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Taylor ME, Harvey LA, Crotty M, Harris IA, Sherrington C, Close JCT. Variation in care and outcomes for people after hip fracture with and without cognitive impairment; results from the Australian and New Zealand Hip Fracture Registry. J Nutr Health Aging 2024; 28:100030. [PMID: 38388111 DOI: 10.1016/j.jnha.2023.100030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 11/20/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND People with dementia have poorer outcomes after hip fracture and this may be due in part to variation in care. We aimed to compare care and outcomes for people with and without cognitive impairment after hip fracture. METHODS Retrospective cohort study using Australian and New Zealand Hip Fracture Registry data for people ≥50 years of age who underwent hip fracture surgery (n = 49,063). Cognitive impairment or known dementia and cognitively healthy groups were defined using preadmission cognitive status. Descriptive statistics and multivariable mixed effects models were used to compare groups. RESULTS In general, cognitively impaired people had worse care and outcomes compared to cognitively healthy older people. A lower proportion of the cognitively impaired group had timely pain assessment (≤30 min of presentation: 61% vs 68%; p < 0.0001), were given the opportunity to mobilise (89% vs 93%; p < 0.0001) and achieved day-1 mobility (34% vs 58%; p < 0.0001) than the cognitively healthy group. A higher proportion of the cognitively impaired group had delayed pain management (>30 mins of presentation: 26% vs 20%; p < 0.0001), were malnourished (27% vs 15%; p < 0.0001), had delirium (44% vs 13%; p < 0.0001) and developed a new pressure injury (4% vs 3%; p < 0.0001) than the cognitively healthy group. Fewer of the cognitively impaired group received rehabilitation (35% vs 64%; p < 0.0001), particularly patients from RACFs (16% vs 39%; p < 0.0001) and were prescribed bone protection medication on discharge (24% vs 27%; p < 0.0001). Significantly more of the cognitively impaired group had a new transfer to residential care (46% vs 11% from private residence; p < 0.0001) and died at 30-days (7% vs 3% from private residence; 15% vs 10% from RACF; both p < 0.0001). In multivariable models adjusting for covariates with facility as the random effect, the cognitively impaired group had a greater odds of being malnourished, not achieving day-1 walking, having delirium in the week after surgery, dying within 30 days, and in those from private residences, having a new transfer to a residential care facility than the cognitively healthy group. CONCLUSIONS We have identified several aspects of care that could be improved for patients with cognitive impairment - management of pain, mobility, nutrition and bone health, as well as delirium assessment, prevention and management strategies and access to rehabilitation. Further research is needed to determine whether improvements in care will reduce hospital complications and improve outcomes for people with dementia after hip fracture.
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Affiliation(s)
- Morag E Taylor
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Sydney, New South Wales, Australia; Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia; UNSW Ageing Futures Research Institute, Sydney, New South Wales, Australia.
| | - Lara A Harvey
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Sydney, New South Wales, Australia; Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Maria Crotty
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; Rehabilitation Unit, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Ian A Harris
- Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, UNSW Sydney, Liverpool Hospital, Liverpool, NSW, Australia
| | - Catherine Sherrington
- Sydney Musculoskeletal Health, Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia; Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jacqueline C T Close
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Sydney, New South Wales, Australia; School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
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Hauer K, Dutzi I, Werner C, Bauer J, Ullrich P. Delirium Prevention in Early Rehabilitation During Acute Hospitalization and Implementation of Programs Specifically Tailored to Older Patients with Cognitive Impairment: A Scoping Review with Meta-Analysis. J Alzheimers Dis 2024; 97:3-29. [PMID: 38073387 DOI: 10.3233/jad-230644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
BACKGROUND No systematic review on delirium prevention within early, hospital-based rehabilitation on implementation of approaches specifically tailored for patients with cognitive impairment (PwCI), such as Alzheimer's disease or vascular dementia, has been published despite the high relevance of specific medical care in this vulnerable population. OBJECTIVE To document design and effectiveness of delirium prevention programs by early rehabilitation during acute, hospital-based medical care and implementation of programs specifically tailored to PwCI. METHODS In a three-step approach, we first identified published systematic reviews of hospital-based, early rehabilitation interventions for older persons (>65 years) in relevant databases. In a second step, we screened each single trial of included reviews according to predefined inclusion criteria. In a third step, we analyzed studies with focus on delirium prevention. RESULTS Among n = 25 studies identified, almost all intervention programs did not specifically target cognitive impairment (CI). Interventions were heterogeneous (modules: n = 2-19); almost all study samples were mixed/unspecified for cognitive status with more affected patients excluded. Only one study exclusively included delirium patients, and only one included CI patients. Results of random effect meta-analysis showed significant effects of generic programs to reduce delirium incidence during hospitalization by 41% (p < 0.001, odds ratio, 95% confidence interval: 0.59 [0.49, 0.71] with modest heterogeneity (I2: 30%). CONCLUSIONS Study results document a lack of implementation for delirium prevention programs specifically tailored to PwCI by early, hospital-based rehabilitation. Specifying existing rehab concepts or augmenting them by CI-specific modules may help to develop, optimize, and implement innovative delirium prevention in PwCI in acute medical care.
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Affiliation(s)
- Klaus Hauer
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Heidelberg, Germany
- Robert Bosch Gesellschaft für Medizinische Forschung mbH, Stuttgart, Germany
| | - Ilona Dutzi
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Heidelberg, Germany
| | - Christian Werner
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Heidelberg, Germany
| | - Jürgen Bauer
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Heidelberg, Germany
| | - Phoebe Ullrich
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Heidelberg, Germany
- Department of Thoracic Oncology, Thoraxklinik Heidelberg, Heidelberg University Hospital, Heidelberg, Germany
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Fong TG, Hshieh TT, Tabloski PA, Metzger ED, Arias F, Heintz HL, Patrick RE, Lapid MI, Schmitt EM, Harper DG, Forester BP, Inouye SK. Identifying Delirium in Persons With Moderate or Severe Dementia: Review of Challenges and an Illustrative Approach. Am J Geriatr Psychiatry 2022; 30:1067-1078. [PMID: 35581117 PMCID: PMC10413471 DOI: 10.1016/j.jagp.2022.04.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 04/02/2022] [Accepted: 04/06/2022] [Indexed: 01/25/2023]
Abstract
Delirium and dementia are common causes of cognitive impairment among older adults, which often coexist. Delirium is associated with poor clinical outcomes, and is more frequent and more severe in patients with dementia. Identifying delirium in the presence of dementia, also described as delirium superimposed on dementia (DSD), is particularly challenging, as symptoms of delirium such as inattention, cognitive dysfunction, and altered level of consciousness, are also features of dementia. Because DSD is associated with poorer clinical outcomes than dementia alone, detecting delirium is important for reducing morbidity and mortality in this population. We review a number of delirium screening instruments that have shown promise for use in DSD, including the 4-DSD, combined Six Item Cognitive Impairment Test (6-CIT) and 4 'A's Test (4AT), Confusion Assessment Method (CAM), and the combined UB2 and 3D-CAM (UB-CAM). Each has advantages and disadvantages. We then describe the operationalization of a CAM-based approach in a current ECT in dementia project as an example of modifying an existing instrument for patients with moderate to severe dementia. Ultimately, any instrument modified will need to be validated against a standard clinical reference, in order to fully establish its sensitivity and specificity in the moderate to severe dementia population. Future work is greatly needed to advance the challenging area of accurate identification of delirium in moderate or severe dementia.
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Affiliation(s)
- Tamara G Fong
- Departments of Neurology (TGF, FA), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School (TGF, TTH, FA, EMS, SKI), Boston, MA.
| | - Tammy T Hshieh
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School (TGF, TTH, FA, EMS, SKI), Boston, MA; Department of Medicine (TTH), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | - Eran D Metzger
- Departments of Psychiatry (EDM), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Franchesca Arias
- Departments of Neurology (TGF, FA), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School (TGF, TTH, FA, EMS, SKI), Boston, MA
| | - Hannah L Heintz
- Division of Geriatric Psychiatry (HLH, REP, DGH, BPF), McLean Hospital, Harvard Medical School, Belmont, MA
| | - Regan E Patrick
- Division of Geriatric Psychiatry (HLH, REP, DGH, BPF), McLean Hospital, Harvard Medical School, Belmont, MA
| | | | - Eva M Schmitt
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School (TGF, TTH, FA, EMS, SKI), Boston, MA
| | - David G Harper
- Division of Geriatric Psychiatry (HLH, REP, DGH, BPF), McLean Hospital, Harvard Medical School, Belmont, MA
| | - Brent P Forester
- Division of Geriatric Psychiatry (HLH, REP, DGH, BPF), McLean Hospital, Harvard Medical School, Belmont, MA
| | - Sharon K Inouye
- Departments of Medicine (SKI), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School (TGF, TTH, FA, EMS, SKI), Boston, MA
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Fong TG, Inouye SK. The inter-relationship between delirium and dementia: the importance of delirium prevention. Nat Rev Neurol 2022; 18:579-596. [PMID: 36028563 PMCID: PMC9415264 DOI: 10.1038/s41582-022-00698-7] [Citation(s) in RCA: 65] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2022] [Indexed: 12/30/2022]
Abstract
Delirium and dementia are two frequent causes of cognitive impairment among older adults and have a distinct, complex and interconnected relationship. Delirium is an acute confusional state characterized by inattention, cognitive dysfunction and an altered level of consciousness, whereas dementia is an insidious, chronic and progressive loss of a previously acquired cognitive ability. People with dementia have a higher risk of developing delirium than the general population, and the occurrence of delirium is an independent risk factor for subsequent development of dementia. Furthermore, delirium in individuals with dementia can accelerate the trajectory of the underlying cognitive decline. Delirium prevention strategies can reduce the incidence of delirium and associated adverse outcomes, including falls and functional decline. Therefore, delirium might represent a modifiable risk factor for dementia, and interventions that prevent or minimize delirium might also reduce or prevent long-term cognitive impairment. Additionally, understanding the pathophysiology of delirium and the connection between delirium and dementia might ultimately lead to additional treatments for both conditions. In this Review, we explore mechanisms that might be common to both delirium and dementia by reviewing evidence on shared biomarkers, and we discuss the importance of delirium recognition and prevention in people with dementia. In this Review, Fong and Inouye explore mechanisms that might be common to both delirium and dementia. They present delirium as a possible modifiable risk factor for dementia and discuss the importance of delirium prevention strategies in reducing this risk. Delirium and dementia are frequent causes of cognitive impairment among older adults and have a distinct, complex and interconnected relationship. Delirium prevention strategies have been shown to reduce not only the incidence of delirium but also the incidence of adverse outcomes associated with delirium such as falls and functional decline. Adverse outcomes associated with delirium, such as the onset of dementia symptoms in individuals with preclinical dementia, and/or the acceleration of cognitive decline in individuals with dementia might also be delayed by the implementation of delirium prevention strategies. Evidence regarding the association of systemic inflammatory and neuroinflammatory biomarkers with delirium is variable, possibly as a result of co-occurring dementia pathology or disruption of the blood–brain barrier. Alzheimer disease pathology, even prior to the onset of symptoms, might have an effect on delirium risk, with potential mechanisms including neuroinflammation and gene–protein interactions with the APOE ε4 allele. Novel strategies, including proteomics, multi-omics, neuroimaging, transcranial magnetic stimulation and EEG, are beginning to reveal how changes in cerebral blood flow, spectral power and connectivity can be associated with delirium; further work is needed to expand these findings to patients with delirium superimposed upon dementia.
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Affiliation(s)
- Tamara G Fong
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA. .,Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
| | - Sharon K Inouye
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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Shih RD, Carpenter CR, Tolia V, Binder EF, Ouslander JG. Balancing Vision With Pragmatism: The Geriatric Emergency Department Guidelines-Realistic Expectations From Emergency Medicine and Geriatric Medicine. J Emerg Med 2022; 62:585-589. [PMID: 35181186 DOI: 10.1016/j.jemermed.2021.12.017] [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: 12/19/2021] [Accepted: 12/24/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND In 2014, the Geriatric Emergency Department (GED) Guidelines were published and endorsed by four major medical organizations. The multidisciplinary GED Guidelines characterized the complex needs of the older emergency department (ED) patient and current best practices, with the goal of promoting more cost-effective and patient-centered care. The recommendations are extensive and most EDs then and now have neither the resources nor the hospital administrative support to provide this additional service. DISCUSSION At the 2021 American Academy of Emergency Medicine's Scientific Assembly, a panel of emergency physicians and geriatricians discussed the GED Guidelines and the current realities of EDs' capacity to provide best practice and guideline-recommended care of GED patients. This article is a synthesis of the panel's presentation and discussion. With the substantial challenges in providing guideline-recommended care in EDs, this article will explore three high-impact GED clinical conditions to highlight guideline recommendations, challenges, and opportunities, and discuss realistically achievable expectations for non-GED-accredited institutions. CONCLUSIONS In 2014, the GED Guidelines were published, describing the current best practices for GED patients. Unfortunately, most of the EDs worldwide do not provide the level of service recommended by the GED Guidelines. The GED Guidelines can best be termed aspirational for U.S. EDs at the present time.
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Affiliation(s)
- Richard D Shih
- Department of Emergency Medicine, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida and Delray Medical Center, Delray Beach, Florida
| | - Christopher R Carpenter
- Department of Emergency Medicine, Emergency Care Research Core, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Vaishal Tolia
- University of California San Diego Health, San Diego, California
| | - Ellen F Binder
- Division of Geriatrics and Nutritional Science, Washington University in St. Louis, School of Medicine, St. Louis, Missouri
| | - Joseph G Ouslander
- Department of Integrated Medical Science, Charles E. Schmidt College of Medicine; Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida
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Increased short-term mortality among patients presenting with altered mental status to the emergency department: A cohort study. Am J Emerg Med 2022; 51:290-295. [PMID: 34785485 PMCID: PMC9376886 DOI: 10.1016/j.ajem.2021.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 10/21/2021] [Accepted: 10/21/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES To evaluate the short-term mortality of adult patients presenting to the emergency department (ED) with altered mental status (AMS) as compared to other common chief complaints. METHODS Observational cohort study of adult patients (age ≥ 40) who presented to an academic ED over a 1-year period with five pre-specified complaints at ED triage: AMS, generalized weakness, chest pain, abdominal pain, and headache. Primary outcomes included 7 and 30-day mortality. Hazard ratios (HR) were calculated with 95% confidence intervals (CI) using Cox proportional hazards models adjusted for age, acuity level, and comorbidities. RESULTS A total of 9850 ED visits were included for analysis from which 101 (1.0%) and 295 (3.0%) died within 7 and 30 days, respectively. Among 683 AMS visits, the 7-day mortality rate was 3.2%. Mortality was lower for all other chief complaints, including generalized weakness (17/1170, 1.5%), abdominal pain (32/3609, 0.9%), chest pain (26/3548, 0.7%), and headache (4/840, 0.5%). After adjusting for key confounders, patients presenting with AMS had a significantly higher risk of death within 7 days of ED arrival than patients presenting with chest pain (HR 3.72, 95% CI 2.05 to 6.76, p < .001). Similarly, we found that patients presenting with AMS had a significantly higher risk of dying within 30 days compared to patients with chest pain (HR 3.65, 95% CI 2.49 to 5.37, p < .001), and headache (HR 2.09, 95% CI 1.09 to 4.01, p = .026). Differences were not statistically significant for comparisons with abdominal pain and generalized weakness, but confidence intervals were wide. CONCLUSION Patients presenting with AMS have worse short-term prognosis than patients presenting to the ED with chest pain or headache. AMS may indicate an underlying brain dysfunction (delirium), which is associated with adverse outcomes and increased mortality.
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