio of 0.56 (95% confidence interval, .52-.60) favoring the postintervention versus preintervention group. Conclusions In this systematic review and meta-analysis, CDS appeared to be effective in decreasing urine culture rates. Prospective trials are needed to confirm these findings and to evaluate their impact on antimicrobial prescribing, patient-relevant outcomes, and potential adverse effects.
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Affiliation(s)
- Leila S Hojat
- Correspondence: Leila S. Hojat, MD, 11100 Euclid Ave., Mailstop FOL5083, Cleveland, OH 44106, USA (). Elie Saade, MPH, MD, 11100 Euclid Ave, Mailstop FOL5083, Cleveland, OH 44106, USA ()
| | - Elie A Saade
- Correspondence: Leila S. Hojat, MD, 11100 Euclid Ave., Mailstop FOL5083, Cleveland, OH 44106, USA (). Elie Saade, MPH, MD, 11100 Euclid Ave, Mailstop FOL5083, Cleveland, OH 44106, USA ()
| | - Adrian V Hernandez
- Health Outcomes, Policy, and Evidence Synthesis (HOPES) Group, Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, Connecticut, USA,Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru
| | - Curtis J Donskey
- Department of Medicine, Division of Infectious Diseases, Case Western Reserve University, Cleveland, Ohio, USA,Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland Veterans’ Affairs Medical Center, Cleveland, Ohio, USA
| | - Abhishek Deshpande
- Center for Value Based Care Research, Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, Ohio, USA,Department of Infectious Diseases, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
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6
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Nursing Effect Analysis of Urinary Tract Infections in Urology Surgery Patients: a Systematic Review and Meta-analysis. Indian J Surg 2022; 85:251-261. [PMID: 35571982 PMCID: PMC9088134 DOI: 10.1007/s12262-022-03438-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 04/29/2022] [Indexed: 10/28/2022] Open
Abstract
This meta-analysis aims to identify urinary tract infections (UTIs) in patients with different levels of age groups. For both diagnosis and treatment of UTIs, antibiotics have been widely used in nursing home settings. We also aimed to evaluate the duration of catheterization in UTI patients to reduce catheter-associated complications. We conducted a systematic review that was performed following the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA) guidelines and recommendations from Cochrane Collaboration. We performed a comprehensive search for published literature in PubMed, ScienceDirect, Taylor & Francis Online, Springer, and Wiley Online databases from 2010 to June 25, 2021. We performed two meta-analysis: the first meta-analysis (meta-analysis I) was performed on data obtained from included studies that compared patients with UTIs (experimental group) and without UTIs (control group); the second meta-analysis (meta-analysis II) was performed to assess the appropriate use of a catheter in UTI patients. All statistical analyses were conducted using the Review Manager 5.4 tool. A total of 15 research articles were included in this systematic review and meta-analysis. Of these, results showed the identification of critical patients with UTIs and without UTIs from nursing resident homes (risk ratio [RR] = 0.80 95% confidence interval CI = 0.69-0.93 p < 0.0001). Risk ratio results with random effects (RE) were obtained as RR = 0.69 95% CI = 0.26-1.83, p = 0.45, along with heterogeneity I 2 (96%) values. No appropriate prescription of antibiotics in UTIs is practiced among nursing home residents. In addition, pooled results between two groups (short-duration vs. long-duration catheterization) showed RR 0.66 95% CI 0.46-0.93 p = 0.02, I 2 = 56, that reduced complications associated with CAUTIs. This systematic review and meta-analysis suggested an appropriate use of agents and catheter insertion for a short duration at nursing homes.
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7
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DeRosa A, Wattengel BA, Carter MT, Sellick JA, Lesse AJ, Mergenhagen KA. Admissions and Mortality Related to Urinary Tract Infections in Male Veterans with Dementia. Sr Care Pharm 2021; 36:681-686. [PMID: 34861908 DOI: 10.4140/tcp.n.2021.681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective To examine mortality and hospital readmission rates in male veterans with dementia diagnosed with urinary tract infection (UTI) compared with patients without dementia. Design Retrospective cohort study. Setting Veterans Healthcare Systems (VA). Participants Male inpatients with a diagnosis of UTI who were treated at any VA Healthcare Center from January 1, 2009, to December 31, 2018. Interventions None. Main Outcome Measures Mortality and hospital readmission for patients with and without dementia at 30, 60, and 90 days from UTI diagnosis. Results 262,515 veterans admitted with UTI were analyzed, and 58,940 (22.5%) had dementia. The mean age for veterans with dementia was 80.0 +/- 9.7 years. Veterans with dementia experienced less mortality than patients without dementia at 30 days (8.3% vs 8.5%; P < 0.001), but more mortality at 60-day (4.9% vs 4.7%; P < 0.001) and 90-day (3.6% vs 3.3%; P < 0.001) intervals. Death was 20% less likely at 30 days in patients with dementia. Veterans with dementia were readmitted more than those without dementia at 30-day (18.4% vs 16.0%), 60-day (4.5% vs 2.8%), and 90-day (3.4% vs 2.5%) intervals; P < 0.0001. Conclusion Though patients with dementia are at an increased risk for death long-term, risk of death is less than those without dementia shortly following UTI diagnosis. This highlights the possibility that veterans with dementia may be hospitalized and diagnosed with UTIs when in actuality they have asymptomatic bacteriuria. Patients with dementia and UTI therefore represent an important group of geriatric patients that could benefit from the oversight of a senior care pharmacist to help prevent unnecessary treatment of asymptomatic bacteriuria.
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Affiliation(s)
- Alicia DeRosa
- 1Veterans Affairs Western New York Healthcare System, Buffalo, New York
| | | | - Michael T Carter
- 1Veterans Affairs Western New York Healthcare System, Buffalo, New York
| | - John A Sellick
- 1Veterans Affairs Western New York Healthcare System, Buffalo, New York
| | - Alan J Lesse
- 1Veterans Affairs Western New York Healthcare System, Buffalo, New York
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8
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Mitchell SL, D'Agata EMC, Hanson LC, Loizeau AJ, Habtemariam DA, Tsai T, Anderson RA, Shaffer ML. The Trial to Reduce Antimicrobial Use in Nursing Home Residents With Alzheimer Disease and Other Dementias (TRAIN-AD): A Cluster Randomized Clinical Trial. JAMA Intern Med 2021; 181:1174-1182. [PMID: 34251396 PMCID: PMC8276127 DOI: 10.1001/jamainternmed.2021.3098] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Antimicrobials are extensively prescribed to nursing home residents with advanced dementia, often without evidence of infection or consideration of the goals of care. OBJECTIVE To test the effectiveness of a multicomponent intervention to improve the management of suspected urinary tract infections (UTIs) and lower respiratory infections (LRIs) for nursing home residents with advanced dementia. DESIGN, SETTING, AND PARTICIPANTS A cluster randomized clinical trial of 28 Boston-area nursing homes (14 per arm) and 426 residents with advanced dementia (intervention arm, 199 residents; control arm, 227 residents) was conducted from August 1, 2017, to April 30, 2020. INTERVENTIONS The intervention content integrated best practices from infectious diseases and palliative care for management of suspected UTIs and LRIs in residents with advanced dementia. Components targeting nursing home practitioners (physicians, physician assistants, nurse practitioners, and nurses) included an in-person seminar, an online course, management algorithms (posters, pocket cards), communication tips (pocket cards), and feedback reports on prescribing of antimicrobials. The residents' health care proxies received a booklet about infections in advanced dementia. Nursing homes in the control arm continued routine care. MAIN OUTCOMES AND MEASURES The primary outcome was antimicrobial treatment courses for suspected UTIs or LRIs per person-year. Outcomes were measured for as many as 12 months. Secondary outcomes were antimicrobial courses for suspected UTIs and LRIs when minimal criteria for treatment were absent per person-year and burdensome procedures used to manage these episodes (bladder catherization, chest radiography, venous blood sampling, or hospital transfer) per person-year. RESULTS The intervention arm had 199 residents (mean [SD] age, 87.7 [8.0] years; 163 [81.9%] women; 36 [18.1%] men), of which 163 (81.9%) were White and 27 (13.6%) were Black. The control arm had 227 residents (mean [SD] age, 85.3 [8.6] years; 190 [83.7%] women; 37 [16.3%] men), of which 200 (88.1%) were White and 22 (9.7%) were Black. There was a 33% (nonsignificant) reduction in antimicrobial treatment courses for suspected UTIs or LRIs per person-year in the intervention vs control arm (adjusted marginal rate difference, -0.27 [95% CI, -0.71 to 0.17]). This reduction was primarily attributable to reduced antimicrobial use for LRIs. The following secondary outcomes did not differ significantly between arms: antimicrobials initiated when minimal criteria were absent, bladder catheterizations, venous blood sampling, and hospital transfers. Chest radiography use was significantly lower in the intervention arm (adjusted marginal rate difference, -0.56 [95% CI, -1.10 to -0.03]). In-person or online training was completed by 88% of the targeted nursing home practitioners. CONCLUSIONS AND RELEVANCE This cluster randomized clinical trial found that despite high adherence to the training, a multicomponent intervention promoting goal-directed care for suspected UTIs and LRIs did not significantly reduce antimicrobial use among nursing home residents with advanced dementia. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03244917.
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Affiliation(s)
- Susan L Mitchell
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Erika M C D'Agata
- Division of Infectious Diseases, Brown University, Providence, Rhode Island
| | - Laura C Hanson
- Palliative Care Program, Division of Geriatric Medicine, University of North Carolina at Chapel Hill, Chapel Hill
| | - Andrea J Loizeau
- Division of Primary Care Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Daniel A Habtemariam
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts
| | - Timothy Tsai
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts
| | - Ruth A Anderson
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill
| | - Michele L Shaffer
- Department of Public Health Sciences, Pennsylvania State College of Medicine, Hershey.,Frank Statistical Consulting LLC, Vashon, Washington
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9
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Langford BJ, Daneman N, Leung V, Langford DJ. Cognitive bias: how understanding its impact on antibiotic prescribing decisions can help advance antimicrobial stewardship. JAC Antimicrob Resist 2020; 2:dlaa107. [PMID: 34223057 DOI: 10.1093/jacamr/dlaa107] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The way clinicians think about decision-making is evolving. Human decision-making shifts between two modes of thinking, either fast/intuitive (Type 1) or slow/deliberate (Type 2). In the healthcare setting where thousands of decisions are made daily, Type 1 thinking can reduce cognitive load and help ensure decision making is efficient and timely, but it can come at the expense of accuracy, leading to systematic errors, also called cognitive biases. This review provides an introduction to cognitive bias and provides explanation through patient vignettes of how cognitive biases contribute to suboptimal antibiotic prescribing. We describe common cognitive biases in antibiotic prescribing both from the clinician and the patient perspective, including hyperbolic discounting (the tendency to favour small immediate benefits over larger more distant benefits) and commission bias (the tendency towards action over inaction). Management of cognitive bias includes encouraging more mindful decision making (e.g., time-outs, checklists), improving awareness of one's own biases (i.e., meta-cognition), and designing an environment that facilitates safe and accurate decision making (e.g., decision support tools, nudges). A basic understanding of cognitive biases can help explain why certain stewardship interventions are more effective than others and may inspire more creative strategies to ensure antibiotics are used more safely and more effectively in our patients.
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Affiliation(s)
- Bradley J Langford
- Public Health Ontario, Toronto, Ontario, Canada.,Hotel Dieu Shaver Health and Rehabilitation Centre, St Catharines, Ontario, Canada
| | - Nick Daneman
- Public Health Ontario, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
| | - Valerie Leung
- Public Health Ontario, Toronto, Ontario, Canada.,Toronto East Health Network, Michael Garron Hospital, Toronto, Ontario, Canada
| | - Dale J Langford
- Department of Anesthesiology and Pain Medicine, School of Medicine, University of Washington, Seattle, WA, USA
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10
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Factors Associated With Antimicrobial Use in Nursing Home Residents With Advanced Dementia. J Am Med Dir Assoc 2020; 22:178-181. [PMID: 32839124 DOI: 10.1016/j.jamda.2020.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/01/2020] [Accepted: 07/03/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Widespread antimicrobial misuse among nursing home (NH) residents with advanced dementia raises concerns regarding the emergence of multidrug-resistant organisms and avoidable treatment burden in this vulnerable population. The objective of this report was to identify facility and resident level characteristics associated with receipt of antimicrobials in this population. DESIGN Cross-sectional analysis of baseline data from the Trial to Reduce Antimicrobial use in Nursing home residents with Alzheimer's disease and other Dementias (TRAIN-AD). SETTING AND PARTICIPANTS Twenty-eight Boston area NHs, 430 long stay NH residents with advanced dementia. MEASURES The outcome was the proportion of residents who received any antimicrobials during the 2 months prior to the start of TRAIN-AD determined by chart review. Multivariable logistic regression was used to identify resident and facility characteristics associated with this outcome. RESULTS A total of 13.7% of NH residents with advanced dementia received antimicrobials in the 2 months prior to the start of TRAIN-AD. Residents in facilities with the following characteristics were significantly more likely to receive antimicrobials: having a full time nurse practitioner/physician assistant on staff [adjusted odds ratio (aOR) 3.02; 95% confidence interval (CI), 1.54, 5.94], fewer existing infectious disease practices (eg, antimicrobial stewardship programs, established algorithms for infection management) (aOR, 2.35; 95% CI 1.14, 4.84), and having fewer residents with severely cognitively impaired residents (aOR 1.96; 95% CI 1.12, 3.40). No resident characteristics were independently associated with receipt of antimicrobials. CONCLUSIONS AND IMPLICATIONS Facility-level characteristics are associated with the receipt of antimicrobials among residents with advanced dementia. Implementation of more intense infectious disease practices and targeting the prescribing practices of nurse practitioners/physician assistants may be critical targets for interventions aimed at reducing antimicrobial use in this population.
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11
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Nicolle LE, Gupta K, Bradley SF, Colgan R, DeMuri GP, Drekonja D, Eckert LO, Geerlings SE, Köves B, Hooton TM, Juthani-Mehta M, Knight SL, Saint S, Schaeffer AJ, Trautner B, Wullt B, Siemieniuk R. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clin Infect Dis 2020; 68:e83-e110. [PMID: 30895288 DOI: 10.1093/cid/ciy1121] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 12/27/2018] [Indexed: 12/22/2022] Open
Abstract
Asymptomatic bacteriuria (ASB) is a common finding in many populations, including healthy women and persons with underlying urologic abnormalities. The 2005 guideline from the Infectious Diseases Society of America recommended that ASB should be screened for and treated only in pregnant women or in an individual prior to undergoing invasive urologic procedures. Treatment was not recommended for healthy women; older women or men; or persons with diabetes, indwelling catheters, or spinal cord injury. The guideline did not address children and some adult populations, including patients with neutropenia, solid organ transplants, and nonurologic surgery. In the years since the publication of the guideline, further information relevant to ASB has become available. In addition, antimicrobial treatment of ASB has been recognized as an important contributor to inappropriate antimicrobial use, which promotes emergence of antimicrobial resistance. The current guideline updates the recommendations of the 2005 guideline, includes new recommendations for populations not previously addressed, and, where relevant, addresses the interpretation of nonlocalizing clinical symptoms in populations with a high prevalence of ASB.
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Affiliation(s)
- Lindsay E Nicolle
- Department of Internal Medicine, School of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Kalpana Gupta
- Division of Infectious Diseases, Veterans Affairs Boston Healthcare System and Boston University School of Medicine, West Roxbury, Massachusetts
| | | | - Richard Colgan
- Department of Family and Community Medicine, University of Maryland, Baltimore
| | - Gregory P DeMuri
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison
| | - Dimitri Drekonja
- Division of Infectious Diseases, University of Minnesota, Minneapolis
| | - Linda O Eckert
- Department of Obstetrics and Gynecology and Department of Global Health, University of Washington, Seattle
| | - Suzanne E Geerlings
- Department of Internal Medicine, Amsterdam University Medical Center, The Netherlands
| | - Béla Köves
- Department of Urology, South Pest Teaching Hospital, Budapest, Hungary
| | - Thomas M Hooton
- Division of Infectious Diseases, University of Miami, Florida
| | | | - Shandra L Knight
- Library and Knowledge Services, National Jewish Health, Denver, Colorado
| | - Sanjay Saint
- Department of Internal Medicine, Veterans Affairs Ann Arbor and University of Michigan, Ann Arbor
| | | | - Barbara Trautner
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Bjorn Wullt
- Division of Microbiology, Immunology and Glycobiology, Lund, Sweden
| | - Reed Siemieniuk
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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12
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Petty LA, Vaughn VM, Flanders SA, Malani AN, Conlon A, Kaye KS, Thyagarajan R, Osterholzer D, Nielsen D, Eschenauer GA, Bloemers S, McLaughlin E, Gandhi TN. Risk Factors and Outcomes Associated With Treatment of Asymptomatic Bacteriuria in Hospitalized Patients. JAMA Intern Med 2019; 179:1519-1527. [PMID: 31449295 PMCID: PMC6714039 DOI: 10.1001/jamainternmed.2019.2871] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
IMPORTANCE Treatment of asymptomatic bacteriuria (ASB) with antibiotics is a common factor in inappropriate antibiotic use, but risk factors and outcomes associated with treatment of ASB in hospitalized patients are not well defined. OBJECTIVE To evaluate factors associated with treatment of ASB among hospitalized patients and the possible association between treatment and clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted from January 1, 2016, through February 1, 2018, at 46 hospitals participating in the Michigan Hospital Medicine Safety Consortium. A total of 2733 hospitalized medical patients with ASB, defined as a positive urine culture without any documented signs or symptoms attributable to urinary tract infection, were included in the analysis. EXPOSURES One or more antibiotic dose for treatment of ASB. MAIN OUTCOMES AND MEASURES Estimators of antibiotic treatment of ASB. Secondary outcomes included 30-day mortality, 30-day hospital readmission, 30-day emergency department visit, discharge to post-acute care settings, Clostridioides difficile infection (formerly known as Clostridium difficile) at 30 days, and duration of hospitalization after urine testing. RESULTS Of 2733 patients with ASB, 2138 were women (78.2%); median age was 77 years (interquartile range [IQR], 66-86 years). A total of 2259 patients (82.7%) were treated with antibiotics for a median of 7 days (IQR, 4-9 days). Factors associated with ASB treatment included older age (odds ratio [OR], 1.10 per 10-year increase; 95% CI, 1.02-1.18), dementia (OR, 1.57; 95% CI, 1.15-2.13), acutely altered mental status (OR, 1.93; 95% CI, 1.23-3.04), urinary incontinence (OR, 1.81; 95% CI, 1.36-2.41), leukocytosis (white blood cell count >10 000/μL) (OR, 1.55; 95% CI, 1.21-2.00), positive urinalysis (presence of leukocyte esterase or nitrite, or >5 white blood cells per high-power field) (OR, 2.83; 95% CI, 2.05-3.93), and urine culture with a bacterial colony count greater than 100 000 colony-forming units per high-power field (OR, 2.30; 95% CI, 1.83-2.91). Treatment of ASB was associated with longer duration of hospitalization after urine testing (4 vs 3 days; relative risk, 1.37; 95% CI, 1.28-1.47). No other differences in secondary outcomes were identified after propensity weighting. CONCLUSIONS AND RELEVANCE Hospitalized patients with ASB commonly receive inappropriate antibiotic therapy. Antibiotic treatment did not appear to be associated with improved outcomes; rather, treatment may be associated with longer duration of hospitalization after urine testing. To possibly reduce inappropriate antibiotic use, stewardship efforts should focus on improving urine testing practices and management strategies for elderly patients with altered mental status.
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Affiliation(s)
- Lindsay A Petty
- Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor
| | - Valerie M Vaughn
- Internal Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor
| | - Scott A Flanders
- Internal Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor
| | - Anurag N Malani
- Internal Medicine, Division of Infectious Diseases, St Joseph Mercy Health System, Ann Arbor, Michigan
| | - Anna Conlon
- Internal Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor
| | - Keith S Kaye
- Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor
| | - Rama Thyagarajan
- Internal Medicine, Division of Infectious Diseases, Beaumont Hospital, Dearborn, Michigan
| | - Danielle Osterholzer
- Internal Medicine, Division of Infectious Diseases, Hurley Medical Center, Flint, Michigan
| | - Daniel Nielsen
- Internal Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor
| | | | - Sarah Bloemers
- Internal Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor
| | - Elizabeth McLaughlin
- Internal Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor
| | - Tejal N Gandhi
- Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor
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13
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Loizeau AJ, D'Agata EMC, Shaffer ML, Hanson LC, Anderson RA, Tsai T, Habtemariam DA, Bergman EH, Carroll RP, Cohen SM, Scott EME, Stevens E, Whyman JD, Bennert EH, Mitchell SL. The trial to reduce antimicrobial use in nursing home residents with Alzheimer's disease and other dementias: study protocol for a cluster randomized controlled trial. Trials 2019; 20:594. [PMID: 31615540 PMCID: PMC6794759 DOI: 10.1186/s13063-019-3675-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 08/23/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Infections are common in nursing home (NH) residents with advanced dementia but are often managed inappropriately. Antimicrobials are extensively prescribed, but frequently with insufficient evidence to support a bacterial infection, promoting the emergence of multidrug-resistant organisms. Moreover, the benefits of antimicrobials remain unclear in these seriously ill residents for whom comfort is often the goal of care. Prior NH infection management interventions evaluated in randomized clinical trials (RCTs) did not consider patient preferences and lack evidence to support their effectiveness in 'real-world' practice. METHODS This report presents the rationale and methodology of TRAIN-AD (Trial to reduce antimicrobial use in nursing home residents with Alzheimer's disease and other dementias), a parallel group, cluster RCT evaluating a multicomponent intervention to improve infection management for suspected urinary tract infections (UTIs) and lower respiratory tract infections (LRIs) among NH residents with advanced dementia. TRAIN-AD is being conducted in 28 facilities in the Boston, USA, area randomized in waves using minimization to achieve a balance on key characteristics (N = 14 facilities/arm). The involvement of the facilities includes a 3-month start-up period and a 24-month implementation/data collection phase. Residents are enrolled during the first 12 months of the 24-month implementation period and followed for up to 12 months. Individual consent is waived, thus almost all eligible residents are enrolled (target sample size, N = 410). The intervention integrates infectious disease and palliative care principles and includes provider training delivered through multiple modalities (in-person seminar, online course, management algorithms, and prescribing feedback) and an information booklet for families. Control facilities employ usual care. The primary outcome, abstracted from the residents' charts, is the number of antimicrobial courses prescribed for UTIs and LRIs per person-year alive. DISCUSSION TRAIN-AD is the first cluster RCT testing a multicomponent intervention to improve infection management in NH residents with advanced dementia. Its findings will provide an evidence base to support the benefit of a program addressing the critical clinical and public health problem of antimicrobial misuse in these seriously ill residents. Moreover, its hybrid efficacy-effectiveness design will inform the future conduct of cluster RCTs evaluating nonpharmacological interventions in the complex NH setting in a way that is both internally valid and adaptable to the 'real-world'. TRIAL REGISTRATION ClinicalTrials.gov, NCT03244917 . Registered on 10 August 2017.
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Affiliation(s)
- Andrea J Loizeau
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, 1200 Centre Street, Boston, MA, 02131, USA.
| | - Erika M C D'Agata
- Division of Infectious Diseases, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Michele L Shaffer
- Department of Statistics, University of Washington, Seattle, WA, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, Palliative Care Program, Chapel Hill, NC, USA
| | - Ruth A Anderson
- School of Nursing, University of North Carolina, Chapel Hill, NC, USA
| | - Timothy Tsai
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, 1200 Centre Street, Boston, MA, 02131, USA
| | - Daniel A Habtemariam
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, 1200 Centre Street, Boston, MA, 02131, USA
| | - Elaine H Bergman
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, 1200 Centre Street, Boston, MA, 02131, USA
| | - Ruth P Carroll
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, 1200 Centre Street, Boston, MA, 02131, USA
| | - Simon M Cohen
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, 1200 Centre Street, Boston, MA, 02131, USA
| | - Erin M E Scott
- Division of Palliative Care and Geriatrics, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Erin Stevens
- Division of Palliative Care and Geriatrics, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jeremy D Whyman
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Susan L Mitchell
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, 1200 Centre Street, Boston, MA, 02131, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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14
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Juthani-Mehta M, Allore HG. Design and analysis of longitudinal trials of antimicrobial use at the end of life: to give or not to give? Ther Adv Drug Saf 2019; 10:2042098618820210. [PMID: 30800269 PMCID: PMC6378640 DOI: 10.1177/2042098618820210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 11/28/2018] [Indexed: 01/22/2023] Open
Abstract
This perspective review considers analytic features of the design of a longitudinal trial regarding antimicrobial therapy in older terminal cancer patients receiving palliative care. We first overview antimicrobial use at the end of life; both the potential hazards and benefits. Antimicrobial prescribing should consider both initiation as well as cessation of medications when analyzing the burden of medications. Approaches to decision making regarding antimicrobial use are presented and the importance of health literacy in these decision processes. We next present aspects of both feasibility and comparative trial design with a health literacy intervention to reduce antimicrobial use in older terminal cancer patients receiving palliative care. Considerations to clustered randomization and given that infections can reoccur over a trial period, we share suggestions of longitudinal modeling of clustered randomized trial data.
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Affiliation(s)
| | - Heather G Allore
- Yale University School of Medicine, 300 George St, Suite 775, New Haven, CT 06511, USA
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15
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Nace DA, Perera SK, Hanlon JT, Saracco S, Anderson G, Schweon SJ, Klein-Fedyshin M, Wessel CB, Mulligan M, Drinka PJ, Crnich CJ. The Improving Outcomes of UTI Management in Long-Term Care Project (IOU) Consensus Guidelines for the Diagnosis of Uncomplicated Cystitis in Nursing Home Residents. J Am Med Dir Assoc 2018; 19:765-769.e3. [PMID: 30037743 PMCID: PMC8043108 DOI: 10.1016/j.jamda.2018.05.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 05/29/2018] [Accepted: 05/31/2018] [Indexed: 11/11/2022]
Abstract
Objectives: To identify a set of signs and symptoms most likely to indicate
uncomplicated cystitis in non-catheterized nursing home residents ≥
65 years of age using consensus based methods informed by a literature
review. Design: Literature review and modified Delphi survey with strict inclusion
criteria. Setting and Participants: Expert panel of 20 physicians certified in geriatric medicine and /
or medical direction, actively practicing in post-acute and long-term care
settings. Methods: The authors performed a literature review to produce a comprehensive
list of potential signs and symptoms of presumptive uncomplicated cystitis,
including non-specific “quality control” items deemed unlikely
to indicate uncomplicated cystitis. The expert panel rated their agreement
for each sign/symptom using a 5-point Likert scale (1= strongly disagree to
5= strongly agree). Agreed upon signs and symptoms were summarized using a
diagnostic algorithm for easy clinical use. Results: The literature review identified 16 signs and symptoms that were
evaluated in three Delphi survey rounds. The response rate was 100% for
round one and 95% for the second two rounds. Consensus agreement for
inclusion was achieved for dysuria on round one with exclusion of the three
quality controls, and “offensive smelling urine”. Consensus in
the second round was reached for including 4 additional items (gross
hematuria, suprapubic pain, urinary frequency, and urinary urgency). Round
three evaluated dysuria alone and combinations of symptoms. Consensus that
dysuria alone is sufficient for diagnosis of cystitis was not reached. Conclusions/Implications The panel identified 5 signs and symptoms likely indicative of uncomplicated
cystitis in nursing home residents and developed a diagnostic algorithm that can be
used to promote antibiotic stewardship in nursing homes. Given similarities in
populations, the algorithm may also be applicable to the older adult and the broader
post-acute / long-term care populations.
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Affiliation(s)
- David A Nace
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, PA.
| | - Subashan K Perera
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, PA; Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA
| | - Joseph T Hanlon
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Stacey Saracco
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Gulsum Anderson
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | | | - Charles B Wessel
- Health Sciences Library System, University of Pittsburgh, Pittsburgh, PA
| | - Mary Mulligan
- AMDA-The Society of Post-Acute and Long-Term Care Medicine, Columbia, MD
| | - Paul J Drinka
- Division of Internal Medicine and Geriatrics, University of Wisconsin, Madison, WI
| | - Christopher J Crnich
- Division of Infectious Diseases, University of Wisconsin School of Medicine and Public Health, Madison, WI; William S. Middleton VA Hospital, Madison, WI
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16
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Bartley MM, Suarez L, Shafi RMA, Baruth JM, Benarroch AJM, Lapid MI. Dementia Care at End of Life: Current Approaches. Curr Psychiatry Rep 2018; 20:50. [PMID: 29936639 DOI: 10.1007/s11920-018-0915-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE OF REVIEW Dementia is a progressive and life-limiting condition that can be described in three stages: early, middle, and late. This article reviews current literature on late-stage dementia. RECENT FINDINGS Survival times may vary across dementia subtypes. Yet, the overall trajectory is characterized by progressive decline until death. Ideally, as people with dementia approach the end of life, care should focus on comfort, dignity, and quality of life. However, barriers prevent optimal end-of-life care in the final stages of dementia. Improved and earlier advanced care planning for persons with dementia and their caregivers can help delineate goals of care and prepare for the inevitable complications of end-stage dementia. This allows for timely access to palliative and hospice care, which ultimately improves dementia end-of-life care.
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Affiliation(s)
| | - Laura Suarez
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Reem M A Shafi
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Joshua M Baruth
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Amanda J M Benarroch
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Maria I Lapid
- Center for Palliative Medicine, Mayo Clinic, Rochester, MN, USA. .,Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
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17
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Dhamapurkar SK, Wilson BA, Rose A, Florschutz G, Watson P, Shiel A. Does a regular Wessex Head Injury Matrix assessment identify early signs of infections in people with Prolonged Disorders of Consciousness? Brain Inj 2018; 32:1103-1109. [PMID: 29894208 DOI: 10.1080/02699052.2018.1484165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND & OBJECTIVE Patients with brain injury are at high risk for infections. Although infection and cognitive deterioration are established for people with dementia, this has not been shown for patients with a prolonged disorder of consciousness (PDOC). This study determines whether regular Wessex Head Injury Matrix (WHIM) assessments can identify early signs of infections in patients with PDOC. METHOD Retrospective and prospective approaches were used to assess the WHIM scores of patients with a PDOC (N = 21 in the retrospective study and 22 in the prospective study). RESULTS The WHIM total scores decreased due to infections in 17 of the 21 cases of infection (p < 0.001) in the retrospective study and 15 (p = 0.001) of the 22 prospective cases of infection. Patients in a minimally conscious state (MCS) showed a bigger proportion of change between their baseline score and the scores taken in the pre-infection stage in both the retrospective and prospective studies when compared to patients in a vegetative state (VS). CONCLUSION The findings suggest the importance of serial WHIM assessments throughout the period of recovery, not only to measure cognitive changes but also to highlight underlying physical changes such as infections that will impact the response to rehabilitation and recovery.
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Affiliation(s)
- Samira Kashinath Dhamapurkar
- a OT Department , The Raphael Hospital , Kent , Tonbridge , UK.,d OT Department , The National University of Ireland , Ireland , Galway
| | - Barbara A Wilson
- a OT Department , The Raphael Hospital , Kent , Tonbridge , UK.,b Neuropsychology Department , Oliver Zangwill Centre , Cambridgeshire , Cambridge , UK
| | - Anita Rose
- a OT Department , The Raphael Hospital , Kent , Tonbridge , UK
| | | | - Peter Watson
- c MRC Cognition and Brain Sciences Unit , Cambridgeshire , Cambridge , UK
| | - Agnes Shiel
- d OT Department , The National University of Ireland , Ireland , Galway
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18
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Sugishita K, Saito T, Iwamoto T. Risk factors for nursing- and healthcare-associated urinary tract infection. Geriatr Gerontol Int 2018; 18:1183-1188. [DOI: 10.1111/ggi.13438] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 03/06/2018] [Accepted: 04/04/2018] [Indexed: 01/28/2023]
Affiliation(s)
- Keiji Sugishita
- Kesennuma City Municipal Motoyoshi Hospital; Kesennuma Japan
| | - Toshiaki Saito
- Kesennuma City Municipal Motoyoshi Hospital; Kesennuma Japan
| | - Takashi Iwamoto
- Kesennuma City Municipal Motoyoshi Hospital; Kesennuma Japan
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19
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Amjad H, Carmichael D, Austin AM, Chang CH, Bynum JPW. Continuity of Care and Health Care Utilization in Older Adults With Dementia in Fee-for-Service Medicare. JAMA Intern Med 2016; 176:1371-8. [PMID: 27454945 PMCID: PMC5061498 DOI: 10.1001/jamainternmed.2016.3553] [Citation(s) in RCA: 122] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
IMPORTANCE Poor continuity of care may contribute to high health care spending and adverse patient outcomes in dementia. OBJECTIVE To examine the association between medical clinician continuity and health care utilization, testing, and spending in older adults with dementia. DESIGN, SETTING, AND PARTICIPANTS This was a study of an observational retrospective cohort from the 2012 national sample in fee-for-service Medicare, conducted from July to December 2015, using inverse probability weighted analysis. A total of 1 416 369 continuously enrolled, community-dwelling, fee-for-service Medicare beneficiaries 65 years or older with a claims-based dementia diagnosis and at least 4 ambulatory visits in 2012 were included. EXPOSURES Continuity of care score measured on patient visits across physicians over 12 months. A higher continuity score is assigned to visit patterns in which a larger share of the patient's total visits are with fewer clinicians. Score range from 0 to 1 was examined in low-, medium-, and high-continuity tertiles. MAIN OUTCOMES AND MEASURES Outcomes include all-cause hospitalization, ambulatory care sensitive condition hospitalization, emergency department visit, imaging, and laboratory testing (computed tomographic [CT] scan of the head, chest radiography, urinalysis, and urine culture), and health care spending (overall, hospital and skilled nursing facility, and physician). RESULTS Beneficiaries with dementia who had lower levels of continuity of care were younger, had a higher income, and had more comorbid medical conditions. Almost 50% of patients had at least 1 hospitalization and emergency department visit during the year. Utilization was lower with increasing level of continuity. Specifically comparing the highest- vs lowest-continuity groups, annual rates per beneficiary of hospitalization (0.83 vs 0.88), emergency department visits (0.84 vs 0.99), CT scan of the head (0.71 vs 0.83), urinalysis (0.72 vs 1.09), and health care spending (total spending, $22 004 vs $24 371) were higher with lower continuity even after accounting for sociodemographic factors and comorbidity burden (P < .001 for all comparisons). The rate of ambulatory care sensitive condition hospitalization was similar across continuity groups. CONCLUSIONS AND RELEVANCE Among older fee-for-service Medicare beneficiaries with a dementia diagnosis, lower continuity of care is associated with higher rates of hospitalization, emergency department visits, testing, and health care spending. Further research into these relationships, including potentially relevant clinical, clinician, and systems factors, can inform whether improving continuity of care in this population may benefit patients and the wider health system.
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Affiliation(s)
- Halima Amjad
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Donald Carmichael
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
| | - Andrea M Austin
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
| | - Chiang-Hua Chang
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
| | - Julie P W Bynum
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire3Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
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