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Kim J, Oh J, Ahn JS, Chung K, Kim MK, Shin CS, Park JY. Clinical Features of Delirium among Patients in the Intensive Care Unit According to Motor Subtype Classification: A Retrospective Longitudinal Study. Yonsei Med J 2023; 64:712-720. [PMID: 37992743 PMCID: PMC10681821 DOI: 10.3349/ymj.2023.0113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 08/04/2023] [Accepted: 08/24/2023] [Indexed: 11/24/2023] Open
Abstract
PURPOSE Delirium in the intensive care unit (ICU) poses a significant safety and socioeconomic burden to patients and caregivers. However, invasive interventions for managing delirium have severe drawbacks. To reduce unnecessary interventions during ICU hospitalization, we aimed to investigate the features of delirium among ICU patients according to the occurrence of hypoactive symptoms, which are not expected to require invasive intervention. MATERIALS AND METHODS Psychiatrists assessed all patients with delirium in the ICU during hospitalization. Patients were grouped into two groups: a "non-hypoactive" group that experienced the non-hypoactive motor subtype once or more or a "hypoactive only" group that only experienced the hypoactive motor subtype. Clinical variables routinely gathered for clinical management were collected from electronic medical records. Group comparisons and logistic regression analyses were conducted. RESULTS The non-hypoactive group had longer and more severe delirium episodes than the hypoactive only group. Although the non-hypoactive group was prescribed more antipsychotics and required restraints longer, the hypoactive only group also received both interventions. In multivariable logistic regression analysis, BUN [odds ratio (OR): 0.993, pH OR: 0.202], sodium (OR: 1.022), RASS score (OR: 1.308) and whether restraints were applied [OR: 1.579 (95% confidence interval 1.194-2.089), p<0.001] were significant predictors of hypoactive only group classification. CONCLUSION Managing and predicting delirium patients based on whether patients experienced non-hypoactive delirium may be clinically important. Variables obtained during the initial 48 hours can be used to determine which patients are likely to require invasive interventions.
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Affiliation(s)
- Junhyung Kim
- Department of Psychiatry, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jooyoung Oh
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Korea
- Department of Psychiatry, Yonsei University College of Medicine, Gangnam Severance Hospital, Yonsei University Health System, Seoul, Korea
| | - Ji Seon Ahn
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Korea
- Department of Psychiatry, Yonsei University College of Medicine, Yongin Severance Hospital, Yonsei University Health System, Yongin, Korea
- Center for Digital Health, Yongin Severance Hospital, Yonsei University Health System, Yongin, Korea
| | - Kyungmi Chung
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Korea
- Department of Psychiatry, Yonsei University College of Medicine, Yongin Severance Hospital, Yonsei University Health System, Yongin, Korea
- Center for Digital Health, Yongin Severance Hospital, Yonsei University Health System, Yongin, Korea
| | - Min-Kyeong Kim
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Korea
- Department of Medical Education, Yonsei University College of Medicine, Seoul, Korea
| | - Cheung Soo Shin
- Department of Anesthesiology, Yonsei University College of Medicine, Yongin Severance Hospital, Yonsei University Health System, Yongin, Korea.
| | - Jin Young Park
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Korea
- Department of Psychiatry, Yonsei University College of Medicine, Yongin Severance Hospital, Yonsei University Health System, Yongin, Korea
- Center for Digital Health, Yongin Severance Hospital, Yonsei University Health System, Yongin, Korea.
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Liang W, Qin G, Yu L, Wang Y. Reducing complications of femoral neck fracture management: a retrospective study on the application of multidisciplinary team. BMC Musculoskelet Disord 2023; 24:338. [PMID: 37120515 PMCID: PMC10148526 DOI: 10.1186/s12891-023-06455-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 04/25/2023] [Indexed: 05/01/2023] Open
Abstract
BACKGROUND Femoral neck fractures are associated with substantial morbidity and mortality for older adults. Multi-system medical diseases and complications can lead to long-term care needs, functional decline and death, so patients sustaining hip fractures usually have comorbid conditions that may benefit from application of multidisciplinary team(MDT). METHODS This is a retrospective cohort study that incorporates medical record review with an outcomes management database. 199 patients were included who had surgery for a new unilateral femoral neck fracture from January 2018 to December 2021 (96 patients in usual care (UC) model and 103 patients in MDT model. High-energy, pathological, old and periprosthetic femoral neck fracture were excluded. Age, gender, comorbidity status, time to surgery, and postoperative complication, length of stay, in-hospital mortality, 30-day readmission rate, 90-day mortality data were collected and analyzed. RESULTS Preoperative general data of sex, age, community dwelling and charlson comorbidity score of MDT group (n = 103) have no statistically significant difference with that of usual care (UC) group. Patients treated in the MDT model had significantly shorter times to surgery (38.5 vs. 73.4 h;P = 0.028) and lower lengths of stay (11.5 vs. 15.2 days;P = 0.031). There were no significant differences between two models in In-hospital mortality (1.0% vs. 2.1%; P = 0.273), 30-day readmission rate (7.8% vs. 11.5%; P = 0.352) and 90-day mortality (2.9% vs. 3.1%; P = 0.782). The MDT model had fewer complications overall (16.5% vs. 31.3%; P = 0.039), with significantly lower risks of delirium, postoperative infection, bleeding, cardiac complication, hypoxia, and thromboembolism. CONCLUSION Application of MDT can provide standardized protocols and a total quality management approach, leading to fewer complications for elderly patients with femoral neck fracture. TRIAL REGISTRATION No.
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Affiliation(s)
- Weiming Liang
- The First Affiliated Hospital of Guangxi University of Science and Technology, Guangxi University of Science and Technology, 124 Yuejin Road, Liuzhou, 545001, Guangxi Province, China
| | - Gang Qin
- The First Affiliated Hospital of Guangxi University of Science and Technology, Guangxi University of Science and Technology, 124 Yuejin Road, Liuzhou, 545001, Guangxi Province, China
| | - Lizhi Yu
- The First Affiliated Hospital of Guangxi University of Science and Technology, Guangxi University of Science and Technology, 124 Yuejin Road, Liuzhou, 545001, Guangxi Province, China
| | - Yingying Wang
- The First Affiliated Hospital of Guangxi University of Science and Technology, Guangxi University of Science and Technology, 124 Yuejin Road, Liuzhou, 545001, Guangxi Province, China.
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Reeves D, Holland F, Morbey H, Hann M, Ahmed F, Davies L, Keady J, Leroi I, Reilly S. Retrospective study of more than 5 million emergency admissions to hospitals in England: Epidemiology and outcomes for people with dementia. PLoS One 2023; 18:e0281158. [PMID: 36888666 PMCID: PMC9994676 DOI: 10.1371/journal.pone.0281158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 01/13/2023] [Indexed: 03/09/2023] Open
Abstract
INTRODUCTION People living with dementia (PwD) admitted in emergency to an acute hospital may be at higher risk of inappropriate care and poorer outcomes including longer hospitalisations and higher risk of emergency re-admission or death. Since 2009 numerous national and local initiatives in England have sought to improve hospital care for PwD. We compared outcomes of emergency admissions for cohorts of patients aged 65+ with and without dementia at three points in time. METHODS We analysed emergency admissions (EAs) from the Hospital Episodes Statistics datasets for England 2010/11, 2012/13 and 2016/17. Dementia upon admission was based on a diagnosis in the patient's hospital records within the last five years. Outcomes were length of hospital stays (LoS), long stays (> = 15 days), emergency re-admissions (ERAs) and death in hospital or within 30 days post-discharge. A wide range of covariates were taken into account, including patient demographics, pre-existing health and reasons for admission. Hierarchical multivariable regression analysis, applied separately for males and females, estimated group differences adjusted for covariates. RESULTS We included 178 acute hospitals and 5,580,106 EAs, of which 356,992 (13.9%) were male PwD and 561,349 (18.6%) female PwD. Uncontrolled differences in outcomes between the patient groups were substantial but were considerably reduced after control for covariates. Covariate-adjusted differences in LoS were similar at all time-points and in 2016/17 were 17% (95%CI 15%-18%) and 12% (10%-14%) longer for male and female PwD respectively compared to patients without dementia. Adjusted excess risk of an ERA for PwD reduced over time to 17% (15%-18%) for males and 17% (16%-19%) for females, but principally due to increased ERA rates amongst patients without dementia. Adjusted overall mortality was 30% to 40% higher for PwD of both sexes throughout the time-period; however, adjusted in-hospital rates of mortality differed only slightly between the patient groups, whereas PwD had around double the risk of dying within 30 days of being discharged. CONCLUSION Over the six-year period, covariate-adjusted hospital LoS, ERA rates and in-hospital mortality rates for PwD were only slightly elevated compared to similar patients without dementia and remaining differences potentially reflect uncontrolled confounding. PwD however, were around twice as likely to die shortly after discharge, the reasons for which require further investigation. Despite being widely used for service evaluation, LoS, ERA and mortality may lack sensitivity to changes in hospital care and support to PwD.
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Affiliation(s)
- David Reeves
- National Institute for Health Research School for Primary Care Research, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Centre for Biostatistics, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- * E-mail:
| | - Fiona Holland
- National Institute for Health Research School for Primary Care Research, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Centre for Biostatistics, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Hazel Morbey
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, United Kingdom
| | - Mark Hann
- National Institute for Health Research School for Primary Care Research, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Centre for Biostatistics, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Faraz Ahmed
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, United Kingdom
| | - Linda Davies
- National Institute for Health Research School for Primary Care Research, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - John Keady
- National Institute for Health Research School for Social Care Research, Division of Nursing, Midwifery & Social Work, University of Manchester, Manchester, United Kingdom
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, United Kingdom
| | - Iracema Leroi
- Department of Psychiatry St James’ Hospital, Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland
| | - Siobhan Reilly
- Centre for Applied Dementia Studies, Faculty of Health Studies, University of Bradford, Bradford, United Kingdom
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Increased short-term mortality among patients presenting with altered mental status to the emergency department: A cohort study. Am J Emerg Med 2022; 51:290-295. [PMID: 34785485 PMCID: PMC9376886 DOI: 10.1016/j.ajem.2021.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 10/21/2021] [Accepted: 10/21/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES To evaluate the short-term mortality of adult patients presenting to the emergency department (ED) with altered mental status (AMS) as compared to other common chief complaints. METHODS Observational cohort study of adult patients (age ≥ 40) who presented to an academic ED over a 1-year period with five pre-specified complaints at ED triage: AMS, generalized weakness, chest pain, abdominal pain, and headache. Primary outcomes included 7 and 30-day mortality. Hazard ratios (HR) were calculated with 95% confidence intervals (CI) using Cox proportional hazards models adjusted for age, acuity level, and comorbidities. RESULTS A total of 9850 ED visits were included for analysis from which 101 (1.0%) and 295 (3.0%) died within 7 and 30 days, respectively. Among 683 AMS visits, the 7-day mortality rate was 3.2%. Mortality was lower for all other chief complaints, including generalized weakness (17/1170, 1.5%), abdominal pain (32/3609, 0.9%), chest pain (26/3548, 0.7%), and headache (4/840, 0.5%). After adjusting for key confounders, patients presenting with AMS had a significantly higher risk of death within 7 days of ED arrival than patients presenting with chest pain (HR 3.72, 95% CI 2.05 to 6.76, p < .001). Similarly, we found that patients presenting with AMS had a significantly higher risk of dying within 30 days compared to patients with chest pain (HR 3.65, 95% CI 2.49 to 5.37, p < .001), and headache (HR 2.09, 95% CI 1.09 to 4.01, p = .026). Differences were not statistically significant for comparisons with abdominal pain and generalized weakness, but confidence intervals were wide. CONCLUSION Patients presenting with AMS have worse short-term prognosis than patients presenting to the ED with chest pain or headache. AMS may indicate an underlying brain dysfunction (delirium), which is associated with adverse outcomes and increased mortality.
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Tommasini NR, Iennaco JD. A Model Program to Manage Behavioral Emergencies and Support Nurses in the Medical Setting. Nurs Adm Q 2022; 46:37-44. [PMID: 34860800 DOI: 10.1097/naq.0000000000000501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Medically hospitalized individuals have high rates of comorbid psychiatric, substance abuse, and behavioral disorders. Disruptive and sometimes aggressive behaviors may arise when mental health needs of patients go unrecognized or are inadequately addressed. Health care workers experience the most workplace violence compared with other professions, with nurses and nursing aides at highest risk. A Behavioral Emergency Support Team (BEST) model can be an effective approach to providing a customized response to a patient's agitation through identification of underlying clinical and environmental contributors to the onset of aggression as well as to provide behavioral education and support of nursing staff. Results from 2 years of BEST model use resulted in 124 events among 96 patients of whom 19 had repeated events. The most common reasons for codes were aggression (79%) and elopement threat/attempt (45%), and the most frequent patient diagnosis was cognitive impairment (54%). Development of a BEST model provides support to nurses that is not otherwise available for events that are disruptive to care in inpatient medical settings and help minimize the occurrence of workplace violence.
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Affiliation(s)
- Nancy R Tommasini
- Behavioral Intervention Team (BIT), Yale New Haven Hospital, New Haven, Connecticut (Ms Tommasini); and Yale University School of Nursing, Orange, Connecticut (Dr Iennaco)
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Franco JG, Oviedo Lugo GF, Patarroyo Rodriguez L, Bernal Miranda J, Carlos Molano J, Rojas Moreno M, Cardeño C, Velasquez Tirado JD. Survey of psychiatrists and psychiatry residents in Colombia about their preventive and therapeutic practices in delirium. REVISTA COLOMBIANA DE PSIQUIATRÍA (ENGLISH ED.) 2021; 50:260-272. [PMID: 34728177 DOI: 10.1016/j.rcpeng.2020.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 02/20/2020] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To describe pharmacological and non-pharmacological practices for delirium, carried out by psychiatry residents and psychiatrists in Colombia. METHODS An anonymous survey was conducted based on the consensus of experts of the Liaison Psychiatry Committee of the Asociación Colombiana de Psiquiatría [Colombian Psychiatric Association] and on the literature review. It was sent by email to the association members. RESULTS 101 clinicians participated. Non-pharmacological preventive measures such as psychoeducation, correction of sensory problems or sleep hygiene are performed by 70% or more. Only about 1 in 10 participants are part of an institutional multi-component prevention programme. The preventive prescription of drugs was less than 20%. Regarding non-pharmacological treatment, more than 75% recommend correction of sensory difficulties, control of stimuli and reorientation. None of the participants indicated that the care at their centres is organised to enhance non-pharmacological treatment. 17.8% do not use medication in the treatment of delirium. Those who use it prefer haloperidol or quetiapine, particularly in hyperactive or mixed motor subtypes. CONCLUSIONS The practices of the respondents coincide with those of other experts around the world. In general, non-pharmacological actions are individual initiatives, which demonstrates the need in Colombian health institutions to commit to addressing delirium, in particular when its prevalence and consequences are indicators of quality of care.
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Affiliation(s)
- José G Franco
- Escuela de Ciencias de la Salud, Facultad de Medicina, Grupo de Investigación en Psiquiatría de Enlace (GIPE), Universidad Pontificia Bolivariana, Medellín, Colombia.
| | - Gabriel Fernando Oviedo Lugo
- Hospital Universitario San Ignacio, Centro de Memoria y Cognición Intellectus, Bogotá, Colombia; Facultad de Medicina, Departamento de Psiquiatría y Salud Mental, Grupo de Investigación: Perspectivas en ciclo vital, salud mental y psiquiatría, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Liliana Patarroyo Rodriguez
- Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia; Facultad de Medicina, Departamento de Salud Mental, Grupo de Investigación Fundamental: Psiquiatría de Enlace Salud Poblacional, Uniandes, Bogotá, Colombia
| | - Jaime Bernal Miranda
- Remeo Medical Center, Cali, Colombia; IBIS Biomedical Research Group, Cali, Colombia
| | - Juan Carlos Molano
- Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia; Facultad de Medicina, Departamento de Salud Mental, Grupo de Investigación Fundamental: Psiquiatría de Enlace Salud Poblacional, Uniandes, Bogotá, Colombia
| | - Monica Rojas Moreno
- Clínica Reina Sofía, Bogotá, Colombia; Psiquiatría de Enlace e Interconsulta, Grupo de Investigación: Salud Mental, Neurodesarrollo y Calidad de Vida, Universidad El Bosque, Bogotá, Colombia
| | - Carlos Cardeño
- Hospital Universitario San Vicente Fundación, Medellín, Colombia; Escuela de Ciencias de la Salud, Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia; Facultad de Medicina, Departamento de Psiquiatría, Grupo de Investigación Clínica Aplicada, Universidad de Antioquia, Medellín, Colombia
| | - Juan David Velasquez Tirado
- Escuela de Ciencias de la Salud, Facultad de Medicina, Grupo de Investigación en Psiquiatría de Enlace (GIPE), Universidad Pontificia Bolivariana, Medellín, Colombia
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Han QYC, Rodrigues NG, Klainin-Yobas P, Haugan G, Wu X. Prevalence, Risk Factors, and Impact of Delirium on Hospitalized Older Adults With Dementia: A Systematic Review and Meta-Analysis. J Am Med Dir Assoc 2021; 23:23-32.e27. [PMID: 34648761 DOI: 10.1016/j.jamda.2021.09.008] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/03/2021] [Accepted: 09/04/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES High prevalence of delirium superimposed on dementia (DSD) was previously reported, with associated negative impact on hospitalized older adults. However, data were conflicting, and no meta-analysis has been conducted. Although dementia is the leading risk factor for delirium, risk factors for DSD have not been adequately studied. This systematic review and meta-analysis aims to elucidate the prevalence, risk factors, and impact of DSD in hospitalized older adults. Comparisons were made between older adults with DSD and persons with dementia alone (PWDs). DESIGN Systematic review and meta-analysis. SETTING AND PARTICIPANTS Observational studies reporting prevalence, risk factors, or impact of DSD in hospitalized older adults. METHODS Database search was conducted till December 2020 in PubMed, Embase, CENTRAL, PsycINFO, CINAHL, Scopus, Web of Science, ProQuest, and OpenGrey for relevant primary and secondary studies. A piloted data collection form was used for data extraction, and methodological quality was assessed using Joanna Briggs Institute critical appraisal checklists. Meta-analyses, with risk ratio and mean differences as effect measures, were performed using random effects model with Review Manager software. Cochran's Q and I2 statistics were used to assess heterogeneity, which was investigated using subgroup analyses. RESULTS A total of 81 studies were eligible. The pooled prevalence of DSD was 48.9%, with the highest prevalence found in the Americas and orthopedic wards. Risk factors, including nonmodifiable hospital-, illness-, and medication-related factors, were found to precipitate DSD. Patients with DSD had longer length of hospitalization, disclosed worse cognitive and functional outcomes, and a higher risk of institutionalization and mortality than patients with dementia. CONCLUSIONS AND IMPLICATIONS These findings suggested high prevalence and detrimental impact of DSD in hospitalized older adults, highlighting a need for early identification, prevention, and treatments. Further research on risk factors of DSD should be conducted as data were sparse and conflicting. Future high-quality studies regarding DSD are warranted to improve knowledge of this common but under-recognized phenomenon.
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Affiliation(s)
- Qin Yun Claudia Han
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Natalie Grace Rodrigues
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Piyanee Klainin-Yobas
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Gørill Haugan
- Department of Public Health and Nursing, Centre for Health Promoting Research, Norwegian University of Science and Technology, Trondheim, Trøndelag, Norway
| | - XiVivien Wu
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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Predictors and Sequelae of Postoperative Delirium in a Geriatric Patient Population With Hip Fracture. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2021; 5:01979360-202105000-00011. [PMID: 33989253 PMCID: PMC8133215 DOI: 10.5435/jaaosglobal-d-20-00221] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 03/18/2021] [Indexed: 12/17/2022]
Abstract
Introduction: Postoperative delirium is common for patients with hip fracture. Predictors of postoperative delirium and its association with preexisting dementia and adverse postoperative outcomes in a geriatric hip fracture population were assessed. Methods: Patients with hip fracture aged 60 years and older were identified in the 2016 and 2017 National Surgical Quality Improvement Program Procedure Targeted Databases. Independent risk factors of postoperative delirium were identified. Associations with mortality, readmission, and revision surgery were evaluated using moderation and mediation analysis. Results: Of 18,754 patients with hip fracture, 30.2% had preoperative dementia, 18.8% had postoperative delirium, and 8.3% had both preoperative dementia and postoperative delirium. Independent predictors of postoperative delirium were as follows: older age, male sex, higher American Society of Anesthesiologists score, dependent functional status, nongeneral anesthesia, preoperative diabetes, bleeding disorder, and preoperative dementia. Preoperative dementia and postoperative delirium each had an independent correlation with 30-day mortality (odds ratios = 2.06 and 1.92, respectively, with P < 0.001 for both). However, when both were present, those with preoperative dementia and postoperative delirium had an even higher odds of mortality based on moderation analysis (odds ratio = 2.25, P < 0.001). Readmissions and reoperations were significantly correlated with postoperative delirium, but not with preoperative dementia. The combination of preoperative dementia and postoperative delirium, however, did have compounding effects. Furthermore, a significant proportion of the total effect of preoperative dementia on mortality and readmission was accounted for by the development of postoperative delirium based on mediation analysis (medeff: 7%, P < 0.001 and medeff: 35%, P < 0.001). Discussion: Postoperative delirium is a potentially preventable postoperative adverse outcome that was seen in 18.8% of 18,754 patients with hip fracture. Those with preoperative dementia seem to be a particularly at-risk subpopulation. Quality improvement initiatives to minimize postoperative delirium in this hip fracture population should be considered and optimized.
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Codling D, Hood C, Bassett P, Smithard D, Crawford MJ. Delirium screening and mortality in patients with dementia admitted to acute hospitals. Aging Ment Health 2021; 25:889-895. [PMID: 32081035 DOI: 10.1080/13607863.2020.1725804] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objectives: Delirium is associated with increased mortality in older adults. National guidance recommends that all people with dementia who are admitted to hospital are screened for delirium. However, the impact of screening for delirium among inpatients with dementia has not been examined. This study aims to examine this relationship.Methods: Secondary analysis of data from 10,047 patients admitted to 199 hospitals in England and Wales that took part in the third round of the National Audit of Dementia. Multilevel logistic regression was used to examine associations between delirium screening and cognitive testing with inpatient mortality, adjusted for age, gender, diagnosis and hospital site as potential confounders.Results: The mean age of study patients was 84 years (SD = 7.9), 40.1% were male and 82.1% white British. 1285 patients (12.8%) died during their admission to hospital. Overall, 4466 (44.5%) patients were screened for delirium, of whom 2603 (58.6%) screened positive. The odds of mortality were lower in patients who underwent delirium screening (OR 0.84, 95% confidence interval 0.73 to 0.96) and in those receiving cognitive testing (OR 0.74, 95%CI 0.63-0.76).Conclusion: These results suggest that, among people with dementia who are admitted to hospital, screening for delirium and assessment of cognitive functioning may be associated with lower mortality. While we cannot be certain that these associations are causal, the findings support efforts that are being made to increase levels of screening for delirium among people with dementia who are admitted to hospital.
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Affiliation(s)
- David Codling
- South London and Maudsley NHS Foundation Trust, Beckenham, London, UK
| | - Chloe Hood
- College Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | | | | | - Mike J Crawford
- College Centre for Quality Improvement, Royal College of Psychiatrists, London, UK.,Centre for Psychiatry, Imperial College, London, UK
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Cognitive Impairment and Length of Stay in Acute Care Hospitals: A Scoping Review of the Literature. Can J Aging 2021; 40:405-423. [PMID: 33843528 DOI: 10.1017/s0714980820000355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Older persons experiencing a longer length of stay (LOS) or delayed discharge (DD) may see a decline in their health and well-being, generating significant costs. This review aimed to identify evidence on the impact of cognitive impairment (CI) on acute care hospital LOS/DD. A scoping review of studies examining the association between CI and LOS/DD was performed. We searched six databases; two reviewers independently screened references until November 2019. A narrative synthesis was used to answer the research question; 58 studies were included of which 33 found a positive association between CI and LOS or DD, 8 studies had mixed results, 3 found an inverse relationship, and 14 showed an indirect link between CI-related syndromes and LOS/DD. Thus, cognitive impairment seemed to be frequently associated with increased LOS/DD. Future research should consider CI together with other risks for LOS/DD and also focus on explaining the association between the two.
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Reynish E, Hapca S, Walesby R, Pusram A, Bu F, Burton JK, Cvoro V, Galloway J, Ebbesen Laidlaw H, Latimer M, McDermott S, Rutherford AC, Wilcock G, Donnan P, Guthrie B. Understanding health-care outcomes of older people with cognitive impairment and/or dementia admitted to hospital: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09080] [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] Open
Abstract
Background
Cognitive impairment is common in older people admitted to hospital, but previous research has focused on single conditions.
Objective
This project sits in phase 0/1 of the Medical Research Council Framework for the Development and Evaluation of Complex Interventions. It aims to develop an understanding of current health-care outcomes. This will be used in the future development of a multidomain intervention for people with confusion (dementia and cognitive impairment) in general hospitals. The research was conducted from January 2015 to June 2018 and used data from people admitted between 2012 and 2013.
Design
For the review of outcomes, the systematic review identified peer-reviewed quantitative epidemiology measuring prevalence and associations with outcomes. Screening for duplication and relevance was followed by full-text review, quality assessment and a narrative review (141 papers). A survey sought opinion on the key outcomes for people with dementia and/or confusion and their carers in the acute hospital (n = 78). For the analysis of outcomes including cost, the prospective cohort study was in a medical admissions unit in an acute hospital in one Scottish health board covering 10% of the Scottish population. The participants (n = 6724) were older people (aged ≥ 65 years) with or without a cognitive spectrum disorder who were admitted as medical emergencies between January 2012 and December 2013 and who underwent a structured nurse assessment. ‘Cognitive spectrum disorder’ was defined as any combination of delirium, known dementia or an Abbreviated Mental Test score of < 8 out of 10 points. The main outcome measures were living at home 30 days after discharge, mortality within 2 years of admission, length of stay, re-admission within 2 years of admission and cost.
Data sources
Scottish Morbidity Records 01 was linked to the Older Persons Routine Acute Assessment data set.
Results
In the systematic review, methodological heterogeneity, especially concerning diagnostic criteria, means that there is significant overlap in conditions of patients presenting to general hospitals with confusion. Patients and their families expect that patients are discharged in the same or a better condition than they were in on admission or, failing that, that they have a satisfactory experience of their admission. Cognitive spectrum disorders were present in more than one-third of patients aged ≥ 65 years, and in over half of those aged ≥ 85 years. Outcomes were worse in those patients with cognitive spectrum disorders than in those without: length of stay 25.0 vs. 11.8 days, 30-day mortality 13.6% vs. 9.0%, 1-year mortality 40.0% vs. 26.0%, 1-year mortality or re-admission 62.4% vs. 51.5%, respectively (all p < 0.01). There was relatively little difference by cognitive spectrum disorder type; for example, the presence of any cognitive spectrum disorder was associated with an increased mortality over the entire period of follow-up, but with different temporal patterns depending on the type of cognitive spectrum disorder. The cost of admission was higher for those with cognitive spectrum disorders, but the average daily cost was lower.
Limitations
A lack of diagnosis and/or standardisation of diagnosis for dementia and/or delirium was a limitation for the systematic review, the quantitative study and the economic study. The economic study was limited to in-hospital costs as data for social or informal care costs were unavailable. The survey was conducted online, limiting its reach to older carers and those people with cognitive spectrum disorders.
Conclusions
Cognitive spectrum disorders are common in older inpatients and are associated with considerably worse health-care outcomes, with significant overlap between individual cognitive spectrum disorders. This suggests the need for health-care systems to systematically identify and develop care pathways for older people with cognitive spectrum disorders, and avoid focusing on only condition-specific pathways.
Future work
Development and evaluation of a multidomain intervention for the management of patients with cognitive spectrum disorders in hospital.
Study registration
This study is registered as PROSPERO CRD42015024492.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Emma Reynish
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Simona Hapca
- School of Medicine, University of Dundee, Dundee, UK
| | - Rebecca Walesby
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Angela Pusram
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Feifei Bu
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Jennifer K Burton
- Deanery of Clinical Sciences, University of Edinburgh, Edinburgh, UK
| | - Vera Cvoro
- Deanery of Clinical Sciences, University of Edinburgh, Edinburgh, UK
| | - James Galloway
- Health Informatics Centre, University of Dundee, Dundee, UK
| | | | - Marion Latimer
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | | | | | - Gordon Wilcock
- Oxford Institute of Population Ageing, University of Oxford, Oxford, UK
| | - Peter Donnan
- School of Medicine, University of Dundee, Dundee, UK
| | - Bruce Guthrie
- School of Medicine, University of Dundee, Dundee, UK
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Tal S. Length of hospital stay among oldest-old patients in acute geriatric ward. Arch Gerontol Geriatr 2021; 94:104352. [PMID: 33513548 DOI: 10.1016/j.archger.2021.104352] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/20/2021] [Accepted: 01/21/2021] [Indexed: 01/06/2023]
Abstract
PURPOSE To examine risk factors for prolonged hospital length of stay (LOS) in the oldest-old inpatients aged ≥ 90. METHODS This retrospective cross-sectional study was performed in acute Geriatrics Department at Kaplan Medical Center. The target population was the oldest-old inpatients aged ≥ 90 hospitalized with acute illness. In total 1536 admissions of 987 patients admitted between January 2007 and December 2010 from the emergency room were included in the study. We retrieved from the electronic hospital records the following data: demographics, admission diagnosis, comorbidities, laboratory tests, drugs, functional and cognitive status, Charlson Comorbidity Index (CCI) score and age-adjusted CCI score. RESULTS The risk factors for a prolonged LOS were tube-feeding, consumption of ≥ 5 drugs, non-independent functional status, diagnosis of urinary tract infection (UTI), pneumonia and malignancy on admission, and comorbidities of congestive heart failure (CHF) and hypoalbuminemia. Multiple linear regression analysis found that UTI, hypoalbuminemia, elevated troponin, pneumonia, number of drugs, malignancy, CHF and number of comorbidities explain a higher risk for a longer LOS. CONCLUSION Hospital LOS in the oldest-old patients in acute geriatric ward was associated with admission diagnosis and comorbidities. Awareness of the risk factors for a longer LOS might contribute to reducing hospitalization stay and its related negative consequences. Accurate prediction of prolonged LOS in this age group of patients may be more challenging and require variables that were not included in our study. Future research is warranted.
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Affiliation(s)
- Sari Tal
- Acute Geriatrics Department, Kaplan Medical Center, Affiliated with the Hebrew University of Jerusalem, 1, Derech Pasternak, st., Rehovot, Israel.
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13
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Franco JG, Oviedo Lugo GF, Patarroyo Rodriguez L, Bernal Miranda J, Molano JC, Rojas Moreno M, Cardeño C, Velasquez Tirado JD. Survey of psychiatrists and psychiatry residents in Colombia about their preventive and therapeutic practices in delirium. REVISTA COLOMBIANA DE PSIQUIATRIA (ENGLISH ED.) 2020; 50:S0034-7450(20)30031-7. [PMID: 33735057 DOI: 10.1016/j.rcp.2020.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 01/02/2020] [Accepted: 02/20/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe pharmacological and non-pharmacological practices for delirium, carried out by psychiatry residents and psychiatrists in Colombia. METHODS An anonymous survey was conducted based on the consensus of experts of the Liaison Psychiatry Committee of the Asociación Colombiana de Psiquiatría [Colombian Psychiatric Association] and on the literature review. It was sent by email to the association members. RESULTS 101 clinicians participated. Non-pharmacological preventive measures such as psychoeducation, correction of sensory problems or sleep hygiene are performed by 70% or more. Only about 1 in 10 participants are part of an institutional multi-component prevention programme. The preventive prescription of drugs was less than 20%. Regarding non-pharmacological treatment, more than 75% recommend correction of sensory difficulties, control of stimuli and reorientation. None of the participants indicated that the care at their centres is organised to enhance non-pharmacological treatment. 17.8% do not use medication in the treatment of delirium. Those who use it prefer haloperidol or quetiapine, particularly in hyperactive or mixed motor subtypes. CONCLUSIONS The practices of the respondents coincide with those of other experts around the world. In general, non-pharmacological actions are individual initiatives, which demonstrates the need in Colombian health institutions to commit to addressing delirium, in particular when its prevalence and consequences are indicators of quality of care.
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Affiliation(s)
- José G Franco
- Escuela de Ciencias de la Salud, Facultad de Medicina, Grupo de Investigación en Psiquiatría de Enlace (GIPE), Universidad Pontificia Bolivariana, Medellín, Colombia.
| | - Gabriel Fernando Oviedo Lugo
- Hospital Universitario San Ignacio, Centro de Memoria y Cognición Intellectus, Bogotá, Colombia; Facultad de Medicina, Departamento de Psiquiatría y Salud Mental, Grupo de Investigación: Perspectivas en ciclo vital, salud mental y psiquiatría, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Liliana Patarroyo Rodriguez
- Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia; Facultad de Medicina, Departamento de Salud Mental, Grupo de Investigación Fundamental: Psiquiatría de Enlace Salud Poblacional, Uniandes, Bogotá, Colombia
| | - Jaime Bernal Miranda
- Remeo Medical Center, Cali, Colombia; IBIS Biomedical Research Group, Cali, Colombia
| | - Juan Carlos Molano
- Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia; Facultad de Medicina, Departamento de Salud Mental, Grupo de Investigación Fundamental: Psiquiatría de Enlace Salud Poblacional, Uniandes, Bogotá, Colombia
| | - Monica Rojas Moreno
- Clínica Reina Sofía, Bogotá, Colombia; Psiquiatría de Enlace e Interconsulta, Grupo de Investigación: Salud Mental, Neurodesarrollo y Calidad de Vida, Universidad El Bosque, Bogotá, Colombia
| | - Carlos Cardeño
- Hospital Universitario San Vicente Fundación, Medellín, Colombia; Escuela de Ciencias de la Salud, Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia; Facultad de Medicina, Departamento de Psiquiatría, Grupo de Investigación Clínica Aplicada, Universidad de Antioquia, Medellín, Colombia
| | - Juan David Velasquez Tirado
- Escuela de Ciencias de la Salud, Facultad de Medicina, Grupo de Investigación en Psiquiatría de Enlace (GIPE), Universidad Pontificia Bolivariana, Medellín, Colombia
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Sanatinia R, Crawford MJ, Quirk A, Hood C, Gordon F, Crome P, Staniszewska S, Zafarani G, Hammond S, Burns A, Seers K. Identifying features associated with higher-quality hospital care and shorter length of admission for people with dementia: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Concerns have repeatedly been expressed about the quality of inpatient care that people with dementia receive. Policies and practices have been introduced that aim to improve this, but their impact is unclear.
Aims
To identify which aspects of the organisation and delivery of acute inpatient services for people with dementia are associated with higher-quality care and shorter length of stay.
Design
Mixed-methods study combining a secondary analysis of data from the third National Audit of Dementia (2016/17) and a nested qualitative exploration of the context, mechanism and outcomes of acute care for people with dementia.
Setting
Quantitative data from 200 general hospitals in England and Wales and qualitative data from six general hospitals in England that were purposively selected based on their performance in the audit.
Participants
Quantitative data from clinical records of 10,106 people with dementia who had an admission to hospital lasting ≥ 72 hours and 4688 carers who took part in a cross-sectional survey of carer experience. Qualitative data from interviews with 56 hospital staff and seven carers of people with dementia.
Main outcome measures
Length of stay, quality of assessment and carer-rated experience.
Results
People with dementia spent less time in hospital when discharge planning was initiated within 24 hours of admission. This is a challenging task when patients have complex needs, and requires named staff to take responsibility for co-ordinating the discharge and effective systems for escalating concerns when obstacles arise. When trust boards review delayed discharges, they can identify recurring problems and work with local stakeholders to try to resolve them. Carers of people with dementia play an important role in helping to ensure that hospital staff are aware of patient needs. When carers are present on the ward, they can reassure patients and help make sure that they eat and drink well, and adhere to treatment and care plans. Clear communication between staff and family carers can help ensure that they have realistic expectations about what the hospital staff can and cannot provide. Dementia-specific training can promote the delivery of person-centred care when it is made available to a wide range of staff and accompanied by ‘hands-on’ support from senior staff.
Limitations
The quantitative component of this research relied on audit data of variable quality. We relied on carers of people with dementia to explore aspects of service quality, rather than directly interviewing people with dementia.
Conclusions
If effective support is provided by senior managers, appropriately trained staff can work with carers of people with dementia to help ensure that patients receive timely and person-centred treatment, and that the amount of time they spend in hospital is minimised.
Future work
Future research could examine new ways to work with carers to co-produce aspects of inpatient care, and to explore the relationship between ethnicity and quality of care in patients with dementia.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 22. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | - Mike J Crawford
- Centre for Psychiatry, Imperial College London, London, UK
- College Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Alan Quirk
- College Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Chloe Hood
- College Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Fabiana Gordon
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Peter Crome
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Sophie Staniszewska
- Warwick Research in Nursing, Warwick Medical School, University of Warwick, Coventry, UK
| | - Gemma Zafarani
- Centre for Psychiatry, Imperial College London, London, UK
| | - Sara Hammond
- Centre for Psychiatry, Imperial College London, London, UK
| | - Alistair Burns
- Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
| | - Kate Seers
- Warwick Research in Nursing, Warwick Medical School, University of Warwick, Coventry, UK
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Scharf AC, Gronewold J, Dahlmann C, Schlitzer J, Kribben A, Gerken G, Frohnhofen H, Dodel R, Hermann DM. Clinical and functional patient characteristics predict medical needs in older patients at risk of functional decline. BMC Geriatr 2020; 20:75. [PMID: 32085737 PMCID: PMC7035632 DOI: 10.1186/s12877-020-1443-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 01/23/2020] [Indexed: 11/10/2022] Open
Abstract
Background The rising number of older multimorbid in-patients has implications for medical care. There is a growing need for the identification of factors predicting the needs of older patients in hospital environments. Our aim was to evaluate the use of clinical and functional patient characteristics for the prediction of medical needs in older hospitalized patients. Methods Two hundred forty-two in-patients (57.4% male) aged 78.4 ± 6.4 years, who were consecutively admitted to internal medicine departments of the University Hospital Essen between July 2015 and February 2017, were prospectively enrolled. Patients were assessed upon admission using the Identification of Seniors at Risk (ISAR) screening followed by comprehensive geriatric assessment (CGA). The CGA included standardized instruments for the assessment of activities of daily living (ADL), cognition, mobility, and signs of depression upon admission. In multivariable regressions we evaluated the association of clinical patient characteristics, the ISAR score and CGA results with length of hospital stay, number of nursing hours and receiving physiotherapy as indicators for medical needs. We identified clinical characteristics and risk factors associated with higher medical needs. Results The 242 patients spent [median(Q1;Q3)]:9.0(4.0;16.0) days in the hospital, needed 2.0(1.5;2.7) hours of nursing each day, and 34.3% received physiotherapy. In multivariable regression analyses including clinical patient characteristics, ISAR and CGA domains, the factors age (β = − 0.19, 95% confidence interval (CI) = − 0.66;-0.13), number of admission diagnoses (β = 0.28, 95% CI = 0.16;0.41), ADL impairment (B = 6.66, 95% CI = 3.312;10.01), and signs of depression (B = 6.69, 95% CI = 1.43;11.94) independently predicted length of hospital stay. ADL impairment (B = 1.14, 95%CI = 0.67;1.61), cognition impairment (B = 0.57, 95% CI = 0.07;1.07) and ISAR score (β =0.26, 95% CI = 0.01;0.28) independently predicted nursing hours. The number of admission diagnoses (risk ratio (RR) = 1.06, 95% CI = 1.04;1.08), ADL impairment (RR = 3.54, 95% CI = 2.29;5.47), cognition impairment (RR = 1.77, 95% CI = 1.20;2.62) and signs of depression (RR = 1.99, 95% CI = 1.39;2.85) predicted receiving physiotherapy. Conclusion Among older in-patients at risk for functional decline, the number of comorbidities, reduced ADL, cognition impairment and signs of depression are important predictors of length of hospital stay, nursing hours, and receiving physiotherapy during hospital stay.
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Affiliation(s)
- Anne-Carina Scharf
- Department of Neurology, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147, Essen, Germany.
| | - Janine Gronewold
- Department of Neurology, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Christian Dahlmann
- Nursing Headquarters, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Jeanina Schlitzer
- Department of Nephrology, Geriatric and Internal Medicine, Alfried Krupp Hospital Essen, Essen, Germany
| | - Andreas Kribben
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Guido Gerken
- Department of Gastroenterology and Hepatology, Faculty of Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Helmut Frohnhofen
- Department of Nephrology, Geriatric and Internal Medicine, Alfried Krupp Hospital Essen, Essen, Germany.,Faculty of Health, Department of Medicine, University Witten-Herdecke, Witten, Germany
| | - Richard Dodel
- Department of Geriatrics, University Hospital Essen, Essen, Germany
| | - Dirk M Hermann
- Department of Neurology, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147, Essen, Germany.
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Greaves D, Psaltis PJ, Lampit A, Davis DHJ, Smith AE, Bourke A, Worthington MG, Valenzuela MJ, Keage HAD. Computerised cognitive training to improve cognition including delirium following coronary artery bypass grafting surgery: protocol for a blinded randomised controlled trial. BMJ Open 2020; 10:e034551. [PMID: 32029497 PMCID: PMC7045123 DOI: 10.1136/bmjopen-2019-034551] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Coronary artery bypass grafting (CABG) surgery is known to improve vascular function and cardiac-related mortality rates; however, it is associated with high rates of postoperative cognitive decline and delirium. Previous attempts to prevent post-CABG cognitive decline using pharmacological and surgical approaches have been largely unsuccessful. Cognitive prehabilitation and rehabilitation are a viable yet untested option for CABG patients. We aim to investigate the effects of preoperative cognitive training on delirium incidence, and preoperative and postoperative cognitive training on cognitive decline at 4 months post-CABG. METHODS AND ANALYSIS This study is a randomised, single-blinded, controlled trial investigating the use of computerised cognitive training (CCT) both pre-CABG and post-CABG (intervention group) compared with usual care (control group) in older adults undergoing CABG in Adelaide, South Australia. Those in the intervention group will complete 1-2 weeks of CCT preoperatively (45-60 min sessions, 3.5 sessions/week) and 12 weeks of CCT postoperatively (commencing 1 month following surgery, 45-60 min sessions, 3 sessions/week). All participants will undergo cognitive testing preoperatively, over their hospital stay including delirium, and postoperatively for up to 1 year. The primary delirium outcome variable will be delirium incidence (presence vs absence); the primary cognitive decline variable will be at 4 months (significant decline vs no significant decline/improvement from baseline). Logistic regression modelling will be used, with age and gender as covariates. Secondary outcomes include cognitive decline from baseline to discharge, and at 6 months and 1 year post-CABG. ETHICS AND DISSEMINATION Ethics approval was obtained from the Central Adelaide Local Health Network Human Research Ethics Committee (South Australia, Australia) and the University of South Australia Human Ethics Committee, with original approval obtained on 13 December 2017. It is anticipated that approximately two to four publications and multiple conference presentations (national and international) will result from this research. TRIAL REGISTRATION NUMBER This clinical trial is registered with the Australian New Zealand Clinical Trials Registry and relates to the pre-results stage. Registration number: ACTRN12618000799257.
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Affiliation(s)
- Danielle Greaves
- Cognitive Ageing and Impairment Neurosciences Laboratory (CAIN), School of Psychology, Social Work and Social Policy, University of South Australia Division of Education, Arts and Social Sciences, Adelaide, South Australia, Australia
| | - Peter J Psaltis
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Vascular Research Centre, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Department of Cardiology, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Amit Lampit
- Academic Unit for Psychiatry of Old Age, Department of Psychiatry, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Daniel H J Davis
- MRC Unit for Lifelong Health and Ageing, University College London, London, UK
| | - Ashleigh E Smith
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), University of South Australia Division of Health Sciences, Adelaide, South Australia, Australia
| | - Alice Bourke
- Department of Geriatric and Rehabilitation Medicine, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Michael G Worthington
- Department of Cardiothoracic Surgery, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Michael J Valenzuela
- Brain and Mind Centre and Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Hannah A D Keage
- Cognitive Ageing and Impairment Neurosciences Laboratory (CAIN), School of Psychology, Social Work and Social Policy, University of South Australia Division of Education, Arts and Social Sciences, Adelaide, South Australia, Australia
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Cappetta K, Lago L, Potter J, Phillipson L. Under-coding of dementia and other conditions indicates scope for improved patient management: A longitudinal retrospective study of dementia patients in Australia. Health Inf Manag 2020; 51:32-44. [PMID: 31971019 DOI: 10.1177/1833358319897928] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Under-coding of dementia during hospitalisation results in an inability to identify all patients with dementia using hospital administrative data. Clinical coding can be viewed as a proxy for management; therefore, under-coding indicates dementia was not considered in the patient's management. While under-coding of dementia is well established, there is sparse evidence on whether dementia is coded in subsequent hospitalisations among patients with a known diagnosis. OBJECTIVE (a) To describe patterns of dementia coding over 5 years after a first-coded (i.e. index) admission for dementia; (b) to identify factors associated with clinical coding of dementia; and (c) to identify patient subgroups at risk of not being coded to inform future interventions to improve hospital identification and management of dementia. METHOD Retrospective study of longitudinal hospital data from 1 July 2006 to 30 June 2015 for 7919 patients hospitalised during the 5 years' post-index admission for dementia in a regional local health district of New South Wales, Australia. RESULTS Dementia was coded in 63.9% of admissions in the 12 months following index admission for dementia; this decreased to 53.7% after 5 years. Patients were 20% more likely to have dementia actively managed when it co-occurred with delirium. Under-coding varied across conditions, with dementia more likely to be coded in admissions for falls and pneumonitis, and less likely for heart failure, pneumonia and urinary tract infection (UTI). CONCLUSION The frequency with which dementia was not coded highlights opportunities to improve identification and management of dementia through dementia-specific care, enhanced clinical protocols, and interventions focused around heart failure, pneumonia and UTI admissions.
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Affiliation(s)
| | | | - Jan Potter
- University of Wollongong, Australia.,Illawarra Shoalhaven Local Health District, Australia
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Ablett AD, McCarthy K, Carter B, Pearce L, Stechman M, Moug S, Hewitt J, Myint PK. Cognitive impairment is associated with mortality in older adults in the emergency surgical setting: Findings from the Older Persons Surgical Outcomes Collaboration (OPSOC): A prospective cohort study. Surgery 2019; 165:978-984. [DOI: 10.1016/j.surg.2018.10.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 09/30/2018] [Accepted: 10/13/2018] [Indexed: 12/29/2022]
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The Impact of Being a Migrant from a Non-English-Speaking Country on Healthcare Outcomes in Frail Older Inpatients: an Australian Study. J Cross Cult Gerontol 2018; 32:447-460. [PMID: 28808814 DOI: 10.1007/s10823-017-9333-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The purpose of this prospective study of 2180 consecutive index admissions to an acute geriatric service was to compare in-hospital outcomes of frail older inpatients born in non-English-speaking counties, referred to as culturally and linguistically diverse (CALD) countries in Australia, with those born in English-speaking countries. Multivariate logistic regression was used to model in-hospital mortality and new nursing home placement. Multivariate Cox proportional hazards regression was used to model length of stay. The mean age of all patients was 83 years and 93% were admitted through the emergency department. In multivariate analyses, patients from CALD and non-CALD backgrounds were equally likely to die (CALD odds ratio [OR] 0.69, 95% confidence interval [95% CI] 0.44-1.10) and be newly placed in a nursing home (OR 0.75, 95% CI 0.51-1.12). Patients from CALD backgrounds unable to speak English were more likely to die (11.5% vs. 7.2%, p = 0.02). While patients from CALD backgrounds had significantly shorter lengths of stay in univariate analysis (median 9 days vs. 10 days, p = 0.02), this was not apparent in multivariate analysis (hazard ratio 1.02, 95% CI 0.91-1.14), where the ability to speak English proved to be a strong confounder. While most of the literature shows poorer outcomes of people from minority ethnic groups, our findings indicate that this is not necessarily the case. Developing culturally appropriate services may mitigate some of the adverse outcomes commonly associated with ethnicity. Our findings are particularly relevant to countries populated by multiple ethnic groups.
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Fogg C, Griffiths P, Meredith P, Bridges J. Hospital outcomes of older people with cognitive impairment: An integrative review. Int J Geriatr Psychiatry 2018; 33:1177-1197. [PMID: 29947150 PMCID: PMC6099229 DOI: 10.1002/gps.4919] [Citation(s) in RCA: 128] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 04/03/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To summarise existing knowledge of outcomes of older hospital patients with cognitive impairment, including the type and frequency of outcomes reported, and the additional risk experienced by this patient group. METHODS Integrative literature review. Health care literature databases, reports, and policy documents on key websites were systematically searched. Papers describing the outcomes of older people with cognitive impairment during hospitalisation and at discharge were analysed and summarised using integrative methods. RESULTS One hundred four articles were included. A range of outcomes were identified, including those occurring during hospitalisation and at discharge. Older people with a dementia diagnosis were at higher risk from death in hospital, nursing home admission, long lengths of stay, as well as intermediate outcomes such as delirium, falls, dehydration, reduction in nutritional status, decline in physical and cognitive function, and new infections in hospital. Fewer studies examined the relationship of all-cause cognitive impairment with outcomes. Patient and carer experiences of hospital admission were often poor. Few studies collected data relating to hospital environment, eg, ward type or staffing levels, and acuity of illness was rarely described. CONCLUSIONS Older people with cognitive impairment have a higher risk of a variety of negative outcomes in hospital. Prevalent intermediate outcomes suggest that changes in care processes are required to ensure maintenance of fundamental care provision and greater attention to patient safety in this vulnerable group. More research is required to understand the most appropriate ways of doing this and how changes in these care processes are best implemented to improve hospital outcomes.
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Affiliation(s)
- Carole Fogg
- Research and InnovationPortsmouth Hospitals NHS TrustPortsmouthUK
- National Institute of Health Research Collaboration for Leadership in Applied Health Research and CareWessexUK
- School of Health Sciences and Social Work, Faculty of ScienceUniversity of PortsmouthPortsmouthUK
- Faculty of Health SciencesUniversity of SouthamptonSouthamptonUK
| | - Peter Griffiths
- National Institute of Health Research Collaboration for Leadership in Applied Health Research and CareWessexUK
- Faculty of Health SciencesUniversity of SouthamptonSouthamptonUK
| | - Paul Meredith
- Research and InnovationPortsmouth Hospitals NHS TrustPortsmouthUK
- National Institute of Health Research Collaboration for Leadership in Applied Health Research and CareWessexUK
| | - Jackie Bridges
- National Institute of Health Research Collaboration for Leadership in Applied Health Research and CareWessexUK
- Faculty of Health SciencesUniversity of SouthamptonSouthamptonUK
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21
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Meagher D, Leonard M. The active management of delirium: improving detection and
treatment. ACTA ACUST UNITED AC 2018. [DOI: 10.1192/apt.bp.107.003723] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The management of delirium requires careful consideration of the potential
value both of pharmacological interventions and of a range of non-drug
strategies. Although placebo-controlled studies of delirium treatment are
lacking, less robust evidence can still inform practice. This review makes
the case for more active management of delirium on the basis of recent
studies of prevention, early identification and treatment both during an
episode and managing the aftermath in survivors. A drug-treatment algorithm
for delirium advising how drug treatments can be tailored to the specific
needs of individual patients is described.
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Sun SH, Yang L, Sun DF, Wu Y, Han J, Liu RC, Wang LJ. Effects of vasodilator and esmolol-induced hemodynamic stability on early post-operative cognitive dysfunction in elderly patients: a randomized trial. Afr Health Sci 2016; 16:1056-1066. [PMID: 28479899 DOI: 10.4314/ahs.v16i4.23] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To investigate the effect of continuous intravenous injection of nicardipine and/or nitroglycerin with or without esmolol on the occurrence of early post-operative cognitive dysfunction (POCD) in elderly patients. METHODS Elderly patients (n=340) who underwent radiofrequency ablation for atrial fibrillation were randomized into five groups: A, nicardipine; B nicardipine+esmolol; C, (nitroglycerin) group; D nitroglycerin+esmolol; E (control) groups. The hemodynamic parameters were recorded, and Mini Mental State Examination was used to assess cognitive function. RESULTS At 30 min and 60 minutes after anesthesia and at the conclusion of surgery, the rate pressure product value was significantly lower in Groups B (10621.1±321.7, 10544.2±321.8, and 10701.3±325.5, respectively) and D (10807.4±351.1, 10784.3±360.3, and 10771.7±345.7, respectively) than in Group E (13217.1±377.6, 13203.5±357.3, and 13119.2±379.5, respectively). The heart rate was significantly higher in Groups A (104.1±10.3, 104.9±11.1, and 103.9±11.8, respectively) and C (103.7±11.3, 105.5±10.5, and 107.7±11.7, respectively) than in Group E (89.3±12.0, 88.5±11.5, and 85.5±11.6, respectively). The incidence of POCD was significantly lower in Groups A and B than in Groups C, D, and E. Univariate regression analysis showed that regimens in Groups A, B, and E and doses of propofol and fentanyl were risk factors for POCD. Multivariate logistic regression analysis revealed significant associations between the incidence of POCD and interventions in Groups A and B. CONCLUSION Maintenance of stable intraoperative hemodynamics using nicardipine and nitroglycerin or their combinations with esmolol, especially nicardipine with esmolol, reduced the incidence of POCD in the elderly with potential cardiovascular diseases.
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Affiliation(s)
- Sheng-Hui Sun
- Class twelve Grade two, The Middle School Attached to Liaoning Normal University, Dalian, Liaoning, China
| | - Lin Yang
- Department of Nerve Electroneurophysiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - De-Feng Sun
- Department of Anesthesiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Yue Wu
- Department of Anesthesiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Jun Han
- Department of Anesthesiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Ruo-Chuan Liu
- Department of Anesthesiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Li-Jie Wang
- Department of Anesthesiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
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23
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Simpkins D, Peisah C, Boyatzis I. Behavioral emergency in the elderly: a descriptive study of patients referred to an Aggression Response Team in an acute hospital. Clin Interv Aging 2016; 11:1559-1565. [PMID: 27826189 PMCID: PMC5096780 DOI: 10.2147/cia.s116376] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aim The management of severely agitated elderly patients is not easy, and limited guidelines are available to assist practitioners. At a Sydney hospital, an Aggression Response Team (ART) comprising clinical and security staff can be alerted when a staff member has safety concerns. Our aims were to describe the patient population referred for ART calls, reasons for and interventions during ART calls, and complications following them. Methods Patients 65 years and older referred for ART calls in the emergency department or wards during 2014 were identified using the Incident Information Management System database and medical records were reviewed. Demographic and clinical data were collected. Results Of 43 elderly patients with ART calls, 30 had repeat ART calls. Thirty-one patients (72%) had underlying dementia, and 22 (51%) were agitated at the time of admission. The main reasons for ART calls were wandering and physical aggression. Pharmacological sedation was used in 88% of the ART calls, with a range of psychotropics, doses, and routes of administration, including intravenous (19%) and, most commonly, midazolam (53%). Complications were documented in 14% of cases where sedation was used. Conclusion We observed a high frequency of pharmacological sedation among the severely agitated elderly, with significant variance in the choice and dose of sedation and a high rate of complications arising from sedation, which may be an underestimate given the lack of post-sedation monitoring. We recommend the development of guidelines on the management of behavioral emergency in the elderly patients, including de-escalation strategies and standardized psychotropic guidelines.
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Affiliation(s)
- Daniel Simpkins
- Division of Rehabilitation and Aged Care, Hornsby Ku-ring-gai Hospital
| | - Carmelle Peisah
- School of Psychiatry, University of New South Wales; Discipline of Psychiatry, University of Sydney, Sydney, NSW, Australia
| | - Irene Boyatzis
- Division of Rehabilitation and Aged Care, Hornsby Ku-ring-gai Hospital
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24
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Park H, Kim KW, Yoon IY. Smoking Cessation and the Risk of Hyperactive Delirium in Hospitalized Patients: A Retrospective Study. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2016; 61:643-51. [PMID: 27310248 PMCID: PMC5348092 DOI: 10.1177/0706743716652401] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The acute cessation of smoking often induces symptoms that are similar to those associated with delirium. We aimed to evaluate effects of sudden nicotine abstinence on the development of delirium and its motoric subtypes in hospitalized patients. METHODS The present study included patients who were referred to psychiatrists by ward physicians due to confusion. The presence of delirium was defined using the Confusion Assessment Method and the Delirium Rating Scale Revised-98, which was also used to assess the severity of delirium. Outcome variables, including the length of hospital stay and 3-month mortality rate, were collected by a retrospective chart review. RESULTS Delirium was confirmed in 210 of the 293 referred patients. Of the motoric subtypes of delirium, the hyperactive subtype was more common (68.1%) and was related to higher 3-month mortality (odds ratio [OR], 2.189; 95% confidence interval [CI], 1.07 to 4.49; P = 0.033) compared with hypoactive delirium. Patients undergoing sudden cessation of smoking (n = 55) were more likely to exhibit hyperactive delirium than were nonsmokers (P = 0.001). A multivariate analysis revealed that smoking cessation was an independent risk factor for hyperactive delirium (OR, 10.33; 95% CI, 2.31 to 46.09; P = 0.002). In addition, the amount of smoking was positively correlated with the severity of hyperactivity (r = 0.421, P = 0.003). Smoking status did not significantly influence overall delirium incidence. CONCLUSIONS The present findings demonstrated that nicotine withdrawal was associated with hyperactive delirium, which suggests that they share common pathophysiologies that involve the dopamine, opioid, and cholinergic systems.
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Affiliation(s)
- HyeYoun Park
- Seoul National University Bundang Hospital, Gyeonggi, Republic of Korea
| | - Ki Woong Kim
- Seoul National University Bundang Hospital, Gyeonggi, Republic of Korea
| | - In-Young Yoon
- Seoul National University Bundang Hospital, Gyeonggi, Republic of Korea
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25
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Dworkin A, Lee DS, An AR, Goodlin SJ. A Simple Tool to Predict Development of Delirium After Elective Surgery. J Am Geriatr Soc 2016; 64:e149-e153. [DOI: 10.1111/jgs.14428] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Andy Dworkin
- Department of Medicine; Legacy Health System; Portland Oregon
| | - David S.H. Lee
- College of Pharmacy; Oregon State University & Oregon Health and Science University; Portland Oregon
| | - Amber R. An
- Geriatrics Section; Veterans Affairs Portland Health Services Center and Oregon Health & Science University; Portland Oregon
| | - Sarah J. Goodlin
- Geriatrics Section; Veterans Affairs Portland Health Services Center and Oregon Health & Science University; Portland Oregon
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26
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Pichora-Fuller MK, Mick P, Reed M. Hearing, Cognition, and Healthy Aging: Social and Public Health Implications of the Links between Age-Related Declines in Hearing and Cognition. Semin Hear 2016; 36:122-39. [PMID: 27516713 DOI: 10.1055/s-0035-1555116] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Sensory input provides the signals used by the brain when listeners understand speech and participate in social activities with other people in a range of everyday situations. When sensory inputs are diminished, there can be short-term consequences to brain functioning, and long-term deprivation can affect brain neuroplasticity. Indeed, the association between hearing loss and cognitive declines in older adults is supported by experimental and epidemiologic evidence, although the causal mechanisms remain unknown. These interactions of auditory and cognitive aging play out in the challenges confronted by people with age-related hearing problems when understanding speech and engaging in social interactions. In the present article, we use the World Health Organization's International Classification of Functioning, Disability and Health and the Selective Optimization with Compensation models to highlight the importance of adopting a healthy aging perspective that focuses on facilitating active social participation by older adults. First, we examine epidemiologic evidence linking ARHL to cognitive declines and other health issues. Next, we examine how social factors influence and are influenced by auditory and cognitive aging and if they may provide a possible explanation for the association between ARHL and cognitive decline. Finally, we outline how audiologists could reposition hearing health care within the broader context of healthy aging.
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Affiliation(s)
- M Kathleen Pichora-Fuller
- Department of Psychology, University of Toronto, Toronto, Ontario, Canada; Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada; Rotman Research Institute, Toronto, Ontario, Canada
| | - Paul Mick
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada; Kelowna General Hospital, Kelowna, British Columbia, Canada; and
| | - Marilyn Reed
- Baycrest Health Sciences, Toronto, Ontario, Canada
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27
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Chang KJ, Lee S, Lee Y, Lee KS, Back JH, Jung YK, Lim KY, Noh JS, Kim HC, Roh HW, Choi SH, Kim SY, Joon Son S, Hong CH. Severity of White Matter Hyperintensities and Length of Hospital Stay in Patients with Cognitive Impairment: A CREDOS (Clinical Research Center for Dementia of South Korea) Study. J Alzheimers Dis 2016; 46:719-26. [PMID: 25854927 DOI: 10.3233/jad-142823] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND & OBJECTIVE White matter hyperintensities (WMHs) contribute to aggravation of dementia or geriatric syndrome, thereby resulting in functional impairment. However, evidence of direct association between WMHs and medical resource utilization indicated by length of hospital stay (LOS) is scarce in patients with cognitive impairment. This study aimed to examine the relationship between the severity of WMHs and LOS in patients with cognitive impairment. METHODS 4,253 older adults with cognitive impairment were enrolled in this study. We defined LOS as the total sum of days from January 1, 2008 to December 31, 2012. The severity of periventricular (PVWMHs), deep (DWMHs), and overall white matter hyperintensities (Overall WMHs) was evaluated by a visual rating scale. We conducted multinomial logistic regression to demonstrate the relationship between LOS and severity of PVWHMs, DWHMs, and Overall WMHs, respectively. RESULTS The median LOS was 20 days. Severe PVWMHs had a higher likelihood of longer LOS (Q3: odd ratio/OR = 1.32, 95% confidence interval/CI = 1.06-1.64; Q4: OR = 1.33, 95% CI = 1.07-1.65; Q5: OR = 1.55, 95% CI = 1.26-1.91). As for DWMHs, moderate DWMHs were related to longer LOS (Q4: OR = 1.33, 95% CI = 1.03-1.71; Q5: OR = 1.63, 95% CI = 1.26-2.11). Finally, severity of overall WMHs was independently associated with LOS, which was similar to the results of DWMHs. CONCLUSION These findings would advocate for prevention of WMHs to stave off excess medical resource utilization in patients with cognitive impairment.
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Affiliation(s)
- Ki Jung Chang
- Department of Psychiatry, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Soojin Lee
- Department of Medicare Administration, Backseok Arts University, Seoul, Republic Korea
| | - Yunhwan Lee
- Department of Preventive Medicine and Public Health, Ajou University School of Medicine, Suwon, Republic of Korea.,Institute on Aging, Ajou University Medical Center, Suwon, Republic of Korea
| | - Kang Soo Lee
- Department of Psychiatry, CHA University School of Medicine, CHA Hospital, Gangnam, Republic of Korea
| | - Joung Hwan Back
- Health Insurance Policy Research Institute, National Health Insurance Service, Seoul, Republic of Korea
| | - Young Ki Jung
- Department of Psychiatry, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Ki Young Lim
- Department of Psychiatry, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Jai Sung Noh
- Department of Psychiatry, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Hyun Chung Kim
- Department of Psychiatry, National Medical Center, Seoul, Republic of Korea
| | - Hyun Woong Roh
- Department of Psychiatry, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Seong Hye Choi
- Department of Neurology, Inha University College of Medicine, Incheon, Republic of Korea
| | - Seong Yoon Kim
- Department of Psychiatry, Asan Medical Center, Seoul, Republic of Korea
| | - Sang Joon Son
- Department of Psychiatry, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Chang Hyung Hong
- Department of Psychiatry, Ajou University School of Medicine, Suwon, Republic of Korea.,Institute on Aging, Ajou University Medical Center, Suwon, Republic of Korea.,Memory impairment center, Ajou University Hospital, Suwon, Republic of Korea
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28
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Cheong CY, Tan JAQ, Foong YL, Koh HM, Chen DZY, Tan JJC, Ng CJ, Yap P. Creative Music Therapy in an Acute Care Setting for Older Patients with Delirium and Dementia. Dement Geriatr Cogn Dis Extra 2016; 6:268-75. [PMID: 27489560 PMCID: PMC4959431 DOI: 10.1159/000445883] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND/AIMS The acute hospital ward can be unfamiliar and stressful for older patients with impaired cognition, rendering them prone to agitation and resistive to care. Extant literature shows that music therapy can enhance engagement and mood, thereby ameliorating agitated behaviours. This pilot study evaluates the impact of a creative music therapy (CMT) programme on mood and engagement in older patients with delirium and/or dementia (PtDD) in an acute care setting. We hypothesize that CMT improves engagement and pleasure in these patients. METHODS Twenty-five PtDD (age 86.5 ± 5.7 years, MMSE 6/30 ± 5.4) were observed for 90 min (30 min before, 30 min during, and 30 min after music therapy) on 3 consecutive days: day 1 (control condition without music) and days 2 and 3 (with CMT). Music interventions included music improvisation such as spontaneous music making and playing familiar songs of patient's choice. The main outcome measures were mood and engagement assessed with the Menorah Park Engagement Scale (MPES) and Observed Emotion Rating Scale (OERS). RESULTS Wilcoxon signed-rank test showed a statistically significant positive change in constructive and passive engagement (Z = 3.383, p = 0.01) in MPES and pleasure and general alertness (Z = 3.188,p = 0.01) in OERS during CMT. The average pleasure ratings of days 2 and 3 were higher than those of day 1 (Z = 2.466, p = 0.014). Negative engagement (Z = 2.582, p = 0.01) and affect (Z = 2.004, p = 0.045) were both lower during CMT compared to no music. CONCLUSION These results suggest that CMT holds much promise to improve mood and engagement of PtDD in an acute hospital setting. CMT can also be scheduled into the patients' daily routines or incorporated into other areas of care to increase patient compliance and cooperation.
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Affiliation(s)
- Chin Yee Cheong
- Department of Geriatric Medicine, Khoo Teck Puat Hospital, Singapore, Singapore
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29
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Teodorczuk A. Understanding safe discharge of patients with dementia from the acute hospital. Br J Hosp Med (Lond) 2016; 77:126-7. [PMID: 26961438 DOI: 10.12968/hmed.2016.77.3.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Andrew Teodorczuk
- Consultant Psychiatrist and Honorary Senior Lecturer in the School of Medical Education, Newcastle University, Newcastle upon Tyne, and Northumberland Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne NE4 6BE
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30
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Grover S, Kate N, Sharma A, Mattoo SK, Basu D, Chakrabarti S, Malhotra S, Avasthi A. Symptom profile of alcohol withdrawal delirium: factor analysis of Delirium Rating Scale-Revised-98 version. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2016; 42:196-202. [PMID: 26905794 DOI: 10.3109/00952990.2015.1130711] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The symptom profile of alcohol withdrawal delirium (AWD), relative to deliriums of other etiology, remains uncertain. OBJECTIVE To evaluate the factor structure of symptoms in patients with AWD, as assessed by the Delirium Rating Scale-Revised-98 (DRS-R-98). METHOD A total of 112 patients aged 18 years or more with AWD were assessed on DRS-R-98. RESULTS The mean age of participants was 44.2 years. About two-third of the patients developed delirium within 24 hours of the last intake of alcohol and the mean duration of delirium at the time of assessment was 3.9 days. In 46% of cases the delirium was attributed solely to alcohol withdrawal; in the remaining subjects alcohol withdrawal was a major contributory factor. Three separate principal component analysis (whole sample, pure AWD and AWD with associated etiologies) were carried out. In all the factor analyses, one of the factors included cognitive symptoms (attention, orientation and visuospatial disturbances) along with or without short- and long-term memory impairment; the second factor included motoric symptoms along with sleep-wake cycle disturbances; the third factor included psychotic symptoms. For the whole group and subgroup of AWD with associated etiologies, items of higher level thinking (i.e. language disturbances and thought process abnormality) loaded along with cognitive symptoms. In pure AWD group, these items along with memory disturbances loaded with psychotic symptoms. CONCLUSIONS Results of the current factor analyses suggest that the factor structure of pure AWD is different from AWD with associated etiologies. Hence, attention to the symptom profile of patients with AWD may provide clues to delirium etiology.
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Affiliation(s)
- Sandeep Grover
- a Department of Psychiatry , Postgraduate Institute of Medical Education & Research , Chandigarh , India
| | - Natasha Kate
- a Department of Psychiatry , Postgraduate Institute of Medical Education & Research , Chandigarh , India
| | - Akhilesh Sharma
- a Department of Psychiatry , Postgraduate Institute of Medical Education & Research , Chandigarh , India
| | - Surendra K Mattoo
- a Department of Psychiatry , Postgraduate Institute of Medical Education & Research , Chandigarh , India
| | - Debasish Basu
- a Department of Psychiatry , Postgraduate Institute of Medical Education & Research , Chandigarh , India
| | - Subho Chakrabarti
- a Department of Psychiatry , Postgraduate Institute of Medical Education & Research , Chandigarh , India
| | - Savita Malhotra
- a Department of Psychiatry , Postgraduate Institute of Medical Education & Research , Chandigarh , India
| | - Ajit Avasthi
- a Department of Psychiatry , Postgraduate Institute of Medical Education & Research , Chandigarh , India
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31
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Cognitive Impairment in Hospitalized Seniors. Geriatrics (Basel) 2016; 1:geriatrics1010004. [PMID: 31022800 PMCID: PMC6371190 DOI: 10.3390/geriatrics1010004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 12/17/2015] [Accepted: 12/29/2015] [Indexed: 11/16/2022] Open
Abstract
Cognitive disorders are highly prevalent in hospitalized seniors, and can be due to delirium, dementia, as well as other disorders. Hospitalization can have adverse cognitive effects, and cognitive dysfunction adversely affects hospital outcomes. In this article, the literature is reviewed on how hospitalization affects cognitive function and how cognitive impairment affects hospital outcomes. Possible interventions in cognitively impaired hospitalized seniors are reviewed.
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32
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Les déterminants de la prolongation des séjours en SSRG et les indicateurs du devenir des patients après leur sortie : Étude rétrospective au CHRU de Strasbourg. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.npg.2015.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Murata A, Mayumi T, Muramatsu K, Ohtani M, Matsuda S. Effect of dementia on outcomes of elderly patients with hemorrhagic peptic ulcer disease based on a national administrative database. Aging Clin Exp Res 2015; 27:717-25. [PMID: 25708828 DOI: 10.1007/s40520-015-0328-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 02/10/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND Little information is available on the effect of dementia on outcomes of elderly patients with hemorrhagic peptic ulcer disease at the population level. AIMS This study aimed to investigate the effect of dementia on outcomes of elderly patients with hemorrhagic peptic ulcer based on a national administrative database. METHODS A total of 14,569 elderly patients (≥80 years) who were treated by endoscopic hemostasis for hemorrhagic peptic ulcer were referred to 1073 hospitals between 2010 and 2012 in Japan. We collected patients' data from the administrative database to compare clinical and medical economic outcomes of elderly patients with hemorrhagic peptic ulcers. Patients were divided into two groups according to the presence of dementia: patients with dementia (n = 695) and those without dementia (n = 13,874). RESULTS There were no significant differences in in-hospital mortality within 30 days and overall mortality between the groups (odds ratio; OR 1.00, 95 % confidence interval; CI 0.68-1.46, p = 0.986 and OR 1.02, 95 % CI 0.74-1.41, p = 0.877). However, the length of stay (LOS) and medical costs during hospitalization were significantly higher in patients with dementia compared with those without dementia. The unstandardized coefficient for LOS was 3.12 days (95 % CI 1.58-4.67 days, p < 0.001), whereas that for medical costs was 1171.7 US dollars (95 % CI 533.8-1809.5 US dollars, p < 0.001). CONCLUSIONS Length of stay and medical costs during hospitalization are significantly increased in elderly patients with dementia undergoing endoscopic hemostasis for hemorrhagic peptic ulcer disease.
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Affiliation(s)
- Atsuhiko Murata
- Department of Preventive Medicine and Community Health, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, Fukuoka, 807-8555, Japan.
| | - Toshihiko Mayumi
- Department of Emergency Medicine, University of Occupational, Environmental and Health, Kitakyushu, Fukuoka, Japan
| | - Keiji Muramatsu
- Department of Preventive Medicine and Community Health, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, Fukuoka, 807-8555, Japan
| | - Makoto Ohtani
- Department of Preventive Medicine and Community Health, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, Fukuoka, 807-8555, Japan
| | - Shinya Matsuda
- Department of Preventive Medicine and Community Health, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, Fukuoka, 807-8555, Japan
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Poor functional recovery after delirium is associated with other geriatric syndromes and additional illnesses. Int Psychogeriatr 2015; 27:793-802. [PMID: 25519779 DOI: 10.1017/s1041610214002658] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Delirious individuals are at increased risk for functional decline, institutionalization and death. Delirium is also associated with other geriatric syndromes, behavioral care issues, and new illnesses. The objectives of this study were to determine how often certain geriatric syndromes, care issues, and additional diagnoses occur in delirious individuals, and to see whether they correlate with worse functional recovery. METHODS Consecutive delirious older medical in-patients (n = 343) were followed for the occurrence of geriatric syndromes (falls, pressure ulcers, poor oral intake, and aspiration), care issues (refusing treatments or care, need for sitters, security services, physical restraints, and new neuroleptic medications) and additional diagnoses occurring after the third day of admission. Poor functional recovery was defined by any one of death, permanent institutionalization or increased dependence for activities of daily living (ADLs) at discharge or three months after discharge from hospital, elicited through chart review or a follow-up telephone interview. RESULTS Poor functional recovery was seen in 237 (69%) delirious patients. Geriatric syndromes and additional illnesses were common and associated with poor functional recovery (falls in 21%, adjusted OR 2.27; possible aspiration in 26%, adjusted OR 3.06; poor oral intake in 49%, adjusted OR = 2.31; additional illnesses in 38%, adjusted OR 3.54). Care issues were also common (range 9%-54%) but not associated with poor recovery. CONCLUSIONS Geriatric syndromes, behavioral care issues and additional illnesses are common in delirium. Future studies should assess whether monitoring for and intervening against geriatric syndromes and additional illnesses may improve functional outcomes after delirium.
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Yang L, Sun DF, Wu Y, Han J, Liu RC, Wang LJ. Intranasal administration of butorphanol benefits old patients undergoing H-uvulopalatopharyngoplasty: a randomized trial. BMC Anesthesiol 2015; 15:20. [PMID: 25972155 PMCID: PMC4429317 DOI: 10.1186/1471-2253-15-20] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2014] [Accepted: 01/23/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To evaluate intranasal administration of butorphanol on postoperative pain and early postoperative cognitive dysfunction in old patients undergoing H-uvulopalatopharyngoplasty (H-UPPP). METHODS A total of 260 male patients (65 to 77 years old) with obstructive sleep apnea hypopnea syndrome and scheduled for H-UPPP were divided randomly to receive intranasal butorphanol, intravenous butorphanol, intranasal fentanyl, or intravenous saline (controls). The definition of preemptive analgesia is that the tested drugs are given before anesthesia induction. Visual analog scale (VAS) and Bruggrmann comfort scale (BCS) scores were recorded at postoperative 1, 6, 12, 18, 24, 36, and 48 h. Postoperative cognitive dysfunction (POCD) was evaluated by Mini-Mental State Examination (MMSE) scores assessed one day before, and 1, 3, and 7 days postsurgery. RESULTS Compared with control group, those given preemptive analgesia required significantly less sufentanil during surgery, had less pain at postoperative 6-12 h; those given butorphanol experienced less nausea and vomiting, less pain at postoperative 6-24 h, and less POCD. Compared with patients given fentanyl, those given butorphanol required significantly less postoperative fentanyl, had less pain at postoperative 18-24 h, less nausea and vomiting, and less POCD. Compared with patients given intravenous butorphanol, those who received butorphanol by nasal route required significantly less postoperative fentanyl, had less pain at 36 and 48 h, and less POCD. CONCLUSION Intranasal administration of butorphanol is safe and effective, reducing postoperative usage of analgesics and the incidence of POCD in old patients undergoing H-UPPP. TRIAL REGISTRATION ChiCTR-TRC-14004121.
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Affiliation(s)
- Lin Yang
- Neuroelectrophysiology Lab, First Affiliated Hospital of Dalian Medical University, Dalian, 116011, P.R.China.
| | - De-feng Sun
- Department of Anesthesiology, First Affiliated Hospital of Dalian Medical University, Dalian, 116011, China.
| | - Yue Wu
- Department of Anesthesiology, First Affiliated Hospital of Dalian Medical University, Dalian, 116011, China.
| | - Jun Han
- Department of Anesthesiology, First Affiliated Hospital of Dalian Medical University, Dalian, 116011, China.
| | - Ruo-chuan Liu
- Department of Anesthesiology, First Affiliated Hospital of Dalian Medical University, Dalian, 116011, China.
| | - Li-jie Wang
- Department of Anesthesiology, First Affiliated Hospital of Dalian Medical University, Dalian, 116011, China.
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Abstract
Objective: To evaluate the impact of frailty, measured using the Canadian Study of Health and Aging Clinical Frailty Scale, on outcomes of older people hospitalized with acute illness. Method: Consecutive patients were randomly allocated to a model development sample or a model validation sample. Multivariate analyses were used to model in-hospital mortality, new nursing home placement, and length of stay. Variables selected in the development samples were tested in the validation samples. Results: The mean age of all 2,125 patients was 82.9 years. Most (93.6%) were admitted through the emergency department. Frailty predicted in-hospital mortality (odds ratio [OR] = 2.97 [2.11, 4.17]), new nursing home placement (OR = 1.60 [1.14, 2.24]), and length of hospital stay (hazard ratio = 0.87 [0.81, 0.93]). Discussion: Frailty is a strong predictor of adverse outcomes in older people hospitalized with acute illness. An increased awareness of its impact may alert clinicians to screen for frailty.
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Ismail Z, Arenovich T, Granger R, Grieve C, Willett P, Patten S, Mulsant BH. Associations of medical comorbidity, psychosis, pain, and capacity with psychiatric hospital length of stay in geriatric inpatients with and without dementia. Int Psychogeriatr 2014; 27:1-9. [PMID: 25330847 DOI: 10.1017/s1041610214002002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ABSTRACT Background: Geriatric psychiatry hospital beds are a limited resource. Our aim was to determine predictors of hospital length of stay (LOS) for geriatric patients with dementia admitted to inpatient psychiatric beds. Methods: Admission and discharge data from a large urban mental health center, from 2005 to 2010 inclusive, were retrospectively analyzed. Using the resident assessment instrument - mental health (RAI-MH), an assessment that is used to collect demographic and clinical information within 72 hours of hospital admission, 169 geriatric patients with dementia were compared with 308 geriatric patients without dementia. Predictors of hospital LOS were determined using a series of general linear models. Results: A diagnosis of dementia did not predict a longer LOS in this geriatric psychiatry inpatient population. The presence of multiple medical co-morbidities had an inverse relationship to length of hospital LOS - a greater number of co-morbidities predicted a shorter hospital LOS in the group of geriatric patients who had dementia compared to the without dementia study group. The presence of incapacity and positive psychotic symptoms predicted longer hospital LOS, irrespective of admission group (patients with dementia compared with those without). Conversely, pain on admission predicted shorter hospital LOS. Conclusions: Specific clinical characteristics generally determined at the time of admission are predictive of hospital LOS in geriatric psychiatry inpatients. Addressing these factors early on during admission and in the community may result in shorter hospital LOS and more optimal use of resources.
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Affiliation(s)
- Zahinoor Ismail
- Hotchkiss Brain Institute,University of Calgary,Calgary,Alberta,Canada
| | - Tamara Arenovich
- Clinical Research Department,Centre for Addiction and Mental Health,Division of Biostatistics,Dalla Lana School of Public Health,University of Toronto,Toronto,Ontario,Canada
| | - Robert Granger
- Department of Psychiatry,University of Alberta,Edmonton,Alberta,Canada
| | | | - Peggie Willett
- Centre for Addiction and Mental Health,Toronto,Ontario,Canada
| | - Scott Patten
- Departments of Psychiatry and Community Health Sciences,University of Calgary,Calgary,Alberta,Canada
| | - Benoit H Mulsant
- Department of Psychiatry,University of Toronto,Centre for Addiction and Mental Health,Toronto,Ontario,Canada
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Sun D, Yang L, Wu Y, Liu R, Han J, Wang L. Effect of intravenous infusion of dobutamine hydrochloride on the development of early postoperative cognitive dysfunction in elderly patients via inhibiting the release of tumor necrosis factor-α. Eur J Pharmacol 2014; 741:150-5. [PMID: 25131356 DOI: 10.1016/j.ejphar.2014.07.055] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 07/18/2014] [Accepted: 07/21/2014] [Indexed: 01/03/2023]
Abstract
To investigate the effects of dobutamine hydrochloride on early postoperative cognitive dysfunction (POCD) and plasma tumor necrosis factor (TNF)-α concentration in patients undergoing hip arthroplasty, 124 patients undergoing unilateral total hip arthroplasty, aged 70-92 years old, were randomly assigned to four groups (n=31) as follows: a control group of patients receiving only saline (intravenous infusion, i.v.); and groups receiving 2, 4, or 6μgkg(-1)min(-1) (i.v.) of dobutamine hydrochloride. Cognitive functions were assessed on the day before surgery (T1), and the 1st day (T2), 3rd day (T3), and 7th day (T4) postsurgery using the Mini Mental State Examination (MMSE). The plasma TNF-α protein level was determined 10min before anesthesia (Ta), and 10min (Tb), 30min (Tc), and 60min (Td) after anesthesia by an enzyme-linked immunosorbent assay. Cognitive disorder was observed within the first 3 days after hip arthroplastic surgery, and it had recovered 7 days after the operation in the control group of patients. Administration of 2 or 4μgkg(-1)min(-1) dobutamine hydrochloride was able to reverse the early POCD. Simultaneously, an increase of plasma TNF-α levels 30min after anesthesia was observed (41.34±9.61 vs. 27.75±5.45), which was significantly suppressed by the administration of low-dose dobutamine hydrochloride (29.23±7.32 vs. 41.34±9.61) but not by high-dose dobutamine hydrochloride (45.9±12.11 vs. 41.34±9.61). Together, our data indicated that the plasma concentration of TNFα was engaged in the effect of dobutamine hydrochloride on POCD.
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Affiliation(s)
- Defeng Sun
- Department of Anesthesiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Lin Yang
- Department of Nerve Electroneurophysiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China.
| | - Yue Wu
- Department of Anesthesiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Ruochuan Liu
- Department of Anesthesiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Jun Han
- Department of Anesthesiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Lijie Wang
- Department of Anesthesiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
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Abstract
To assess the prevalence and the team interaction in cases of missed delirium in acute care veterans coded as not having a diagnosis of delirium in admission or discharge notes. In this retrospective study, the records of 183 hospitalized veterans admitted to the emergency department (ED), medicine, surgery and psychiatry services and coded as not having a diagnosis of delirium were analyzed. Clinical notes of each case were examined using DSM IV TR criteria for delirium. Of the 52 cases assessed to have delirium, 5 cases had been miscoded as not having delirium. In the remaining 47 cases the diagnosis of delirium had been missed. The rates of undiagnosed delirium were ED 46/160, medicine 39/132, surgery 4/17, psychiatry 4/29 and consult liaison (CL) 0/9. Of the 5 cases of delirium identified by the CL service, 2 consult diagnoses were accepted and 3 were rejected. Nursing notes had words suggesting delirium in 70.2 % of 47 cases compared to 41.3 and 43.6 % of the clinician case notes for these patients admitted to ED and medicine respectively. No delirium or cognitive screening scales were utilized in the work up of the 52 cases involving delirium. The study results suggest that continuing education by the CL service of all hospital personnel involved in patient care may improve the diagnosis of delirium. Also, increased clinician-nursing intra-team communication, in addition to careful scrutiny of the nursing and clinician notes may contribute to the reduced incidence of missed delirium.
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Diagnoses, problems and healthcare interventions amongst older people with an unscheduled hospital admission who have concurrent mental health problems: a prevalence study. BMC Geriatr 2014; 14:43. [PMID: 24694034 PMCID: PMC3992161 DOI: 10.1186/1471-2318-14-43] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 03/26/2014] [Indexed: 11/16/2022] Open
Abstract
Background Frail older people with mental health problems including delirium, dementia and depression are often admitted to general hospitals. However, hospital admission may cause distress, and can be associated with complications. Some commentators suggest that their healthcare needs could be better met elsewhere. Methods We studied consecutive patients aged 70 or older admitted for emergency medical or trauma care to an 1800 bed general hospital which provided sole emergency medical and trauma services for its local population. Patients were screened for mental health problems, and those screening positive were invited to take part. 250 participants were recruited and a sub-sample of 53 patients was assessed by a geriatrician for diagnoses, impairments and disabilities, healthcare interventions and outstanding needs. Results Median age was 86 years, median Mini-Mental State Examination score at admission was 16/30, and 45% had delirium. 19% lived in a care home prior to admission. All the patients were complex. A wide range of main admission diagnoses was recorded, and these were usually complicated by falls, immobility, pain, delirium, dehydration or incontinence. There was a median of six active diagnoses, and eight active problems. One quarter of problems was unexplained. A median of 13 interventions was recorded, and a median of a further four interventions suggested by the geriatrician. Those with more severe cognitive impairment had no less medical need. Conclusions This patient group, admitted to hospital in the United Kingdom, had numerous healthcare problems, and by implication, extensive healthcare needs. Patients with simpler conditions were not identified, but may have already been rapidly discharged or redirected to non-hospital services by the time assessments were made. To meet the needs of this group outside the hospital would need considerable investment in medical, nursing, therapy and diagnostic facilities. In the meantime, acute hospitals should adapt to deliver comprehensive geriatric assessment, and provide for their mental health needs.
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Vetrano DL, Landi F, De Buyser SL, Carfì A, Zuccalà G, Petrovic M, Volpato S, Cherubini A, Corsonello A, Bernabei R, Onder G. Predictors of length of hospital stay among older adults admitted to acute care wards: a multicentre observational study. Eur J Intern Med 2014; 25:56-62. [PMID: 24054859 DOI: 10.1016/j.ejim.2013.08.709] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 08/20/2013] [Accepted: 08/28/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND Reduction in length of hospital stay (LOS) is considered as a potential strategy to optimize resource consumption and reduce health care costs. We analysed predictors of increased LOS among older patients admitted to acute care wards according to type of admission (through the Emergency Room [ER] or elective). METHODS We analysed data of 1123 older patients, aged 65years or older, consecutively admitted to seven acute care wards. LOS was defined as the number of days from admission to discharge (or death) and categorized according to its median value (10days). RESULTS Mean age of participants was 81±7years and 56% were women. Patients admitted through ER had a shorter LOS compared with those elective (10.4±6.7 vs. 12.0±6.7days; p<0.0001). Factors associated with LOS >10days, for patients admitted through ER, were female gender (OR 0.58; 95% C.I. 0.37-0.90), erythrocyte sedimentation rate (OR 1.02; 95% C.I. 1.01-1.03), and excessive polypharmacy (use of ≥10 drugs during stay) (OR 3.60; 95% C.I. 1.40-9.25). Predictors for elective patients were chronic alcohol consumption (OR 0.54; 95% C.I. 0.32-0.93), walking speed ≥0.8m/s (OR 0.31; 95% C.I. 0.14-0.72), excessive polypharmacy (OR 4.78; 95% C.I. 1.92-11.90), pressure ulcers (OR 2.60; 95% C.I. 1.01-6.79), cerebrovascular disease (OR 0.49; 95% C.I. 0.24-0.99) and dementia (OR 0.18; 95% C.I. 0.08-0.39). CONCLUSIONS LOS differed between patients admitted through emergency and through elective admission. Demographic and clinical parameters can affect LOS and polypharmacy was the strongest and the only common risk factor in both groups.
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Affiliation(s)
- Davide L Vetrano
- Department of Geriatrics, Orthopaedics and Neurosciences, Catholic University of Sacred Heart, Rome, Italy.
| | - Francesco Landi
- Department of Geriatrics, Orthopaedics and Neurosciences, Catholic University of Sacred Heart, Rome, Italy
| | | | - Angelo Carfì
- Department of Geriatrics, Orthopaedics and Neurosciences, Catholic University of Sacred Heart, Rome, Italy
| | - Giuseppe Zuccalà
- Emergency Department, Catholic University of Sacred Heart, Rome, Italy
| | - Mirko Petrovic
- Department of Geriatrics, Ghent University Hospital, Ghent, Belgium
| | - Stefano Volpato
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Antonio Cherubini
- Geriatrics, Research Hospital of Ancona, IRCCS, Italian National Research Centre on Aging (INRCA), Ancona, Italy
| | - Andrea Corsonello
- Unit of Geriatric Pharmaco-epidemiology, IRCCS, Italian National Research Centre on Aging (INRCA), Cosenza, Italy
| | - Roberto Bernabei
- Department of Geriatrics, Orthopaedics and Neurosciences, Catholic University of Sacred Heart, Rome, Italy
| | - Graziano Onder
- Department of Geriatrics, Orthopaedics and Neurosciences, Catholic University of Sacred Heart, Rome, Italy
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Whittamore KH, Goldberg SE, Gladman JRF, Bradshaw LE, Jones RG, Harwood RH. The diagnosis, prevalence and outcome of delirium in a cohort of older people with mental health problems on general hospital wards. Int J Geriatr Psychiatry 2014; 29:32-40. [PMID: 23606365 DOI: 10.1002/gps.3961] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 02/06/2013] [Indexed: 11/11/2022]
Abstract
OBJECTIVES This paper aimed to measure the prevalence and outcomes of delirium for patients over 70 admitted to a general hospital for acute medical care and to assess the validity of the Delirium Rating Scale-Revised-98 (DRS-R-98) in this setting. METHODS Prospective study in a British acute general hospital providing sole emergency medical services for its locality. We screened consecutive patients over 70 with an unplanned emergency hospital admission and recruited a cohort of 249 patients likely to have mental health problems. They were assessed for health status at baseline and followed over 6 months. A sub-sample of 93 participants was assessed clinically for delirium. RESULTS 27% (95% confidence interval (CI) 23-31) of all older medical patients admitted to hospital had DRS-diagnosed delirium, and 41% (95% CI 37-45) had dementia (including 19% with co-morbid delirium and dementia). Compared with clinician diagnosis, DRS-R-98 sensitivity was at least 0.75, specificity 0.71. Compared with reversible cognitive impairment, sensitivity was at least 0.50, specificity 0.67. DRS-diagnosed delirium was associated with cognitive impairment, mood, behavioural and psychological symptoms, activities of daily living, and number of drugs prescribed, supporting construct validity. Of those with DRS-diagnosed delirium, 37% died within 6 months (relative risk 1.4, 95% CI 0.97-2.2), 43% had reversible cognitive impairment, but only 25% had clinically important recovery in activities of daily living. Behavioural and psychological symptoms were common and mostly resolved, but new symptoms frequently developed. CONCLUSION Delirium is common. Some, but not all, features are reversible. DRS-R-98 has reasonable validity in populations where co-morbid dementia is prevalent.
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Affiliation(s)
- Kathy H Whittamore
- Health Care of Older People, Nottingham University Hospitals NHS Trust, Queens Medical Centre, Nottingham, UK
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Erden Aki O, Derle E, Karagol A, Turkyilmaz C, Taskintuna N. The prevalence and recognition rate of delirium in hospitalized elderly patients in Turkey. Int J Psychiatry Clin Pract 2014; 18:52-7. [PMID: 24236908 DOI: 10.3109/13651501.2013.865754] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Delirium is frequently observed, but generally under recognized in elderly hospitalized patients. The aims of this study were to determine the prevalence of delirium in elderly patients hospitalized at a university hospital, and to determine the recognition rate by hospital staff during hospitalization. METHODS The study included 108 consecutive patients aged ≥ 65 years that were hospitalized in the medical and surgical inpatient departments at Başkent University Hospital, Ankara, Turkey. All the patients were evaluated using the Mini Mental State Examination (MMSE) upon admission and Confusion Assessment Method (CAM) on a daily basis during hospitalization. Written documents and consultation requests from psychiatry and/or neurology departments were reviewed for recognition of delirium by hospital staff. RESULTS Among the 108 patients in the study, delirium was noted in 18 (16.7%) during their hospital stay. Consultation from psychiatry or neurology departments was requested for 5 of the 18 patients, only 1 with a delirium diagnosis, indicating that 17 of the cases (94.4%) were not recognized by their primary physicians. CONCLUSIONS The delirium non-recognition rate in elderly hospitalized patients was very high. We think that hospital staff must be trained to recognize the symptoms of delirium and identify high-risk patients.
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LaMantia MA, Messina FC, Hobgood CD, Miller DK. Screening for delirium in the emergency department: a systematic review. Ann Emerg Med 2013; 63:551-560.e2. [PMID: 24355431 DOI: 10.1016/j.annemergmed.2013.11.010] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2013] [Revised: 10/09/2013] [Accepted: 11/11/2013] [Indexed: 01/08/2023]
Abstract
Older adults who visit emergency departments (EDs) often experience delirium, but it is infrequently recognized. A systematic review was therefore conducted to identify what delirium screening tools have been used in ED-based epidemiologic studies of delirium, whether there is a validated set of screening instruments to identify delirium among older adults in the ED or prehospital environments, and an ideal schedule during an older adult's visit to perform a delirium evaluation. MEDLINE/EMBASE, Cochrane, PsycINFO, and CINAHL databases were searched from inception through February 2013 for original, English-language research articles reporting on the assessment of older adults' mental status for delirium. Twenty-two articles met all study inclusion criteria. Overall, 7 screening instruments were identified, though only 1 has undergone initial validation for use in the ED environment and a second instrument is currently undergoing such validation. Minimal information was identified to suggest the ideal scheduling of a delirium assessment process to maximize the recognition of this condition in the ED. Study results indicate that several delirium screening tools have been used in investigations in the ED, though validation of these instruments for this particular environment has been minimal to date. The ideal interval(s) during which a delirium screening process should take place has yet to be determined. Research will be needed both to validate delirium screening instruments to be used for investigation and clinical care in the ED and to define the ideal timing and form of the delirium assessment process for older adults.
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Affiliation(s)
- Michael A LaMantia
- Indiana University Center for Aging Research and Regenstrief Institute, Inc., Indianapolis, IN; Department of Medicine, Indiana University School of Medicine, Indianapolis, IN.
| | - Frank C Messina
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Cherri D Hobgood
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Douglas K Miller
- Indiana University Center for Aging Research and Regenstrief Institute, Inc., Indianapolis, IN; Department of Medicine, Indiana University School of Medicine, Indianapolis, IN; Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN.
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Hare M, Arendts G, Wynaden D, Leslie G. Nurse screening for delirium in older patients attending the emergency department. PSYCHOSOMATICS 2013; 55:235-42. [PMID: 24314593 DOI: 10.1016/j.psym.2013.08.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 08/20/2013] [Accepted: 08/21/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Delirium in older emergency department (ED) patients is common, associated with many adverse outcomes, and costly to manage. Delirium detection in the ED is almost universally poor. OBJECTIVES The authors aimed to develop a simple clinical risk screening tool that could be used by ED nurses as part of their initial assessment to identify patients at risk of delirium. METHODS A prospective cross-sectional study of patients 65 years and older attending a single ED. RESULTS Of 320 enrolled patients, 23 (7.2%) had delirium. Logistic regression analysis revealed 3 risk factors strongly associated with delirium risk: cognitive impairment, depression, and an abnormal heart rate/rhythm. Weighting these variables based on the strength of their association with delirium yielded a risk score from 0-4 inclusive. A cutoff of 2 or more in that score would have given a sensitivity of 87%, specificity of 70%, and NPV of 99%, while avoiding further diagnostic workup for delirium in approximately two-thirds of all patients, when used as an initial screen. CONCLUSIONS A simple risk screening tool using factors evident on initial nurse assessment can be used to identify patients at risk of delirium. Further trials are needed to test whether the tool improves patient outcomes.
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Affiliation(s)
| | - Glenn Arendts
- University of Western Australia, Nedlands, Australia.
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Khan BA, Calvo-Ayala E, Campbell N, Perkins A, Ionescu R, Tricker J, Campbell T, Zawahiri M, Buckley JD, Farber MO, Boustani MA. Clinical decision support system and incidence of delirium in cognitively impaired older adults transferred to intensive care. Am J Crit Care 2013; 22:257-62. [PMID: 23635936 DOI: 10.4037/ajcc2013447] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Elderly patients with cognitive impairment are at increased risk of developing delirium, especially in the intensive care unit. OBJECTIVE To evaluate the efficacy of a computer-based clinical decision support system that recommends consulting a geriatrician and discontinuing use of urinary catheters, physical restraints, and unnecessary anticholinergic drugs in reducing the incidence of delirium. METHODS Data for a subgroup of patients enrolled in a large clinical trial who were transferred to the intensive care units of a tertiary-care, urban public hospital in Indianapolis were analyzed. Data were collected on frequency of orders for consultation with a geriatrician; discontinuation of urinary catheterization, physical restraints, or anticholinergic drugs; and the incidence of delirium. RESULTS The sample consisted of 60 adults with cognitive impairment. Mean age was 74.6 years; 45% were African American, and 52% were women. No differences were detected between the intervention and the control groups in orders for consultation with a geriatrician (33% vs 40%; P = .79) or for discontinuation of urinary catheters (72% vs 76%; P = .99), physical restraints (12% vs 0%; P=.47), or anticholinergic drugs (67% vs 36%; P=.37). The 2 groups did not differ in the incidence of delirium (27% vs 29%; P = .85). CONCLUSION Use of a computer-based clinical decision support system may not be effective in changing prescribing patterns or in decreasing the incidence of delirium.
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Affiliation(s)
- Babar A Khan
- Regenstrief Institute, Inc, Indianapolis, IN, USA.
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Rajlakshmi AK, Mattoo SK, Grover S. Relationship between cognitive and non-cognitive symptoms of delirium. Asian J Psychiatr 2013; 6:106-12. [PMID: 23466105 DOI: 10.1016/j.ajp.2012.09.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2012] [Revised: 09/03/2012] [Accepted: 09/06/2012] [Indexed: 10/27/2022]
Abstract
AIM To study relationship between the cognitive and the non-cognitive symptoms of delirium. METHODS Eighty-four patients referred to psychiatry liaison services and met DSM-IVTR criteria of delirium were assessed using the Delirium Rating Scale Revised-1998 (DRSR-98) and Cognitive Test for Delirium (CTD). RESULTS The mean DRS-R-98 severity score was 17.19 and DRS-R-98 total score was 23.36. The mean total score on CTD was 11.75. The mean scores on CTD were highest for comprehension (3.47) and lowest for vigilance (1.71). Poor attention was associated with significantly higher motor retardation and higher DRS-R-98 severity scores minus the attention scores. There were no significant differences between those with and without poor attention. Higher attention deficits were associated with higher dysfunction on all other domains of cognition on CTD. There was significant correlation between cognitive functions as assessed on CTD and total DRS-R-98 score, DRS-R-98 severity score and DRS-R-98 severity score without the attention item score. However, few correlations emerged between CTD domains and CTD total scores with cognitive symptom total score of DRS-R-98 (items 9-13) and non-cognitive symptom total score of DRS-R-98 (items 1-8). CONCLUSIONS Our study suggests that in delirium, cognitive deficits are quite prevalent and correlate with overall severity of delirium. Attention deficit is a core symptom of delirium.
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Affiliation(s)
- Aarya Krishnan Rajlakshmi
- Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh 160012, India
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O'Regan N, Fitzgerald J, Timmons S, O'Connell H, Meagher D. Delirium: A key challenge for perioperative care. Int J Surg 2013; 11:136-44. [DOI: 10.1016/j.ijsu.2012.12.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2012] [Accepted: 12/19/2012] [Indexed: 01/10/2023]
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Tsang LF, Yeung CH, Tse CC, Lam KB, Cheung LP, Chu KK, Tsang CK, Wong CK, Law HW, Hung T, Lau PY. Developing a predictive tool for post-operative delirium in orthopaedic settings in Hong Kong. Int J Orthop Trauma Nurs 2012. [DOI: 10.1016/j.ijotn.2012.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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