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Nawan A, Wang G, Zhao C, Zhang W, Jiang B, Feng Y. A Novel Preoperative Electroencephalogram-Derived Index to Predict Early Postoperative Delirium in Elderly Patients After Hip Fracture Surgeries: Development of a Prediction Model. Geriatr Orthop Surg Rehabil 2024; 15:21514593241258654. [PMID: 38835410 PMCID: PMC11149441 DOI: 10.1177/21514593241258654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 03/16/2024] [Accepted: 04/28/2024] [Indexed: 06/06/2024] Open
Abstract
Introduction It is appealing to accurately predict postoperative delirium (POD) before surgeries. In this study, it was hypothesized that a novel electroencephalogram-derived index, the delirium index (DELi), could extract latent information regarding the predisposing factors of POD preoperatively. This study was aimed at developing a concise model that incorporated this DELi score to predict the early POD of elderly patients after hip surgeries. Materials and Methods Elderly patients scheduled for elective hip fracture surgeries were prospectively enrolled in a tertiary care hospital from November 2020 to June 2022. DELi scores and patient characteristics (age, sex, types of fracture and surgery, the time interval between fracture and surgery, cognitive function assessed using the Montreal Cognitive Assessment (MoCA), and frailty status assessed using the FRAIL scale) were collected preoperatively as candidate predictors. POD diagnosed using the confusion assessment method (CAM) was the outcome. Least absolute shrinkage and selection operator (LASSO) regression analysis was used to select predictors. Then, these predictors were entered into a backward logistical regression analysis to develop a prediction model. Discrimination, calibration and clinical utility were validated using the bootstrapping method. Results All data (144 qualified patients of 170) were used for development. POD was observed in 71 patients (49.3%). Preoperative DELi scores predicted early POD (the area under the curve (AUC) = .786, 95% confidence interval (CI): .712, .860, in internal validation). A nomogram with MoCA, FRAIL scale and DELi score was constructed with excellent discrimination (AUC = .920, 95% CI: .876, .963, in internal validation), accredited calibration (P = .733, Hosmer‒Lemeshow test), and a wide range of threshold probabilities (5% to 95%). Conclusions Preoperative DELi scores predicted the early POD of elderly patients after hip surgeries. A concise prediction model was developed and demonstrated excellent discrimination.
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Affiliation(s)
- Ayixia Nawan
- Department of Anaesthesiology, Peking University People's Hospital, Beijing, China
- Department of Anaesthesiology, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Geng Wang
- Department of Anaesthesiology, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Congcong Zhao
- Department of Anaesthesiology, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Wenchao Zhang
- Department of Anaesthesiology, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Bailin Jiang
- Department of Anaesthesiology, Peking University People's Hospital, Beijing, China
| | - Yi Feng
- Department of Anaesthesiology, Peking University People's Hospital, Beijing, China
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Igwe EO, Nealon J, O'Shaughnessy P, Bowden A, Chang HCR, Ho MH, Montayre J, Montgomery A, Rolls K, Chou KR, Chen KH, Traynor V, Smerdely P. Incidence of postoperative delirium in older adults undergoing surgical procedures: A systematic literature review and meta-analysis. Worldviews Evid Based Nurs 2023. [PMID: 37128953 DOI: 10.1111/wvn.12649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 03/05/2023] [Accepted: 03/11/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND With the increase in life expectancy around the globe, the incidence of postoperative delirium (POD) among older people (≥65 years) is growing. Previous studies showed a wide variation in the incidence of POD, from 4% to 53%, with a lack of specific evidence about the incidence of POD by specific surgery type among older people. The aim of this systematic review and meta-analysis was to determine the incidence of POD by surgery type within populations 65 years and over. METHODS Databases including PubMed, Cochrane library, Embase, and CINAHL were searched until October 2020. Due to the relatively higher number of meta-analyses undertaken in this area of research, a streamlined systematic meta-analysis was proposed. RESULTS A total of 28 meta-analyses (comprising 284 individual studies) were reviewed. Data from relevant individual studies (n = 90) were extracted and included in the current study. Studies were grouped into eight surgery types and the incidence of POD for orthopedic, vascular, spinal, cardiac, colorectal, abdominal, urologic, and mixed surgeries was 20%, 14%, 13%, 32%, 14%, 30%, 10%, and 26%, respectively. POD detection instruments were different across the studies, with Confusion Assessment Method (CAM & CAM-ICU) being the most frequently adopted. LINKING EVIDENCE TO ACTION This study showed that POD incidence in older people undergoing surgery varied widely across surgery type. The more complex surgeries like cardiac and abdominal surgeries were associated with a higher risk of POD. This highlights the need to include the level of surgery complexity as a risk factor in preoperative assessments.
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Affiliation(s)
- Ezinne Oyidia Igwe
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
- Illawarra Health and Medical Research Institute (IHMRI), Wollongong, New South Wales, Australia
| | - Jessica Nealon
- Illawarra Health and Medical Research Institute (IHMRI), Wollongong, New South Wales, Australia
- School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Pauline O'Shaughnessy
- School of Mathematics and Applied Statistics, Faculty of Engineering and Information Sciences, University of Wollongong, Wollongong, New South Wales, Australia
| | - Alera Bowden
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
- Illawarra Health and Medical Research Institute (IHMRI), Wollongong, New South Wales, Australia
- Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Hui-Chen Rita Chang
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
- Illawarra Health and Medical Research Institute (IHMRI), Wollongong, New South Wales, Australia
- School of Nursing and Midwifery, Western Sydney University, Penrith, New South Wales, Australia
| | - Mu-Hsing Ho
- School of Nursing, LKS Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Jed Montayre
- School of Nursing, Hong Kong Polytechnic University, Hung Hom, Hong Kong SAR
| | - Amy Montgomery
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
- Illawarra Health and Medical Research Institute (IHMRI), Wollongong, New South Wales, Australia
| | - Kaye Rolls
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Kuei-Ru Chou
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
- Center for Nursing and Healthcare Research in Clinical Practice Application, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Department of Nursing, Taipei Medical University-Shuang Ho Hospital, New Taipei, Taiwan
- Psychiatric Research Center, Taipei Medical University Hospital, Taipei, Taiwan
| | - Kee-Hsin Chen
- Post-Baccalaureate Program in Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
- Center for Nursing and Healthcare Research in Clinical Practice Application, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Evidence-based Knowledge Translation Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Victoria Traynor
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
- Illawarra Health and Medical Research Institute (IHMRI), Wollongong, New South Wales, Australia
| | - Peter Smerdely
- School of Population Health, UNSW Medicine, Sydney, New South Wales, Australia
- St George Hospital, Kogarah, New South Wales, Australia
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Dakhil S, Saltvedt I, Benth JŠ, Thingstad P, Watne LO, Bruun Wyller T, Helbostad JL, Frihagen F, Johnsen LG, Taraldsen K. Longitudinal trajectories of functional recovery after hip fracture. PLoS One 2023; 18:e0283551. [PMID: 36989248 PMCID: PMC10057789 DOI: 10.1371/journal.pone.0283551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 03/01/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND There is limited evidence regarding predictors of functional trajectories after hip fracture. We aimed to identify groups with different trajectories of functional recovery the first year after hip fracture, and to determine predictors for belonging to such groups. METHODS This longitudinal study combined data from two large randomized controlled trials including patients with hip fracture. Participants were assessed at baseline, four and 12 months. We used the Nottingham Extended Activities of Daily Living (NEADL) as a measure of instrumental ADL (iADL) and Barthel Index for personal ADL (pADL). A growth mixture model was estimated to identify groups of patients following distinct trajectories of functioning. Baseline characteristics potentially predicting group-belonging were assessed by multiple nominal regression. RESULTS Among 726 participants (mean age 83.0; 74.7% women), we identified four groups of patients following distinct ADL trajectories. None of the groups regained their pre-fracture ADL. For one of the groups identified in both ADL outcomes, a steep decline in function was shown the first four months after surgery, and none of the groups showed functional recovery between four and 12 months after surgery. CONCLUSIONS No groups regained their pre-fracture ADL. Some of the patients with relatively high pre-fracture function, had a steep ADL decline. For this group there is a potential for recovery, but more knowledge and research is needed in this group. These findings could be useful in uncovering groups of patients with different functioning after a hip fracture, and aid in discharge planning.
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Affiliation(s)
- Shams Dakhil
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ingvild Saltvedt
- Department of Geriatric Medicine, St. Olav University Hospital, Trondheim, Norway
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Jūratė Šaltytė Benth
- Institute of Clinical Medicine, Campus Ahus, University of Oslo, Oslo, Norway
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - Pernille Thingstad
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Leiv Otto Watne
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - Torgeir Bruun Wyller
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jorunn L Helbostad
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Frede Frihagen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Orthopaedic Surgery, Østfold Hospital Trust, Grålum, Norway
| | - Lars Gunnar Johnsen
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Orthopedic Trauma Unit, Department of Orthopedic Surgery, St. Olav University Hospital, Trondheim, Norway
| | - Kristin Taraldsen
- Department of Rehabilitation Science and Health Technology, OsloMet, Oslo Metropolitan University, Oslo, Norway
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Chu NM, Bae S, Chen X, Ruck J, Gross AL, Albert M, Neufeld KJ, Segev DL, McAdams-DeMarco MA. Delirium, changes in cognitive function, and risk of diagnosed dementia after kidney transplantation. Am J Transplant 2022; 22:2892-2902. [PMID: 35980673 PMCID: PMC10138281 DOI: 10.1111/ajt.17176] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 07/25/2022] [Accepted: 08/15/2022] [Indexed: 01/25/2023]
Abstract
Kidney transplant (KT) recipients with delirium, a preventable surgical complication, are likely to reap cognitive benefits from restored kidney function, but may be more vulnerable to longer-term neurotoxic stressors post-KT (i.e., aging, immunosuppression). In this prospective cohort study, we measured delirium (chart-based), global cognitive function (3MS), and executive function (Trail Making Test Part B minus Part A) in 894 recipients (2009-2021) at KT, 1/3/6-months, 1-year, and annually post-KT. Dementia was ascertained using linked Medicare claims. We described repeated measures of cognitive performance (mixed effects model) and quantified dementia risk (Fine & Gray competing risk) by post-KT delirium. Of 894 recipients, 43(4.8%) had post-KT delirium. Delirium was not associated with global cognitive function at KT (difference = -3.2 points, 95%CI: -6.7, 0.4) or trajectories post-KT (0.03 points/month, 95%CI: -0.27, 0.33). Delirium was associated with worse executive function at KT (55.1 s, 95%CI: 25.6, 84.5), greater improvements in executive function <2 years post-KT (-2.73 s/month, 95%CI: -4.46,-0.99), and greater decline in executive function >2 years post-KT (1.72 s/month, 95%CI: 0.22, 3.21). Post-KT delirium was associated with over 7-fold greater risk of dementia post-KT (adjusted subdistribution hazard ratio = 7.84, 95%CI: 1.22, 50.40). Transplant centers should be aware of cognitive risks associated with post-KT delirium and implement available preventative interventions to reduce delirium risk.
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Affiliation(s)
- Nadia M. Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Sunjae Bae
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Xiaomeng Chen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jessica Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Alden L. Gross
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
- Department of Mental Health, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Marilyn Albert
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Karin J. Neufeld
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Dorry L. Segev
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Mara A. McAdams-DeMarco
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
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Akushevich I, Yashkin AP, Kravchenko J, Kertai MD. Extended anesthesia exposure for abdominal and pelvic procedures in older adults with colorectal cancer: Associations with chart dementia diagnoses. Exp Gerontol 2022; 164:111830. [PMID: 35525395 PMCID: PMC10112329 DOI: 10.1016/j.exger.2022.111830] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 05/01/2022] [Accepted: 05/02/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND We hypothesized that cumulative anesthesia exposure over the course of routine treatment of colorectal cancer in older adults can increase long-term risk of Alzheimer's disease (AD), Alzheimer's disease-related dementias (ADRD), and other chronic neurocognitive disorders (CND). METHODS We conducted a SEER-Medicare-based retrospective cohort study of 84,770 individuals age 65 years and older diagnosed with colorectal cancer between 1998 and 2007 using a proportional hazards model with inverse probability weighted estimators. The primary exploratory variable was a time-variant measure of cumulative anesthesia exposure for abdominal and pelvic procedures, updated continuously. RESULTS Our primary outcomes, AD and ADRD, occurred in 6005/84,770 (7.1%) and 14,414/83,444 (17.3%) individuals respectively. No statistically significant association was found between cumulative anesthesia exposure and AD (hazard ratio [HR], 0.993; 95% CI, 0.973-1.013). However, it was moderately associated with the risk of ADRD (HR, 1.016; 95% CI, 1.004-1.029) and some secondary outcomes including most notably: cerebral degeneration (HR, 1.048; 95% CI, 1.033-1.063), hepatic encephalopathy (HR, 1.133; 95% CI, 1.101-1.167), encephalopathy-not elsewhere classified (HR,1.095; 95% CI: 1.076-1.115), and incident/perioperative delirium (HR, 1.022; 95% CI, 1.012-1.032). Furthermore, we observed an association between perioperative delirium and increased risk of AD (HR, 2.05; 95% CI, 1.92-2.09). CONCLUSION Cumulative anesthesia exposure for abdominal and pelvic procedures was not associated with increased risk of AD directly and had a small but statistically significant association with ADRD and a number of other CNDs. Cumulative anesthesia exposure was also associated with perioperative delirium, which had an independent adverse association with AD risk.
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Affiliation(s)
- Igor Akushevich
- Biodemography of Aging Research Unit, Center for Population Health and Aging, Duke University, Durham, NC, United States
| | - Arseniy P Yashkin
- Biodemography of Aging Research Unit, Center for Population Health and Aging, Duke University, Durham, NC, United States
| | - Julia Kravchenko
- Department of Surgery, Duke University School of Medicine, Durham, NC, United States
| | - Miklos D Kertai
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, United States.
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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] [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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Jaatinen R, Luukkaala T, Hongisto MT, Helminen H, Nuotio MS. In-Hospital Delirium as a Prognostic Factor for New Cognitive Disorder in a 1-Year Post-Hip Fracture Follow-Up. Dement Geriatr Cogn Disord 2021; 50:296-302. [PMID: 34515089 DOI: 10.1159/000518487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/10/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Older hip fracture patients are at high risk of delirium during acute hospital care. Pre-fracture dementia is known to increase the risk of in-hospital delirium. Data on the development of new cognitive disorders in patients with delirium are scarce. OBJECTIVE The objective of this study is to evaluate the prognostic significance of in-hospital delirium on the development of new cognitive disorders in a 1-year follow-up in older hip fracture patients. MATERIAL AND METHODS Data consisted of 476 hip fracture patients aged 65 years or more with no known cognitive disorder on admission. Delirium was assessed using the Confusion Assessment Method (CAM). Cognitive disorders were diagnosed following the national guidelines. Information on the new diagnoses of cognitive disorders (NDCD) at 1-year follow-up was elicited in a telephone interview and confirmed from the electronic patient files. Logistic regression analyses were conducted to examine the association of delirium with NDCDs. RESULTS Of the 476 patients, 87 (18%) had delirium during hospital stay. Patients with delirium were older, they had poorer nutritional status, lower mobility level, and more supported living arrangements than did patients without delirium. At the 1-year time point, 205 (43%) had NDCDs or were strongly suspected of this. CAM result was statistically significantly associated with development of NDCD in multivariable-adjusted analysis (odds ratio [OR] 2.29; 95% confidence interval [CI]: 1.39-3.79). Also, poor nutritional status continued to be associated with NDCDs (multivariable-adjusted OR 1.58; 95% CI: 1.03-2.43). CONCLUSION Delirium during hospitalization and poor nutritional status on admission are independent prognostic factors for development of subsequent cognitive disorders in older hip fracture patients.
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Affiliation(s)
- Roope Jaatinen
- Department of Geriatric Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland.,Division of Geriatric Medicine, Department of Clinical Medicine, University of Turku, Turku, Finland
| | - Tiina Luukkaala
- Research, Development and Innovation Center, Tampere University Hospital, Tampere, Finland.,Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Markus T Hongisto
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Orthopaedics, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Heli Helminen
- Department of Surgery, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Maria S Nuotio
- Department of Geriatric Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland.,Division of Geriatric Medicine, Department of Clinical Medicine, University of Turku, Turku, Finland.,Research Services and Department of Clinical Medicine, Turku University Hospital, Turku, Finland.,Turku University Hospital and University of Turku, Turku, Finland
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8
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Barriers to completing the 4AT for delirium and its clinical implementation in two hospitals: a mixed-methods study. Eur Geriatr Med 2021; 13:163-172. [PMID: 34782986 PMCID: PMC8860947 DOI: 10.1007/s41999-021-00582-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 10/27/2021] [Indexed: 12/28/2022]
Abstract
Aim To assess the clinical implementation and barriers to completing the 4AT for delirium in general medical and geriatric patients over 75 years upon admission to Wellington and Kenepuru Hospitals. Findings The 4AT is a feasible and sustainable tool for the assessment of delirium in the hospital setting. Most of the identified barriers to completing the 4AT are potentially reversible. Message Implementation of the 4AT may improve through education about these barriers and emphasising its validity in specific groups. Purpose To assess the clinical implementation and barriers to completing the 4AT for delirium in general medical and geriatric patients over 75 years upon admission to Wellington and Kenepuru Hospitals during the first eight months of 2017, 2018 and 2019. Methods Retrospective data from electronic health records were analysed using an explanatory-sequential mixed-methods approach. The initial quantitative phase measured doctors’ adherence to the 4AT and the rate of positive 4ATs (≥ 4). The subsequent qualitative phase identified doctors’ main reasons for omitting the 4AT through conventional content analysis. Results The quantitative population included 7799 acute admissions (mean age 84, 58.2% female). There was good clinical implementation of the 4AT, evidenced by an overall adherence rate of 83.2% and a rate of positive 4ATs of 14.8% that is in keeping with expected delirium rates in similar settings. The qualitative sample consisted of 875 acute admissions (mean age 84, 56.3% female) with documented reasons for omitting the 4AT. The main barriers to completing the 4AT were: reduced patient alertness, communication barriers (language, deafness, aphasia and dysarthria), prioritising patients’ wellness and comfort (addressing critical illnesses, symptoms, end-of-life issues and promoting sleep), pre-existing cognitive disorders, and unstructured delirium assessments. Conclusion Adherence to the 4AT was high and sustainable in both hospitals. Most barriers to completing the 4AT were potentially avoidable. Education about the 4AT in relation to these barriers may improve its implementation.
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9
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Halaas NB, Zetterberg H, Idland AV, Knapskog AB, Watne LO, Blennow K. Cerebrospinal Fluid Concentration of Neurogranin in Hip Fracture Patients with Delirium. J Alzheimers Dis 2021; 81:667-677. [PMID: 33814433 DOI: 10.3233/jad-201341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Delirium is associated with an increased risk of incident dementia and accelerated progression of existing cognitive symptoms. Reciprocally, dementia increases the risk of delirium. Cerebrospinal fluid (CSF) concentration of the dendritic protein neurogranin has been shown to increase in early Alzheimer's disease (AD), likely reflecting synaptic dysfunction and/or degeneration. OBJECTIVE To elucidate the involvement of synaptic dysfunction in delirium pathophysiology, we tested the association between CSF neurogranin concentration and delirium in hip fracture patients with different AD-biomarker profiles, while comparing them to cognitively unimpaired older adults (CUA) and AD patients. METHODS The cohort included hip fracture patients with (n = 70) and without delirium (n = 58), CUA undergoing elective surgery (n = 127), and AD patients (n = 46). CSF was collected preoperatively and diagnostically in surgery and AD patients respectively. CSF neurogranin concentrations were analyzed in all samples with an in-house ELISA. Delirium was assessed pre-and postoperatively in hip fracture patients by trained investigators using the Confusion Assessment Method. Hip fracture patients were further stratified based on pre-fracture dementia status, delirium subtype, and AD fluid biomarkers. RESULTS No association was found between delirium and CSF neurogranin concentration (main analysis: delirium versus no delirium, p = 0.68). Hip fracture patients had lower CSF neurogranin concentration than AD patients (p = 0.001) and CUA (p = 0.035) in age-adjusted sensitivity analyses. CONCLUSION The findings suggest that delirium is not associated with increased CSF neurogranin concentration in hip fracture patients, possibly due to advanced neurodegenerative disease and age and/or because synaptic degeneration is not an important pathophysiological process in delirium.
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Affiliation(s)
- Nathalie Bodd Halaas
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.,Research Group for Lifespan Changes in Brain and Cognition, Department of Psychology, University of Oslo, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, United Kingdom.,UK Dementia Research Institute at UCL, London, United Kingdom
| | - Ane-Victoria Idland
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Leiv Otto Watne
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
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10
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Henjum K, Godang K, Quist-Paulsen E, Idland AV, Neerland BE, Sandvig H, Brugård A, Raeder J, Frihagen F, Wyller TB, Hassel B, Bollerslev J, Watne LO. Cerebrospinal fluid catecholamines in delirium and dementia. Brain Commun 2021; 3:fcab121. [PMID: 34423298 PMCID: PMC8374970 DOI: 10.1093/braincomms/fcab121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2021] [Indexed: 11/28/2022] Open
Abstract
Dopamine and noradrenaline are functionally connected to delirium and have been targets for pharmacological interventions but the biochemical evidence to support this notion is limited. To study the CSF levels of dopamine, noradrenaline and the third catecholamine adrenaline in delirium and dementia, these were quantified in three patient cohorts: (i) cognitively normal elderly patients (n = 122); (ii) hip fracture patients with or without delirium and dementia (n = 118); and (iii) patients with delirium precipitated by another medical condition (medical delirium, n = 26). Delirium was assessed by the Confusion Assessment Method. The hip fracture cohort had higher CSF levels of noradrenaline and adrenaline than the two other cohorts (both P < 0.001). Within the hip fracture cohort those with delirium (n = 65) had lower CSF adrenaline and dopamine levels than those without delirium (n = 52, P = 0.03, P = 0.002). Similarly, the medical delirium patients had lower CSF dopamine levels than the cognitively normal elderly (P < 0.001). Age did not correlate with the CSF catecholamine levels. These findings with lower CSF dopamine levels in hip fracture- and medical delirium patients challenge the theory of dopamine excess in delirium and question use of antipsychotics in delirium. The use of alpha-2 agonists with the potential to reduce noradrenaline release needs further examination.
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Affiliation(s)
- Kristi Henjum
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, 0424 Oslo, Norway.,Department of Geriatric Medicine, Institute of Clinical Medicine, University of Oslo, 0424 Oslo, Norway
| | - Kristin Godang
- Section of Specialized Endocrinology, Department of Endocrinology, Oslo University Hospital, 0424 Oslo, Norway
| | | | - Ane-Victoria Idland
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, 0424 Oslo, Norway
| | - Bjørn Erik Neerland
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, 0424 Oslo, Norway
| | - Heidi Sandvig
- Medical Department, Kristiansund Hospital, Møre og Romsdal Hospital Trust, 6508 Kristiansund, Norway
| | - Anniken Brugård
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, 0424 Oslo, Norway
| | - Johan Raeder
- Department of Anesthesiology, Oslo University Hospital, 0424 Oslo, Norway
| | - Frede Frihagen
- Division of Orthopedic Surgery, Oslo University Hospital, 0424 Oslo, Norway
| | - Torgeir Bruun Wyller
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, 0424 Oslo, Norway.,Department of Geriatric Medicine, Institute of Clinical Medicine, University of Oslo, 0424 Oslo, Norway
| | - Bjørnar Hassel
- Department of Neurohabilitation, Oslo University Hospital, 0424 Oslo, Norway
| | - Jens Bollerslev
- Department of Geriatric Medicine, Institute of Clinical Medicine, University of Oslo, 0424 Oslo, Norway.,Section of Specialized Endocrinology, Department of Endocrinology, Oslo University Hospital, 0424 Oslo, Norway
| | - Leiv Otto Watne
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, 0424 Oslo, Norway
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11
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Burton JK, Fearon P, Noel-Storr AH, McShane R, Stott DJ, Quinn TJ. Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) for the detection of dementia within a secondary care setting. Cochrane Database Syst Rev 2021; 7:CD010772. [PMID: 34278561 PMCID: PMC8406705 DOI: 10.1002/14651858.cd010772.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The diagnosis of dementia relies on the presence of new-onset cognitive impairment affecting an individual's functioning and activities of daily living. The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) is a questionnaire instrument, completed by a suitable 'informant' who knows the patient well, designed to assess change in functional performance secondary to cognitive change; it is used as a tool for identifying those who may have dementia. In secondary care there are two specific instances where patients may be assessed for the presence of dementia. These are in the general acute hospital setting, where opportunistic screening may be undertaken, or in specialist memory services where individuals have been referred due to perceived cognitive problems. To ensure an instrument is suitable for diagnostic use in these settings, its test accuracy must be established. OBJECTIVES To determine the accuracy of the informant-based questionnaire IQCODE for detection of dementia in a secondary care setting. SEARCH METHODS We searched the following sources on the 28th of January 2013: ALOIS (Cochrane Dementia and Cognitive Improvement Group), MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO (Ovid SP), BIOSIS Previews (Thomson Reuters Web of Science), Web of Science Core Collection (includes Conference Proceedings Citation Index) (Thomson Reuters Web of Science), CINAHL (EBSCOhost) and LILACS (BIREME). We also searched sources specific to diagnostic test accuracy: MEDION (Universities of Maastricht and Leuven); DARE (Database of Abstracts of Reviews of Effects - via the Cochrane Library); HTA Database (Health Technology Assessment Database via the Cochrane Library) and ARIF (Birmingham University). We also checked reference lists of relevant studies and reviews, used searches of known relevant studies in PubMed to track related articles, and contacted research groups conducting work on IQCODE for dementia diagnosis to try to find additional studies. We developed a sensitive search strategy; search terms were designed to cover key concepts using several different approaches run in parallel and included terms relating to cognitive tests, cognitive screening and dementia. We used standardised database subject headings such as MeSH terms (in MEDLINE) and other standardised headings (controlled vocabulary) in other databases, as appropriate. SELECTION CRITERIA We selected those studies performed in secondary-care settings, which included (not necessarily exclusively) IQCODE to assess for the presence of dementia and where dementia diagnosis was confirmed with clinical assessment. For the 'secondary care' setting we included all studies which assessed patients in hospital (e.g. acute unscheduled admissions, referrals to specialist geriatric assessment services etc.) and those referred for specialist 'memory' assessment, typically in psychogeriatric services. DATA COLLECTION AND ANALYSIS We screened all titles generated by electronic database searches, and reviewed abstracts of all potentially relevant studies. Two independent assessors checked full papers for eligibility and extracted data. We determined quality assessment (risk of bias and applicability) using the QUADAS-2 tool, and reporting quality using the STARD tool. MAIN RESULTS From 72 papers describing IQCODE test accuracy, we included 13 papers, representing data from 2745 individuals (n = 1413 (51%) with dementia). Pooled analysis of all studies using data presented closest to a cut-off of 3.3 indicated that sensitivity was 0.91 (95% CI 0.86 to 0.94); specificity 0.66 (95% CI 0.56 to 0.75); the positive likelihood ratio was 2.7 (95% CI 2.0 to 3.6) and the negative likelihood ratio was 0.14 (95% CI 0.09 to 0.22). There was a statistically significant difference in test accuracy between the general hospital setting and the specialist memory setting (P = 0.019), suggesting that IQCODE performs better in a 'general' setting. We found no significant differences in the test accuracy of the short (16-item) versus the 26-item IQCODE, or in the language of administration. There was significant heterogeneity in the included studies, including a highly varied prevalence of dementia (10.5% to 87.4%). Across the included papers there was substantial potential for bias, particularly around sampling of included participants and selection criteria, which may limit generalisability. There was also evidence of suboptimal reporting, particularly around disease severity and handling indeterminate results, which are important if considering use in clinical practice. AUTHORS' CONCLUSIONS The IQCODE can be used to identify older adults in the general hospital setting who are at risk of dementia and require specialist assessment; it is useful specifically for ruling out those without evidence of cognitive decline. The language of administration did not affect test accuracy, which supports the cross-cultural use of the tool. These findings are qualified by the significant heterogeneity, the potential for bias and suboptimal reporting found in the included studies.
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Affiliation(s)
- Jennifer K Burton
- Academic Geriatric Medicine, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Patricia Fearon
- Academic Section of Geriatric Medicine, University of Glasgow, Glasgow, UK
| | | | | | - David J Stott
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow , UK
| | - Terry J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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12
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Burton JK, Fearon P, Noel-Storr AH, McShane R, Stott DJ, Quinn TJ. Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) for the detection of dementia within a general practice (primary care) setting. Cochrane Database Syst Rev 2021; 7:CD010771. [PMID: 34278564 PMCID: PMC8406468 DOI: 10.1002/14651858.cd010771.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The IQCODE (Informant Questionnaire for Cognitive Decline in the Elderly) is a commonly used questionnaire based tool that uses collateral information to assess for cognitive decline and dementia. Brief tools that can be used for dementia "screening" or "triage" may have particular utility in primary care / general practice healthcare settings but only if they have suitable test accuracy. A synthesis of the available data regarding IQCODE accuracy in a primary care setting should help inform cognitive assessment strategies for clinical practice; research and policy. OBJECTIVES To determine the accuracy of the informant-based questionnaire IQCODE, for detection of dementia in a primary care setting. SEARCH METHODS A search was performed in the following sources on the 28th of January 2013: ALOIS (Cochrane Dementia and Cognitive Improvement Group), MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO (Ovid SP), BIOSIS (Ovid SP), ISI Web of Science and Conference Proceedings (ISI Web of Knowledge), CINHAL (EBSCOhost) and LILACs (BIREME). We also searched sources specific to diagnostic test accuracy: MEDION (Universities of Maastricht and Leuven); DARE (York University); HTA Database (Health Technology Assessments Database via The Cochrane Library) and ARIF (Birmingham University). We developed a sensitive search strategy; search terms were designed to cover key concepts using several different approaches run in parallel and included terms relating to cognitive tests, cognitive screening and dementia. We used standardized database subject headings such as MeSH terms (in MEDLINE) and other standardized headings (controlled vocabulary) in other databases, as appropriate. SELECTION CRITERIA We selected those studies performed in primary care settings, which included (not necessarily exclusively) IQCODE to assess for the presence of dementia and where dementia diagnosis was confirmed with clinical assessment. For the "primary care" setting, we included those healthcare settings where unselected patients, present for initial, non-specialist assessment of memory or non-memory related symptoms; often with a view to onward referral for more definitive assessment. DATA COLLECTION AND ANALYSIS We screened all titles generated by electronic database searches and abstracts of all potentially relevant studies were reviewed. Full papers were assessed for eligibility and data extracted by two independent assessors. Quality assessment (risk of bias and applicability) was determined using the QUADAS-2 tool. Reporting quality was determined using the STARDdem extension to the STARD tool. MAIN RESULTS From 71 papers describing IQCODE test accuracy, we included 1 paper, representing data from 230 individuals (n=16 [7%] with dementia). The paper described those patients consulting a primary care service who self-identified as Japanese-American. Dementia diagnosis was made using Benson & Cummings criteria and the IQCODE was recorded as part of a longer interview with the informant. IQCODE accuracy was assessed at various test thresholds, with a "trade-off" between sensitivity and specificity across these cutpoints. At an IQCODE threshold of 3.2 sensitivity: 100%, specificity: 76%; for IQCODE 3.7 sensitivity: 75%, specificity: 98%. Applying the QUADAS-2 assessments, the study was at high risk of bias in all categories. In particular degree of blinding was unclear and not all participants were included in the final analysis. AUTHORS' CONCLUSIONS It is not possible to give definitive guidance on the test accuracy of IQCODE for the diagnosis of dementia in a primary care setting based on the single study identified. We are surprised by the lack of research using the IQCODE in primary care as this is, arguably, the most appropriate setting for targeted case finding of those with undiagnosed dementia in order to maximise opportunities to intervene and provide support for the individual and their carers.
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Affiliation(s)
- Jennifer K Burton
- Academic Geriatric Medicine, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Patricia Fearon
- Academic Section of Geriatric Medicine, University of Glasgow, Glasgow, UK
| | | | - Rupert McShane
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - David J Stott
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow , UK
| | - Terry J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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13
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Quinn TJ, Fearon P, Noel-Storr AH, Young C, McShane R, Stott DJ. Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) for the detection of dementia within community dwelling populations. Cochrane Database Syst Rev 2021; 7:CD010079. [PMID: 34278562 PMCID: PMC8407460 DOI: 10.1002/14651858.cd010079.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Various tools exist for initial assessment of possible dementia with no consensus on the optimal assessment method. Instruments that use collateral sources to assess change in cognitive function over time may have particular utility. The most commonly used informant dementia assessment is the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). A synthesis of the available data regarding IQCODE accuracy will help inform cognitive assessment strategies for clinical practice, research and policy. OBJECTIVES Our primary obective was to determine the accuracy of the informant-based questionnaire IQCODE for detection of dementia within community dwelling populations. Our secondary objective was to describe the effect of heterogeneity on the summary estimates. We were particularly interested in the traditional 26-item scale versus the 16-item short form; and language of administration. We explored the effect of varying the threshold IQCODE score used to define 'test positivity'. SEARCH METHODS We searched the following sources on 28 January 2013: ALOIS (Cochrane Dementia and Cognitive Improvement Group), MEDLINE (OvidSP), EMBASE (OvidSP), PsycINFO (OvidSP), BIOSIS Previews (ISI Web of Knowledge), Web of Science with Conference Proceedings (ISI Web of Knowledge), LILACS (BIREME). We also searched sources relevant or specific to diagnostic test accuracy: MEDION (Universities of Maastrict and Leuven); DARE (York University); ARIF (Birmingham University). We used sensitive search terms based on MeSH terms and other controlled vocabulary. SELECTION CRITERIA We selected those studies performed in community settings that used (not necessarily exclusively) the IQCODE to assess for presence of dementia and, where dementia diagnosis was confirmed with clinical assessment. Our intention with limiting the search to a 'community' setting was to include those studies closest to population level assessment. Within our predefined community inclusion criteria, there were relevant papers that fulfilled our definition of community dwelling but represented a selected population, for example stroke survivors. We included these studies but performed sensitivity analyses to assess the effects of these less representative populations on the summary results. DATA COLLECTION AND ANALYSIS We screened all titles generated by the electronic database searches and abstracts of all potentially relevant studies were reviewed. Full papers were assessed for eligibility and data extracted by two independent assessors. For quality assessment (risk of bias and applicability) we used the QUADAS 2 tool. We included test accuracy data on the IQCODE used at predefined diagnostic thresholds. Where data allowed, we performed meta-analyses to calculate summary values of sensitivity and specificity with corresponding 95% confidence intervals (CIs). We pre-specified analyses to describe the effect of IQCODE format (traditional or short form) and language of administration for the IQCODE. MAIN RESULTS From 16,144 citations, 71 papers described IQCODE test accuracy. We included 10 papers (11 independent datasets) representing data from 2644 individuals (n = 379 (14%) with dementia). Using IQCODE cut-offs commonly employed in clinical practice (3.3, 3.4, 3.5, 3.6) the sensitivity and specificity of IQCODE for diagnosis of dementia across the studies were generally above 75%. Taking an IQCODE threshold of 3.3 (or closest available) the sensitivity was 0.80 (95% CI 0.75 to 0.85); specificity was 0.84 (95% CI 0.78 to 0.90); positive likelihood ratio was 5.2 (95% CI 3.7 to 7.5) and the negative likelihood ratio was 0.23 (95% CI 0.19 to 0.29). Comparative analysis suggested no significant difference in the test accuracy of the 16 and 26-item IQCODE tests and no significant difference in test accuracy by language of administration. There was little difference in sensitivity across our predefined diagnostic cut-points. There was substantial heterogeneity in the included studies. Sensitivity analyses removing potentially unrepresentative populations in these studies made little difference to the pooled data estimates. The majority of included papers had potential for bias, particularly around participant selection and sampling. The quality of reporting was suboptimal particularly regarding timing of assessments and descriptors of reproducibility and inter-observer variability. AUTHORS' CONCLUSIONS Published data suggest that if using the IQCODE for community dwelling older adults, the 16 item IQCODE may be preferable to the traditional scale due to lesser test burden and no obvious difference in accuracy. Although IQCODE test accuracy is in a range that many would consider 'reasonable', in the context of community or population settings the use of the IQCODE alone would result in substantial misdiagnosis and false reassurance. Across the included studies there were issues with heterogeneity, several potential biases and suboptimal reporting quality.
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Affiliation(s)
- Terry J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Patricia Fearon
- Academic Section of Geriatric Medicine, University of Glasgow, Glasgow, UK
| | | | - Camilla Young
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | - David J Stott
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow , UK
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14
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Burton JK, Stott DJ, McShane R, Noel-Storr AH, Swann-Price RS, Quinn TJ. Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) for the early detection of dementia across a variety of healthcare settings. Cochrane Database Syst Rev 2021; 7:CD011333. [PMID: 34275145 PMCID: PMC8406787 DOI: 10.1002/14651858.cd011333.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) is a structured interview based on informant responses that is used to assess for possible dementia. IQCODE has been used for retrospective or contemporaneous assessment of cognitive decline. There is considerable interest in tests that may identify those at future risk of developing dementia. Assessing a population free of dementia for the prospective development of dementia is an approach often used in studies of dementia biomarkers. In theory, questionnaire-based assessments, such as IQCODE, could be used in a similar way, assessing for dementia that is diagnosed on a later (delayed) assessment. OBJECTIVES To determine the accuracy of the informant-based questionnaire IQCODE for the early detection of dementia across a variety of health care settings. SEARCH METHODS We searched these sources on 16 January 2016: ALOIS (Cochrane Dementia and Cognitive Improvement Group), MEDLINE Ovid SP, Embase Ovid SP, PsycINFO Ovid SP, BIOSIS Previews on Thomson Reuters Web of Science, Web of Science Core Collection (includes Conference Proceedings Citation Index) on Thomson Reuters Web of Science, CINAHL EBSCOhost, and LILACS BIREME. We also searched sources specific to diagnostic test accuracy: MEDION (Universities of Maastricht and Leuven); DARE (Database of Abstracts of Reviews of Effects, in the Cochrane Library); HTA Database (Health Technology Assessment Database, in the Cochrane Library), and ARIF (Birmingham University). We checked reference lists of included studies and reviews, used searches of included studies in PubMed to track related articles, and contacted research groups conducting work on IQCODE for dementia diagnosis to try to find additional studies. We developed a sensitive search strategy; search terms were designed to cover key concepts using several different approaches run in parallel, and included terms relating to cognitive tests, cognitive screening, and dementia. We used standardised database subject headings, such as MeSH terms (in MEDLINE) and other standardised headings (controlled vocabulary) in other databases, as appropriate. SELECTION CRITERIA We selected studies that included a population free from dementia at baseline, who were assessed with the IQCODE and subsequently assessed for the development of dementia over time. The implication was that at the time of testing, the individual had a cognitive problem sufficient to result in an abnormal IQCODE score (defined by the study authors), but not yet meeting dementia diagnostic criteria. DATA COLLECTION AND ANALYSIS We screened all titles generated by the electronic database searches, and reviewed abstracts of all potentially relevant studies. Two assessors independently checked the full papers for eligibility and extracted data. We determined quality assessment (risk of bias and applicability) using the QUADAS-2 tool, and reported quality using the STARDdem tool. MAIN RESULTS From 85 papers describing IQCODE, we included three papers, representing data from 626 individuals. Of this total, 22% (N = 135/626) were excluded because of prevalent dementia. There was substantial attrition; 47% (N = 295) of the study population received reference standard assessment at first follow-up (three to six months) and 28% (N = 174) received reference standard assessment at final follow-up (one to three years). Prevalence of dementia ranged from 12% to 26% at first follow-up and 16% to 35% at final follow-up. The three studies were considered to be too heterogenous to combine, so we did not perform meta-analyses to describe summary estimates of interest. Included patients were poststroke (two papers) and hip fracture (one paper). The IQCODE was used at three thresholds of positivity (higher than 3.0, higher than 3.12 and higher than 3.3) to predict those at risk of a future diagnosis of dementia. Using a cut-off of 3.0, IQCODE had a sensitivity of 0.75 (95%CI 0.51 to 0.91) and a specificity of 0.46 (95%CI 0.34 to 0.59) at one year following stroke. Using a cut-off of 3.12, the IQCODE had a sensitivity of 0.80 (95%CI 0.44 to 0.97) and specificity of 0.53 (95C%CI 0.41 to 0.65) for the clinical diagnosis of dementia at six months after hip fracture. Using a cut-off of 3.3, the IQCODE had a sensitivity of 0.84 (95%CI 0.68 to 0.94) and a specificity of 0.87 (95%CI 0.76 to 0.94) for the clinical diagnosis of dementia at one year after stroke. In generaI, the IQCODE was sensitive for identification of those who would develop dementia, but lacked specificity. Methods for both excluding prevalent dementia at baseline and assessing for the development of dementia were varied, and had the potential to introduce bias. AUTHORS' CONCLUSIONS Included studies were heterogenous, recruited from specialist settings, and had potential biases. The studies identified did not allow us to make specific recommendations on the use of the IQCODE for the future detection of dementia in clinical practice. The included studies highlighted the challenges of delayed verification dementia research, with issues around prevalent dementia assessment, loss to follow-up over time, and test non-completion potentially limiting the studies. Future research should recognise these issues and have explicit protocols for dealing with them.
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Affiliation(s)
- Jennifer K Burton
- Academic Geriatric Medicine, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - David J Stott
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow , UK
| | | | | | | | - Terry J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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15
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Ding G, Hua S, Chen J, Yang S, Xie R. Does cognitive decline/dementia increase Delirium risk after stroke? Psychogeriatrics 2021; 21:605-611. [PMID: 34018278 DOI: 10.1111/psyg.12720] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 04/20/2021] [Accepted: 05/09/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Delirium is a common contributor to mortality and hospital costs in stroke patients. Different observational studies have showed inconsistent results regarding the association between cognitive decline/dementia and delirium after acute stroke. Therefore, we performed this meta-analysis with the aim of determining whether cognitive decline/dementia is related to the risk of delirium after acute stroke. METHODS We systematically searched PubMed, Embase, Google Scholar, and Web of Science for relevant studies from inception to September 2020. We calculated the pooled odds ratio (OR) with 95% confidence interval (CI) by using fixed or random effects models based on heterogeneity measured by the I2 index. RESULTS The association between cognitive decline/dementia and post-stroke delirium was examined in 13 studies with 3183 participants. After pooled analysis, we found that cognitive decline/dementia was significantly associated with susceptibility to delirium in post-stroke patients (OR = 3.70, 95%CI: 2.90-4.71, P < 0.001). Subgroup analysis suggested that cognitive decline/dementia was associated with an increased risk of delirium in Caucasians (OR = 3.73, 95%CI: 2.73-5.11, P < 0.001), non-Caucasians (OR = 3.65, 95%CI: 2.50-5.33, P < 0.001), samples with <200 subjects (OR = 3.70, 95%CI: 2.17-6.31, P < 0.001), samples with ≥200 subjects (OR = 3.70, 95%CI: 2.82-4.85, P < 0.001), studies published in 1990-2009 (OR = 3.17, 95%CI: 1.48-6.77, P = 0.003), and studies published in 2010-2020 (OR = 3.76, 95%CI: 2.92-4.86, P < 0.001). CONCLUSIONS We identified an association between cognitive decline/dementia and the risk of developing delirium. Cognitive decline/dementia may be a promising predictor for delirium in post-stroke patients.
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Affiliation(s)
- Guanfu Ding
- Department of Neurosurgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Institute of Neurology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Diseases, Ministry of Education, Gannan Medical University, Ganzhou, China
| | - Shunde Hua
- Department of Neurosurgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Institute of Neurology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Diseases, Ministry of Education, Gannan Medical University, Ganzhou, China
| | - Jinming Chen
- Department of Neurosurgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Institute of Neurology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Diseases, Ministry of Education, Gannan Medical University, Ganzhou, China
| | - Shaochun Yang
- Department of Neurosurgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Institute of Neurology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Diseases, Ministry of Education, Gannan Medical University, Ganzhou, China
| | - Ruilu Xie
- Department of Neurosurgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Institute of Neurology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Diseases, Ministry of Education, Gannan Medical University, Ganzhou, China
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Pereira JVB, Aung Thein MZ, Nitchingham A, Caplan GA. Delirium in older adults is associated with development of new dementia: a systematic review and meta-analysis. Int J Geriatr Psychiatry 2021; 36:993-1003. [PMID: 33638566 DOI: 10.1002/gps.5508] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 01/31/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Observational studies have examined the association between delirium and development of new dementia. However, no recent review has collectively assessed the available evidence quantitatively and qualitatively. We systematically reviewed and critically evaluated the literature regarding the association between delirium and dementia, and calculated the odds of developing new dementia after having delirium. METHODS This systematic review and meta-analysis was conducted according to Preferred reporting items for systematic reviews and meta-analyses guidelines. MEDLINE, EMBASE and PsycINFO, were searched for English-language articles that compared the incidence of new dementia in older adult (≥65) inpatients with delirium, to inpatients without delirium. A random effects model was used for meta-analysis, and overall effect size was calculated using reported raw data of event counts. The Newcastle-Ottawa Quality Assessment scale assessed risk of bias. RESULTS Six observational studies met eligibility criteria, with follow-up times ranging from six months to five years. Four looked at hip fracture surgical patients; one was on cardiac surgery patients and one examined geriatric medical patients. All studies excluded patients with pre-existing dementia. Pooled meta-analysis revealed that older adult inpatients who developed delirium had almost twelve times the odds of subsequently developing new dementia compared to non-delirious patients (OR = 11.9 [95% CI: 7.29-19.6]; p < 0.001). CONCLUSIONS Older adult inpatients who develop delirium are at significant risk of subsequently developing dementia. This emphasises the importance of delirium prevention and cognitive monitoring post-delirium. The included studies mainly examined post-surgical patients-further research on medical and intensive care unit cohorts is warranted. Future studies should assess whether delirium duration, severity and subtype influence the risk of developing dementia.
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Affiliation(s)
| | | | - Anita Nitchingham
- Department of Geriatric Medicine, Prince of Wales Hospital, Prince of Wales Clinical School University of New South Wales, Sydney, Australia
| | - Gideon A Caplan
- Department of Geriatric Medicine, Prince of Wales Hospital, Prince of Wales Clinical School University of New South Wales, Sydney, Australia
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Predictors of delirium in older patients at the emergency department: a prospective multicentre derivation study. CAN J EMERG MED 2021; 23:330-336. [PMID: 33959922 DOI: 10.1007/s43678-020-00004-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/14/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The objective of this study was to identify the predictors of incident delirium in this high-risk population. METHODS This study was a planned sub-analysis of the INDEED multicentre cohort study. We recruited patients aged ≥ 65, independent/semi-independent, with an emergency department (ED) length of stay ≥ 8 h and admitted to any hospital ward. Patients were followed up during their ED stay up to 24 h after ward admission. Sociodemographic characteristics, comorbidities, functional status (OARS), illness severity, level of frailty, cognitive status (TICS-m) and ED/patient environment evaluation were collected during initial interview. Patients were screened for delirium twice a day using the Confusion Assessment Method. Multivariate logistic regression was performed to identify the predictors of delirium. RESULTS Incident delirium was detected in 68 patients of the 612 patients included (11%). Initially, seven candidate predictors were included in a regression model, of which four were retained using a stepwise selection procedure. Presence of cognitive impairment at baseline (OR 3.6, p < 0.001), absence of mobilization during the whole ED length of stay (OR 3.3, p = 0.002), longer ED length of stay (OR 1.02, p = 0.006) were associated with a higher risk of incident delirium while higher functional status was associated with a lower risk (OR 0.8, p < 0.001). CONCLUSION More work is needed to determine which tool(s) are most appropriate for the ED use to increase delirium screening compliance among health professionals working in this department. It is really the first step to be able to suggest interventions to decrease delirium incidence.
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MacLullich AM, Shenkin SD, Goodacre S, Godfrey M, Hanley J, Stíobhairt A, Lavender E, Boyd J, Stephen J, Weir C, MacRaild A, Steven J, Black P, Diernberger K, Hall P, Tieges Z, Fox C, Anand A, Young J, Siddiqi N, Gray A. The 4 'A's test for detecting delirium in acute medical patients: a diagnostic accuracy study. Health Technol Assess 2020; 23:1-194. [PMID: 31397263 DOI: 10.3310/hta23400] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Delirium is a common and serious neuropsychiatric syndrome, usually triggered by illness or drugs. It remains underdetected. One reason for this is a lack of brief, pragmatic assessment tools. The 4 'A's test (Arousal, Attention, Abbreviated Mental Test - 4, Acute change) (4AT) is a screening tool designed for routine use. This project evaluated its usability, diagnostic accuracy and cost. METHODS Phase 1 - the usability of the 4AT in routine practice was measured with two surveys and two qualitative studies of health-care professionals, and a review of current clinical use of the 4AT as well as its presence in guidelines and reports. Phase 2 - the 4AT's diagnostic accuracy was assessed in newly admitted acute medical patients aged ≥ 70 years. Its performance was compared with that of the Confusion Assessment Method (CAM; a longer screening tool). The performance of individual 4AT test items was related to cognitive status, length of stay, new institutionalisation, mortality at 12 weeks and outcomes. The method used was a prospective, double-blind diagnostic test accuracy study in emergency departments or in acute general medical wards in three UK sites. Each patient underwent a reference standard delirium assessment and was also randomised to receive an assessment with either the 4AT (n = 421) or the CAM (n = 420). A health economics analysis was also conducted. RESULTS Phase 1 found evidence that delirium awareness is increasing, but also that there is a need for education on delirium in general and on the 4AT in particular. Most users reported that the 4AT was useful, and it was in widespread use both in the UK and beyond. No changes to the 4AT were considered necessary. Phase 2 involved 785 individuals who had data for analysis; their mean age was 81.4 (standard deviation 6.4) years, 45% were male, 99% were white and 9% had a known dementia diagnosis. The 4AT (n = 392) had an area under the receiver operating characteristic curve of 0.90. A positive 4AT score (> 3) had a specificity of 95% [95% confidence interval (CI) 92% to 97%] and a sensitivity of 76% (95% CI 61% to 87%) for reference standard delirium. The CAM (n = 382) had a specificity of 100% (95% CI 98% to 100%) and a sensitivity of 40% (95% CI 26% to 57%) in the subset of participants whom it was possible to assess using this. Patients with positive 4AT scores had longer lengths of stay (median 5 days, interquartile range 2.0-14.0 days) than did those with negative 4AT scores (median 2 days, interquartile range 1.0-6.0 days), and they had a higher 12-week mortality rate (16.1% and 9.2%, respectively). The estimated 12-week costs of an initial inpatient stay for patients with delirium were more than double the costs of an inpatient stay for patients without delirium (e.g. in Scotland, £7559, 95% CI £7362 to £7755, vs. £4215, 95% CI £4175 to £4254). The estimated cost of false-positive cases was £4653, of false-negative cases was £8956, and of a missed diagnosis was £2067. LIMITATIONS Patients were aged ≥ 70 years and were assessed soon after they were admitted, limiting generalisability. The treatment of patients in accordance with reference standard diagnosis limited the ability to assess comparative cost-effectiveness. CONCLUSIONS These findings support the use of the 4AT as a rapid delirium assessment instrument. The 4AT has acceptable diagnostic accuracy for acute older patients aged > 70 years. FUTURE WORK Further research should address the real-world implementation of delirium assessment. The 4AT should be tested in other populations. TRIAL REGISTRATION Current Controlled Trials ISRCTN53388093. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 40. See the NIHR Journals Library website for further project information. The funder specified that any new delirium assessment tool should be compared against the CAM, but had no other role in the study design or conduct of the study.
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Affiliation(s)
| | - Susan D Shenkin
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Steve Goodacre
- Emergency Medicine, University of Sheffield, Sheffield, UK
| | - Mary Godfrey
- Health and Social Care, Leeds Institute of Health Sciences, School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Janet Hanley
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Antaine Stíobhairt
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Elizabeth Lavender
- Health and Social Care, Leeds Institute of Health Sciences, School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Julia Boyd
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK.,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Christopher Weir
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK.,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Allan MacRaild
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Jill Steven
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Polly Black
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Katharina Diernberger
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Peter Hall
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Zoë Tieges
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Christopher Fox
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Atul Anand
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - John Young
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK
| | - Najma Siddiqi
- Psychiatry, University of York, York.,Hull York Medical School, York, UK.,Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Alasdair Gray
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
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Zhang W, Wang T, Wang G, Yang M, Zhou Y, Yuan Y. Effects of Dexmedetomidine on Postoperative Delirium and Expression of IL-1β, IL-6, and TNF-α in Elderly Patients After Hip Fracture Operation. Front Pharmacol 2020; 11:678. [PMID: 32477139 PMCID: PMC7235357 DOI: 10.3389/fphar.2020.00678] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 04/24/2020] [Indexed: 12/18/2022] Open
Abstract
Objective Postoperative delirium (POD) is a common surgical complication in elderly patients. This study investigated the effects of dexmedetomidine on POD and pro-inflammatory markers in elderly patients with hip fracture. Methods This randomized, double-blind, controlled trial enrolled patients ≥65 years of age who underwent an operation for hip fracture at Beijing JiShuiTan Hospital from October 2016 to January 2017. The patients were divided into the DEX group (injected with dexmedetomidine 0.5 µg/kg/h) and the NS group (injected with normal saline). After surgery, the incidence of delirium at postoperative day 1 (T1), 2 (T2), and 3 (T3) was assessed using the Confusion Assessment Method delirium scale. Interleukin (IL)-1β, IL-6, and tumor necrosis factor (TNF)-α blood levels were detected at T0 (before surgery), T1, and T3. Results Data from 240 patients were analyzed, with 120/group (intent-to-treat analysis). Dexmedetomidine decreased POD incidence (18.2 vs. 30.6%, P = 0.033). Compared to T0, all three pro-inflammatory markers were higher at T1 and then decreased at T3 (time interaction, all P < 0.001). IL-6 (P < 0.001) levels were lower in the DEX group at T1, and TNF-α (P = 0.003) levels were lower in the DEX group at T1 and T3, but IL-1β levels were similar between the two groups. The rate of adverse events was similar in the two groups. Conclusion Dexmedetomidine reduced the incidence of POD in elderly patients on the first day after hip fracture surgery, and reduced IL-6 and TNF-α levels over the first 3 days after surgery.
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Affiliation(s)
- Wenchao Zhang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Geng Wang
- Department of Anesthesiology, Beijing Jishuitan Hospital, Beijing, China
| | - Minghui Yang
- Department of Orthopaedics & Traumatology, Beijing Jishuitan Hospital, Beijing, China
| | - Yan Zhou
- Department of Anesthesiology, Beijing Jishuitan Hospital, Beijing, China
| | - Yi Yuan
- Department of Anesthesiology, Beijing Jishuitan Hospital, Beijing, China
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20
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Kristoffersen MH, Dybvik E, Steihaug OM, Kristensen TB, Engesaeter LB, Ranhoff AH, Gjertsen JE. Cognitive impairment influences the risk of reoperation after hip fracture surgery: results of 87,573 operations reported to the Norwegian Hip Fracture Register. Acta Orthop 2020; 91:146-151. [PMID: 31928100 PMCID: PMC7144309 DOI: 10.1080/17453674.2019.1709712] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - About one-fourth of hip fracture patients have cognitive impairment. We investigated whether patients' cognitive function affects surgical treatment, risk of reoperation, and mortality after hip fracture, based on data in the Norwegian Hip Fracture Register (NHFR).Patients and methods - This prospective cohort study included 87,573 hip fractures reported to the NHFR in 2005-2017. Hazard rate ratios (HRRs) for risk of reoperation and mortality were calculated using Cox regression adjusted for sex, age, ASA class, fracture type, and surgical method.Results - Cognitive impairment was reported in 27% of patients. They were older (86 vs. 82 years) and had higher ASA class than non-impaired patients. There were no differences in fracture type or operation methods. Cognitively impaired patients had a lower overall reoperation rate (4.7% vs. 8.9%, HRR 0.71; 95% CI 0.66-0.76) and lower risk of reoperation after osteosynthesis (HRR 0.58; CI 0.53-0.63) than non-impaired patients. Cognitively impaired hip fracture patients had an increased reoperation risk after hemiarthroplasty (HRR 1.2; CI 1.1-1.4), mainly due to dislocations (1.5% vs. 1.0%, HRR 1.7; CI 1.3-2.1). Risk of dislocation was particularly high following the posterior approach (4.7% vs. 2.8%, HRR 1.8; CI 1.2-2.7). Further, they had a higher risk of reoperation due to periprosthetic fracture after uncemented hemiarthroplasty (HRR 1.6; CI 1.0-2.6). Cognitively impaired hip fracture patients had higher 1-year mortality than those without cognitive impairment (38% vs. 16%, HRR 2.1; CI 2.1-2.2).Interpretation - Our findings support giving cognitively impaired patients the same surgical treatment as non-impaired patients. But since the risk of hemiprosthesis dislocation and periprosthetic fracture was higher in cognitively impaired patients, they should probably not have posterior approach surgery or uncemented implants.
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Affiliation(s)
- Målfrid Holen Kristoffersen
- Norwegian Hip Fracture Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen; ,Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen; ,Correspondence:
| | - Eva Dybvik
- Norwegian Hip Fracture Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen;
| | | | - Torbjørn Berge Kristensen
- Norwegian Hip Fracture Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen; ,Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen;
| | - Lars Birger Engesaeter
- Norwegian Hip Fracture Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen;
| | - Anette Hylen Ranhoff
- Diakonhjemmet Hospital, Oslo; ,Department of Clinical Sciences, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Jan-Erik Gjertsen
- Norwegian Hip Fracture Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen; ,Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen;
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21
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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] [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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Menzenbach J, Guttenthaler V, Kirfel A, Ricchiuto A, Neumann C, Adler L, Kieback M, Velten L, Fimmers R, Mayr A, Wittmann M. Estimating patients' risk for postoperative delirium from preoperative routine data - Trial design of the PRe-Operative prediction of postoperative DElirium by appropriate SCreening (PROPDESC) study - A monocentre prospective observational trial. Contemp Clin Trials Commun 2019; 17:100501. [PMID: 31890984 PMCID: PMC6926123 DOI: 10.1016/j.conctc.2019.100501] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/14/2019] [Accepted: 11/21/2019] [Indexed: 11/09/2022] Open
Abstract
Background Postoperative Delirium (POD) is the most common complication of elderly patients after surgery associated with increased postoperative morbidity, persistent care dependency and even mortality. Prevention of POD requires detection of patients at high risk prior to surgery. PROPDESC intends to provide an instrument for preoperative routine screening of patients' risk for POD. Methods PROPDESC is a monocentric prospective observatory trial including 1000 patients older than 60 years from various disciplines of a university hospital planned for surgery of at least 60 min. To develop a score predicting the risk for POD, anesthesiological stratifications, laboratory values, medication and known risk factors as well as quality of life and cognitive performance are taken into account. POD assessment is performed daily on the first five days after the operation respectively the end of sedation in the intensive care units and normal wards. The score is evaluated from 600 data sets and subsequently validated internally. The most appropriate predictors are determined by a component-wise gradient boosting approach. Discussion Based on retrospective investigations, etiology of POD is considered multifactorial. By a prospective analysis of various factors, PROPDESC intends to provide an applicable tool to predict the risk for POD from preoperative routine data and assessment of cognitive function. Objective is to establish an automatically generating score in preoperative routine to screen patients for increased risk of POD as starting point for POD reduction and management. Model compilation requires a high significance and enhancement within compound as well as regular availability of the selected predictors. Trial registration DRKS, DRKS00015715. Registered 13 December 2018 - Retrospectively registered, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00015715.
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Affiliation(s)
- Jan Menzenbach
- Clinic for Anesthesiology of University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Vera Guttenthaler
- Clinic for Anesthesiology of University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Andrea Kirfel
- Clinic for Anesthesiology of University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Arcangelo Ricchiuto
- Institute for Medical Biometry, Informatics and Epidemiology at the University of Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Claudia Neumann
- Clinic for Anesthesiology of University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Linda Adler
- Clinic for Anesthesiology of University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Marjetka Kieback
- Clinic for Anesthesiology of University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Lisa Velten
- Clinic for Anesthesiology of University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Rolf Fimmers
- Institute for Medical Biometry, Informatics and Epidemiology at the University of Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Andreas Mayr
- Institute for Medical Biometry, Informatics and Epidemiology at the University of Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Maria Wittmann
- Clinic for Anesthesiology of University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
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Lee SJ, Jung SH, Lee SU, Lim JY, Yoon KS, Lee SY. Postoperative delirium after hip surgery is a potential risk factor for incident dementia: A systematic review and meta-analysis of prospective studies. Arch Gerontol Geriatr 2019; 87:103977. [PMID: 31751902 DOI: 10.1016/j.archger.2019.103977] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 11/07/2019] [Accepted: 11/07/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Although a few trials have explored the relationship between postoperative delirium (POD) and incident dementia in patients with hip surgery, the numbers of participants in each study are relatively small. Thus, we performed a meta-analysis to examine whether POD after hip surgery is a risk factor for incident dementia. METHODS Six prospective cohort studies investigating the development of incident dementia in patients with POD after hip surgery were retrieved from PubMed, Embase, and the Cochrane Library. We performed a pairwise meta-analysis using fixed- and random- effect models. RESULTS POD significantly increased the risk of incident dementia and cognitive decline (overall odds ratio [ORs] = 8.957; 95 % confidence interval [CI], 5.444-14.737; P < 0.001 in fixed-effects model; overall ORs = 8.962; 95 % CI, 5.344-15.029; P < 0.001 in random-effects model). A publication bias was not evident in this study. CONCLUSIONS Our meta-analysis revealed that POD after hip surgery is a risk factor for incident dementia. Early identification of cognitive function should be needed after surgery and appropriate prevention and treatment for dementia will be required, especially in cases with POD.
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Affiliation(s)
- Soong Joon Lee
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Se Hee Jung
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Shi-Uk Lee
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Jae-Young Lim
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Kang-Sup Yoon
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Sang Yoon Lee
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea.
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24
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Kristoffersen MH, Dybvik E, Steihaug OM, Bartz-Johannesen CA, Martinsen MI, Ranhoff AH, Engesæter LB, Gjertsen JE. Validation of orthopaedic surgeons' assessment of cognitive function in patients with acute hip fracture. BMC Musculoskelet Disord 2019; 20:268. [PMID: 31153373 PMCID: PMC6545206 DOI: 10.1186/s12891-019-2633-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Accepted: 05/16/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND About one fourth of patients with hip fracture have cognitive impairment. These patients are at higher risk of surgical and medical complications and are often excluded from participating in clinical research. The aim of the present study was to investigate orthopaedic surgeons' ability to determine the cognitive status of patients with acute hip fracture and to compare the treatment given to patients with and without cognitive impairment. METHODS The cognitive function of 1474 hip fracture patients reported by the orthopaedic surgeons to the nationwide Norwegian Hip Fracture Register was compared with data registered in quality databases in two hospitals with orthogeriatric service on the same patients. Cognitive function registered in the quality databases was determined either by the short form of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) or by pre-fracture diagnosis of dementia. The information registered in the quality databases was defined as the reference standard. Cognitive function in the Norwegian Hip Fracture Register was reported as: Chronic cognitive impairment? "Yes", "Uncertain" or "No" by the orthopaedic surgeons. Sensitivity, specificity, negative and positive predictive values for chronic cognitive impairment reported to the Norwegian Hip Fracture Register by the orthopaedic surgeons was calculated. Baseline data and treatment of hip fractures in patients with and without cognitive impairment in the Norwegian Hip Fracture Register were compared. RESULTS Orthopaedic surgeons reported chronic cognitive impairment in 31% of the patients. Using documented dementia or IQCODE > 4.0 as the reference, this assessment of cognitive impairment by the orthopaedic surgeons had a sensitivity of 69%, a specificity of 90%, a positive predictive value of 78%, and a negative predictive value of 84% compared to information registered in the two hospital quality databases. There were no differences in type of hip fracture or type of surgical treatment by cognitive function. CONCLUSION The treatment of hip fractures was similar in patients with chronic cognitive impairment and cognitively well-functioning patients. The surgeons had an acceptable ability to identify and report chronic cognitive impairment in the peri-operative period, indicating that the Norwegian Hip Fracture Register is a valuable resource for future registry-based research also on hip fracture patients with chronic cognitive impairment.
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Affiliation(s)
- Målfrid Holen Kristoffersen
- Norwegian Hip Fracture Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Jonas Lies vei 65, N 5021, Bergen, Norway. .,Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Haukelandsveien 28, N 5009, Bergen, Norway.
| | - Eva Dybvik
- Norwegian Hip Fracture Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Jonas Lies vei 65, N 5021, Bergen, Norway
| | | | | | | | - Anette Hylen Ranhoff
- Diakonhjemmet Hospital, Postboks 23 Vindern, N 0319, Oslo, Norway.,Department of Clinical Sciences, Faculty of Medicine, University of Bergen, Haukelandsveien 28, N 5009, Bergen, Norway
| | - Lars Birger Engesæter
- Norwegian Hip Fracture Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Jonas Lies vei 65, N 5021, Bergen, Norway.,Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Haukelandsveien 28, N 5009, Bergen, Norway
| | - Jan-Erik Gjertsen
- Norwegian Hip Fracture Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Jonas Lies vei 65, N 5021, Bergen, Norway.,Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Haukelandsveien 28, N 5009, Bergen, Norway
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Duggan MC, Morrell ME, Chandrasekhar R, Marra A, Frimpong K, Nair DR, Girard TD, Pandharipande PP, Ely EW, Jackson JC. A Brief Informant Screening Instrument for Dementia in the ICU: The Diagnostic Accuracy of the AD8 in Critically Ill Adults Suspected of Having Pre-Existing Dementia. Dement Geriatr Cogn Disord 2019; 48:241-249. [PMID: 32259825 PMCID: PMC9528182 DOI: 10.1159/000490379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 05/24/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIM The diagnostic accuracy of brief informant screening instruments to detect dementia in critically ill adults is unknown. We sought to determine the diagnostic accuracy of the 2- to 3-min Ascertain Dementia 8 (AD8) completed by surrogates in detecting dementia among critically ill adults suspected of having pre-existing dementia by comparing it to the Clinical Dementia Rating Scale (CDR). METHODS This substudy of BRAIN-ICU included a subgroup of 75 critically ill medical/surgical patients determined to be at medium risk of having pre-existing dementia (Informant Questionnaire on Cognitive Decline in the Elderly [IQCODE] score ≥3.3). We calculated the sensitivity, specificity, positive and negative predictive values (PPV and NPV), and AUC for the standard AD8 cutoff of ≥2 versus the reference standard CDR score of ≥1 for mild dementia. RESULTS By the CDR, 38 patients had very mild or no dementia and 37 had mild dementia or greater. For diagnosing mild dementia, the AD8 had a sensitivity of 97% (95% CI 86-100), a specificity of 16% (6-31), a PPV of 53% (40-65), an NPV of 86% (42-100), and an AUC of 0.738 (0.626-0.850). CONCLUSIONS Among critically ill patients judged at risk for pre-existing dementia, the 2- to 3-min AD8 is highly sensitive and has a high NPV. These data indicate that the brief tool can serve to rule out dementia in a specific patient population.
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Affiliation(s)
- Maria C. Duggan
- Geriatric Research Education and Clinical Center (GRECC), Department of Veteran Affairs, Tennessee Valley Healthcare System, Nashville, TN, USA;,Division of Geriatric Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Madeline E. Morrell
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Rameela Chandrasekhar
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Annachiara Marra
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA;,Department of Neurosciences, Reproductive and Odontostomatological Sciences, Department of Public Health, University of Naples, Naples, Italy
| | - Kwame Frimpong
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA;,Center for Health Services Research, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Deepanjali R. Nair
- Center for Health Services Research, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Timothy D. Girard
- Geriatric Research Education and Clinical Center (GRECC), Department of Veteran Affairs, Tennessee Valley Healthcare System, Nashville, TN, USA;,Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA;,Center for Health Services Research, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Pratik P. Pandharipande
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN, USA;,Anesthesia Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - E. Wesley Ely
- Geriatric Research Education and Clinical Center (GRECC), Department of Veteran Affairs, Tennessee Valley Healthcare System, Nashville, TN, USA;,Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA;,Center for Health Services Research, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - James C. Jackson
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA;,Center for Health Services Research, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA;,Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, TN, USA;,Research Service, Department of Veteran Affairs, Tennessee Valley Healthcare System, Nashville, TN, USA
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Henjum K, Quist-Paulsen E, Zetterberg H, Blennow K, Nilsson LNG, Watne LO. CSF sTREM2 in delirium-relation to Alzheimer's disease CSF biomarkers Aβ42, t-tau and p-tau. J Neuroinflammation 2018; 15:304. [PMID: 30390679 PMCID: PMC6215363 DOI: 10.1186/s12974-018-1331-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 10/09/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Delirium and dementia share symptoms of cognitive dysfunctions, and mechanisms of neuroinflammation appear involved in both conditions. Triggering receptor expressed on myeloid cells 2 (TREM2) is linked to dementia and neurodegenerative disease. It encodes expression of an innate immune receptor in the brain expressed by microglia. The level of the soluble fragment of TREM2 (sTREM2) is reported to increase in the cerebrospinal fluid (CSF) already in prodromal and asymptomatic Alzheimer's disease. METHODS We analyzed the level of CSF sTREM2 in relation to delirium and dementia. The study included patients with or without pre-existing dementia who underwent acute hip fracture surgery (n = 120), and some of the patients developed delirium (n = 65). A medical delirium cohort (n = 26) was also examined. ELISA was used to determine the level of sTREM2 in CSF. RESULTS Delirium was associated with a higher level of CSF sTREM2 only among those without pre-existing dementia (p = 0.046, n = 15, n = 44), particularly among patients developing delirium after CSF sampling (p = 0.02, n = 7, n = 44). Between patients with dementia, there was no group difference, but the CSF sTREM2 level increased with waiting time for surgery (rS = 0.39, p = 0.002, n = 60) and correlated well with the CSF Alzheimer's disease biomarkers, Aβ42, and t-tau/p-tau (rS = 0.40, p = 0.002, rS = 0.46, p < 0.001/ rS = 0.49, p < 0.001, n = 60). Among patients with dementia, the level of Aβ38 and Aβ40 also correlated positively with sTREM2 in CSF (Aβ38MSDrS = 0.44, p = 0.001; Aβ40MSDrS = 0.48, p < 0.001; Aβ42MSDrS = 0.43, p < 0.001, n = 60). CONCLUSION The findings reinforce the involvement of neuroinflammation in delirium, yet with separate responses in patients with or without pre-existing dementia. Our findings support the concept of primed microglia in neurodegenerative disease and central immune activation after a peripheral trauma in such patients. A CSF biomarker panel of neuroinflammation might be valuable to prevent delirium by identifying patients at risk.
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Affiliation(s)
- Kristi Henjum
- Department of Pharmacology, Institute of Clinical Medicine, University of Oslo and Oslo University Hospital, P.O. box 1057 Blindern, 0316, Oslo, Norway.
| | - Else Quist-Paulsen
- Department of Infectious Diseases, Oslo University Hospital, Ullevaal Hospital, P.O. Box 4956 Nydalen, N-0450, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, P.O. Box 1171 Blindern, 0318, Oslo, Norway
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, SE-431 80, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, SE-431 80, Mölndal, Sweden.,Department of Degenerative Disease, UCL Institute of Neurology, Queen Square, Gower Street, London, WC1E 6BT, UK.,UK Dementia Research Institute at UCL, Gower Street, London, WC1E 6BT, UK
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, SE-431 80, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, SE-431 80, Mölndal, Sweden
| | - Lars N G Nilsson
- Department of Pharmacology, Institute of Clinical Medicine, University of Oslo and Oslo University Hospital, P.O. box 1057 Blindern, 0316, Oslo, Norway
| | - Leiv Otto Watne
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, PO box 4950 Nydalen, N-0424, Oslo, Norway.,Institute of Basic Medical Sciences, University of Oslo, Domus Medica, Sognsvannsveien 9, N-0372, Oslo, Norway
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27
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Beyond orthogeriatric co-management model: benefits of implementing a process management system for hip fracture. Arch Osteoporos 2018; 13:81. [PMID: 30046907 DOI: 10.1007/s11657-018-0497-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 07/17/2018] [Indexed: 02/03/2023]
Abstract
UNLABELLED Hip fracture is a major health care problem worldwide. Business process management systems (PMSs) have made significant contributions in health care environments to improve patient care standards. The effectiveness of PMS applied to hip fracture in older adults in the acute phase has been demonstrated. INTRODUCTION Fragility fracture is a major health care problem worldwide. Business PMSs have made significant contributions in health care environments to improve patient care standards. It is a new way of management that defines a homogeneous application procedure involving eliminating steps that add no value and developing explicit supervision criteria, in addition to identifying the appropriate managers. PURPOSE The aim of our trial was to assess the effectiveness of the PMS applied to hip fracture versus the orthogeriatric co-management model in the acute phase. METHODS All consecutive patients aged ≥ 65 who were admitted to Hospital Universitario Infanta Leonor between January 1, 2009, and December 31, 2016, for acute hip fracture surgery were included. We compared the effectiveness indicators in the acute phase between the preprocess period (orthogeriatric co-management) and the process period. RESULTS One thousand two hundred twenty-two patients were included (76.6% women). Mean age (SD) was 83.9 (6.4) years. Effectiveness management indicators are the following: length of hospital stay, time to admission to the ward from the emergency department, preoperative stay, surgery in < 48 h, and the operating room availability which were all improved in the process period with statistical significance. Effectiveness clinical indicators are the following: the numbers of patients with operated limb loading approved after surgery, discharged to home, and with osteoporosis treatment postfracture at the time of discharge which were statistically significantly higher in the process period, and the number of patients who suffered from delirium was statistically significantly lower in the process period. The number of in-hospital deaths was lower during the process period without statistical significance. CONCLUSION Our results demonstrated the effectiveness of the PMS applied to hip fracture in older adults compared with an orthogeriatric co-management model in the acute phase, based on both management indicators and clinical indicators.
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28
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Olofsson B, Persson M, Bellelli G, Morandi A, Gustafson Y, Stenvall M. Development of dementia in patients with femoral neck fracture who experience postoperative delirium-A three-year follow-up study. Int J Geriatr Psychiatry 2018; 33:623-632. [PMID: 29292537 DOI: 10.1002/gps.4832] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 11/02/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVES It remains unclear to what extent postoperative delirium (POD) affects the incidence of dementia in hip fracture patients, and the methods used to detect delirium and dementia require validation. The aim of this study was to investigate the development of dementia within 3 years of femoral neck fracture repair surgery, with a focus on POD as a potential predictive factor. METHODS Patients were assessed for cognition, delirium, depression, psychological well-being, and nutritional status during their hospitalization as well as 4, 12, and 36 months after the operation. Logistic regression models were used to analyse factors associated with POD and factors associated with the development of dementia. RESULTS The study sample consisted of 135 patients without a history of dementia, of whom 20 (14.8%) were delirious preoperatively and 75 (55.5%) postoperatively. Three years after their operations, 43/135 patients (31.8%) were diagnosed with dementia. A greater portion of patients diagnosed with dementia (39/43, 90.6%) than patients with no dementia (36/92, 39.1%) were included among the 75 patients who had experienced POD (P < 0.001). In a logistic regression model, after adjustment for covariates (age, sex, diabetes, delirium pre-and postoperatively, hyperactive delirium, days with delirium, urinary tract infection, and Mini Nutritional Assessment score), POD emerged an independent predictor for the development of new dementia (odds ratio, 15.6; 95% confidence interval, 2.6-91.6) within 3 years after the operation. CONCLUSION Geriatric hip fracture patients who exhibit POD should be monitored closely for the development of dementia.
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Affiliation(s)
- B Olofsson
- Department of Nursing, Umeå University, Umeå, Sweden.,Department of Surgical and Perioperative Science, Orthopaedics, Umeå University, Umeå, Sweden
| | - M Persson
- Department of Nursing, Umeå University, Umeå, Sweden
| | - G Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - A Morandi
- Department of Rehabilitation, Ancelle Hospital Cremona, Italy
| | - Y Gustafson
- Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, Umeå, Sweden
| | - M Stenvall
- Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, Umeå, Sweden
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29
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Blandfort S, Gregersen M, Borris LC, Damsgaard EM. Blood transfusion strategy and risk of postoperative delirium in nursing homes residents with hip fracture. A post hoc analysis based on the TRIFE randomized controlled trial. Aging Clin Exp Res 2017; 29:459-466. [PMID: 27251666 DOI: 10.1007/s40520-016-0587-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 05/05/2016] [Indexed: 01/05/2023]
Abstract
OBJECTIVES To investigate whether a liberal blood transfusion strategy [Hb levels ≥11.3 g/dL (7 mmol/L)] reduces the risk of postoperative delirium (POD) on day 10, among nursing home residents with hip fracture, compared to a restrictive transfusion strategy [Hb levels ≥9.7 g/dL (6 mmol/L)]. Furthermore, to investigate whether POD influences mortality within 90 days after hip surgery. METHODS This is a post hoc analysis based on The TRIFE - a randomized controlled trial. Frail anemic patients from the Orthopedic Surgical Ward at Aarhus University Hospital were enrolled consecutively between January 18, 2010 and June 6, 2013. These patients (aged ≥65 years) had been admitted from nursing homes for unilateral hip fracture surgery. After surgery, 179 patients were included in this study. On the first day of hospitalization, all enrolled patients were examined for cognitive impairment (assessed by MMSE) and delirium (assessed by CAM). Delirium was also assessed on the tenth postoperative day. RESULTS The prevalence of delirium was 10 % in patients allocated to a liberal blood transfusion strategy (LB) and 21 % in the group with a restrictive blood transfusion strategy (RB). LB prevents development of delirium on day 10, compared to RB, odds ratio 0.41 (95 % CI 0.17-0.96), p = 0.04. Development of POD on day 10 increased the risk of 90-day death, hazard ratio 3.14 (95 % CI 1.72-5.78), p < 0.001. CONCLUSION In nursing home residents undergoing surgery for hip fracture, maintaining hemoglobin level above 11.3 g/dL reduces the rate of POD on day 10 compared to a RB. Development of POD is associated with increased mortality.
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Affiliation(s)
- Sif Blandfort
- Department of Geriatrics, Aarhus University Hospital, P.P. Ørumsgade 11, Building 7, 8000, Aarhus C, Denmark.
| | - Merete Gregersen
- Department of Geriatrics, Aarhus University Hospital, P.P. Ørumsgade 11, Building 7, 8000, Aarhus C, Denmark
| | - Lars Carl Borris
- Department of Orthopedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Else Marie Damsgaard
- Department of Geriatrics, Aarhus University Hospital, P.P. Ørumsgade 11, Building 7, 8000, Aarhus C, Denmark
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Abstract
A comprehensive geriatric assessment, combined with a battery of imaging and blood tests, should be able to identify those hip fracture patients who are at higher risk of short- and long-term complications. This comprehensive assessment should be followed by the implementation of a comprehensive multidimensional care plan aimed to prevent negative outcomes in the postoperative period (short and long term), thus assuring a safe and prompt functional recovery while also preventing future falls and fractures.
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Beishuizen SJE, van Munster BC, de Jonghe A, Abu-Hanna A, Buurman BM, de Rooij SE. Distinct Cognitive Trajectories in the First Year After Hip Fracture. J Am Geriatr Soc 2017; 65:1034-1042. [PMID: 28152178 DOI: 10.1111/jgs.14754] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Change in cognitive functioning is often observed after hip fracture. Different patterns, with both improvement and decline, are expected, depending on premorbid cognitive functioning and events that occur during hospitalization. These patterns are unknown and important for older hip fracture patients with different levels of premorbid cognitive functioning. DESIGN, SETTING, PARTICIPANTS, MEASUREMENTS We conducted a secondary analysis of a multi-center randomized controlled trial. 302 consecutive patients aged 65-102 years old, admitted for hip fracture surgery, were enrolled. The Mini Mental State Examination (MMSE) was obtained at hospital admission, at discharge, and at 3 and 12 months after discharge. Cognitive trajectories were identified with Group Based Trajectory Modelling, using the repeated MMSE measurements as outcome variable. To illustrate the specific characteristics of this relative novel methodological approach, it was contrasted with results obtained from linear mixed effects modeling. RESULTS 146 (48.3%) patients had premorbid cognitive impairment and 85 patients (28.1%) experienced delirium during admission. Three distinct cognitive trajectories were identified and labeled based on different MMSE course over time: improvement (57.9%), stable (28.1%), and rapid decline (13.9%), with an annual MMSE change of 1.7, 0.8, and -3.5 points respectively. With mixed effects modeling an overall annual increase of 0.7 MMSE points was estimated for the group as a whole. CONCLUSION Three distinct cognitive trajectories were identified in a population of older hip fracture patients. These trajectory groups can be used as a starting point to inform patients and caregivers on the possible prognosis after hip fracture. Group based trajectory modelling is a useful technique when the purpose is to describe patterns of change within a population and a variety of trajectories are expected to exist.
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Affiliation(s)
- Sara J E Beishuizen
- Department of Internal Medicine, Geriatrics Section, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Barbara C van Munster
- Department of Geriatrics, Gelre Hospitals, Apeldoorn, The Netherlands.,Department of Internal Medicine, University Center of Geriatric Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Ameen Abu-Hanna
- Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Bianca M Buurman
- Department of Internal Medicine, Geriatrics Section, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Sophia E de Rooij
- Department of Internal Medicine, Geriatrics Section, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Department of Internal Medicine, University Center of Geriatric Medicine, University Medical Center Groningen, Groningen, The Netherlands
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Barth A, Vatterrott A, Zhou Y, Fink A, Doblhammer G. Extremity injuries and dementia disproportionately increase the risk for long-term care at older age in an analysis of German Health Insurance routine data for the years 2006 to 2010. Eur Rev Aging Phys Act 2016; 13:9. [PMID: 27980691 PMCID: PMC5139115 DOI: 10.1186/s11556-016-0169-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 11/23/2016] [Indexed: 11/13/2022] Open
Abstract
Background Extremity injuries (EI) and dementia are important causes of long-term care (LTC), but they can also cause each other and are often present concurrently. Mobility-limiting EI can increase the risk of dementia, and dementia increases the risk for falls, which are often the cause of EI. When EI and dementia are present together, they can increase their negative effect on long-term care risk. This study aims to assess the strength of this interaction and the role of different body regions and severities of EI regarding LTC risk. Methods We use Cox proportional-hazard models on LTC as dependent variable. EI (primarily fractures) and dementia (all types) are the central independent variables. We control for age, sex, rehabilitation and 18 relevant comorbidities. Analyses are based on health claims records for 2004–2010 for a random sample of about 122.000 insurants of Germany's largest public health insurance "AOK" aged 65+, about 25.000 of whom entered LTC. Results Without concurrent dementia, non-severe EI (NSEI) of the lower and both extremities and all kinds of severe EI (SEI) increase LTC risk (HR: hazard ratio with 95% confidence interval. Lower NSEI: HR = 1.09 [1.05–1.14]; both NSEI: HR = 1.36 [1.29–1.44]. Lower SEI: HR = 1.67 [1.57–1.79]; upper SEI: HR = 1.27 [1.19–1.37]; both SEI: HR = 1.94 [1.81–2.07]). Dementia alone increases LTC risk more than fourfold (HR = 4.23 [4.11–4.35]). Taking the interaction of EI and dementia into account, the concurrent presence of EI and dementia tends to increase the LTC risk more than expected for lower as well as upper NSEI and SEI. Summarily, when lower or upper EI and dementia are both present, the LTC risk tends to be higher than expected, suggesting synergistic effects. Conclusions EI and dementia are important independent risk factors for long-term care. When lower or upper EI and dementia are present together, the resulting long-term care risk is increased disproportionately. Since the concurrent presence of both conditions increases the risk for care need, and a working treatment for dementia is not in sight, preventing EI, lessening the impact of EI and improving the outlook after an EI could help to reduce LTC need in the coming decades.
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Affiliation(s)
- Alexander Barth
- Empirical Social Research and Demography, Institute of Sociology and Demography, University of Rostock, Ulmenstr. 69, 18057 Rostock, Germany
| | - Anja Vatterrott
- Empirical Social Research and Demography, Institute of Sociology and Demography, University of Rostock, Ulmenstr. 69, 18057 Rostock, Germany
| | - Ying Zhou
- Empirical Social Research and Demography, Institute of Sociology and Demography, University of Rostock, Ulmenstr. 69, 18057 Rostock, Germany
| | - Anne Fink
- German Center for Neurodegenerative Diseases, Rostock, Germany
| | - Gabriele Doblhammer
- Empirical Social Research and Demography, Institute of Sociology and Demography, University of Rostock, Ulmenstr. 69, 18057 Rostock, Germany ; Rostock Center for the Study of Demographic Change, Rostock, Germany ; German Center for Neurodegenerative Diseases, Bonn/Rostock, Germany
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Harrison JK, Stott DJ, McShane R, Noel‐Storr AH, Swann‐Price RS, Quinn TJ. Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) for the early diagnosis of dementia across a variety of healthcare settings. Cochrane Database Syst Rev 2016; 11:CD011333. [PMID: 27869298 PMCID: PMC6477966 DOI: 10.1002/14651858.cd011333.pub2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) is a structured interview based on informant responses that is used to assess for possible dementia. IQCODE has been used for retrospective or contemporaneous assessment of cognitive decline. There is considerable interest in tests that may identify those at future risk of developing dementia. Assessing a population free of dementia for the prospective development of dementia is an approach often used in studies of dementia biomarkers. In theory, questionnaire-based assessments, such as IQCODE, could be used in a similar way, assessing for dementia that is diagnosed on a later (delayed) assessment. OBJECTIVES To determine the diagnostic accuracy of IQCODE in a population free from dementia for the delayed diagnosis of dementia (test accuracy with delayed verification study design). SEARCH METHODS We searched these sources on 16 January 2016: ALOIS (Cochrane Dementia and Cognitive Improvement Group), MEDLINE Ovid SP, Embase Ovid SP, PsycINFO Ovid SP, BIOSIS Previews on Thomson Reuters Web of Science, Web of Science Core Collection (includes Conference Proceedings Citation Index) on Thomson Reuters Web of Science, CINAHL EBSCOhost, and LILACS BIREME. We also searched sources specific to diagnostic test accuracy: MEDION (Universities of Maastricht and Leuven); DARE (Database of Abstracts of Reviews of Effects, in the Cochrane Library); HTA Database (Health Technology Assessment Database, in the Cochrane Library), and ARIF (Birmingham University). We checked reference lists of included studies and reviews, used searches of included studies in PubMed to track related articles, and contacted research groups conducting work on IQCODE for dementia diagnosis to try to find additional studies. We developed a sensitive search strategy; search terms were designed to cover key concepts using several different approaches run in parallel, and included terms relating to cognitive tests, cognitive screening, and dementia. We used standardised database subject headings, such as MeSH terms (in MEDLINE) and other standardised headings (controlled vocabulary) in other databases, as appropriate. SELECTION CRITERIA We selected studies that included a population free from dementia at baseline, who were assessed with the IQCODE and subsequently assessed for the development of dementia over time. The implication was that at the time of testing, the individual had a cognitive problem sufficient to result in an abnormal IQCODE score (defined by the study authors), but not yet meeting dementia diagnostic criteria. DATA COLLECTION AND ANALYSIS We screened all titles generated by the electronic database searches, and reviewed abstracts of all potentially relevant studies. Two assessors independently checked the full papers for eligibility and extracted data. We determined quality assessment (risk of bias and applicability) using the QUADAS-2 tool, and reported quality using the STARDdem tool. MAIN RESULTS From 85 papers describing IQCODE, we included three papers, representing data from 626 individuals. Of this total, 22% (N = 135/626) were excluded because of prevalent dementia. There was substantial attrition; 47% (N = 295) of the study population received reference standard assessment at first follow-up (three to six months) and 28% (N = 174) received reference standard assessment at final follow-up (one to three years). Prevalence of dementia ranged from 12% to 26% at first follow-up and 16% to 35% at final follow-up.The three studies were considered to be too heterogenous to combine, so we did not perform meta-analyses to describe summary estimates of interest. Included patients were poststroke (two papers) and hip fracture (one paper). The IQCODE was used at three thresholds of positivity (higher than 3.0, higher than 3.12 and higher than 3.3) to predict those at risk of a future diagnosis of dementia. Using a cut-off of 3.0, IQCODE had a sensitivity of 0.75 (95%CI 0.51 to 0.91) and a specificity of 0.46 (95%CI 0.34 to 0.59) at one year following stroke. Using a cut-off of 3.12, the IQCODE had a sensitivity of 0.80 (95%CI 0.44 to 0.97) and specificity of 0.53 (95C%CI 0.41 to 0.65) for the clinical diagnosis of dementia at six months after hip fracture. Using a cut-off of 3.3, the IQCODE had a sensitivity of 0.84 (95%CI 0.68 to 0.94) and a specificity of 0.87 (95%CI 0.76 to 0.94) for the clinical diagnosis of dementia at one year after stroke.In generaI, the IQCODE was sensitive for identification of those who would develop dementia, but lacked specificity. Methods for both excluding prevalent dementia at baseline and assessing for the development of dementia were varied, and had the potential to introduce bias. AUTHORS' CONCLUSIONS Included studies were heterogenous, recruited from specialist settings, and had potential biases. The studies identified did not allow us to make specific recommendations on the use of the IQCODE for the future diagnosis of dementia in clinical practice. The included studies highlighted the challenges of delayed verification dementia research, with issues around prevalent dementia assessment, loss to follow-up over time, and test non-completion potentially limiting the studies. Future research should recognise these issues and have explicit protocols for dealing with them.
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Affiliation(s)
- Jennifer K Harrison
- University of EdinburghCentre for Cognitive Ageing and Cognitive Epidemiology and the Alzheimer Scotland Dementia Research CentreDepartment of Geriatric Medicine, The Royal Infirmary of Edinburgh, Room S164251 Little France CrescentEdinburghUKEH16 4SB
| | - David J Stott
- University of GlasgowInstitute of Cardiovascular and Medical SciencesNew Lister BuildingGlasgow Royal InfirmaryGlasgowStrathclydeUKG4 0SFR
| | - Rupert McShane
- University of OxfordRadcliffe Department of MedicineJohn Radcliffe HospitalLevel 4, Main Hospital, Room 4401COxfordOxfordshireUKOX3 9DU
| | - Anna H Noel‐Storr
- University of OxfordRadcliffe Department of MedicineJohn Radcliffe HospitalLevel 4, Main Hospital, Room 4401COxfordOxfordshireUKOX3 9DU
| | | | - Terry J Quinn
- University of GlasgowInstitute of Cardiovascular and Medical SciencesNew Lister BuildingGlasgow Royal InfirmaryGlasgowStrathclydeUKG4 0SFR
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Bellelli G, Morandi A, Di Santo SG, Mazzone A, Cherubini A, Mossello E, Bo M, Bianchetti A, Rozzini R, Zanetti E, Musicco M, Ferrari A, Ferrara N, Trabucchi M. "Delirium Day": a nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool. BMC Med 2016; 14:106. [PMID: 27430902 PMCID: PMC4950237 DOI: 10.1186/s12916-016-0649-8] [Citation(s) in RCA: 154] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 06/23/2016] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND To date, delirium prevalence in adult acute hospital populations has been estimated generally from pooled findings of single-center studies and/or among specific patient populations. Furthermore, the number of participants in these studies has not exceeded a few hundred. To overcome these limitations, we have determined, in a multicenter study, the prevalence of delirium over a single day among a large population of patients admitted to acute and rehabilitation hospital wards in Italy. METHODS This is a point prevalence study (called "Delirium Day") including 1867 older patients (aged 65 years or more) across 108 acute and 12 rehabilitation wards in Italian hospitals. Delirium was assessed on the same day in all patients using the 4AT, a validated and briefly administered tool which does not require training. We also collected data regarding motoric subtypes of delirium, functional and nutritional status, dementia, comorbidity, medications, feeding tubes, peripheral venous and urinary catheters, and physical restraints. RESULTS The mean sample age was 82.0 ± 7.5 years (58 % female). Overall, 429 patients (22.9 %) had delirium. Hypoactive was the commonest subtype (132/344 patients, 38.5 %), followed by mixed, hyperactive, and nonmotoric delirium. The prevalence was highest in Neurology (28.5 %) and Geriatrics (24.7 %), lowest in Rehabilitation (14.0 %), and intermediate in Orthopedic (20.6 %) and Internal Medicine wards (21.4 %). In a multivariable logistic regression, age (odds ratio [OR] 1.03, 95 % confidence interval [CI] 1.01-1.05), Activities of Daily Living dependence (OR 1.19, 95 % CI 1.12-1.27), dementia (OR 3.25, 95 % CI 2.41-4.38), malnutrition (OR 2.01, 95 % CI 1.29-3.14), and use of antipsychotics (OR 2.03, 95 % CI 1.45-2.82), feeding tubes (OR 2.51, 95 % CI 1.11-5.66), peripheral venous catheters (OR 1.41, 95 % CI 1.06-1.87), urinary catheters (OR 1.73, 95 % CI 1.30-2.29), and physical restraints (OR 1.84, 95 % CI 1.40-2.40) were associated with delirium. Admission to Neurology wards was also associated with delirium (OR 2.00, 95 % CI 1.29-3.14), while admission to other settings was not. CONCLUSIONS Delirium occurred in more than one out of five patients in acute and rehabilitation hospital wards. Prevalence was highest in Neurology and lowest in Rehabilitation divisions. The "Delirium Day" project might become a useful method to assess delirium across hospital settings and a benchmarking platform for future surveys.
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Affiliation(s)
- Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy. .,Geriatric Unit, San Gerardo University Hospital, Monza, Italy. .,Geriatric Research Group, Brescia, Italy.
| | - Alessandro Morandi
- Geriatric Research Group, Brescia, Italy.,Department of Rehabilitation and Aged Care "Fondazione Camplani" Hospital, Cremona, Italy
| | - Simona G Di Santo
- Department of Clinical and Behavioral Neurology, Neuropsychiatry Laboratory, IRCCS Foundation S Lucia, Roma, Italy
| | | | | | - Enrico Mossello
- Research Unit of Medicine of Ageing, Department of Experimental and Clinical Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Mario Bo
- Section of Geriatrics, Città della Salute e della Scienza - Molinette, Torino, Italy
| | - Angelo Bianchetti
- Medicine and Rehabilitation Department, Istituto Clinico S. Anna, Brescia, Italy
| | - Renzo Rozzini
- Department of Geriatric and Internal Medicine, Poliambulanza Hospital, Brescia, Italy
| | | | - Massimo Musicco
- Institute of Biomedical Technologies, National Research Council, Segrate (Milan), Italy.,Italian Society of Neurology for Dementia (SINDEM), Siena, Italy
| | - Alberto Ferrari
- Geriatric Unit, Department of Neuromotor Physiology, ASMN Hospital, Reggio Emilia, Italy.,Italian Society of Hospital and Community Geriatrics (SIGOT), Roma, Italy
| | - Nicola Ferrara
- Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy.,Salvatore Maugeri Foundation, IRCCS, Scientific Institute of Telese, Telese Terme (BN), Italy.,Italian Society of Gerontology and Geriatrics (SIGG), Florence, Italy
| | - Marco Trabucchi
- Geriatric Research Group, Brescia, Italy.,Tor Vergata, Rome University, Rome, Italy.,Italian Psychogeriatric Association (AIP), Brescia, Italy
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Neerland BE, Hall RJ, Seljeflot I, Frihagen F, MacLullich AMJ, Raeder J, Wyller TB, Watne LO. Associations Between Delirium and Preoperative Cerebrospinal Fluid C-Reactive Protein, Interleukin-6, and Interleukin-6 Receptor in Individuals with Acute Hip Fracture. J Am Geriatr Soc 2016; 64:1456-63. [DOI: 10.1111/jgs.14238] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Bjørn Erik Neerland
- Oslo Delirium Research Group; Department of Geriatric Medicine; Oslo University Hospital; Oslo Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - Roanna J. Hall
- Edinburgh Delirium Research Group; University of Edinburgh; Edinburgh UK
- Centre for Cognitive Ageing and Cognitive Epidemiology; University of Edinburgh; Edinburgh UK
| | - Ingebjørg Seljeflot
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
- Center for Clinical Heart Research; Department of Cardiology; Oslo University Hospital; Oslo Norway
| | - Frede Frihagen
- Department of Orthopedic Surgery; Oslo University Hospital; Oslo Norway
| | - Alasdair M. J. MacLullich
- Edinburgh Delirium Research Group; University of Edinburgh; Edinburgh UK
- Centre for Cognitive Ageing and Cognitive Epidemiology; University of Edinburgh; Edinburgh UK
| | - Johan Raeder
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
- Department of Anesthesiology; Oslo University Hospital; Oslo Norway
| | - Torgeir Bruun Wyller
- Oslo Delirium Research Group; Department of Geriatric Medicine; Oslo University Hospital; Oslo Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - Leiv Otto Watne
- Oslo Delirium Research Group; Department of Geriatric Medicine; Oslo University Hospital; Oslo Norway
- Institute of Basic Medical Sciences; University of Oslo; Oslo Norway
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Eide LSP, Ranhoff AH, Fridlund B, Haaverstad R, Hufthammer KO, Kuiper KKJ, Nordrehaug JE, Norekvål TM. Delirium as a Predictor of Physical and Cognitive Function in Individuals Aged 80 and Older After Transcatheter Aortic Valve Implantation or Surgical Aortic Valve Replacement. J Am Geriatr Soc 2016; 64:1178-86. [DOI: 10.1111/jgs.14165] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | - Anette H. Ranhoff
- Department of Clinical Science; University of Bergen; Bergen Norway
- Kavli Research Center for Geriatrics and Dementia; Haraldsplass Hospital; Bergen Norway
| | - Bengt Fridlund
- School of Health and Welfare; Jönköping University; Jönköping Sweden
- Department of Heart Disease; Haukeland University Hospital; Bergen Norway
| | - Rune Haaverstad
- Department of Clinical Science; University of Bergen; Bergen Norway
- Department of Heart Disease; Haukeland University Hospital; Bergen Norway
| | | | - Karel K. J. Kuiper
- Department of Heart Disease; Haukeland University Hospital; Bergen Norway
| | - Jan E. Nordrehaug
- Department of Clinical Science; University of Bergen; Bergen Norway
- Department of Cardiology; Stavanger University Hospital; Stavanger Norway
| | - Tone M. Norekvål
- Department of Clinical Science; University of Bergen; Bergen Norway
- Department of Heart Disease; Haukeland University Hospital; Bergen Norway
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Bliemel C, Lechler P, Oberkircher L, Colcuc C, Balzer-Geldsetzer M, Dodel R, Ruchholtz S, Buecking B. Effect of Preexisting Cognitive Impairment on In-Patient Treatment and Discharge Management among Elderly Patients with Hip Fractures. Dement Geriatr Cogn Disord 2016; 40:33-43. [PMID: 25896170 DOI: 10.1159/000381334] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2015] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To examine the influence of cognitive impairment on the functional outcomes and complication rates of patients with hip fracture during in-patient treatment. METHODS A total of 402 patients who were surgically treated for hip fractures were consecutively enrolled at a single trauma center. The patients were grouped according to their results on the Mini-Mental State Examination (MMSE), i.e., ≥20 points (group I) and ≤19 points (group II). Complication and in-hospital mortality rates as well as postoperative functional outcomes according to the Barthel Index (BI) were compared between the groups. A multivariate regression analysis was performed to control for additional factors. RESULTS 33% of the patients had MMSE scores ≤19 points. The complication rates were similar between the groups (p > 0.05). Likewise, the overall in-hospital mortality rates were similar between the patients in group I (4.5%) and those in group II (9.8%; β = 0.218, p < 0.740). Functional outcomes, as assessed by the BI, were lower in group II (β = -0.266, p < 0.001). The patients in group II were transferred to a rehabilitation clinic less frequently (52.3 vs. 76.0%, p < 0.001). CONCLUSIONS Patients with lower MMSE scores are at a higher risk for poorer functional outcomes. Perioperative care should focus on the preservation of functional abilities to protect these patients from an additional loss of independence and disadvantageous clinical course.
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Affiliation(s)
- Christopher Bliemel
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Giessen and Marburg, Marburg, Germany
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Zhou Y, Putter H, Doblhammer G. Years of life lost due to lower extremity injury in association with dementia, and care need: a 6-year follow-up population-based study using a multi-state approach among German elderly. BMC Geriatr 2016; 16:9. [PMID: 26758623 PMCID: PMC4710990 DOI: 10.1186/s12877-016-0184-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 01/04/2016] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Dementia and care need are challenging aging populations worldwide. Lower extremity injury (LEI) in the elderly makes matters worse. Using a multi-state approach, we express the effect of LEI on dementia, care need, and mortality in terms of remaining life expectancy at age 75 (rLE) and years of life lost (YLL). METHODS A population-based random sample of beneficiaries aged 75-95 years was drawn from the largest public health insurer in Germany in 2004 and followed until 2010 (N 62,103; Mean Age ± SD 81.5 ± 4.8 years; Female 71.2%). We defined a five-state model (Healthy, Dementia, Care, Dementia & Care, Dead), and calculated transition-specific hazard ratios of LEI using Cox regression. The transition probabilities as well as the YLL due to LEI were estimated. RESULTS LEI significantly increased the risk for each transition, with a maximum risk for the transition from Healthy to Care (HR: 1.70, 95% CI: 1.63-1.77) and a minimum risk for the transition from Care to Dead (HR: 1.16, 95% CI: 1.10-1.22). If the elderly had LEI-history, their age-specific mortality was generally higher and their probabilities of transient states peaked at younger ages. At age 75, initially dementia-free and care-independent elderly experiencing LEI lost about 2 years of life, of which more than 90% were life years free of dementia or care need. Dementia patients lost about one and a half year, more than 60% were free of long-term care need. CONCLUSIONS LEI not only casts a large health burden on care need, but is also associated with cognitive decline and shortened rLE. LEI plus dementia extend the relative life time in need of care, despite generally shortening rLE. Using the composite measure YLL may help to better convey these results to the elderly, families, and health professionals. This may strengthen preventive measures as well as improve timely and rehabilitative treatment of LEI, not only in cognitive and physically intact elderly.
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Affiliation(s)
- Ying Zhou
- Institute for Sociology and Demography, University of Rostock, Ulmenstrasse 69, 18057, Rostock, Germany.,Rostock Center for the Study of Demographic Change, Konrad-Zuse-Str. 1, 18057, Rostock, Germany
| | - Hein Putter
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Centre, Einthovenweg 20, 2333 ZC, Leiden, Netherlands
| | - Gabriele Doblhammer
- Institute for Sociology and Demography, University of Rostock, Ulmenstrasse 69, 18057, Rostock, Germany. .,Rostock Center for the Study of Demographic Change, Konrad-Zuse-Str. 1, 18057, Rostock, Germany. .,German Center for Neurodegenerative Disease, Ludwig-Erhard-Allee 2, 53175, Bonn, Germany.
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Krogseth M, Watne LO, Juliebø V, Skovlund E, Engedal K, Frihagen F, Wyller TB. Delirium is a risk factor for further cognitive decline in cognitively impaired hip fracture patients. Arch Gerontol Geriatr 2015; 64:38-44. [PMID: 26952375 DOI: 10.1016/j.archger.2015.12.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 12/08/2015] [Accepted: 12/11/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Delirium is a risk factor for dementia in cognitively intact patients. Whether an episode of delirium accelerates cognitive decline in patients with known dementia, is less explored. METHODS This is a prospective follow-up study of 287 hip fracture patients with pre-fracture cognitive impairment. During the hospitalization, the patients were screened daily for delirium using the Confusion Assessment Method. Pre-fracture cognitive impairment was defined as a score of 3.44 or higher on the pre-fracture Informant Questionnaire on Cognitive Decline in the Elderly Short Form (IQCODE-SF). At follow-up after 4-6 months, the caregivers rated cognitive changes emerging after the fracture using the IQCODE-SF, and the patients were tested with the Mini Mental State Examination (MMSE). A sub-group of the patients had a pre-fracture MMSE score which was used to calculate the yearly decline on the MMSE in patients with and without delirium. RESULTS 201 of the 287 patients developed delirium in the acute phase. In linear regression analysis, delirium was a significant and independent predictor of a more prominent cognitive decline at follow-up measured by the IQCODE-SF questionnaire (p=0.002). Among patients having a pre-fracture MMSE score, the patients developing delirium had a median (IQR) yearly decline of 2.4 points (1.1-3.9), compared to 1.0 points (0-1.9) in the group without delirium (p=0.001, Mann-Whitney test). CONCLUSIONS Hip fracture patients with pre-fracture dementia run a higher risk of developing delirium. Delirium superimposed on dementia is a significant predictor of an accelerated further cognitive decline.
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Affiliation(s)
- Maria Krogseth
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Norway; Institute of Clinical Medicine, University of Oslo, Norway; Old Age Psychiatry Research Network, Telemark Hospital Trust and Vestfold Hospital Trust, 3710 Skien, Norway.
| | - Leiv Otto Watne
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Norway; Institute of Clinical Medicine, University of Oslo, Norway
| | - Vibeke Juliebø
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Norway; Department of Cardiology, Rikshospitalet, Oslo University Hospital, Norway
| | - Eva Skovlund
- Department of Public Health and General Practice, NTNU, Trondheim, Norway; Norwegian Institute of Public Health, Oslo, Norway
| | - Knut Engedal
- Institute of Clinical Medicine, University of Oslo, Norway; Norwegian Centre for Ageing and Health, Oslo University Hospital, Norway
| | - Frede Frihagen
- Department of Orthopaedic Surgery, Oslo University Hospital, Norway
| | - Torgeir Bruun Wyller
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Norway; Institute of Clinical Medicine, University of Oslo, Norway.
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Abstract
It has recently been proposed that heart failure is a risk factor for Alzheimer's disease. Decreased cerebral blood flow and neurohormonal activation due to heart failure may contribute to the dysfunction of the neurovascular unit and cause an energy crisis in neurons. This leads to the impaired clearance of amyloid beta and hyperphosphorylation of tau protein, resulting in the formation of amyloid beta plaques and neurofibrillary tangles. In this article, we will summarize the current understanding of the relationship between heart failure and Alzheimer's disease based on epidemiological studies, brain imaging research, pathological findings and the use of animal models. The importance of atherosclerosis, myocardial infarction, atrial fibrillation, blood pressure and valve disease as well as the effect of relevant medications will be discussed.
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Affiliation(s)
- P Cermakova
- Division for Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Karolinska InstitutetHuddinge, Sweden
- International Clinical Research Center and St. Anne's University HospitalBrno, Czech Republic
| | - M Eriksdotter
- Department of Geriatric Medicine, Karolinska University HospitalStockholm, Sweden
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Karolinska InstitutetStockholm, Sweden
| | - L H Lund
- Department of Cardiology, Karolinska University HospitalStockholm, Sweden
- Unit of Cardiology, Department of Medicine, Karolinska InstitutetStockholm, Sweden
| | - B Winblad
- Division for Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Karolinska InstitutetHuddinge, Sweden
- Department of Geriatric Medicine, Karolinska University HospitalStockholm, Sweden
| | - P Religa
- Department of Medicine, Center for Molecular Medicine, Karolinska InstitutetStockholm, Sweden
| | - D Religa
- Division for Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Karolinska InstitutetHuddinge, Sweden
- Department of Geriatric Medicine, Karolinska University HospitalStockholm, Sweden
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Harrison JK, Fearon P, Noel-Storr AH, McShane R, Stott DJ, Quinn TJ. Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) for the diagnosis of dementia within a secondary care setting. Cochrane Database Syst Rev 2015:CD010772. [PMID: 25754745 DOI: 10.1002/14651858.cd010772.pub2] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The diagnosis of dementia relies on the presence of new-onset cognitive impairment affecting an individual's functioning and activities of daily living. The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) is a questionnaire instrument, completed by a suitable 'informant' who knows the patient well, designed to assess change in functional performance secondary to cognitive change; it is used as a tool to identifying those who may have dementia.In secondary care there are two specific instances where patients may be assessed for the presence of dementia. These are in the general acute hospital setting, where opportunistic screening may be undertaken, or in specialist memory services where individuals have been referred due to perceived cognitive problems. To ensure an instrument is suitable for diagnostic use in these settings, its test accuracy must be established. OBJECTIVES To determine the diagnostic accuracy of the informant-based questionnaire IQCODE, for detection of all-cause (undifferentiated) dementia in adults presenting to secondary-care services. SEARCH METHODS We searched the following sources on the 28th of January 2013: ALOIS (Cochrane Dementia and Cognitive Improvement Group), MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO (Ovid SP), BIOSIS Previews (Thomson Reuters Web of Science), Web of Science Core Collection (includes Conference Proceedings Citation Index) (Thomson Reuters Web of Science), CINAHL (EBSCOhost) and LILACS (BIREME). We also searched sources specific to diagnostic test accuracy: MEDION (Universities of Maastricht and Leuven); DARE (Database of Abstracts of Reviews of Effects - via the Cochrane Library); HTA Database (Health Technology Assessment Database via the Cochrane Library) and ARIF (Birmingham University). We also checked reference lists of relevant studies and reviews, used searches of known relevant studies in PubMed to track related articles, and contacted research groups conducting work on IQCODE for dementia diagnosis to try to find additional studies. We developed a sensitive search strategy; search terms were designed to cover key concepts using several different approaches run in parallel and included terms relating to cognitive tests, cognitive screening and dementia. We used standardised database subject headings such as MeSH terms (in MEDLINE) and other standardised headings (controlled vocabulary) in other databases, as appropriate. SELECTION CRITERIA We selected those studies performed in secondary-care settings, which included (not necessarily exclusively) IQCODE to assess for the presence of dementia and where dementia diagnosis was confirmed with clinical assessment. For the 'secondary care' setting we included all studies which assessed patients in hospital (e.g. acute unscheduled admissions, referrals to specialist geriatric assessment services etc.) and those referred for specialist 'memory' assessment, typically in psychogeriatric services. DATA COLLECTION AND ANALYSIS We screened all titles generated by electronic database searches, and reviewed abstracts of all potentially relevant studies. Two independent assessors checked full papers for eligibility and extracted data. We determined quality assessment (risk of bias and applicability) using the QUADAS-2 tool, and reporting quality using the STARD tool. MAIN RESULTS From 72 papers describing IQCODE test accuracy, we included 13 papers, representing data from 2745 individuals (n = 1413 (51%) with dementia). Pooled analysis of all studies using data presented closest to a cut-off of 3.3 indicated that sensitivity was 0.91 (95% CI 0.86 to 0.94); specificity 0.66 (95% CI 0.56 to 0.75); the positive likelihood ratio was 2.7 (95% CI 2.0 to 3.6) and the negative likelihood ratio was 0.14 (95% CI 0.09 to 0.22).There was a statistically significant difference in test accuracy between the general hospital setting and the specialist memory setting (P = 0.019), suggesting that IQCODE performs better in a 'general' setting.We found no significant differences in the test accuracy of the short (16-item) versus the 26-item IQCODE, or in the language of administration.There was significant heterogeneity in the included studies, including a highly varied prevalence of dementia (10.5% to 87.4%). Across the included papers there was substantial potential for bias, particularly around sampling of included participants and selection criteria, which may limit generalisability. There was also evidence of suboptimal reporting, particularly around disease severity and handling indeterminate results, which are important if considering use in clinical practice. AUTHORS' CONCLUSIONS The IQCODE can be used to identify older adults in the general hospital setting who are at risk of dementia and require specialist assessment; it is useful specifically for ruling out those without evidence of cognitive decline. The language of administration did not affect test accuracy, which supports the cross-cultural use of the tool. These findings are qualified by the significant heterogeneity, the potential for bias and suboptimal reporting found in the included studies.
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Affiliation(s)
- Jennifer K Harrison
- Department of Cardiovascular Sciences, University of Leicester, Leicester Royal Infirmary, Leicester, UK, LE1 5WW
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Neerland BE, Hov KR, Bruun Wyller V, Qvigstad E, Skovlund E, MacLullich AMJ, Bruun Wyller T. The protocol of the Oslo Study of Clonidine in Elderly Patients with Delirium; LUCID: a randomised placebo-controlled trial. BMC Geriatr 2015; 15:7. [PMID: 25887557 PMCID: PMC4336683 DOI: 10.1186/s12877-015-0006-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 01/23/2015] [Indexed: 12/11/2022] Open
Abstract
Background Delirium affects 15% of hospitalised patients and is linked with poor outcomes, yet few pharmacological treatment options exist. One hypothesis is that delirium may in part result from exaggerated and/or prolonged stress responses. Dexmedetomidine, a parenterally-administered alpha2-adrenergic receptor agonist which attenuates sympathetic nervous system activity, shows promise as treatment in ICU delirium. Clonidine exhibits similar pharmacodynamic properties and can be administered orally. We therefore wish to explore possible effects of clonidine upon the duration and severity of delirium in general medical inpatients. Methods/Design The Oslo Study of Clonidine in Elderly Patients with Delirium (LUCID) is a randomised, placebo-controlled, double-blinded, parallel group study with 4-month prospective follow-up. We will recruit 100 older medical inpatients with delirium or subsyndromal delirium in the acute geriatric ward. Participants will be randomised to oral clonidine or placebo until delirium free for 2 days (Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria), or after a maximum of 7 days treatment. Assessment of haemodynamics (blood pressure, heart rate and electrocardiogram) and delirium will be performed daily until discharge or a maximum of 7 days after end of treatment. The primary endpoint is the trajectory of delirium over time (measured by Memorial Delirium Assessment Scale). Secondary endpoints include the duration of delirium, use of rescue medication for delirium, pharmacokinetics and pharmacodynamics of clonidine, cognitive function after 4 months, length of hospital stay and need for institutionalisation. Discussion LUCID will explore the efficacy and safety of clonidine for delirium in older medical inpatients. Trial registration ClinicalTrials.gov NCT01956604. EudraCT Number: 2013-000815-26
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Affiliation(s)
- Bjørn Erik Neerland
- Oslo Delirium Research Group, Department of Geriatric Medicine, University of Oslo, Pb 4956, N-0424, Oslo, Norway.
| | - Karen Roksund Hov
- Oslo Delirium Research Group, Department of Geriatric Medicine, University of Oslo, Pb 4956, N-0424, Oslo, Norway. .,Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.
| | - Vegard Bruun Wyller
- Department of Pediatrics, Akershus University Hospital, Lørenskog, Norway. .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Eirik Qvigstad
- Department of Cardiology, Oslo University Hospital, Oslo, Norway.
| | - Eva Skovlund
- School of Pharmacy, University of Oslo, Oslo, Norway.
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, University of Edinburgh, Room F1424, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK.
| | - Torgeir Bruun Wyller
- Oslo Delirium Research Group, Department of Geriatric Medicine, University of Oslo, Pb 4956, N-0424, Oslo, Norway. .,Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.
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Antonova E, Boye ME, Sen N, O’Sullivan AK, Burge R. Can Bundled Payment Improve Quality and Efficiency of Care for Patients with Hip Fractures? J Aging Soc Policy 2015; 27:1-20. [DOI: 10.1080/08959420.2015.970844] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Johnsen LG, Watne LO, Frihagen F, Helbostad JL, Prestmo A, Saltvedt I, Sletvold O, Wyller TB. Hvorfor ortogeriatri? TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2015; 135:523-4. [DOI: 10.4045/tidsskr.15.0188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Tsai CH, Chuang CS, Hung CH, Lin CL, Sung FC, Tang CH, Hsu HC, Chung CJ. Fracture as an independent risk factor of dementia: a nationwide population-based cohort study. Medicine (Baltimore) 2014; 93:e188. [PMID: 25474435 PMCID: PMC4616393 DOI: 10.1097/md.0000000000000188] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Dementia is among various diseases affecting the elderly, who is also at a high risk for fractures. This study aimed to evaluate the association between fracture history and sequential risk of dementia in Taiwan.A retrospective cohort study was designed using the claims data of the entire insured residents covered by Taiwan's universal health insurance from 1998 to 2010. A total of 66,797 patients with fractures and 133,594 control subjects without fractures were matched in terms of age (±5 years), sex, and index year and then recruited. Fractures and dementia were defined in accordance with the International Classification of Diseases, 9th Revision, Clinical Modification. The influence of fractures on the risk of dementia was analyzed using a Cox proportional hazards model.After a 12-year follow-up period, 2775 and 3991 incident cases of dementia were reported in exposed and unexposed cohorts, respectively. The overall incidence rate of dementia in individuals with fractures was 41% higher than that in individuals without fractures (6.05 vs 4.30 per 1000 person-years) at an adjusted hazard ratio of 1.38 (95% confidence interval 1.32-1.45) after age, sex, urbanization, and individual disorders or comorbidities were adjusted. Considering fracture location, we found that patients with hip fractures were at a slightly high risk for dementia. The occurrence of multiple fractures at a single visit was also significantly associated with an increased risk of dementia.Fracture history is regarded as an independent risk factor of dementia in individuals aged ≥65 years, particularly those who suffered from multiple fractures and/or fractures located in the hip. Further studies are needed to support an independent role of fracture in dementia considering the clinical information and other comorbidities.
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Affiliation(s)
- Chun-Hao Tsai
- From the Graduate Institute of Clinical Medicine (C-HT, H-CH); Department of Orthopedics, China Medical University Hospital, Taichung (C-HT, C-HH, C-HT, H-CH); Graduate Institute of Clinical Medicine, College of Medicine, China Medical University, Taichung, Taiwan (C-HT, C-HT, H-CH); Department of Orthopedics, China Medical University Hospital, Taichung, Taiwan (C-HT,C-HH, H-CH); Department of Neurology, Changhua Christian Hospital, Changhua (C-SC); Department of Life Sciences, National Chung-Hsing University (C-SC); Management Office for Health Data, China Medical University Hospital (C-LL); Department of Public Health, China Medical University (C-LL, F-CS); Department of Pharmacology, School of Medicine (C-HT); Department of Medical Research, China Medical University Hospital (C-JC); and Department of Health Risk Management, China Medical University, Taichung, Taiwan (C-JC)
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Hussain M, Berger M, Eckenhoff RG, Seitz DP. General anesthetic and the risk of dementia in elderly patients: current insights. Clin Interv Aging 2014; 9:1619-28. [PMID: 25284995 PMCID: PMC4181446 DOI: 10.2147/cia.s49680] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
In this review, we aim to provide clinical insights into the relationship between surgery, general anesthesia (GA), and dementia, particularly Alzheimer’s disease (AD). The pathogenesis of AD is complex, involving specific disease-linked proteins (amyloid-beta [Aβ] and tau), inflammation, and neurotransmitter dysregulation. Many points in this complex pathogenesis can potentially be influenced by both surgery and anesthetics. It has been demonstrated in some in vitro, animal, and human studies that some anesthetics are associated with increased aggregation and oligomerization of Aβ peptide and enhanced accumulation and hyperphosphorylation of tau protein. Two neurocognitive syndromes that have been studied in relation to surgery and anesthesia are postoperative delirium and postoperative cognitive dysfunction, both of which occur more commonly in older adults after surgery and anesthesia. Neither the route of anesthesia nor the type of anesthetic appears to be significantly associated with the development of postoperative delirium or postoperative cognitive dysfunction. A meta-analysis of case-control studies found no association between prior exposure to surgery utilizing GA and incident AD (pooled odds ratio =1.05, P=0.43). The few cohort studies on this topic have shown varying associations between surgery, GA, and AD, with one showing an increased risk, and another demonstrating a decreased risk. A recent randomized trial has shown that patients who received sevoflurane during spinal surgery were more likely to have progression of preexisting mild cognitive impairment compared to controls and to patients who received propofol or epidural anesthesia. Given the inconsistent evidence on the association between surgery, anesthetic type, and AD, well-designed and adequately powered studies with longer follow-up periods are required to establish a clear causal association between surgery, GA, and AD.
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Affiliation(s)
- Maria Hussain
- Division of Geriatric Psychiatry, Department of Psychiatry, Queen's University, Durham, NC, USA
| | - Miles Berger
- Anesthesiology Department, Duke University Medical Center, Durham, NC, USA
| | - Roderic G Eckenhoff
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Dallas P Seitz
- Division of Geriatric Psychiatry, Department of Psychiatry, Queen's University, Durham, NC, USA
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Harrison JK, Fearon P, Noel-Storr AH, McShane R, Stott DJ, Quinn TJ. Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) for the diagnosis of dementia within a general practice (primary care) setting. Cochrane Database Syst Rev 2014:CD010771. [PMID: 24990271 DOI: 10.1002/14651858.cd010771.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND The IQCODE (Informant Questionnaire for Cognitive Decline in the Elderly) is a commonly used questionnaire based tool that uses collateral information to assess for cognitive decline and dementia. Brief tools that can be used for dementia "screening" or "triage" may have particular utility in primary care / general practice healthcare settings but only if they have suitable test accuracy.A synthesis of the available data regarding IQCODE accuracy in a primary care setting should help inform cognitive assessment strategies for clinical practice; research and policy. OBJECTIVES We sought to describe the accuracy of IQCODE (the index test) against a clinical diagnosis of dementia (the reference standard). In this review we focus on those studies conducted in a primary care (general practice) setting. SEARCH METHODS A search was performed in the following sources on the 28th of January 2013: ALOIS (Cochrane Dementia and Cognitive Improvement Group), MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO (Ovid SP), BIOSIS (Ovid SP), ISI Web of Science and Conference Proceedings (ISI Web of Knowledge), CINHAL (EBSCOhost) and LILACs (BIREME). We also searched sources specific to diagnostic test accuracy: MEDION (Universities of Maastricht and Leuven); DARE (York University); HTA Database (Health Technology Assessments Database via The Cochrane Library) and ARIF (Birmingham University). We developed a sensitive search strategy; search terms were designed to cover key concepts using several different approaches run in parallel and included terms relating to cognitive tests, cognitive screening and dementia. We used standardized database subject headings such as MeSH terms (in MEDLINE) and other standardized headings (controlled vocabulary) in other databases, as appropriate. SELECTION CRITERIA We selected those studies performed in primary care settings, which included (not necessarily exclusively) IQCODE to assess for the presence of dementia and where dementia diagnosis was confirmed with clinical assessment. For the "primary care" setting, we included those healthcare settings where unselected patients, present for initial, non-specialist assessment of memory or non-memory related symptoms; often with a view to onward referral for more definitive assessment. DATA COLLECTION AND ANALYSIS We screened all titles generated by electronic database searches and abstracts of all potentially relevant studies were reviewed. Full papers were assessed for eligibility and data extracted by two independent assessors. Quality assessment (risk of bias and applicability) was determined using the QUADAS-2 tool. Reporting quality was determined using the STARDdem extension to the STARD tool. MAIN RESULTS From 71 papers describing IQCODE test accuracy, we included 1 paper, representing data from 230 individuals (n=16 [7%] with dementia). The paper described those patients consulting a primary care service who self-identified as Japanese-American. Dementia diagnosis was made using Benson & Cummings criteria and the IQCODE was recorded as part of a longer interview with the informant.IQCODE accuracy was assessed at various test thresholds, with a "trade-off" between sensitivity and specificity across these cutpoints. At an IQCODE threshold of 3.2 sensitivity: 100%, specificity: 76%; for IQCODE 3.7 sensitivity: 75%, specificity: 98%.Applying the QUADAS-2 assessments, the study was at high risk of bias in all categories. In particular degree of blinding was unclear and not all participants were included in the final analysis. AUTHORS' CONCLUSIONS It is not possible to give definitive guidance on the test accuracy of IQCODE for the diagnosis of dementia in a primary care setting based on the single study identified. We are surprised by the lack of research using the IQCODE in primary care as this is, arguably, the most appropriate setting for targeted case finding of those with undiagnosed dementia in order to maximise opportunities to intervene and provide support for the individual and their carers.
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Affiliation(s)
- Jennifer K Harrison
- Department of Cardiovascular Sciences, University of Leicester, Leicester Royal Infirmary, Leicester, UK, LE1 5WW
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Watne LO, Torbergsen AC, Conroy S, Engedal K, Frihagen F, Hjorthaug GA, Juliebo V, Raeder J, Saltvedt I, Skovlund E, Wyller TB. The effect of a pre- and postoperative orthogeriatric service on cognitive function in patients with hip fracture: randomized controlled trial (Oslo Orthogeriatric Trial). BMC Med 2014; 12:63. [PMID: 24735588 PMCID: PMC4022270 DOI: 10.1186/1741-7015-12-63] [Citation(s) in RCA: 120] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 03/17/2014] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Delirium is a common complication in patients with hip fractures and is associated with an increased risk of subsequent dementia. The aim of this trial was to evaluate the effect of a pre- and postoperative orthogeriatric service on the prevention of delirium and longer-term cognitive decline. METHODS This was a single-center, prospective, randomized controlled trial in which patients with hip fracture were randomized to treatment in an acute geriatric ward or standard orthopedic ward. Inclusion and randomization took place in the Emergency Department at Oslo University hospital. The key intervention in the acute geriatric ward was Comprehensive Geriatric Assessment including daily interdisciplinary meetings. Primary outcome was cognitive function four months after surgery measured using a composite outcome incorporating the Clinical Dementia Rating Scale (CDR) and the 10 words learning and recalls tasks from the Consortium to Establish a Registry for Alzheimer's Disease battery (CERAD). Secondary outcomes were pre- and postoperative delirium, delirium severity and duration, mortality and mobility (measured by the Short Physical Performance Battery (SPPB)). Patients were assessed four and twelve months after surgery by evaluators blind to allocation. RESULTS A total of 329 patients were included. There was no significant difference in cognitive function four months after surgery between patients treated in the acute geriatric and the orthopedic wards (mean 54.7 versus 52.9, 95% confidence interval for the difference -5.9 to 9.5; P = 0.65). There was also no significant difference in delirium rates (49% versus 53%, P = 0.51) or four month mortality (17% versus 15%, P = 0.50) between the intervention and the control group. In a pre-planned sub-group analysis, participants living in their own home at baseline who were randomized to orthogeriatric care had better mobility four months after surgery compared with patients randomized to the orthopedic ward, measured with SPPB (median 6 versus 4, 95% confidence interval for the median difference 0 to 2; P = 0.04). CONCLUSIONS Pre- and postoperative orthogeriatric care given in an acute geriatric ward was not effective in reducing delirium or long-term cognitive impairment in patients with hip fracture. The intervention had, however, a positive effect on mobility in patients not admitted from nursing homes. TRIAL REGISTRATION ClinicalTrials.gov NCT01009268 Registered November 5, 2009.
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Affiliation(s)
- Leiv Otto Watne
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.
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Quinn TJ, Fearon P, Noel-Storr AH, Young C, McShane R, Stott DJ. Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) for the diagnosis of dementia within community dwelling populations. Cochrane Database Syst Rev 2014:CD010079. [PMID: 24719028 DOI: 10.1002/14651858.cd010079.pub2] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Various tools exist for initial assessment of possible dementia with no consensus on the optimal assessment method. Instruments that use collateral sources to assess change in cognitive function over time may have particular utility. The most commonly used informant dementia assessment is the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE).A synthesis of the available data regarding IQCODE accuracy will help inform cognitive assessment strategies for clinical practice, research and policy. OBJECTIVES Our primary objective was to determine the diagnostic accuracy of the informant based questionnaire IQCODE, for detection of all cause (undifferentiated) dementia in community-dwelling adults with no previous cognitive assessment. We sought to describe the accuracy of IQCODE (the index test) against a clinical diagnosis of dementia (the reference standard). Our secondary objective was to describe the effect of heterogeneity on the summary estimates. We were particularly interested in the traditional 26-item scale versus the 16-item short form; and language of administration. We explored the effect of varying the threshold IQCODE score used to define 'test positivity'. SEARCH METHODS We searched the following sources on 28 January 2013: ALOIS (Cochrane Dementia and Cognitive Improvement Group), MEDLINE (OvidSP), EMBASE (OvidSP), PsycINFO (OvidSP), BIOSIS Previews (ISI Web of Knowledge), Web of Science with Conference Proceedings (ISI Web of Knowledge), LILACS (BIREME). We also searched sources relevant or specific to diagnostic test accuracy: MEDION (Universities of Maastrict and Leuven); DARE (York University); ARIF (Birmingham University). We used sensitive search terms based on MeSH terms and other controlled vocabulary. SELECTION CRITERIA We selected those studies performed in community settings that used (not necessarily exclusively) the IQCODE to assess for presence of dementia and, where dementia diagnosis was confirmed, with clinical assessment. Our intention with limiting the search to a 'community' setting was to include those studies closest to population level assessment. Within our predefined community inclusion criteria, there were relevant papers that fulfilled our definition of community dwelling but represented a selected population, for example stroke survivors. We included these studies but performed sensitivity analyses to assess the effects of these less representative populations on the summary results. DATA COLLECTION AND ANALYSIS We screened all titles generated by the electronic database searches and abstracts of all potentially relevant studies were reviewed. Full papers were assessed for eligibility and data extracted by two independent assessors. For quality assessment (risk of bias and applicability) we used the QUADAS 2 tool. We included test accuracy data on the IQCODE used at predefined diagnostic thresholds. Where data allowed, we performed meta-analyses to calculate summary values of sensitivity and specificity with corresponding 95% confidence intervals (CIs). We pre-specified analyses to describe the effect of IQCODE format (traditional or short form) and language of administration for the IQCODE. MAIN RESULTS From 16,144 citations, 71 papers described IQCODE test accuracy. We included 10 papers (11 independent datasets) representing data from 2644 individuals (n = 379 (14%) with dementia). Using IQCODE cut-offs commonly employed in clinical practice (3.3, 3.4, 3.5, 3.6) the sensitivity and specificity of IQCODE for diagnosis of dementia across the studies were generally above 75%.Taking an IQCODE threshold of 3.3 (or closest available) the sensitivity was 0.80 (95% CI 0.75 to 0.85); specificity was 0.84 (95% CI 0.78 to 0.90); positive likelihood ratio was 5.2 (95% CI 3.7 to 7.5) and the negative likelihood ratio was 0.23 (95% CI 0.19 to 0.29).Comparative analysis suggested no significant difference in the test accuracy of the 16 and 26-item IQCODE tests and no significant difference in test accuracy by language of administration. There was little difference in sensitivity across our predefined diagnostic cut-points.There was substantial heterogeneity in the included studies. Sensitivity analyses removing potentially unrepresentative populations in these studies made little difference to the pooled data estimates.The majority of included papers had potential for bias, particularly around participant selection and sampling. The quality of reporting was suboptimal particularly regarding timing of assessments and descriptors of reproducibility and inter-observer variability. AUTHORS' CONCLUSIONS Published data suggest that if using the IQCODE for community dwelling older adults, the 16 item IQCODE may be preferable to the traditional scale due to lesser test burden and no obvious difference in accuracy. Although IQCODE test accuracy is in a range that many would consider 'reasonable', in the context of community or population settings the use of the IQCODE alone would result in substantial misdiagnosis and false reassurance. Across the included studies there were issues with heterogeneity, several potential biases and suboptimal reporting quality.
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Affiliation(s)
- Terry J Quinn
- Cardiovascular and Medical Sciences, University of Glasgow, Walton Building, Glasgow Royal Infirmary, Glasgow, UK, G4 0SF
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Abstract
Delirium is an acute disorder of attention and cognition in elderly people (ie, those aged 65 years or older) that is common, serious, costly, under-recognised, and often fatal. A formal cognitive assessment and history of acute onset of symptoms are necessary for diagnosis. In view of the complex multifactorial causes of delirium, multicomponent non-pharmacological risk factor approaches are the most effective strategy for prevention. No convincing evidence shows that pharmacological prevention or treatment is effective. Drug reduction for sedation and analgesia and non-pharmacological approaches are recommended. Delirium offers opportunities to elucidate brain pathophysiology--it serves both as a marker of brain vulnerability with decreased reserve and as a potential mechanism for permanent cognitive damage. As a potent indicator of patients' safety, delirium provides a target for system-wide process improvements. Public health priorities include improvements in coding, reimbursement from insurers, and research funding, and widespread education for clinicians and the public about the importance of delirium.
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Affiliation(s)
- Sharon K Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.
| | - Rudi G J Westendorp
- Leiden University Medical Center, Leiden, Netherlands; Leyden Academy on Vitality and Ageing, Leiden, Netherlands
| | - Jane S Saczynski
- Division of Geriatric Medicine and Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA, USA
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