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Hshieh TT. Incident dementia or cognitive decline after elective surgery in older adults: Highlighting the importance of shared decision-making. J Am Geriatr Soc 2024; 72:1315-1317. [PMID: 38407451 PMCID: PMC11090701 DOI: 10.1111/jgs.18823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 01/22/2024] [Indexed: 02/27/2024]
Abstract
This editorial comments on the articles by Tang et al. and Reich et al. in this issue.
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Affiliation(s)
- Tammy T Hshieh
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Ward M, Hshieh TT, Schmitt EM, Arnold SE, Cavallari M, Dickerson BC, Dillon ST, Fong TG, Jones RN, Libermann TA, Pascual-Leone A, Shafi MM, Touroutoglou A, Weng K, Xu G, Earp BE, Kunze L, Lange J, Vlassakov K, Marcantonio ER, Inouye SK, Travison TG. Successful aging after elective surgery II: Study cohort description. J Am Geriatr Soc 2024; 72:209-218. [PMID: 37823746 PMCID: PMC10841894 DOI: 10.1111/jgs.18627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/31/2023] [Accepted: 09/17/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND The Successful Aging after Elective Surgery (SAGES) II Study was designed to examine the relationship between delirium and Alzheimer's disease and related dementias (AD/ADRD), by capturing novel fluid biomarkers, neuroimaging markers, and neurophysiological measurements. The goal of this paper is to provide the first complete description of the enrolled cohort, which details the baseline characteristics and data completion. We also describe the study modifications necessitated by the COVID-19 pandemic, and lay the foundation for future work using this cohort. METHODS SAGES II is a prospective observational cohort study of community-dwelling adults age 65 and older undergoing major non-cardiac surgery. Participants were assessed preoperatively, throughout hospitalization, and at 1, 2, 6, 12, and 18 months following discharge to assess cognitive and physical functioning. Since participants were enrolled throughout the COVID-19 pandemic, procedural modifications were designed to reduce missing data and allow for high data quality. RESULTS About 420 participants were enrolled with a mean (standard deviation) age of 73.4 (5.6) years, including 14% minority participants. Eighty-eight percent of participants had either total knee or hip replacements; the most common surgery was total knee replacement with 210 participants (50%). Despite the challenges posed by the COVID-19 pandemic, which required the use of novel procedures such as video assessments, there were minimal missing interviews during hospitalization and up to 1-month follow-up; nearly 90% of enrolled participants completed interviews through 6-month follow-up. CONCLUSION While there are many longitudinal studies of older adults, this study is unique in measuring health outcomes following surgery, along with risk factors for delirium through the application of novel biomarkers-including fluid (plasma and cerebrospinal fluid), imaging, and electrophysiological markers. This paper is the first to describe the characteristics of this unique cohort and the data collected, enabling future work using this novel and important resource.
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Affiliation(s)
- Michelle Ward
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Tammy T Hshieh
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Eva M Schmitt
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Steven E Arnold
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michele Cavallari
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Center for Neurological Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Bradford C Dickerson
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Simon T Dillon
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Tamara G Fong
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Berenson-Allen Center for Noninvasive Brain Stimulation, Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Richard N Jones
- Department of Psychiatry and Human Behavior, Department of Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Towia A Libermann
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Alvaro Pascual-Leone
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Deanna and Sidney Wolk Center for Memory Health, HebrewSeniorLife, Boston, Massachusetts, USA
- Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
| | - Mouhsin M Shafi
- Harvard Medical School, Boston, Massachusetts, USA
- Berenson-Allen Center for Noninvasive Brain Stimulation, Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Alexandra Touroutoglou
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Karen Weng
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Guoquan Xu
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Brandon E Earp
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Orthopedic Surgery, Brigham and Women's Faulkner Hospital, Boston, Massachusetts, USA
| | - Lisa Kunze
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jeffrey Lange
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kamen Vlassakov
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Edward R Marcantonio
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Sharon K Inouye
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Thomas G Travison
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Liu J, Gou RY, Jones RN, Schmitt EM, Metzger E, Tabloski PA, Arias F, Hshieh TT, Travison TG, Marcantonio ER, Fong T, Inouye SK. Association of Loneliness With Change in Physical and Emotional Health of Older Adults During the COVID-19 Shutdown. Am J Geriatr Psychiatry 2023; 31:1102-1113. [PMID: 37940227 PMCID: PMC10797604 DOI: 10.1016/j.jagp.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVES To examine factors influencing loneliness and the effect of loneliness on physical and emotional health, in the context of the COVID-19 pandemic. DESIGN Prospective, observational cohort. SETTING Community-dwelling participants. PARTICIPANTS Older adults (n = 238) enrolled in a longitudinal study. MEASUREMENTS Interviews were completed July-December 2020. Loneliness was measured with the UCLA 3-item loneliness scale. Data including age, marriage, education, cognitive functioning, functional impairment, vision or hearing impairment, depression, anxiety, medical comorbidity, social network size, technology use, and activity engagement were collected. Health outcomes included self-rated health, and physical and mental composites from the 12-item Short Form Survey. Physical function was measured by a PROMIS-scaled composite score. RESULTS Thirty-nine (16.4%) participants reported loneliness. Vulnerability factors for loneliness included age (RR = 1.08, 95% CI 1.02-1.14); impairment with instrumental activities of daily living (RR = 2.08, 95% CI 1.14-3.80); vision impairment (RR = 2.09, 95% CI 1.10-3.97); depression (RR = 1.34, 95% CI 1.25-1.43); and anxiety (RR = 1.92, 95% CI 1.55-2.39). Significant resilience factors included high cognitive functioning (RR = 0.88, 95% CI 0.83-0.94); large social network size (RR = 0.92, 95% CI 0.88-0.96); technology use (RR = 0.81, 95% CI 0.73-0.90); and social and physical activity engagement (RR = 0.91, 95% CI 0.85-0.98). Interaction analyses showed that larger social network size moderated the effect of loneliness on physical function (protective interaction effect, RR = 0.64, 95% CI 0.15-1.13, p <.01), and activity engagement moderated the effect of loneliness on mental health (protective interaction effect, RR = 0.65, 95% CI 0.25-1.05, p <.001). CONCLUSIONS Resilience factors may mitigate the adverse health outcomes associated with loneliness. Interventions to enhance resilience may help to diminish the detrimental effects of loneliness and hold great importance for vulnerable older adults.
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Affiliation(s)
- Julianna Liu
- Aging Brain Center (JL, RYG, EMS, FA, TTH, TGT, TF, SKI), Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Ray Yun Gou
- Aging Brain Center (JL, RYG, EMS, FA, TTH, TGT, TF, SKI), Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Richard N Jones
- Department of Psychiatry and Human Behavior (RNJ), Brown University, Providence, RI
| | - Eva M Schmitt
- Aging Brain Center (JL, RYG, EMS, FA, TTH, TGT, TF, SKI), Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Eran Metzger
- Department of Psychiatry (EM), Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Franchesca Arias
- Aging Brain Center (JL, RYG, EMS, FA, TTH, TGT, TF, SKI), Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA; Harvard Medical School (FA, TTH, TGT, ERM, TF, SKI), Boston, MA; Department of Medicine (FA, TTH), Brigham and Women's Hospital, Boston, MA
| | - Tammy T Hshieh
- Aging Brain Center (JL, RYG, EMS, FA, TTH, TGT, TF, SKI), Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA; Harvard Medical School (FA, TTH, TGT, ERM, TF, SKI), Boston, MA; Department of Medicine (FA, TTH), Brigham and Women's Hospital, Boston, MA
| | - Thomas G Travison
- Aging Brain Center (JL, RYG, EMS, FA, TTH, TGT, TF, SKI), Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA; Harvard Medical School (FA, TTH, TGT, ERM, TF, SKI), Boston, MA
| | - Edward R Marcantonio
- Harvard Medical School (FA, TTH, TGT, ERM, TF, SKI), Boston, MA; Divisions of General Medicine and Gerontology (ERM), Beth Israel Deaconess Medical Center, Boston, MA
| | - Tamara Fong
- Aging Brain Center (JL, RYG, EMS, FA, TTH, TGT, TF, SKI), Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA; Harvard Medical School (FA, TTH, TGT, ERM, TF, SKI), Boston, MA; Department of Neurology (TF), Beth Israel Deaconess Medical Center, Boston, MA.
| | - Sharon K Inouye
- Aging Brain Center (JL, RYG, EMS, FA, TTH, TGT, TF, SKI), Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA; Harvard Medical School (FA, TTH, TGT, ERM, TF, SKI), Boston, MA; Department of Medicine (SKI), Beth Israel Deaconess Medical Center, Boston, MA
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Hshieh TT, Gou RY, Jones RN, Leslie DL, Marcantonio ER, Xu G, Travison TG, Fong TG, Schmitt EM, Inouye SK. One-year Medicare costs associated with delirium in older hospitalized patients with and without Alzheimer's disease dementia and related disorders. Alzheimers Dement 2023; 19:1901-1912. [PMID: 36354163 PMCID: PMC10169545 DOI: 10.1002/alz.12826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 09/02/2022] [Accepted: 09/19/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION One-year health-care costs associated with delirium in older hospitalized patients with and without Alzheimer's disease and related dementias (ADRD) have not been examined previously. METHODS Medicare costs were determined prospectively at discharge, and at 30, 90, and 365 days in a cohort (n = 311) of older adults after hospital admission. RESULTS Seventy-six (24%) patients had ADRD and were more likely to develop delirium (51% vs. 24%, P < 0.001) and die within 1 year (38% vs. 21%, P = 0.002). In ADRD patients with versus without delirium, adjusted mean difference in costs associated with delirium were $34,828; most of the excess costs were incurred between 90 and 365 days (P = 0.03). In non-ADRD patients, delirium was associated with increased costs at all timepoints. Excess costs associated with delirium in ADRD patients increased progressively over 1 year, whereas in non-ADRD patients the increase was consistent across time periods. DISCUSSION Our findings highlight the complexity of health-care costs for ADRD patients who develop delirium, a potentially preventable source of expenditures. HIGHLIGHTS Novel examination of health-care costs of delirium in persons with and without Alzheimer's disease and related dementias (ADRD). Increased 1-year costs of $34,828 in ADRD patients with delirium (vs. without). Increased costs for delirium in ADRD occur later during the 365-day study period. For ADRD patients, cost differences between those with and without delirium increased over 1 year. For non-ADRD patients, the parallel cost differences were consistent over time.
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Affiliation(s)
- Tammy T Hshieh
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Ray Yun Gou
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Richard N Jones
- Department of Psychiatry and Human Behavior, Department of Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Douglas L Leslie
- Center for Applied Studies in Health Economics, Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Edward R Marcantonio
- Harvard Medical School, Boston, Massachusetts, USA
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Guoquan Xu
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Thomas G Travison
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Tamara G Fong
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Eva M Schmitt
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Sharon K Inouye
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Hshieh TT, Schmitt EM, Fong TG, Arnold S, Cavallari M, Dickerson BC, Dillon ST, Jones RN, Libermann TA, Marcantonio ER, Pascual-Leone A, Shafi MM, Touroutoglou A, Travison TG, Gou RY, Tommet D, Abdeen A, Earp B, Kunze L, Lange J, Vlassakov K, Inouye SK. Successful aging after elective surgery II: Study design and methods. J Am Geriatr Soc 2023; 71:46-61. [PMID: 36214228 PMCID: PMC9870853 DOI: 10.1111/jgs.18065] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 08/30/2022] [Accepted: 09/04/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND The Successful Aging after Elective Surgery (SAGES) II study was designed to increase knowledge of the pathophysiology and linkages between delirium and dementia. We examine novel biomarkers potentially associated with delirium, including inflammation, Alzheimer's disease (AD) pathology and neurodegeneration, neuroimaging markers, and neurophysiologic markers. The goal of this paper is to describe the study design and methods for the SAGES II study. METHODS The SAGES II study is a 5-year prospective observational study of 400-420 community dwelling persons, aged 65 years and older, assessed prior to scheduled surgery and followed daily throughout hospitalization to observe for development of delirium and other clinical outcomes. Delirium is measured with the Confusion Assessment Method (CAM), long form, after cognitive testing. Cognitive function is measured with a detailed neuropsychologic test battery, summarized as a weighted composite, the General Cognitive Performance (GCP) score. Other key measures include magnetic resonance imaging (MRI), transcranial magnetic stimulation (TMS)/electroencephalography (EEG), and Amyloid positron emission tomography (PET) imaging. We describe the eligibility criteria, enrollment flow, timing of assessments, and variables collected at baseline and during repeated assessments at 1, 2, 6, 12, and 18 months. RESULTS This study describes the hospital and surgery-related variables, delirium, long-term cognitive decline, clinical outcomes, and novel biomarkers. In inter-rater reliability assessments, the CAM ratings (weighted kappa = 0.91, 95% confidence interval, CI = 0.74-1.0) in 50 paired assessments and GCP ratings (weighted kappa = 0.99, 95% CI 0.94-1.0) in 25 paired assessments. We describe procedures for data quality assurance and Covid-19 adaptations. CONCLUSIONS This complex study presents an innovative effort to advance our understanding of the inter-relationship between delirium and dementia via novel biomarkers, collected in the context of major surgery in older adults. Strengths include the integration of MRI, TMS/EEG, PET modalities, and high-quality longitudinal data.
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Affiliation(s)
- Tammy T. Hshieh
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Division of Aging, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Eva M. Schmitt
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Tamara G. Fong
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Steve Arnold
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michele Cavallari
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Department of Radiology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | | | - Simon T. Dillon
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Richard N. Jones
- Department of Psychiatry and Human Behavior, Department of Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Towia A. Libermann
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Edward R. Marcantonio
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Alvaro Pascual-Leone
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Deanna and Sidney Wolk Center for Memory Health, HebrewSeniorLife, Boston, Massachusetts, USA
- Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
| | - Mouhsin M. Shafi
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Thomas G. Travison
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Ray Yun Gou
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Douglas Tommet
- Department of Psychiatry and Human Behavior, Department of Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Ayesha Abdeen
- Department of Orthopedic Surgery, Boston Medical Center, Boston, Massachusetts, USA
| | - Brandon Earp
- Department of Orthopedic Surgery, Brigham and Women’s Faulkner Hospital, Boston, Massachusetts, USA
| | - Lisa Kunze
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jeffrey Lange
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Kamen Vlassakov
- Department of Anesthesia, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Sharon K. Inouye
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
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Fong TG, Hshieh TT, Tabloski PA, Metzger ED, Arias F, Heintz HL, Patrick RE, Lapid MI, Schmitt EM, Harper DG, Forester BP, Inouye SK. Identifying Delirium in Persons With Moderate or Severe Dementia: Review of Challenges and an Illustrative Approach. Am J Geriatr Psychiatry 2022; 30:1067-1078. [PMID: 35581117 PMCID: PMC10413471 DOI: 10.1016/j.jagp.2022.04.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 04/02/2022] [Accepted: 04/06/2022] [Indexed: 01/25/2023]
Abstract
Delirium and dementia are common causes of cognitive impairment among older adults, which often coexist. Delirium is associated with poor clinical outcomes, and is more frequent and more severe in patients with dementia. Identifying delirium in the presence of dementia, also described as delirium superimposed on dementia (DSD), is particularly challenging, as symptoms of delirium such as inattention, cognitive dysfunction, and altered level of consciousness, are also features of dementia. Because DSD is associated with poorer clinical outcomes than dementia alone, detecting delirium is important for reducing morbidity and mortality in this population. We review a number of delirium screening instruments that have shown promise for use in DSD, including the 4-DSD, combined Six Item Cognitive Impairment Test (6-CIT) and 4 'A's Test (4AT), Confusion Assessment Method (CAM), and the combined UB2 and 3D-CAM (UB-CAM). Each has advantages and disadvantages. We then describe the operationalization of a CAM-based approach in a current ECT in dementia project as an example of modifying an existing instrument for patients with moderate to severe dementia. Ultimately, any instrument modified will need to be validated against a standard clinical reference, in order to fully establish its sensitivity and specificity in the moderate to severe dementia population. Future work is greatly needed to advance the challenging area of accurate identification of delirium in moderate or severe dementia.
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Affiliation(s)
- Tamara G Fong
- Departments of Neurology (TGF, FA), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School (TGF, TTH, FA, EMS, SKI), Boston, MA.
| | - Tammy T Hshieh
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School (TGF, TTH, FA, EMS, SKI), Boston, MA; Department of Medicine (TTH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | - Eran D Metzger
- Departments of Psychiatry (EDM), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Franchesca Arias
- Departments of Neurology (TGF, FA), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School (TGF, TTH, FA, EMS, SKI), Boston, MA
| | - Hannah L Heintz
- Division of Geriatric Psychiatry (HLH, REP, DGH, BPF), McLean Hospital, Harvard Medical School, Belmont, MA
| | - Regan E Patrick
- Division of Geriatric Psychiatry (HLH, REP, DGH, BPF), McLean Hospital, Harvard Medical School, Belmont, MA
| | | | - Eva M Schmitt
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School (TGF, TTH, FA, EMS, SKI), Boston, MA
| | - David G Harper
- Division of Geriatric Psychiatry (HLH, REP, DGH, BPF), McLean Hospital, Harvard Medical School, Belmont, MA
| | - Brent P Forester
- Division of Geriatric Psychiatry (HLH, REP, DGH, BPF), McLean Hospital, Harvard Medical School, Belmont, MA
| | - Sharon K Inouye
- Departments of Medicine (SKI), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School (TGF, TTH, FA, EMS, SKI), Boston, MA
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Hshieh TT, DuMontier C, Jaung T, Bahl NE, Hawley CE, Mozessohn L, Stone RM, Soiffer RJ, Driver JA, Abel GA. Association of Polypharmacy and Potentially Inappropriate Medications With Frailty Among Older Adults With Blood Cancers. J Natl Compr Canc Netw 2022; 20:915-923.e5. [PMID: 35948031 PMCID: PMC10106100 DOI: 10.6004/jnccn.2022.7033] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/13/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Polypharmacy and potentially inappropriate medications (PIMs) are common among older adults with blood cancers, but their association with frailty and how to manage them optimally remain unclear. PATIENTS AND METHODS From 2015 to 2019, patients aged ≥75 years presenting for initial oncology consult underwent screening geriatric assessment. Patients were determined to be robust, prefrail, or frail via deficit accumulation and phenotypic approaches. We quantified each patient's total number of medications and PIMs using the Anticholinergic Risk Scale (ARS) and a scale we generated using the NCCN Medications of Concern called the Geriatric Oncology Potentially Inappropriate Medications (GO-PIM) scale. We assessed cross-sectional associations of PIMs with frailty in multivariable regression models adjusting for age, gender, and comorbidity. RESULTS Of 785 patients assessed, 603 (77%) were taking ≥5 medications and 421 (54%) were taking ≥8 medications; 201 (25%) were taking at least 1 PIM based on the ARS and 343 (44%) at least 1 PIM based on the GO-PIM scale. Among the 468 (60%) patients on active cancer treatment, taking ≥8 medications was associated with frailty (adjusted odds ratio [aOR], 2.82; 95% CI, 1.92-4.17). With each additional medication, the odds of being prefrail or frail increased 8% (aOR, 1.08; 95% CI, 1.04-1.12). With each 1-point increase on the ARS, the odds of being prefrail or frail increased 19% (aOR, 1.19; 95% CI, 1.03-1.39); with each additional PIM based on the GO-PIM scale, the odds increased 65% (aOR, 1.65; 95% CI, 1.34-2.04). CONCLUSIONS Polypharmacy and PIMs are prevalent among older patients with blood cancers; taking ≥8 medications is strongly associated with frailty. These data suggest careful medication reconciliation for this population may be helpful, and deprescribing when possible is high-yield, especially for PIMs on the GO-PIM scale.
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Affiliation(s)
- Tammy T Hshieh
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Clark DuMontier
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- New England Geriatric Research Education and Clinical Center, Bedford, Massachusetts
| | - Timothy Jaung
- New England Geriatric Research Education and Clinical Center, Bedford, Massachusetts
| | - Nupur E Bahl
- New England Geriatric Research Education and Clinical Center, Bedford, Massachusetts
| | - Chelsea E Hawley
- New England Geriatric Research Education and Clinical Center, Bedford, Massachusetts
| | - Lee Mozessohn
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; and
| | - Richard M Stone
- Harvard Medical School, Boston, Massachusetts
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Robert J Soiffer
- Harvard Medical School, Boston, Massachusetts
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jane A Driver
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Gregory A Abel
- Harvard Medical School, Boston, Massachusetts
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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8
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Vasunilashorn SM, Fong TG, Helfand BKI, Hshieh TT, Marcantonio ER, Metzger ED, Schmitt EM, Tabloski PA, Travison TG, Gou Y, Jones RN, Inouye SK. Psychometric Properties of a Delirium Severity Score for Older Adults and Association With Hospital and Posthospital Outcomes. JAMA Netw Open 2022; 5:e226129. [PMID: 35357447 PMCID: PMC8972033 DOI: 10.1001/jamanetworkopen.2022.6129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
IMPORTANCE The ability to rate delirium severity is key to providing optimal care for older adults, and such ratings would allow clinicians to target patients with severe delirium and monitor response to treatment, recovery time, and prognosis; assess nursing burden and staffing needs; and, ultimately, provide more appropriate patient-centered care. Current delirium severity measures have been limited in their content, gradations, and measurement characteristics. OBJECTIVE To examine the internal consistency, reliability, and validity for clinical outcomes of the DEL-S delirium severity score, a measure of delirium severity that was developed using advanced psychometric approaches, analogous to those of the Patient-Reported Outcomes Measurement Information System initiative. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study was conducted at a large academic medical center in Boston, Massachusetts. Adults aged 70 years or older who were admitted or transferred to medical or surgical services as either emergency or elective admissions were enrolled between October 20, 2015, and March 15, 2017, and were monitored for 1 year. Data analysis was performed from June 2020 to August 2021. EXPOSURES Delirium severity, measured by scores on the delirium severity score short-form (SF; 6 items, scored 0-13, with higher scores indicating more severe delirium) and long-form (LF; 17 items, scored 0-21), considered continuously and grouped into 5 categories. MAIN OUTCOMES AND MEASURES The primary outcomes were in-hospital outcomes, including length of stay and hospital costs, and posthospital (30, 90, and 365 days) outcomes, including death, health care costs, and rehospitalization. RESULTS The 352 participants had a median (IQR) age of 79.7 (74.6-85.5) years, 204 (58.0%) were women, and they were highly educated (median [IQR] duration of education, 14 [7-20] years). Patients in the highest delirium severity score SF group (scores 6-9) had a longer length of stay (13.3 vs 6.9 days; P for trend < .001), greater in-hospital costs ($57 700 vs $34 200), greater cumulative health care costs ($168 700 vs $106 500; P for trend = .01), and increased mortality at 1 year (50% vs 17%; P for trend = .02) compared with patients in the lowest delirium severity score SF group (score 0). Similar trends and significant findings were demonstrated for the delirium severity score LF. CONCLUSIONS AND RELEVANCE These findings suggest that the delirium severity score provides an approach for measuring delirium severity that is associated with adverse clinical outcomes in a direct exposure-response association and that the delirium severity score may help advance patient-centered care for delirium.
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Affiliation(s)
- Sarinnapha M. Vasunilashorn
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Tamara G. Fong
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Tammy T. Hshieh
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Edward R. Marcantonio
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Eran D. Metzger
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Eva M. Schmitt
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Patricia A. Tabloski
- Department of Nursing, William F. Connell School of Nursing at Boston College, Boston, Massachusetts
| | - Thomas G. Travison
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Yun Gou
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Richard N. Jones
- Department of Psychiatry and Human Behavior, Brown University Warren Alpert Medical School, Providence, Rhode Island
- Department of Neurology, Brown University Warren Alpert Medical School, Providence, Rhode Island
| | - Sharon K. Inouye
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Associate Editor, JAMA Network Open
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9
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Cooper L, Loewenthal J, Frain LN, Tulebaev S, Cardin K, Hshieh TT, Dumontier C, Streiter S, Joseph C, Hilt A, Theou O, Rockwood K, Orkaby AR, Javedan H. From research to bedside: Incorporation of a CGA-based frailty index among multiple comanagement services. J Am Geriatr Soc 2022; 70:90-98. [PMID: 34519037 PMCID: PMC9056009 DOI: 10.1111/jgs.17446] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/04/2021] [Accepted: 08/06/2021] [Indexed: 01/03/2023]
Abstract
The comprehensive geriatric assessment (CGA) is the core tool used by geriatricians across diverse clinical settings to identify vulnerabilities and estimate physiologic reserve in older adults. In this paper, we demonstrate the iterative process at our institution to identify and develop a feasible, acceptable, and sustainable bedside CGA-based frailty index tool (FI-CGA) that not only quantifies and grades frailty but also provides a uniform way to efficiently communicate complex geriatric concepts such as reserve and vulnerability with other teams. We describe our incorporation of the FI-CGA into the electronic health record (EHR) and dissemination among clinical services. We demonstrate that an increasing number of patients have documented FI-CGA in their initial assessment from 2018 to 2020, while additional comanagement services were established (Figure 2). The acceptability and sustainability of the FI-CGA, and its routine use by geriatricians in our division, were demonstrated by a survey where the majority of clinicians report using the FI-CGA when assessing a new patient and that the FI-CGA informs their clinical management. Finally, we demonstrate how we refined and updated the FI-CGA, we provide examples of applications of the FI-CGA across the institution and describe areas of ongoing process improvement and challenges for the use of this tailored yet standardized tool across diverse inpatient and outpatient services. The process outlined can be used by other geriatric departments to introduce and incorporate an FI-CGA.
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Affiliation(s)
- Lisa Cooper
- Division of Aging, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Julia Loewenthal
- Division of Aging, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Laura N. Frain
- Division of Aging, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Samir Tulebaev
- Division of Aging, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Kristin Cardin
- Division of Aging, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Tammy T. Hshieh
- Division of Aging, Brigham and Women’s Hospital, Boston, Massachusetts, USA,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Clark Dumontier
- Division of Aging, Brigham and Women’s Hospital, Boston, Massachusetts, USA,New England Geriatric Research, Education, and Clinical Center (GRECC), VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Shoshana Streiter
- Division of Aging, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Carly Joseph
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Austin Hilt
- Department of Psychiatry and Behavioral Sciences, University of California, Davis, California, USA,Department of Family and Community Medicine, University of California, Davis, California, USA
| | - Olga Theou
- Physiotherapy, Dalhousie University, Halifax, Nova Scotia, Canada,Geriatric Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kenneth Rockwood
- Geriatric Medicine, Dalhousie University, Halifax, Nova Scotia, Canada,Centre for Health Care of the Elderly, Nova Scotia Health, Halifax, Nova Scotia, Canada
| | - Ariela R. Orkaby
- Division of Aging, Brigham and Women’s Hospital, Boston, Massachusetts, USA,New England Geriatric Research, Education, and Clinical Center (GRECC), VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Houman Javedan
- Division of Aging, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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10
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Jones RN, Tommet D, Steingrimsson J, Racine AM, Fong TG, Gou Y, Hshieh TT, Metzger ED, Schmitt EM, Tabloski PA, Travison TG, Vasunilashorn SM, Abdeen A, Earp B, Kunze L, Lange J, Vlassakov K, Dickerson BC, Marcantonio ER, Inouye SK. Development and internal validation of a predictive model of cognitive decline 36 months following elective surgery. Alzheimers Dement (Amst) 2021; 13:e12201. [PMID: 34046520 PMCID: PMC8140204 DOI: 10.1002/dad2.12201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 04/09/2021] [Accepted: 04/13/2021] [Indexed: 12/03/2022]
Abstract
INTRODUCTION Our goal was to determine if features of surgical patients, easily obtained from the medical chart or brief interview, could be used to predict those likely to experience more rapid cognitive decline following surgery. METHODS We analyzed data from an observational study of 560 older adults (≥70 years) without dementia undergoing major elective non-cardiac surgery. Cognitive decline was measured using change in a global composite over 2 to 36 months following surgery. Predictive features were identified as variables readily obtained from chart review or a brief patient assessment. We developed predictive models for cognitive decline (slope) and predicting dichotomized cognitive decline at a clinically determined cut. RESULTS In a hold-out testing set, the regularized regression predictive model achieved a root mean squared error (RMSE) of 0.146 and a model r-square (R2 ) of .31. Prediction of "rapid" decliners as a group achieved an area under the curve (AUC) of .75. CONCLUSION Some of our models could predict persons with increased risk for accelerated cognitive decline with greater accuracy than relying upon chance, and this result might be useful for stratification of surgical patients for inclusion in future clinical trials.
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Affiliation(s)
- Richard N. Jones
- Department of Psychiatry and Human BehaviorBrown University Warren Alpert Medical SchoolProvidenceRhode IslandUSA
- Department of NeurologyBrown University Warren Alpert Medical SchoolProvidenceRhode IslandUSA
| | - Douglas Tommet
- Department of Psychiatry and Human BehaviorBrown University Warren Alpert Medical SchoolProvidenceRhode IslandUSA
| | - Jon Steingrimsson
- Department of BiostatisticsBrown University School of Public HealthProvidenceRhode IslandUSA
| | | | - Tamara G. Fong
- Biogen IncCambridgeMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of NeurologyBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
| | - Yun Gou
- Biogen IncCambridgeMassachusettsUSA
| | - Tammy T. Hshieh
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of MedicineBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
| | - Eran D. Metzger
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of PsychiatryBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
| | | | | | - Thomas G. Travison
- Biogen IncCambridgeMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Sarinnapha M. Vasunilashorn
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of MedicineBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
| | - Ayesha Abdeen
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of Orthopedic SurgeryBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
| | - Brandon Earp
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of Orthopedic SurgeryBrigham and Women's HospitalBostonMassachusettsUSA
| | - Lisa Kunze
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of AnesthesiaBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
| | - Jeffrey Lange
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of Orthopedic SurgeryBrigham and Women's HospitalBostonMassachusettsUSA
| | - Kamen Vlassakov
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of AnesthesiaBrigham and Women's HospitalBostonMassachusettsUSA
| | - Bradford C. Dickerson
- Department of Neurology and Massachusetts Alzheimer's Disease Research CenterMassachusetts General HospitalBostonMassachusettsUSA
| | - Edward R. Marcantonio
- Biogen IncCambridgeMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of MedicineBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
| | - Sharon K. Inouye
- Biogen IncCambridgeMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of MedicineBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
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11
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Gou RY, Hshieh TT, Marcantonio ER, Cooper Z, Jones RN, Travison TG, Fong TG, Abdeen A, Lange J, Earp B, Schmitt EM, Leslie DL, Inouye SK. One-Year Medicare Costs Associated With Delirium in Older Patients Undergoing Major Elective Surgery. JAMA Surg 2021; 156:430-442. [PMID: 33625501 DOI: 10.1001/jamasurg.2020.7260] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Importance Delirium is a common, serious, and potentially preventable problem for older adults, associated with adverse outcomes. Coupled with its preventable nature, these adverse sequelae make delirium a significant public health concern; understanding its economic costs is important for policy makers and health care leaders to prioritize care. Objective To evaluate current 1-year health care costs attributable to postoperative delirium in older patients undergoing elective surgery. Design, Setting, and Participants This prospective cohort study included 497 patients from the Successful Aging after Elective Surgery (SAGES) study, an ongoing cohort study of older adults undergoing major elective surgery. Patients were enrolled from June 18, 2010, to August 8, 2013. Eligible patients were 70 years or older, English-speaking, able to communicate verbally, and scheduled to undergo major surgery at 1 of 2 Harvard-affiliated hospitals with an anticipated length of stay of at least 3 days. Eligible surgical procedures included total hip or knee replacement; lumbar, cervical, or sacral laminectomy; lower extremity arterial bypass surgery; open abdominal aortic aneurysm repair; and open or laparoscopic colectomy. Data were analyzed from October 15, 2019, to September 15, 2020. Exposures Major elective surgery and hospitalization. Main Outcomes and Measures Cumulative and period-specific costs (index hospitalization, 30-day, 90-day, and 1-year follow-up) were examined using Medicare claims and extensive clinical data. Total inflation-adjusted health care costs were determined using data from Medicare administrative claims files for the 2010 to 2014 period. Delirium was rated using the Confusion Assessment Method. We also examined whether increasing delirium severity was associated with higher cumulative and period-specific costs. Delirium severity was measured with the Confusion Assessment Method-Severity long form. Regression models were used to determine costs associated with delirium after adjusting for patient demographic and clinical characteristics. Results Of the 566 patients who were eligible for the study, a total of 497 patients (mean [SD] age, 76.8 [5.1] years; 281 women [57%]; 461 White participants [93%]) were enrolled after exclusion criteria were applied. During the index hospitalization, 122 patients (25%) developed postoperative delirium, whereas 375 (75%) did not. Patients with delirium had significantly higher unadjusted health care costs than patients without delirium (mean [SD] cost, $146 358 [$140 469] vs $94 609 [$80 648]). After adjusting for relevant confounders, the cumulative health care costs attributable to delirium were $44 291 (95% CI, $34 554-$56 673) per patient per year, with the majority of costs coming from the first 90 days: index hospitalization ($20 327), subsequent rehospitalizations ($27 797), and postacute rehabilitation stays ($2803). Health care costs increased directly and significantly with level of delirium severity (none-mild, $83 534; moderate, $99 756; severe, $140 008), suggesting an exposure-response relationship. The adjusted mean cumulative costs attributable to severe delirium were $56 474 (95% CI, $40 927-$77 440) per patient per year. Extrapolating nationally, the health care costs attributable to postoperative delirium were estimated at $32.9 billion (95% CI, $25.7 billion-$42.2 billion) per year. Conclusions and Relevance These findings suggest that the economic outcomes of delirium and severe delirium after elective surgery are substantial, rivaling costs associated with cardiovascular disease and diabetes. These results highlight the need for policy imperatives to address delirium as a large-scale public health issue.
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Affiliation(s)
- Ray Yun Gou
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Tammy T Hshieh
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Edward R Marcantonio
- Harvard Medical School, Boston, Massachusetts.,Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Zara Cooper
- Harvard Medical School, Boston, Massachusetts.,Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Richard N Jones
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island.,Department of Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Thomas G Travison
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Tamara G Fong
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Ayesha Abdeen
- Harvard Medical School, Boston, Massachusetts.,Department of Orthopedic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jeffrey Lange
- Harvard Medical School, Boston, Massachusetts.,Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Brandon Earp
- Harvard Medical School, Boston, Massachusetts.,Department of Orthopedic Surgery, Brigham and Women's Faulkner Hospital, Boston, Massachusetts
| | - Eva M Schmitt
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Douglas L Leslie
- Department of Orthopedic Surgery, Brigham and Women's Faulkner Hospital, Boston, Massachusetts.,Center for Applied Studies in Health Economics, Department of Public Health Sciences, Pennsylvania State College of Medicine, Hershey, Pennsylvania
| | - Sharon K Inouye
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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12
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Racine AM, Tommet D, D'Aquila ML, Fong TG, Gou Y, Tabloski PA, Metzger ED, Hshieh TT, Schmitt EM, Vasunilashorn SM, Kunze L, Vlassakov K, Abdeen A, Lange J, Earp B, Dickerson BC, Marcantonio ER, Steingrimsson J, Travison TG, Inouye SK, Jones RN. Machine Learning to Develop and Internally Validate a Predictive Model for Post-operative Delirium in a Prospective, Observational Clinical Cohort Study of Older Surgical Patients. J Gen Intern Med 2021; 36:265-273. [PMID: 33078300 PMCID: PMC7878663 DOI: 10.1007/s11606-020-06238-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 09/11/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Our objective was to assess the performance of machine learning methods to predict post-operative delirium using a prospective clinical cohort. METHODS We analyzed data from an observational cohort study of 560 older adults (≥ 70 years) without dementia undergoing major elective non-cardiac surgery. Post-operative delirium was determined by the Confusion Assessment Method supplemented by a medical chart review (N = 134, 24%). Five machine learning algorithms and a standard stepwise logistic regression model were developed in a training sample (80% of participants) and evaluated in the remaining hold-out testing sample. We evaluated three overlapping feature sets, restricted to variables that are readily available or minimally burdensome to collect in clinical settings, including interview and medical record data. A large feature set included 71 potential predictors. A smaller set of 18 features was selected by an expert panel using a consensus process, and this smaller feature set was considered with and without a measure of pre-operative mental status. RESULTS The area under the receiver operating characteristic curve (AUC) was higher in the large feature set conditions (range of AUC, 0.62-0.71 across algorithms) versus the selected feature set conditions (AUC range, 0.53-0.57). The restricted feature set with mental status had intermediate AUC values (range, 0.53-0.68). In the full feature set condition, algorithms such as gradient boosting, cross-validated logistic regression, and neural network (AUC = 0.71, 95% CI 0.58-0.83) were comparable with a model developed using traditional stepwise logistic regression (AUC = 0.69, 95% CI 0.57-0.82). Calibration for all models and feature sets was poor. CONCLUSIONS We developed machine learning prediction models for post-operative delirium that performed better than chance and are comparable with traditional stepwise logistic regression. Delirium proved to be a phenotype that was difficult to predict with appreciable accuracy.
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Affiliation(s)
- Annie M Racine
- Aging Brain Center, Institute for Aging Research, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Douglas Tommet
- Department of Psychiatry & Human Behavior, and Neurology, Brown University Warren Alpert Medical School, Providence, RI, USA
| | | | - Tamara G Fong
- Aging Brain Center, Institute for Aging Research, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Yun Gou
- Aging Brain Center, Institute for Aging Research, Boston, MA, USA
| | | | - Eran D Metzger
- Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Tammy T Hshieh
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Eva M Schmitt
- Aging Brain Center, Institute for Aging Research, Boston, MA, USA
| | - Sarinnapha M Vasunilashorn
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Lisa Kunze
- Harvard Medical School, Boston, MA, USA
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Kamen Vlassakov
- Harvard Medical School, Boston, MA, USA
- William F Connell School of Nursing at Boston College, Boston, MA, USA
| | - Ayesha Abdeen
- Harvard Medical School, Boston, MA, USA
- Department of Orthopedic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jeffrey Lange
- Harvard Medical School, Boston, MA, USA
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Brandon Earp
- Harvard Medical School, Boston, MA, USA
- Department of Orthopedics, Brigham and Women's Faulkner Hospital, Boston, MA, USA
| | - Bradford C Dickerson
- Department of Neurology and Massachusetts Alzheimer's Disease Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Edward R Marcantonio
- Aging Brain Center, Institute for Aging Research, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Thomas G Travison
- Aging Brain Center, Institute for Aging Research, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Sharon K Inouye
- Aging Brain Center, Institute for Aging Research, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Richard N Jones
- Department of Psychiatry & Human Behavior, and Neurology, Brown University Warren Alpert Medical School, Providence, RI, USA.
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Helfand BKI, D'Aquila ML, Tabloski P, Erickson K, Yue J, Fong TG, Hshieh TT, Metzger ED, Schmitt EM, Boudreaux ED, Inouye SK, Jones RN. Detecting Delirium: A Systematic Review of Identification Instruments for Non-ICU Settings. J Am Geriatr Soc 2020; 69:547-555. [PMID: 33135780 DOI: 10.1111/jgs.16879] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/14/2020] [Accepted: 09/20/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND/OBJECTIVES Delirium manifests clinically in varying ways across settings. More than 40 instruments currently exist for characterizing the different manifestations of delirium. We evaluated all delirium identification instruments according to their psychometric properties and frequency of citation in published research. DESIGN We conducted the systematic review by searching Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, Excerpta Medica Database (Embase), PsycINFO, PubMed, and Web of Science from January 1, 1974, to January 31, 2020, with the keywords "delirium" and "instruments," along with their known synonyms. We selected only systematic reviews, meta-analyses, or narrative literature reviews including multiple delirium identification instruments. MEASUREMENTS Two reviewers assessed the eligibility of articles and extracted data on all potential delirium identification instruments. Using the original publication on each instrument, the psychometric properties were examined using the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) framework. RESULTS Of 2,542 articles identified, 75 met eligibility criteria, yielding 30 different delirium identification instruments. A count of citations was determined using Scopus for the original publication for each instrument. Each instrument underwent methodological quality review of psychometric properties using COSMIN definitions. An expert panel categorized key domains for delirium identification based on criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III through DSM-5. Four instruments were notable for having at least two of three of the following: citation count of 200 or more, strong validation methodology in their original publication, and fulfillment of DSM-5 criteria. These were, alphabetically, Confusion Assessment Method, Delirium Observation Screening Scale, Delirium Rating Scale-Revised-98, and Memorial Delirium Assessment Scale. CONCLUSION Four commonly used and well-validated instruments can be recommended for clinical and research use. An important area for future investigation is to harmonize these measures to compare and combine studies on delirium.
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Affiliation(s)
- Benjamin K I Helfand
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA.,Departments of Psychiatry and Human Behavior and Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Madeline L D'Aquila
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts, USA
| | - Patricia Tabloski
- William F. Connell School of Nursing, Boston College, Boston, Massachusetts, USA
| | - Kristen Erickson
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts, USA
| | - Jirong Yue
- Department of Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Tamara G Fong
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Tammy T Hshieh
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Division of Gerontology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Eran D Metzger
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Eva M Schmitt
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts, USA
| | - Edwin D Boudreaux
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Sharon K Inouye
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts, USA
| | - Richard N Jones
- Departments of Psychiatry and Human Behavior and Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
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14
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Hshieh TT, Fong TG, Schmitt EM, Marcantonio ER, Xu G, Gou YR, Travison TG, Metzger ED, Jones RN, Inouye SK. Does Alzheimer's Disease and Related Dementias Modify Delirium Severity and Hospital Outcomes? J Am Geriatr Soc 2020; 68:1722-1730. [PMID: 32255521 DOI: 10.1111/jgs.16420] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 02/25/2020] [Accepted: 02/27/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES We examined the association between delirium severity and outcomes of delirium among persons with and without Alzheimer's disease and related dementias (ADRD). DESIGN Prospective cohort study. SETTING Academic tertiary medical center. PARTICIPANTS A total of 352 medical and surgical patients. MEASUREMENTS Delirium incidence and severity were rated daily using the Confusion Assessment Method (CAM) and CAM-Severity (CAM-S) score during hospitalization. Severe delirium was defined as a CAM-S Short Form score in the highest tertile (3-7 points out of 7). ADRD status was determined by a clinical consensus process. Clinical outcomes included prolonged length of stay (>6 d), discharge to post-acute nursing facility, any decline in activities of daily living (ADLs) at 1 month from prehospital baseline, ongoing nursing facility stay, and mortality. RESULTS Patients with ADRD (n = 85 [24%]) had a significantly higher relative risk (RR) for incident delirium (RR = 2.31; 95% confidence interval [CI] = 1.64-3.28) and higher peak CAM-S scores (mean difference = 1.24 points; CI = .83-1.65; P < .001). Among patients with ADRD, severe delirium significantly increased the RR for nursing facility stay (RR = 2.22; CI = 1.05-4.69; P = .04) and increased the RR for mortality (RR = 2.10; CI = .89-4.98; P = .09). Among patients without ADRD, severe delirium was associated with a significantly increased risk for all poor outcomes except mortality including prolonged length of stay in the hospital (RR = 1.47; CI = 1.18-1.82) and discharge to a post-acute nursing facility (RR = 2.17; CI = 1.58-2.98) plus decline in ADLs (RR = 1.30; CI = 1.05-1.60) and nursing facility stay at 1 month (RR = 1.93; CI = 1.31-2.83). CONCLUSION Severe delirium is associated with increased risk for poor clinical outcomes in patients with and without ADRD. In both groups, severe delirium increased risk of nursing home placement. In patients with ADRD, delirium was more severe and associated with a trend toward increased mortality at 1 month. Although the increased risk remains substantial by RR, the study had limited power to examine the rarer outcome of death. J Am Geriatr Soc 68:1722-1730, 2020.
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Affiliation(s)
- Tammy T Hshieh
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, USA.,Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Tamara G Fong
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Eva M Schmitt
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, USA
| | - Edward R Marcantonio
- Harvard Medical School, Boston, Massachusetts, USA.,Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Guoquan Xu
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, USA
| | - Yun R Gou
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, USA
| | - Thomas G Travison
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Eran D Metzger
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Richard N Jones
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA.,Department of Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Sharon K Inouye
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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15
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Vasunilashorn SM, Schulman-Green D, Tommet D, Fong TG, Hshieh TT, Marcantonio ER, Metzger ED, Schmitt EM, Tabloski PA, Travison TG, Gou Y, Helfand B, Inouye SK, Jones RN. New Delirium Severity Indicators: Generation and Internal Validation in the Better Assessment of Illness (BASIL) Study. Dement Geriatr Cogn Disord 2020; 49:77-90. [PMID: 32554974 PMCID: PMC7484102 DOI: 10.1159/000506700] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 02/20/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Delirium is a common and preventable geriatric syndrome. Moving beyond the binary classification of delirium present/absent, delirium severity represents a potentially important outcome for evaluating preventive and treatment interventions and tracking the course of patients. Although several delirium severity assessment tools currently exist, most have been developed in the absence of advanced measurement methodology and have not been evaluated with rigorous validation studies. OBJECTIVE We aimed to report our development of new delirium severity items and the results of item reduction and selection activities guided by psychometric analysis of data derived from a field study. METHODS Building on our literature review of delirium instruments and expert panel process to identify domains of delirium severity, we adapted items from existing delirium severity instruments and generated new items. We then fielded these items among a sample of 352 older hospitalized patients. RESULTS We used an expert panel process and psychometric data analysis techniques to narrow a set of 303 potential items to 17 items for use in a new delirium severity instrument. The 17-item set demonstrated good internal validity and favorable psychometric characteristics relative to comparator instruments, including the Confusion Assessment Method - Severity (CAM-S) score, the Delirium Rating Scale Revised 98, and the Memorial Delirium Assessment Scale. CONCLUSION We more fully conceptualized delirium severity and identified characteristics of an ideal delirium severity instrument. These characteristics include an instrument that is relatively quick to administer, is easy to use by raters with minimal training, and provides a severity rating with good content validity, high internal consistency reliability, and broad domain coverage across delirium symptoms. We anticipate these characteristics to be represented in the subsequent development of our final delirium severity instrument.
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Affiliation(s)
- Sarinnapha M. Vasunilashorn
- Harvard Medical School, Boston, MA, USA,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA,Department of Epidemiology, Harvard T.H. Chan School of Public Health, USA
| | | | - Douglas Tommet
- Department of Psychiatry and Human Behavior, Brown University Warren Alpert Medical School, Providence, RI
| | - Tamara G. Fong
- Harvard Medical School, Boston, MA, USA,Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA;,Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Tammy T. Hshieh
- Harvard Medical School, Boston, MA, USA,Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Edward R. Marcantonio
- Harvard Medical School, Boston, MA, USA,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA,Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Eran D. Metzger
- Harvard Medical School, Boston, MA, USA,Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, MA
| | - Eva M. Schmitt
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | | | - Thomas G. Travison
- Harvard Medical School, Boston, MA, USA,Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Yun Gou
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | | | - Sharon K. Inouye
- Harvard Medical School, Boston, MA, USA,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA,Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Richard N. Jones
- Department of Psychiatry and Human Behavior, Brown University Warren Alpert Medical School, Providence, RI;,Department of Neurology, Brown University Warren Alpert Medical School, Providence, RI
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16
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Ward RE, Orkaby AR, Chen J, Hshieh TT, Driver JA, Gaziano JM, Djousse L. Association between Diet Quality and Frailty Prevalence in the Physicians' Health Study. J Am Geriatr Soc 2019; 68:770-776. [PMID: 31840808 DOI: 10.1111/jgs.16286] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 11/15/2019] [Accepted: 11/16/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Limited data suggest that a healthy diet is associated with a lower risk of frailty. We sought to assess the relationship between three measures of diet quality and frailty among male physicians. DESIGN Cross-sectional analysis of a cohort study. SETTING Physicians' Health Study. PARTICIPANTS A total of 9861 initially healthy US men, aged 60 years or older, who provided data on frailty status and dietary habits. MEASUREMENTS A cumulative deficit frailty index (FI) was calculated using 33 variables encompassing domains of comorbidity, functional status, mood, general health, social isolation, and change in weight. Diet quality was measured using the Alternative Healthy Eating Index (aHEI), Mediterranean Diet Score (MDS), and Dietary Approaches to Stop Hypertension (DASH). RESULTS The FI identified 38% of physicians as non-frail, 44% as pre-frail, and 18% as frail. Multinomial logistic regression models adjusted for age, smoking status, and energy intake showed that compared with the lowest aHEI quintiles, those in the highest quintiles had lower odds of frailty and pre-frailty compared with non-frailty (odds ratio [OR] for frailty = .47; 95% confidence interval [CI] = .39-.58; for pre-frailty: OR = .75; CI = .65-.87). Exercise did not modify this association (P interaction >.1). Similar relationships were observed for DASH and MDS quintiles with frailty and pre-frailty. Restricted cubic splines showed an inverse dose-response relationship of diet quality scores with odds of frailty and pre-frailty. CONCLUSION Cross-sectional data show an inverse dose-response relationship of diet quality with pre-frailty and frailty. Future longitudinal studies are needed to investigate whether healthier diet is a modifiable risk factor for frailty. ClinicalTrials.gov identifier: NCT00000500. J Am Geriatr Soc 68:770-776, 2020.
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Affiliation(s)
- Rachel E Ward
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, Massachusetts.,New England GRECC (Geriatric Research, Education, and Clinical Center), VA Boston Healthcare System, Boston, Massachusetts.,Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
| | - Ariela R Orkaby
- New England GRECC (Geriatric Research, Education, and Clinical Center), VA Boston Healthcare System, Boston, Massachusetts.,Division of Aging, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jiaying Chen
- Division of Aging, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tammy T Hshieh
- Division of Aging, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Jane A Driver
- New England GRECC (Geriatric Research, Education, and Clinical Center), VA Boston Healthcare System, Boston, Massachusetts.,Division of Aging, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - J Michael Gaziano
- New England GRECC (Geriatric Research, Education, and Clinical Center), VA Boston Healthcare System, Boston, Massachusetts.,Division of Aging, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Luc Djousse
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, Massachusetts.,Division of Aging, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
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17
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Hshieh TT, Vasunilashorn SM, D'Aquila ML, Arnold SE, Dickerson BC, Fong TG, Jones RN, Marcantonio ER, Schmitt EM, Xu G, Gou Y, Chen F, Kunze LJ, Vlassakov KV, Abdeen AR, Lange JK, Earp BE, Touroutoglou A, Carlyle BC, Kivisakk-Webb P, Travison TG, Dillon ST, Libermann TA, Inouye SK. The Role of Inflammation after Surgery for Elders (RISE) study: Study design, procedures, and cohort profile. Alzheimers Dement (Amst) 2019; 11:752-762. [PMID: 31737775 PMCID: PMC6849121 DOI: 10.1016/j.dadm.2019.09.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Introduction The Role of Inflammation after Surgery for Elders study correlates novel inflammatory markers measured in blood, cerebrospinal fluid (CSF) assays, and [11C]-PBR28 positron-emission tomography imaging. Methods This study involved a prospective cohort design with patients who underwent elective hip and knee arthroplasty under spinal anesthesia. Sixty-five adults participated with their family members. Inflammatory biomarker assays were measured preoperatively on day 1 and postoperatively at one month. Results On average, participants were 75 years old, and 72% were female. 54% underwent total knee arthroplasty, and 46% underwent total hip arthroplasty. The mean Modified Mini-Mental State (3MS) Examination score was 89.3; four patients (6%) scored ≤77 points. Plasma assays were completed in 63 (97%) participants, cerebrospinal fluid assays in 61 (94%), and PET imaging in 44 (68%). Discussion This complex study presents an innovative effort to correlate peripheral and central inflammatory biomarkers before and after major surgery in older adults. Strengths include collecting concurrent blood, cerebrospinal fluid, and positron-emission tomography with detailed clinical characterization of delirium, cognition, and functional status. We describe the methodology of the Role of Inflammation after Surgery for Elders Study. This is a prospective cohort of elective hip/knee arthroplasty patients 70 years or older. We examine inflammation in blood, cerebrospinal fluid and positron emission tomography. We collect novel biomarkers preoperatively and one-month postoperatively. There is clinical characterization of delirium, cognition and functional status.
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Affiliation(s)
- Tammy T Hshieh
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Sarinnapha M Vasunilashorn
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Madeline L D'Aquila
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Steven E Arnold
- Harvard Medical School, Boston, MA, USA.,Department of Neurology, Massachusetts Alzheimer's Disease Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Bradford C Dickerson
- Harvard Medical School, Boston, MA, USA.,Department of Neurology, Massachusetts Alzheimer's Disease Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Tamara G Fong
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Richard N Jones
- Department of Psychiatry and Human Behavior, Brown University Warren Alpert Medical School, Providence, RI, USA.,Department of Neurology, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Edward R Marcantonio
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Eva M Schmitt
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Guoquan Xu
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Yun Gou
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Fan Chen
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Lisa J Kunze
- Harvard Medical School, Boston, MA, USA.,Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Kamen V Vlassakov
- Harvard Medical School, Boston, MA, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Ayesha R Abdeen
- Harvard Medical School, Boston, MA, USA.,Department of Orthopedic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jeffrey K Lange
- Harvard Medical School, Boston, MA, USA.,Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Brandon E Earp
- Harvard Medical School, Boston, MA, USA.,Department of Orthopedic Surgery, Brigham and Women's Faulkner Hospital, Boston, MA, USA
| | - Alexandra Touroutoglou
- Harvard Medical School, Boston, MA, USA.,Department of Neurology, Massachusetts Alzheimer's Disease Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Becky C Carlyle
- Harvard Medical School, Boston, MA, USA.,Department of Neurology, Massachusetts Alzheimer's Disease Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Pia Kivisakk-Webb
- Department of Neurology, Massachusetts Alzheimer's Disease Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Thomas G Travison
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Simon T Dillon
- Harvard Medical School, Boston, MA, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Towia A Libermann
- Harvard Medical School, Boston, MA, USA.,Genomics, Proteomics, Bioinformatics and Systems Biology Center, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Sharon K Inouye
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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18
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Fong TG, Racine AM, Fick DM, Tabloski P, Gou Y, Schmitt EM, Hshieh TT, Metzger E, Bertrand SE, Marcantonio ER, Jones RN, Inouye SK. The Caregiver Burden of Delirium in Older Adults With Alzheimer Disease and Related Disorders. J Am Geriatr Soc 2019; 67:2587-2592. [PMID: 31605539 DOI: 10.1111/jgs.16199] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 08/27/2019] [Accepted: 09/02/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To measure the burden of delirium in older adults with or without Alzheimer disease or related disorders (ADRDs). DESIGN Prospective, observational cohort. SETTING Inpatient hospital and study participants' homes. PARTICIPANTS A subset (n = 267) of older medical and surgical patients and their caregivers enrolled in the Better Assessment of Illness study. MEASUREMENTS Delirium burden was measured using the DEL-B instrument (range = 0-40, with higher scores indicating greater burden) in caregivers (DEL-B-C) and patients 1 month after hospitalization. Severity of cognitive impairment (Montreal Cognitive Assessment [MoCA]), delirium presence (Confusion Assessment Method [CAM]), and delirium severity (CAM-Severity [CAM-S]) were measured during hospitalization and at 1-month follow-up. ADRD diagnosis was determined by a clinical consensus process. RESULTS For patients with (n = 56) and without (n = 211) ADRD, both DEL-B instruments had good internal consistency. DEL-B-C scores had a median (interquartile range) among caregivers of patients with and without ADRD of 9 (5-15) and 5 (1-11), respectively (P < .05). If the patient developed delirium, caregivers experienced greater burden (β[delirium × ADRD] = -.29; P = .42), regardless of ADRD status. Further, caregiver burden was modestly correlated with patient MoCA scores (Spearman correlation coefficient, ρ = -0.18; P = .01). Patients with ADRD who developed delirium self-reported less burden than those without ADRD (β[delirium × ADRD] = -.67; P = .044). As with caregivers, delirium burden was modestly correlated with patient MoCA score (ρ = -0.18; P = .005) and correlated with the CAM-S in patients without ADRD (ρ = 0.38; P < .001) but not for patients with ADRD (ρ = -0.07; P = .61). CONCLUSIONS Delirium resulted in the same degree of increased caregiver burden regardless of whether a patient had ADRD, signifying delirium is equally stressful to caregivers, even among those with experience caring for someone with a chronic cognitive disorder. Delirium burden is only modestly associated with degree of cognitive impairment, suggesting that other aspects of delirium contribute to burden. J Am Geriatr Soc 67:2587-2592, 2019.
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Affiliation(s)
- Tamara G Fong
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts.,Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Annie M Racine
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts.,Frontotemporal Disorders Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Donna M Fick
- College of Nursing and Center for Geriatric Nursing Excellence, Pennsylvania State University, University Park, Pennsylvania
| | - Patricia Tabloski
- Boston College William F. Connell School of Nursing, Boston, Massachusetts
| | - Yun Gou
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
| | - Eva M Schmitt
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
| | - Tammy T Hshieh
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts.,Division of Aging, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eran Metzger
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts.,Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Sylvie E Bertrand
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
| | - Edward R Marcantonio
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Richard N Jones
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts.,Department of Psychiatry and Human Behavior, Department of Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Sharon K Inouye
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts.,College of Nursing and Center for Geriatric Nursing Excellence, Pennsylvania State University, University Park, Pennsylvania
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Hshieh TT, Jung WF, Grande LJ, Chen J, Stone RM, Soiffer RJ, Driver JA, Abel GA. Prevalence of Cognitive Impairment and Association With Survival Among Older Patients With Hematologic Cancers. JAMA Oncol 2019; 4:686-693. [PMID: 29494732 DOI: 10.1001/jamaoncol.2017.5674] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance As the population ages, cognitive impairment has promised to become increasingly common among patients with cancer. Little is known about how specific domains of cognitive impairment may be associated with survival among older patients with hematologic cancers. Objective To determine the prevalence of domain-specific cognitive impairment and its association with overall survival among older patients with blood cancer. Design, Setting, and Participants This prospective observational cohort study included all patients 75 years and older who presented for initial consultation in the leukemia, myeloma, or lymphoma clinics of a large tertiary hospital in Boston, Massachusetts, from February 1, 2015, to March 31, 2017. Patients underwent screening for frailty and cognitive dysfunction and were followed up for survival. Exposures The Clock-in-the-Box (CIB) test was used to screen for executive dysfunction. A 5-word delayed recall test was used to screen for impairment in working memory. The Fried frailty phenotype and Rockwood cumulative deficit model of frailty were also assessed to characterize participants as robust, prefrail, or frail. Results Among 420 consecutive patients approached, 360 (85.7%) agreed to undergo frailty assessment (232 men [64.4%] and 128 women [35.6%]; mean [SD] age, 79.8 [3.9] years), and 341 of those (94.7%) completed both cognitive screening tests. One hundred twenty-seven patients (35.3%) had probable executive dysfunction on the CIB, and 62 (17.2%) had probable impairment in working memory on the 5-word delayed recall. Impairment in either domain was modestly correlated with the Fried frailty phenotype (CIB, ρ = 0.177; delayed recall, ρ = 0.170; P = .01 for both), and many phenotypically robust patients also had probable cognitive impairment (24 of 104 [23.1%] on CIB and 9 of 104 [8.7%] on delayed recall). Patients with impaired working memory had worse median survival (10.9 [SD, 12.9] vs 12.2 [SD, 14.7] months; log-rank P < .001), including when stratified by indolent cancer (log-rank P = .01) and aggressive cancer (P < .001) and in multivariate analysis when adjusting for age, comorbidities, and disease aggressiveness (odds ratio, 0.26; 95% CI, 0.13-0.50). Impaired working memory was also associated with worse survival for those undergoing intensive treatment (log-rank P < .001). Executive dysfunction was associated with worse survival only among patients who underwent intensive treatment (log-rank P = .03). Conclusions and Relevance These data suggest that domains of cognitive dysfunction may be prevalent in older patients with blood cancer and may have differential predictive value for survival. Targeted interventions are needed for this vulnerable patient population.
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Affiliation(s)
- Tammy T Hshieh
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Wooram F Jung
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Laura J Grande
- Psychology Service, Veterans Affairs Boston Healthcare System, Boston, Massachusetts.,Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts
| | - Jiaying Chen
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Richard M Stone
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Robert J Soiffer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jane A Driver
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Geriatric Research, Education, and Clinical Center, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Gregory A Abel
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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Liu MA, DuMontier C, Murillo A, Hshieh TT, Bean JF, Soiffer RJ, Stone RM, Abel GA, Driver JA. Gait speed, grip strength, and clinical outcomes in older patients with hematologic malignancies. Blood 2019; 134:374-382. [PMID: 31167800 PMCID: PMC6659254 DOI: 10.1182/blood.2019000758] [Citation(s) in RCA: 118] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 04/18/2019] [Indexed: 12/27/2022] Open
Abstract
This study aimed to evaluate whether gait speed and grip strength predicted clinical outcomes among older adults with blood cancers. We prospectively recruited 448 patients aged 75 years and older presenting for initial consultation at the myelodysplastic syndrome/leukemia, myeloma, or lymphoma clinic of a large tertiary hospital, who agreed to assessment of gait and grip. A subset of 314 patients followed for ≥6 months at local institutions was evaluated for unplanned hospital or emergency department (ED) use. We used Cox proportional hazard models calculated hazard ratios (HRs) and 95% confidence intervals (CIs) for survival, and logistic regression to calculate odds ratios (ORs) for hospital or ED use. Mean age was 79.7 (± 4.0 standard deviation) years. After adjustment for age, sex, Charlson comorbidity index, cognition, treatment intensity, and cancer aggressiveness/type, every 0.1-m/s decrease in gait speed was associated with higher mortality (HR, 1.20; 95% CI, 1.12-1.29), odds of unplanned hospitalizations (OR, 1.33; 95% CI, 1.16-1.51), and ED visits (OR, 1.34; 95% CI, 1.17-1.53). Associations held among patients with good Eastern Cooperative Oncology Group performance status (0 or 1). Every 5-kg decrease in grip strength was associated with worse survival (adjusted HR, 1.24; 95% CI, 1.07-1.43) but not hospital or ED use. A model with gait speed and all covariates had comparable predictive power to comprehensive validated frailty indexes (phenotype and cumulative deficit) and all covariates. In summary, gait speed is an easily obtained "vital sign" that accurately identifies frailty and predicts outcomes independent of performance status among older patients with blood cancers.
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Affiliation(s)
- Michael A Liu
- Harvard T.H. Chan School of Public Health, Boston, MA
- Division of Aging, Brigham and Women's Hospital, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
| | - Clark DuMontier
- Dana-Farber Cancer Institute, Boston, MA
- Division of Gerontology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | | | - Tammy T Hshieh
- Division of Aging, Brigham and Women's Hospital, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
| | - Jonathan F Bean
- Spaulding Rehabilitation Hospital, Boston, MA; and
- Geriatric Research, Education and Clinical Center, VA Boston Healthcare System, Boston, MA
| | | | | | | | - Jane A Driver
- Division of Aging, Brigham and Women's Hospital, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
- Geriatric Research, Education and Clinical Center, VA Boston Healthcare System, Boston, MA
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21
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Jones RN, Cizginer S, Pavlech L, Albuquerque A, Daiello LA, Dharmarajan K, Gleason LJ, Helfand B, Massimo L, Oh E, Okereke OI, Tabloski P, Rabin LA, Yue J, Marcantonio ER, Fong TG, Hshieh TT, Metzger ED, Erickson K, Schmitt EM, Inouye SK. Assessment of Instruments for Measurement of Delirium Severity: A Systematic Review. JAMA Intern Med 2019; 179:231-239. [PMID: 30556827 PMCID: PMC6382582 DOI: 10.1001/jamainternmed.2018.6975] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Importance Measurement of delirium severity has been recognized as highly important for tracking prognosis, monitoring response to treatment, and estimating burden of care for patients both during and after hospitalization. Rather than simply rating delirium as present or absent, the ability to quantify its severity would enable development and monitoring of more effective treatment approaches for the condition. Objectives To present a comprehensive review of delirium severity instruments, conduct a methodologic quality rating of the original validation study of the most commonly used instruments, and select a group of top-rated instruments. Evidence Review This systematic review was conducted using literature from Embase, PsycINFO, PubMed, Web of Science, and Cumulative Index to Nursing and Allied Health Literature, from January 1, 1974, through March 31, 2017, with the key words delirium, severity, tests, measures, and intensity. Inclusion criteria were original articles assessing delirium severity and using a delirium-specific severity instrument. Final listings of articles were supplemented with hand searches of reference listings to ensure completeness. At least 2 reviewers independently completed each step of the review process: article selection, data extraction, and methodologic quality assessment of relevant articles using a validated rating scale. All discrepancies between raters were resolved by consensus. Findings Of 9409 articles identified, 228 underwent full text review, and we identified 42 different instruments of delirium severity. Eleven of the 42 tools were multidomain, delirium-specific instruments providing a quantitative rating of delirium severity; these instruments underwent a methodologic quality review. Applying prespecified criteria related to frequency of use, methodologic quality, construct or predictive validity, and broad domain coverage, an expert panel used an iterative modified Delphi process to select 6 final high-quality instruments meeting these criteria: the Confusion Assessment Method-Severity Score, Confusional State Examination, Delirium-O-Meter, Delirium Observation Scale, Delirium Rating Scale, and Memorial Delirium Assessment Scale. Conclusions and Relevance The 6 instruments identified may enable accurate measurement of delirium severity to improve clinical care for patients with this condition. This work may stimulate increased usage and head-to-head comparison of these instruments.
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Affiliation(s)
- Richard N Jones
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island
- Department of Neurology, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Sevdenur Cizginer
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Laura Pavlech
- Hirsh Health Sciences Library, Tufts University, Boston, Massachusetts
| | - Asha Albuquerque
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Lori A Daiello
- Department of Neurology, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Kumar Dharmarajan
- Center for Outcomes Research & Evaluation, Yale University School of Medicine, New Haven, Connecticut
| | - Lauren J Gleason
- Section of Geriatrics and Palliative Medicine, Department of Medicine, University of Chicago Medicine, Chicago, Illinois
| | - Benjamin Helfand
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island
- Department of Neurology, Warren Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
- University of Massachusetts Medical School, Worcester
| | - Lauren Massimo
- Frontotemporal Degeneration Center, University of Pennsylvania School of Medicine, Philadelphia
| | - Esther Oh
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Olivia I Okereke
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Psychiatry, Massachusetts General Hospital, Boston
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Patricia Tabloski
- Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts
| | - Laura A Rabin
- Department of Psychology, Brooklyn College and the Graduate Center of City University of New York, Brooklyn, New York
| | - Jirong Yue
- Department of Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Edward R Marcantonio
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Tamara G Fong
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Tammy T Hshieh
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Eran D Metzger
- Harvard Medical School, Boston, Massachusetts
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kristen Erickson
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Eva M Schmitt
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Sharon K Inouye
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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22
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Affiliation(s)
- Tammy T Hshieh
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jane A Driver
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Geriatric Research, Education, and Clinical Center, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Gregory A Abel
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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Hshieh TT, Yang T, Gartaganis SL, Yue J, Inouye SK. Hospital Elder Life Program: Systematic Review and Meta-analysis of Effectiveness. Am J Geriatr Psychiatry 2018; 26:1015-1033. [PMID: 30076080 PMCID: PMC6362826 DOI: 10.1016/j.jagp.2018.06.007] [Citation(s) in RCA: 202] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 06/15/2018] [Accepted: 06/18/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Delirium, defined as an acute disorder of attention and cognition with high morbidity and mortality, can be prevented by multicomponent nonpharmacological interventions. The Hospital Elder Life Program (HELP) is the original evidence-based approach targeted to delirium risk factors, which has been widely disseminated. OBJECTIVE To summarize the current state of the evidence regarding HELP and to highlight its effectiveness and cost savings. METHODS Systematic review of Ovid MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from 1999 to 2017, using a combination of controlled vocabulary and keyword terms. RESULTS Of the 44 final articles included, 14 were included in the meta-analysis for effectiveness and 30 were included for examining cost savings, adherence and adaptations, role of volunteers, successes and barriers, and issues in sustainability. The results for delirium incidence, falls, length of stay, and institutionalization were pooled for meta-analyses. Overall, 14 studies demonstrated significant reductions in delirium incidence (odds ratio [OR] 0.47, 95% confidence interval [CI] 0.37-0.59). The rate of falls was reduced by 42% among intervention patients in three comparative studies (OR 0.58, 95% CI 0.35-0.95). In nine studies on cost savings, the program saved $1600-$3800 (2018 U.S. dollars) per patient in hospital costs and over $16,000 (2018 U.S. dollars) per person-year in long-term care costs in the year following delirium. The systematic review revealed that programs were generally successful in adhering to or appropriately adapting HELP (n = 13 studies) and in finding the volunteer role to be valuable (n = 6 studies). Successes and barriers to implementation were examined in 6 studies, including ensuring effective clinician leadership, finding senior administrative champions, and shifting organizational culture. Sustainability factors were examined in 10 studies, including adapting to local circumstances, documenting positive impact and outcomes, and securing long-term funding. CONCLUSION The Hospital Elder Life Program is effective in reducing incidence of delirium and rate of falls, with a trend toward decreasing length of stay and preventing institutionalization. With ongoing efforts in continuous program improvement, implementation, adaptations, and sustainability, HELP has emerged as a reference standard model for improving the quality and effectiveness of hospital care for older persons worldwide.
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Affiliation(s)
- Tammy T. Hshieh
- Division of Aging, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School,Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife
| | - Tinghan Yang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | | | - Jirong Yue
- Department of Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Sharon K. Inouye
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School
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24
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Hshieh TT, Fong TG, Schmitt EM, Marcantonio ER, D'Aquila ML, Gallagher J, Xu G, Guo YR, Abrantes TF, Bertrand SE, Jones RN, Inouye SK. The Better Assessment of Illness Study for Delirium Severity: Study Design, Procedures, and Cohort Description. Gerontology 2018; 65:20-29. [PMID: 30032141 DOI: 10.1159/000490386] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 05/25/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND/OBJECTIVES To describe the design, procedures, and cohort for the Better ASsessment of ILlness -(BASIL) study, which is conducted to develop and test new delirium severity measures, compare them with existing measures, and examine related clinical outcomes. METHODS Prospective cohort study with 1 year follow-up of study participants at a large teaching hospital in Boston, Massachusetts. After brief cognitive testing and the Delirium Symptom Interview, delirium and delirium severity were rated daily in the hospital using the Confusion Assessment Method (CAM) and CAM-Severity score, the Delirium Rating Scale-Revised-98 (DRS-R-98), and the Memorial Delirium Assessment Scale (MDAS). Other key study variables included comorbidity, physical function (basic and instrumental activities of daily living [ADL]), ratings of subjective health and well-being, and clinical outcomes (length of stay, 30 day rehospitalization, nursing home admission, healthcare utilization). Follow-up interviews occurred at 1- and 12-month with patients and families. In 42 patient interviews, inter-rater reliability for key variables was assessed. RESULTS Of 768 eligible patients approached, 469 were screened and 352 enrolled, yielding an overall study response rate of 67% for potentially eligible participants. The mean participant was 80.3 years old (SD 6.8) and 203 (58%) were female. The majority of patients were medically complex with Charlson Comorbidity Scores ≥2 (192 patients, 55%), and 102 (29%) met criteria for dementia. Inter-rater reliability assessments (n = 42 pairs) were high for overall ratings of presence or absence of delirium by CAM (κ = 1.0), delirium severity by DRS-R-98 and MDAS (weighted kappa, κ = 1.0 for each) and for ADL impairment (κ = 1.0). For eligible participants at each time point, 278 out of 308 (90%) completed the 1-month follow-up and 132 out of 256 (53%) have completed the 12-month follow-up to date, which is still in progress. Among those who completed interviews, there was only 1-3% missing data on most major outcomes (delirium, basic ADL, and readmission). CONCLUSION The BASIL study presents an innovative effort to advance the conceptualization and measurement of delirium severity. Unique strengths include the diverse cohort with complete high quality data and longitudinal follow-up, along with detailed collection of multiple delirium measures daily during hospitalization.
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Affiliation(s)
- Tammy T Hshieh
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, .,Department of Medicine, Division of Aging, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts,
| | - Tamara G Fong
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA.,Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Eva M Schmitt
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Edward R Marcantonio
- Department of Medicine, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Madeline L D'Aquila
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Jacqueline Gallagher
- Department of Medicine, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Guoquan Xu
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Yun R Guo
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Tatiana F Abrantes
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Sylvie E Bertrand
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Richard N Jones
- Department of Psychiatry and Human Behavior, Department of Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Sharon K Inouye
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA.,Department of Medicine, Division of Gerontology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Abstract
Delirium is defined as an acute disturbance in attention and cognition, with significant associated morbidity and mortality. This article discusses the basic epidemiology of delirium and approaches to diagnosing, assessing, and working up patients for delirium. It delineates the pathophysiology and underlying predisposing and precipitating factors for delirium. It also discusses recent advances in prevention and treatment, particularly multicomponent, nonpharmacological interventions.
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Affiliation(s)
- Tammy T Hshieh
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 1620 Tremont Street, One Brigham Circle, 3rd Floor, Boston, MA 02120, USA.
| | - Sharon K Inouye
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, 1200 Centre Street, Boston, MA 02131, USA
| | - Esther S Oh
- Division of Geriatric Medicine and Gerontology, Department of Medicine, The Johns Hopkins University School of Medicine, Mason F. Lord Building, 5200 Eastern Avenue, 7th Floor, Room 721, Baltimore, MD 21224, USA
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Abstract
IMPORTANCE Delirium is defined as an acute disorder of attention and cognition. It is a common, serious, and often fatal condition among older patients. Although often underrecognized, delirium has serious adverse effects on the individual's function and quality of life, as well as broad societal effects with substantial health care costs. OBJECTIVE To summarize the current state of the art in diagnosis and treatment of delirium and to highlight critical areas for future research to advance the field. EVIDENCE REVIEW Search of Ovid MEDLINE, Embase, and the Cochrane Library for the past 6 years, from January 1, 2011, until March 16, 2017, using a combination of controlled vocabulary and keyword terms. Since delirium is more prevalent in older adults, the focus was on studies in elderly populations; studies based solely in the intensive care unit (ICU) and non-English-language articles were excluded. FINDINGS Of 127 articles included, 25 were clinical trials, 42 cohort studies, 5 systematic reviews and meta-analyses, and 55 were other categories. A total of 11 616 patients were represented in the treatment studies. Advances in diagnosis have included the development of brief screening tools with high sensitivity and specificity, such as the 3-Minute Diagnostic Assessment; 4 A's Test; and proxy-based measures such as the Family Confusion Assessment Method. Measures of severity, such as the Confusion Assessment Method-Severity Score, can aid in monitoring response to treatment, risk stratification, and assessing prognosis. Nonpharmacologic approaches focused on risk factors such as immobility, functional decline, visual or hearing impairment, dehydration, and sleep deprivation are effective for delirium prevention and also are recommended for delirium treatment. Current recommendations for pharmacologic treatment of delirium, based on recent reviews of the evidence, recommend reserving use of antipsychotics and other sedating medications for treatment of severe agitation that poses risk to patient or staff safety or threatens interruption of essential medical therapies. CONCLUSIONS AND RELEVANCE Advances in diagnosis can improve recognition and risk stratification of delirium. Prevention of delirium using nonpharmacologic approaches is documented to be effective, while pharmacologic prevention and treatment of delirium remains controversial.
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Affiliation(s)
- Esther S Oh
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tamara G Fong
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Aging Brain Center, Hebrew SeniorLife, Boston, Massachusetts
| | - Tammy T Hshieh
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sharon K Inouye
- Aging Brain Center, Hebrew SeniorLife, Boston, Massachusetts
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Kimchi EY, Hshieh TT, Guo R, Wong B, O'Connor M, Marcantonio ER, Metzger ED, Strauss J, Arnold SE, Inouye SK, Fong TG. Consensus Approaches to Identify Incident Dementia in Cohort Studies: Systematic Review and Approach in the Successful Aging after Elective Surgery Study. J Am Med Dir Assoc 2017; 18:1010-1018.e1. [PMID: 28927945 DOI: 10.1016/j.jamda.2017.07.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 07/19/2017] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To survey the current methods used to ascertain dementia and mild cognitive impairment (MCI) in longitudinal cohort studies, to categorize differences in approaches and to identify key components of expert panel methodology in current use. METHODS We searched PubMed for the past 10 years, from March 6, 2007 to March 6, 2017 using a combination of controlled vocabulary and keyword terms to identify expert panel consensus methods used to diagnose MCI or dementia in large cohort studies written in English. From these results, we identified a framework for reporting standards and describe as an exemplar the clinical consensus procedure used in an ongoing study of elective surgery patients (the Successful Aging after Elective Surgery study). RESULTS Thirty-one articles representing unique cohorts were included. Among published methods, membership of experts panel varied significantly. There was more similarity in what types of information was use to ascertain disease status. However, information describing the diagnostic decision process and resolution of disagreements was often lacking. CONCLUSIONS Methods used for expert panel diagnosis of MCI and dementia in large cohort studies are widely variable, and there is a need for more standardized reporting of these approaches. By describing the procedure in which our expert panel achieved consensus diagnoses, we hope to encourage the development and publication of well-founded and reproducible methods for diagnosis of MCI and dementia in longitudinal studies.
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Affiliation(s)
- Eyal Y Kimchi
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Tammy T Hshieh
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ray Guo
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Bonnie Wong
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Margaret O'Connor
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Edward R Marcantonio
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Eran D Metzger
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jason Strauss
- Department of Psychiatry, Cambridge Health Alliance, Cambridge, MA; Harvard Medical School, Boston, MA
| | - Steven E Arnold
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Sharon K Inouye
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA; Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Tamara G Fong
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA; Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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28
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Bunker L, Hshieh TT, Wong B, Schmitt EM, Travison T, Yee J, Palihnich K, Metzger E, Fong TG, Inouye SK. The SAGES telephone neuropsychological battery: correlation with in-person measures. Int J Geriatr Psychiatry 2017; 32:991-999. [PMID: 27507320 PMCID: PMC5299071 DOI: 10.1002/gps.4558] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 06/28/2016] [Accepted: 06/30/2016] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Neuropsychological test batteries are administered in person to assess cognitive function in both clinical and research settings. However, in-person administration holds a number of logistical challenges that makes it difficult to use in large or remote populations or for multiple serial assessments over time. The purpose of this descriptive study was to determine whether a telephone-administered neuropsychological test battery correlated well with in-person testing. METHODS Fifty English-speaking patients without dementia, over 70 years old, and part of a cohort of patients in a prospective cohort study examining cognitive outcomes following elective surgery were enrolled in this study. Five well-validated neuropsychological tests were administered by telephone to each participant by a trained interviewer within 2-4 weeks of the most recent in-person interview. Tests included the Hopkins Verbal Learning Test-Revised, Digit Span, Category Fluency, Phonemic Fluency, and Boston Naming Test. A General Cognitive Performance composite score was calculated from individual subtest scores as a Z-score. RESULTS Mean age was 74.9 years (SD = 4.1), 66% female, and 4% non-White. Mean and interquartile distributions of telephone scores were similar to in-person scores. Correlation analysis of test scores revealed significant correlations between telephone and in-person results for each individual subtest, as well as for the overall composite score. A Bland-Altman plot revealed no bias or trends in scoring for either test administration type. CONCLUSIONS In this descriptive study, the telephone version of a neuropsychological test battery correlated well with the in-person version and may provide a feasible supplement in clinical and research applications. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
| | - Tammy T. Hshieh
- Division of Aging, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston,Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston
| | - Bonnie Wong
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA,Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Eva M. Schmitt
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston
| | - Thomas Travison
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston
| | - Jacqueline Yee
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston
| | - Kerry Palihnich
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston. MA
| | - Eran Metzger
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston,Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Tamara G. Fong
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA,Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sharon K. Inouye
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston. MA
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Cavallari M, Dai W, Guttmann CRG, Meier DS, Ngo LH, Hshieh TT, Fong TG, Schmitt E, Press DZ, Travison TG, Marcantonio ER, Jones RN, Inouye SK, Alsop DC. Longitudinal diffusion changes following postoperative delirium in older people without dementia. Neurology 2017; 89:1020-1027. [PMID: 28779010 DOI: 10.1212/wnl.0000000000004329] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 06/13/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate the effect of postoperative delirium on longitudinal brain microstructural changes, as measured by diffusion tensor imaging. METHODS We studied a subset of the larger Successful Aging after Elective Surgery (SAGES) study cohort of older adults (≥70 years) without dementia undergoing elective surgery: 113 participants who had diffusion tensor imaging before and 1 year after surgery. Postoperative delirium severity and occurrence were assessed during the hospital stay using the Confusion Assessment Method and a validated chart review method. We investigated the association of delirium severity and occurrence with longitudinal diffusion changes across 1 year, adjusting for age, sex, vascular comorbidity, and baseline cognitive performance. We also assessed the association between changes in diffusion and cognitive performance across the 1-year follow-up period, adjusting for age, sex, education, and baseline cognitive performance. RESULTS Postoperative delirium occurred in 25 participants (22%). Delirium severity and occurrence were associated with longitudinal diffusion changes in the periventricular, frontal, and temporal white matter. Diffusion changes were also associated with changes in cognitive performance across 1 year, although the cognitive changes did not show significant association with delirium severity or occurrence. CONCLUSIONS Our study raises the possibility that delirium has an effect on the development of brain microstructural abnormalities, which may reflect brain changes underlying cognitive trajectories. Future studies are warranted to clarify whether delirium is the driving factor of the observed changes or rather a correlate of a vulnerable brain that is at high risk for neurodegenerative processes.
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Affiliation(s)
- Michele Cavallari
- From the Center for Neurological Imaging, Department of Radiology (M.C., C.R.G.G., D.S.M.), and Division of Aging (T.T.H.), Brigham and Women's Hospital, and Departments of Radiology (W.D., D.C.A.), Medicine (L.H.N., T.G.T., E.R.M., S.K.I.), and Neurology (T.G.F., D.Z.P.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Computer Science (W.D.), State University of New York at Binghamton; Aging Brain Center (T.T.H., T.G.F., E.S., T.G.T., S.K.I.), Institute for Aging Research, Hebrew SeniorLife, Boston, MA; and Departments of Psychiatry and Human Behavior and Neurology (R.N.J.), Brown University Warren Alpert Medical School, Providence, RI
| | - Weiying Dai
- From the Center for Neurological Imaging, Department of Radiology (M.C., C.R.G.G., D.S.M.), and Division of Aging (T.T.H.), Brigham and Women's Hospital, and Departments of Radiology (W.D., D.C.A.), Medicine (L.H.N., T.G.T., E.R.M., S.K.I.), and Neurology (T.G.F., D.Z.P.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Computer Science (W.D.), State University of New York at Binghamton; Aging Brain Center (T.T.H., T.G.F., E.S., T.G.T., S.K.I.), Institute for Aging Research, Hebrew SeniorLife, Boston, MA; and Departments of Psychiatry and Human Behavior and Neurology (R.N.J.), Brown University Warren Alpert Medical School, Providence, RI
| | - Charles R G Guttmann
- From the Center for Neurological Imaging, Department of Radiology (M.C., C.R.G.G., D.S.M.), and Division of Aging (T.T.H.), Brigham and Women's Hospital, and Departments of Radiology (W.D., D.C.A.), Medicine (L.H.N., T.G.T., E.R.M., S.K.I.), and Neurology (T.G.F., D.Z.P.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Computer Science (W.D.), State University of New York at Binghamton; Aging Brain Center (T.T.H., T.G.F., E.S., T.G.T., S.K.I.), Institute for Aging Research, Hebrew SeniorLife, Boston, MA; and Departments of Psychiatry and Human Behavior and Neurology (R.N.J.), Brown University Warren Alpert Medical School, Providence, RI
| | - Dominik S Meier
- From the Center for Neurological Imaging, Department of Radiology (M.C., C.R.G.G., D.S.M.), and Division of Aging (T.T.H.), Brigham and Women's Hospital, and Departments of Radiology (W.D., D.C.A.), Medicine (L.H.N., T.G.T., E.R.M., S.K.I.), and Neurology (T.G.F., D.Z.P.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Computer Science (W.D.), State University of New York at Binghamton; Aging Brain Center (T.T.H., T.G.F., E.S., T.G.T., S.K.I.), Institute for Aging Research, Hebrew SeniorLife, Boston, MA; and Departments of Psychiatry and Human Behavior and Neurology (R.N.J.), Brown University Warren Alpert Medical School, Providence, RI
| | - Long H Ngo
- From the Center for Neurological Imaging, Department of Radiology (M.C., C.R.G.G., D.S.M.), and Division of Aging (T.T.H.), Brigham and Women's Hospital, and Departments of Radiology (W.D., D.C.A.), Medicine (L.H.N., T.G.T., E.R.M., S.K.I.), and Neurology (T.G.F., D.Z.P.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Computer Science (W.D.), State University of New York at Binghamton; Aging Brain Center (T.T.H., T.G.F., E.S., T.G.T., S.K.I.), Institute for Aging Research, Hebrew SeniorLife, Boston, MA; and Departments of Psychiatry and Human Behavior and Neurology (R.N.J.), Brown University Warren Alpert Medical School, Providence, RI
| | - Tammy T Hshieh
- From the Center for Neurological Imaging, Department of Radiology (M.C., C.R.G.G., D.S.M.), and Division of Aging (T.T.H.), Brigham and Women's Hospital, and Departments of Radiology (W.D., D.C.A.), Medicine (L.H.N., T.G.T., E.R.M., S.K.I.), and Neurology (T.G.F., D.Z.P.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Computer Science (W.D.), State University of New York at Binghamton; Aging Brain Center (T.T.H., T.G.F., E.S., T.G.T., S.K.I.), Institute for Aging Research, Hebrew SeniorLife, Boston, MA; and Departments of Psychiatry and Human Behavior and Neurology (R.N.J.), Brown University Warren Alpert Medical School, Providence, RI
| | - Tamara G Fong
- From the Center for Neurological Imaging, Department of Radiology (M.C., C.R.G.G., D.S.M.), and Division of Aging (T.T.H.), Brigham and Women's Hospital, and Departments of Radiology (W.D., D.C.A.), Medicine (L.H.N., T.G.T., E.R.M., S.K.I.), and Neurology (T.G.F., D.Z.P.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Computer Science (W.D.), State University of New York at Binghamton; Aging Brain Center (T.T.H., T.G.F., E.S., T.G.T., S.K.I.), Institute for Aging Research, Hebrew SeniorLife, Boston, MA; and Departments of Psychiatry and Human Behavior and Neurology (R.N.J.), Brown University Warren Alpert Medical School, Providence, RI
| | - Eva Schmitt
- From the Center for Neurological Imaging, Department of Radiology (M.C., C.R.G.G., D.S.M.), and Division of Aging (T.T.H.), Brigham and Women's Hospital, and Departments of Radiology (W.D., D.C.A.), Medicine (L.H.N., T.G.T., E.R.M., S.K.I.), and Neurology (T.G.F., D.Z.P.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Computer Science (W.D.), State University of New York at Binghamton; Aging Brain Center (T.T.H., T.G.F., E.S., T.G.T., S.K.I.), Institute for Aging Research, Hebrew SeniorLife, Boston, MA; and Departments of Psychiatry and Human Behavior and Neurology (R.N.J.), Brown University Warren Alpert Medical School, Providence, RI
| | - Daniel Z Press
- From the Center for Neurological Imaging, Department of Radiology (M.C., C.R.G.G., D.S.M.), and Division of Aging (T.T.H.), Brigham and Women's Hospital, and Departments of Radiology (W.D., D.C.A.), Medicine (L.H.N., T.G.T., E.R.M., S.K.I.), and Neurology (T.G.F., D.Z.P.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Computer Science (W.D.), State University of New York at Binghamton; Aging Brain Center (T.T.H., T.G.F., E.S., T.G.T., S.K.I.), Institute for Aging Research, Hebrew SeniorLife, Boston, MA; and Departments of Psychiatry and Human Behavior and Neurology (R.N.J.), Brown University Warren Alpert Medical School, Providence, RI
| | - Thomas G Travison
- From the Center for Neurological Imaging, Department of Radiology (M.C., C.R.G.G., D.S.M.), and Division of Aging (T.T.H.), Brigham and Women's Hospital, and Departments of Radiology (W.D., D.C.A.), Medicine (L.H.N., T.G.T., E.R.M., S.K.I.), and Neurology (T.G.F., D.Z.P.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Computer Science (W.D.), State University of New York at Binghamton; Aging Brain Center (T.T.H., T.G.F., E.S., T.G.T., S.K.I.), Institute for Aging Research, Hebrew SeniorLife, Boston, MA; and Departments of Psychiatry and Human Behavior and Neurology (R.N.J.), Brown University Warren Alpert Medical School, Providence, RI
| | - Edward R Marcantonio
- From the Center for Neurological Imaging, Department of Radiology (M.C., C.R.G.G., D.S.M.), and Division of Aging (T.T.H.), Brigham and Women's Hospital, and Departments of Radiology (W.D., D.C.A.), Medicine (L.H.N., T.G.T., E.R.M., S.K.I.), and Neurology (T.G.F., D.Z.P.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Computer Science (W.D.), State University of New York at Binghamton; Aging Brain Center (T.T.H., T.G.F., E.S., T.G.T., S.K.I.), Institute for Aging Research, Hebrew SeniorLife, Boston, MA; and Departments of Psychiatry and Human Behavior and Neurology (R.N.J.), Brown University Warren Alpert Medical School, Providence, RI
| | - Richard N Jones
- From the Center for Neurological Imaging, Department of Radiology (M.C., C.R.G.G., D.S.M.), and Division of Aging (T.T.H.), Brigham and Women's Hospital, and Departments of Radiology (W.D., D.C.A.), Medicine (L.H.N., T.G.T., E.R.M., S.K.I.), and Neurology (T.G.F., D.Z.P.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Computer Science (W.D.), State University of New York at Binghamton; Aging Brain Center (T.T.H., T.G.F., E.S., T.G.T., S.K.I.), Institute for Aging Research, Hebrew SeniorLife, Boston, MA; and Departments of Psychiatry and Human Behavior and Neurology (R.N.J.), Brown University Warren Alpert Medical School, Providence, RI
| | - Sharon K Inouye
- From the Center for Neurological Imaging, Department of Radiology (M.C., C.R.G.G., D.S.M.), and Division of Aging (T.T.H.), Brigham and Women's Hospital, and Departments of Radiology (W.D., D.C.A.), Medicine (L.H.N., T.G.T., E.R.M., S.K.I.), and Neurology (T.G.F., D.Z.P.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Computer Science (W.D.), State University of New York at Binghamton; Aging Brain Center (T.T.H., T.G.F., E.S., T.G.T., S.K.I.), Institute for Aging Research, Hebrew SeniorLife, Boston, MA; and Departments of Psychiatry and Human Behavior and Neurology (R.N.J.), Brown University Warren Alpert Medical School, Providence, RI
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Hshieh TT, Dai W, Cavallari M, Guttmann CR, Meier DS, Schmitt EM, Dickerson BC, Press DZ, Marcantonio ER, Jones RN, Gou YR, Travison TG, Fong TG, Ngo L, Inouye SK, Alsop DC. Cerebral blood flow MRI in the nondemented elderly is not predictive of post-operative delirium but is correlated with cognitive performance. J Cereb Blood Flow Metab 2017; 37:1386-1397. [PMID: 27401806 PMCID: PMC5453459 DOI: 10.1177/0271678x16656014] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Three-dimensional Arterial Spin Labeling (ASL) MRI was performed before surgery in a cohort of 146 prospectively enrolled subjects ≥ 70 years old scheduled to undergo elective surgery. We investigated the prospective association between ASL-derived measures of cerebral blood flow (CBF) before surgery with postoperative delirium incidence and severity using whole-brain and globally normalized voxel-wise analysis. We also investigated the cross-sectional association of CBF with patients' baseline performance on specific neuropsychological tests, and with a composite general cognitive performance measure (GCP). Out of 146 subjects, 32 (22%) developed delirium. We found no significant association between global and voxel-wise CBF with delirium incidence or severity. We found the most significant positive associations between CBF of the posterior cingulate and precuneus and the Hopkins Verbal Learning Test - Revised total score, Visual Search and Attention Test (VSAT) score and the GCP composite. VSAT score was also strongly associated with right parietal lobe CBF. ASL can be employed in a large, well-characterized older cohort to examine associations between CBF and age-related cognitive performance. Although ASL CBF measures in regions previously associated with preclinical Alzheimer's Disease were correlated with cognition, they were not found to be indicators of baseline pathology that may increase risk for delirium.
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Affiliation(s)
- Tammy T Hshieh
- 1 Division of Aging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,2 Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Weiying Dai
- 3 Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.,4 Department of Computer Science, State University of New York at Binghamton, Binghamton, NY, USA
| | - Michele Cavallari
- 5 Center for Neurological Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Charles Rg Guttmann
- 5 Center for Neurological Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Dominik S Meier
- 5 Center for Neurological Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eva M Schmitt
- 2 Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Bradford C Dickerson
- 6 Martinos Center for Biomedical Imaging, Psychiatric Neuroimaging Division, Department of Psychiatry, and Frontotemporal Disorders Unit, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
| | - Daniel Z Press
- 7 Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Edward R Marcantonio
- 8 Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Richard N Jones
- 2 Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.,9 Departments of Psychiatry and Human Behavior and Neurology, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Yun Ray Gou
- 2 Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Thomas G Travison
- 2 Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.,8 Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Tamara G Fong
- 2 Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.,7 Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Long Ngo
- 8 Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sharon K Inouye
- 2 Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.,8 Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - David C Alsop
- 3 Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Orkaby AR, Hshieh TT, Gaziano JM, Djousse L, Driver JA. Comparison of two frailty indices in the physicians' health study. Arch Gerontol Geriatr 2017; 71:21-27. [PMID: 28242579 DOI: 10.1016/j.archger.2017.02.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 01/17/2017] [Accepted: 02/10/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND As the population ages it is important to identify frailty, a powerful predictor of morbidity and mortality, and often an important unmeasured confounder. We sought to develop a frailty index in the Physician's Health Study (PHS) and estimate the association with mortality. METHODS Prospective cohort study. Annual questionnaire assessed mood, function and health status. Two frailty scores were compared - cumulative deficit frailty index (PHS FI) and modified Study of Osteoporotic Fracture (mSOF) frailty score. Endpoints committee confirmed mortality. RESULTS 12,180 male physicians ≥60 years were analyzed. Mean(SD) follow-up was 10(3) years, 2168 deaths occurred. PHS FI identified 4412 (36%) physicians robust, 5305 (44%) pre-frail, and 2463 (20%) frail, while mSOF identified 7323 (61%) robust, 3505 (29%) pre-frail and 1215 (10%) frail. Age-standardized rate of death was lower among subjects identified as robust using the PHS FI, 11/1000 person-years (PY) (95% Confidence Interval (CI): 9.5-11.9) compared to 14/1000PY (95% CI: 13.5-15.4) using mSOF [P-difference <0.001]. In the prefrail group, death rates were 16/1000PY in PHS FI and 21/1000PY in mSOF, [P-difference <0.001]. There was no difference in age-adjusted mortality rates in the frail group according to each definition (35 vs 33/1000PY). Survival analysis showed an increased risk of mortality in each frailty category using either definition, (log-rank p<0.001). CONCLUSION The PHS FI outperformed mSOF in identifying risk of death particularly in robust and pre-frail categories. Similar indices can be created in existing datasets to identify frail individuals and where appropriate account for frailty, an often unmeasured confounder.
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Affiliation(s)
- Ariela R Orkaby
- Division of Aging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; VA Boston Healthcare System, Geriatric Research, Education, and Clinical Center (GRECC), Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC), Boston, MA, USA.
| | - Tammy T Hshieh
- Division of Aging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John M Gaziano
- Division of Aging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; VA Boston Healthcare System, Geriatric Research, Education, and Clinical Center (GRECC), Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC), Boston, MA, USA
| | - Luc Djousse
- Division of Aging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; VA Boston Healthcare System, Geriatric Research, Education, and Clinical Center (GRECC), Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC), Boston, MA, USA
| | - Jane A Driver
- Division of Aging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; VA Boston Healthcare System, Geriatric Research, Education, and Clinical Center (GRECC), Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC), Boston, MA, USA
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Cavallari M, Dai W, Guttmann CRG, Meier DS, Ngo LH, Hshieh TT, Callahan AE, Fong TG, Schmitt E, Dickerson BC, Press DZ, Marcantonio ER, Jones RN, Inouye SK, Alsop DC. Neural substrates of vulnerability to postsurgical delirium as revealed by presurgical diffusion MRI. Brain 2016; 139:1282-94. [PMID: 26920674 DOI: 10.1093/brain/aww010] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 12/16/2015] [Indexed: 12/20/2022] Open
Abstract
Despite the significant impact of postoperative delirium on surgical outcomes and the long-term prognosis of older patients, its neural basis has not yet been clarified. In this study we investigated the impact of premorbid brain microstructural integrity, as measured by diffusion tensor imaging before surgery, on postoperative delirium incidence and severity, as well as the relationship among presurgical cognitive performance, diffusion tensor imaging abnormalities and postoperative delirium. Presurgical diffusion tensor imaging scans of 136 older (≥70 years), dementia-free subjects from the prospective Successful Aging after Elective Surgery study were analysed blind to the clinical data and delirium status. Primary outcomes were postoperative delirium incidence and severity during the hospital stay, as assessed by the Confusion Assessment Method. We measured cognition before surgery using general cognitive performance, a composite score based on a battery of neuropsychological tests. We investigated the association between presurgical diffusion tensor imaging parameters of brain microstructural integrity (i.e. fractional anisotropy, axial, mean and radial diffusivity) with postoperative delirium incidence and severity. Analyses were adjusted for the following potential confounders: age, gender, vascular comorbidity status, and general cognitive performance. Postoperative delirium occurred in 29 of 136 subjects (21%) during hospitalization. Presurgical diffusion tensor imaging abnormalities of the cerebellum, cingulum, corpus callosum, internal capsule, thalamus, basal forebrain, occipital, parietal and temporal lobes, including the hippocampus, were associated with delirium incidence and severity, after controlling for age, gender and vascular comorbidities. After further controlling for general cognitive performance, diffusion tensor imaging abnormalities of the cerebellum, hippocampus, thalamus and basal forebrain still remained associated with delirium incidence and severity. This study raises the intriguing possibility that structural dysconnectivity involving interhemispheric and fronto-thalamo-cerebellar networks, as well as microstructural changes of structures involved in limbic and memory functions predispose to delirium under the stress of surgery. While the diffusion tensor imaging abnormalities observed in the corpus callosum, cingulum, and temporal lobe likely constitute the neural substrate for the association between premorbid cognition, as measured by general cognitive performance, and postoperative delirium, the microstructural changes observed in the cerebellum, hippocampus, thalamus and basal forebrain seem to constitute a separate phenomenon that predisposes to postsurgical delirium independent of presurgical cognitive status.
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Affiliation(s)
- Michele Cavallari
- Center for Neurological Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Weiying Dai
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA Department of Computer Science, State University of New York at Binghamton, Binghamton, NY, USA
| | - Charles R G Guttmann
- Center for Neurological Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Dominik S Meier
- Center for Neurological Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Long H Ngo
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Tammy T Hshieh
- Division of Aging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Amy E Callahan
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Tamara G Fong
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Eva Schmitt
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Bradford C Dickerson
- Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, 149 13th St., Charlestown, MA, USA Psychiatric Neuroimaging Division, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, 149 13th St., Charlestown, MA, USA Frontotemporal Disorders Unit, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 149 13th St., Charlestown, MA, USA
| | - Daniel Z Press
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Edward R Marcantonio
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Richard N Jones
- Departments of Psychiatry and Human Behavior and Neurology, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Sharon K Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - David C Alsop
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Fong TG, Hshieh TT, Wong B, Tommet D, Jones RN, Schmitt EM, Puelle MR, Saczynski JS, Marcantonio ER, Inouye SK. Neuropsychological profiles of an elderly cohort undergoing elective surgery and the relationship between cognitive performance and delirium. J Am Geriatr Soc 2015; 63:977-82. [PMID: 25944109 DOI: 10.1111/jgs.13383] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To examine baseline (preoperative) neuropsychological test performance in a cohort of elderly individuals undergoing elective surgery and the association between specific neuropsychological domains and postoperative delirium. DESIGN Ongoing prospective cohort study. SETTING Successful Aging after Elective Surgery Study. PARTICIPANTS Elderly adults (N=300) scheduled for elective (noncardiac) surgery. MEASUREMENTS Neuropsychological testing, including standardized assessments of memory, divided and sustained attention, speed of mental processing, verbal fluency, working memory, language, and an overall measure of premorbid cognitive functioning, was performed 2 to 4 weeks before surgery. The relationship between the individual neuropsychological tests and delirium status was examined using linear regression, adjusting for age, sex, and education. RESULTS Study participants were generally highly educated (mean years of education 15.0±2.9), with minimal or no cognitive impairment (mean Modified Mini-Mental State Examination score 93.2 out of 100). After adjustment, participants who developed postoperative delirium had performed significantly lower preoperatively on measures of speed of mental processing and divided attention (Trail-Making Test Part B, mean difference 17.55, P=.02), category fluency (animal naming, mean difference -1.94, P=.01), sustained visual attention (Visual Search and Attention, mean difference -3.19, P<.001), and working memory with new learning and recall (Hopkins Verbal Learning Test-Revised Total mean difference -0.53 to -0.79, P<.01). CONCLUSION Individuals who later develop delirium have lower scores on tests evaluating the areas of complex attention, executive functioning, and rapid access to verbal knowledge or semantic networks at baseline. Future studies to better understand how the cognitive profiles identified may predispose individuals to developing delirium may help pave the way to greater understanding of the mechanisms of delirium.
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Affiliation(s)
- Tamara G Fong
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Tammy T Hshieh
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Division of Aging, Brigham and Women's Hospital, Boston, Massachusetts
| | - Bonnie Wong
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Doug Tommet
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Psychiatry, Warren Alpert Medical School, Brown University, Providence, Rhode Island.,Department of Human Behavior and Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Richard N Jones
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Psychiatry, Warren Alpert Medical School, Brown University, Providence, Rhode Island.,Department of Human Behavior and Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Eva M Schmitt
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Margaret R Puelle
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Jane S Saczynski
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,University of Massachusetts Medical School, Worcester, Massachusetts
| | - Edward R Marcantonio
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Sharon K Inouye
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Chen P, Dowal S, Schmitt E, Habtemariam D, Hshieh TT, Victor R, Boockvar KS, Inouye SK. Hospital Elder Life Program in the real world: the many uses of the Hospital Elder Life Program website. J Am Geriatr Soc 2015; 63:797-803. [PMID: 25877747 DOI: 10.1111/jgs.13343] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The Hospital Elder Life Program (HELP) can prevent delirium, a common condition in older hospitalized adults associated with substantial morbidity, mortality, and healthcare costs. In 2011, HELP transitioned to a web-based dissemination model to provide accessible resources, including implementation materials; information for healthcare professionals, patients, and families; and a searchable reference database. It was hypothesized that, although intended to assist sites to establish HELP, the resources that the HELP website offer might have broader applications. An e-mail was sent to all HELP website registrants from September 10, 2012, to March 15, 2013, requesting participation in an online survey to examine uses of the resources on the website and to evaluate knowledge diffusion related to these resources. Of 102 responding sites, 73 (72%) completed the survey. Thirty-nine (53%) had implemented and maintained an active HELP model. Twenty-six (35%) sites had used the HELP website resources to plan for implementation of the HELP model and 35 (50%) sites to implement and support the program during and after launch. Sites also used the resources for the development of non-HELP delirium prevention programs and guidelines. Forty-five sites (61%) used the website resources for educational purposes, targeting healthcare professionals, patients, families, or volunteers. The results demonstrated that HELP resources were used for implementation of HELP and other delirium prevention programs and were also disseminated broadly in innovative educational efforts across the professional and lay communities.
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Affiliation(s)
- Pei Chen
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Abstract
IMPORTANCE Delirium, an acute disorder with high morbidity and mortality, is often preventable through multicomponent nonpharmacological strategies. The efficacy of these strategies for preventing subsequent adverse outcomes has been limited to small studies to date. OBJECTIVE To evaluate available evidence on multicomponent nonpharmacological delirium interventions in reducing incident delirium and preventing poor outcomes associated with delirium. DATA SOURCES PubMed, Google Scholar, ScienceDirect, and the Cochrane Database of Systematic Reviews from January 1, 1999, to December 31, 2013. STUDY SELECTION Studies examining the following outcomes were included: delirium incidence, falls, length of stay, rate of discharge to a long-term care institution (institutionalization), and change in functional or cognitive status. DATA EXTRACTION AND SYNTHESIS Two experienced physician reviewers independently and blindly abstracted data on outcome measures using a standardized approach. The reviewers conducted quality ratings based on the Cochrane risk-of-bias criteria for each study. MAIN OUTCOMES AND MEASURES We identified 14 interventional studies. The results for outcomes of delirium incidence, falls, length of stay, and institutionalization were pooled for the meta-analysis, but heterogeneity limited our meta-analysis of the results for change in functional or cognitive status. Overall, 11 studies demonstrated significant reductions in delirium incidence (odds ratio [OR], 0.47; 95% CI, 0.38-0.58). Four randomized or matched trials reduced delirium incidence by 44% (OR, 0.56; 95% CI, 0.42-0.76). The rate of falls decreased significantly among intervention patients in 4 studies (OR, 0.38; 95% CI, 0.25-0.60); in 2 randomized or matched trials, the rate of falls was reduced by 64% (OR, 0.36; 95% CI, 0.22-0.61). Length of stay and institutionalization also trended toward decreases in the intervention groups, with a mean difference of -0.16 (95% CI, -0.97 to 0.64) day shorter and the odds of institutionalization 5% lower (OR, 0.95; 95% CI, 0.71-1.26). Among higher-quality randomized or matched trials, length of stay trended -0.33 (95% CI, -1.38 to 0.72) day shorter, and the odds of institutionalization trended 6% lower (OR, 0.94; 95% CI, 0.69-1.30). CONCLUSIONS AND RELEVANCE Multicomponent nonpharmacological delirium prevention interventions are effective in reducing delirium incidence and preventing falls, with a trend toward decreasing length of stay and avoiding institutionalization. Given the current focus on prevention of hospital-based complications and improved cost-effectiveness of care, this meta-analysis supports the use of these interventions to advance acute care for older persons.
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Affiliation(s)
- Tammy T Hshieh
- Division of Aging, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts2Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Jirong Yue
- Department of Geriatrics, West China Hospital, Sichuan University, Chengdu
| | - Esther Oh
- Division of Geriatric Medicine and Gerontology, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Margaret Puelle
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Sarah Dowal
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Thomas Travison
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts5Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Sharon K Inouye
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts5Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Cavallari M, Hshieh TT, Guttmann CRG, Ngo LH, Meier DS, Schmitt EM, Marcantonio ER, Jones RN, Kosar CM, Fong TG, Press D, Inouye SK, Alsop DC. Brain atrophy and white-matter hyperintensities are not significantly associated with incidence and severity of postoperative delirium in older persons without dementia. Neurobiol Aging 2015; 36:2122-9. [PMID: 25824618 DOI: 10.1016/j.neurobiolaging.2015.02.024] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Revised: 02/02/2015] [Accepted: 02/23/2015] [Indexed: 12/17/2022]
Abstract
Postoperative delirium is a common complication in older people and is associated with increased mortality, morbidity, institutionalization, and caregiver burden. Although delirium is an acute confusional state characterized by global impairments in attention and cognition, it has been implicated in permanent cognitive impairment and dementia. The pathogenesis of delirium and the mechanisms leading to these disabling consequences remain unclear. The present study is the first to address the potential predisposing role of brain morphologic changes toward postoperative delirium in a large prospective cohort of patients undergoing elective surgery using state-of-the-art magnetic resonance imaging (MRI) techniques conducted before admission. We investigated the association of MRI-derived quantitative measures of white-matter damage, global brain, and hippocampal volume with the incidence and severity of delirium. Presurgical white-matter hyperintensities (WMHs), whole brain, and hippocampal volume were measured in 146 consecutively enrolled subjects, ≥70 years old, without dementia who were undergoing elective surgery. These 3 presurgical MRI indices were tested as predictors of incidence and severity of subsequent delirium. Out of 146 subjects, 32 (22%) developed delirium. We found no statistically significant differences in WMH, whole brain, or hippocampal volume between subjects with and without delirium. Both unadjusted and adjusted (age, gender, vascular comorbidity, and general cognitive performance) regression analyses demonstrated no statistically significant association between any of the MRI measures with respect to delirium incidence or severity. In persons without dementia, preexisting cerebral WMHs, general and hippocampal atrophy may not predispose to postoperative delirium or worsen its severity.
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Affiliation(s)
- Michele Cavallari
- Center for Neurological Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Tammy T Hshieh
- Division of Aging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Charles R G Guttmann
- Center for Neurological Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Long H Ngo
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Dominik S Meier
- Center for Neurological Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eva M Schmitt
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Edward R Marcantonio
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Richard N Jones
- Department of Psychiatry and Human Behavior, Brown University Warren Alpert Medical School, Providence, RI, USA; Department of Neurology, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Cyrus M Kosar
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Tamara G Fong
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA; Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Daniel Press
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sharon K Inouye
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA; Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - David C Alsop
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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Hshieh TT, Petrone AB, Gaziano JM, Djoussé L. Nut consumption and risk of mortality in the Physicians' Health Study. Am J Clin Nutr 2015; 101:407-12. [PMID: 25646339 PMCID: PMC4307210 DOI: 10.3945/ajcn.114.099846] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 11/21/2014] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Previous studies have suggested that nut consumption is associated with beneficial cardiovascular outcomes. However, limited data are available on the association between nut intake and all-cause mortality. OBJECTIVE Our aim was to test the hypothesis that nut consumption is inversely associated with the risk of all-cause mortality. DESIGN In this prospective cohort study in 20,742 male physicians, we assessed nut intake between 1999 and 2002 via a food-frequency questionnaire and ascertained deaths through an endpoint committee. We used Cox regression to estimate multivariable-adjusted HRs for death according to nut consumption. In secondary analyses, we evaluated associations of nut consumption with cause-specific mortality. RESULTS During a mean follow-up of 9.6 y, there were 2732 deaths. The mean (±SD) age at baseline was 66.6 ± 9.3 y. Median nut consumption was 1 serving/wk. Multivariable-adjusted HRs (95% CIs) were 1.0 (reference), 0.92 (0.83, 1.01), 0.85 (0.76, 0.96), 0.86 (0.75, 0.98), and 0.74 (0.63, 0.87) for nut consumption of never or <1 serving/mo, 1-3 servings/mo, 1 serving/wk, 2-4 servings/wk, and ≥5 servings/wk, respectively (P-linear trend < 0.0001), after adjustment for age, body mass index, alcohol use, smoking, exercise, prevalent diabetes and hypertension, and intakes of energy, saturated fat, fruit and vegetables, and red meat. In a secondary analysis, results were consistent for cardiovascular disease mortality but only suggestive and non-statistically significant for coronary artery disease and cancer mortality. CONCLUSION Our data are consistent with an inverse association between nut consumption and the risk of all-cause and cardiovascular disease mortality in US male physicians.
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Affiliation(s)
- Tammy T Hshieh
- From the Divisions of Aging (TTH, ABP, JMG, and LD) and Preventive Medicine (JMG), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; the Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA (TTH); and the Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC), Geriatric Research (GRECC) and VA Boston Healthcare System, Boston, MA (JMG and LD)
| | - Andrew B Petrone
- From the Divisions of Aging (TTH, ABP, JMG, and LD) and Preventive Medicine (JMG), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; the Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA (TTH); and the Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC), Geriatric Research (GRECC) and VA Boston Healthcare System, Boston, MA (JMG and LD)
| | - J Michael Gaziano
- From the Divisions of Aging (TTH, ABP, JMG, and LD) and Preventive Medicine (JMG), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; the Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA (TTH); and the Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC), Geriatric Research (GRECC) and VA Boston Healthcare System, Boston, MA (JMG and LD)
| | - Luc Djoussé
- From the Divisions of Aging (TTH, ABP, JMG, and LD) and Preventive Medicine (JMG), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; the Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA (TTH); and the Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC), Geriatric Research (GRECC) and VA Boston Healthcare System, Boston, MA (JMG and LD)
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Abstract
BACKGROUND/AIMS The international normalized ratio (INR) has not been validated as a predictor of bleeding risk in cirrhotics. The aim of this study was to determine whether elevation in the INR correlated with risk of esophageal variceal hemorrhage and whether correction of the INR prior to endoscopic therapy affects failure to control bleeding. PATIENTS AND METHODS Patient records were retrospectively reviewed from January 1, 2000 to December 31, 2010. Cases were cirrhotics admitted to the hospital due to bleeding esophageal varices. Controls were cirrhotics with a history of non-bleeding esophageal varices admitted with ascites or encephalopathy. All variceal bleeders were treated with octreotide, antibiotics, and band ligation. Failure to control bleeding was defined according to the Baveno V criteria. RESULTS We analyzed 74 cases and 74 controls. The mean INR at presentation was lower in those with bleeding varices compared to non-bleeders (1.61 vs 1.74, P = 0.03). Those with bleeding varices had higher serum sodium (136.1 vs 133.8, P = 0.02), lower hemoglobin (9.59 vs 11.0, P < 0.001), and lower total bilirubin (2.47 vs 5.50, P < 0.001). Multivariable logistic regression showed total bilirubin to inversely correlate with bleeding (OR = 0.74). Bleeders received a mean of 1.14 units of fresh frozen plasma (FFP) prior to endoscopy (range 0-11 units). Of the 14 patients (20%) with failure to control bleeding, median INR (1.8 vs 1.5, P = 0.02) and median units of FFP transfused (2 vs 0, P = 0.01) were higher than those with hemostasis after the initial endoscopy. CONCLUSIONS The INR reflects liver dysfunction, not bleeding risk. Correction of INR with FFP has little effect on hemostasis.
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Affiliation(s)
- Tammy T. Hshieh
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston Massachusetts, US
| | - Aung Kaung
- Department of Medicine and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, US
| | - Syed Hussain
- Division of Digestive Diseases, University of Cincinnati College of Medicine, Cincinnati, Ohio, US
| | - Michael P. Curry
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston Massachusetts, US
| | - Vinay Sundaram
- Department of Medicine and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, US,Address for correspondence: Dr. Vinay Sundaram, 8900 Beverly Boulevard, Los Angeles, CA 90048. E-mail:
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Hshieh TT, Sundaram V. Liver transplantation for hepatocellular carcinoma: are international guidelines possible? Hepatobiliary Surg Nutr 2013; 2:113-6. [PMID: 24570925 PMCID: PMC3924664 DOI: 10.3978/j.issn.2304-3881.2012.10.03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2012] [Accepted: 10/09/2012] [Indexed: 01/19/2023]
Affiliation(s)
- Tammy T. Hshieh
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, USA
| | - Vinay Sundaram
- Department of Medicine and Transplant Institute, Loma Linda University Medical Center, Loma Linda Medical School, USA
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Hshieh TT, Sundaram V, Najarian RM, Hanto DW, Karp SJ, Curry MP. Hepatitis B surface antigen as a marker for recurrent, metastatic hepatocellular carcinoma after liver transplantation. Liver Transpl 2012; 18:995-8. [PMID: 22829419 DOI: 10.1002/lt.23465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Hshieh TT, Fong TG, Marcantonio ER, Inouye SK. Cholinergic deficiency hypothesis in delirium: a synthesis of current evidence. J Gerontol A Biol Sci Med Sci 2008; 63:764-72. [PMID: 18693233 DOI: 10.1093/gerona/63.7.764] [Citation(s) in RCA: 332] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Deficits in cholinergic function have been postulated to cause delirium and cognitive decline. This review examines current understanding of the cholinergic deficiency hypothesis in delirium by synthesizing evidence on potential pathophysiological pathways. Acetylcholine synthesis involves various precursors, enzymes, and receptors, and dysfunction in these components can lead to delirium. Insults to the brain, like ischemia and immunological stressors, can precipitously alter acetylcholine levels. Imbalances between cholinergic and other neurotransmitter pathways may result in delirium. Furthermore, genetic, enzymatic, and immunological overlaps exist between delirium and dementia related to the cholinergic pathway. Important areas for future research include identifying biomarkers, determining genetic contributions, and evaluating response to cholinergic drugs in delirium. Understanding how the cholinergic pathway relates to delirium may yield innovative approaches in the diagnosis, prevention, and treatment of this common, costly, and morbid condition.
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Affiliation(s)
- Tammy T Hshieh
- Warren Alpert Medical School of Brown University, Providence, RI, USA
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von Arnim CAF, Kinoshita A, Peltan ID, Tangredi MM, Herl L, Lee BM, Spoelgen R, Hshieh TT, Ranganathan S, Battey FD, Liu CX, Bacskai BJ, Sever S, Irizarry MC, Strickland DK, Hyman BT. The low density lipoprotein receptor-related protein (LRP) is a novel beta-secretase (BACE1) substrate. J Biol Chem 2005; 280:17777-85. [PMID: 15749709 DOI: 10.1074/jbc.m414248200] [Citation(s) in RCA: 204] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACE is a transmembrane protease with beta-secretase activity that cleaves the amyloid precursor protein (APP). After BACE cleavage, APP becomes a substrate for gamma-secretase, leading to release of amyloid-beta peptide (Abeta), which accumulates in senile plaques in Alzheimer disease. APP and BACE are co-internalized from the cell surface to early endosomes. APP is also known to interact at the cell surface and be internalized by the low density lipoprotein receptor-related protein (LRP), a multifunctional endocytic and signaling receptor. Using a new fluorescence resonance energy transfer (FRET)-based assay of protein proximity, fluorescence lifetime imaging (FLIM), and co-immunoprecipitation we demonstrate that the light chain of LRP interacts with BACE on the cell surface in association with lipid rafts. Surprisingly, the BACE-LRP interaction leads to an increase in LRP C-terminal fragment, release of secreted LRP in the media and subsequent release of the LRP intracellular domain from the membrane. Taken together, these data suggest that there is a close interaction between BACE and LRP on the cell surface, and that LRP is a novel BACE substrate.
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Affiliation(s)
- Christine A F von Arnim
- Alzheimer Disease Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts 02129, USA
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