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Boucher E, Jell A, Singh S, Davies J, Smith T, Pill A, Varnai K, Woods K, Walliker D, McColl A, Shepperd S, Pendlebury S. Protocol for the Development and Analysis of the Oxford and Reading Cognitive Comorbidity, Frailty and Ageing Research Database-Electronic Patient Records (ORCHARD-EPR). BMJ Open 2024; 14:e085126. [PMID: 38816052 PMCID: PMC11141189 DOI: 10.1136/bmjopen-2024-085126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 05/01/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND Hospital electronic patient records (EPRs) offer the opportunity to exploit large-scale routinely acquired data at relatively low cost and without selection. EPRs provide considerably richer data, and in real-time, than retrospective administrative data sets in which clinical complexity is often poorly captured. With population ageing, a wide range of hospital specialties now manage older people with multimorbidity, frailty and associated poor outcomes. We, therefore, set-up the Oxford and Reading Cognitive Comorbidity, Frailty and Ageing Research Database-Electronic Patient Records (ORCHARD-EPR) to facilitate clinically meaningful research in older hospital patients, including algorithm development, and to aid medical decision-making, implementation of guidelines, and inform policy. METHODS AND ANALYSIS ORCHARD-EPR uses routinely acquired individual patient data on all patients aged ≥65 years with unplanned admission or Same Day Emergency Care unit attendance at four acute general hospitals serving a population of >800 000 (Oxfordshire, UK) with planned extension to the neighbouring Berkshire regional hospitals (>1 000 000). Data fields include diagnosis, comorbidities, nursing risk assessments, frailty, observations, illness acuity, laboratory tests and brain scan images. Importantly, ORCHARD-EPR contains the results from mandatory hospital-wide cognitive screening (≥70 years) comprising the 10-point Abbreviated-Mental-Test and dementia and delirium diagnosis (Confusion Assessment Method-CAM). Outcomes include length of stay, delayed transfers of care, discharge destination, readmissions and death. The rich multimodal data are further enhanced by linkage to secondary care electronic mental health records. Selection of appropriate subgroups or linkage to existing cohorts allows disease-specific studies. Over 200 000 patient episodes are included to date with data collection ongoing of which 129 248 are admissions with a length of stay ≥1 day in 64 641 unique patients. ETHICS AND DISSEMINATION ORCHARD-EPR is approved by the South Central Oxford C Research Ethics Committee (ref: 23/SC/0258). Results will be widely disseminated through peer-reviewed publications and presentations at conferences, and regional meetings to improve hospital data quality and clinical services.
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Affiliation(s)
- Emily Boucher
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Aimee Jell
- Informatics Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sudhir Singh
- Department of Acute General (Internal) Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Department of Geratology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jim Davies
- Department of Computer Science, University of Oxford, Oxford, UK
| | - Tanya Smith
- Research Informatics Team, Research and Development Department, Oxford Health NHS Foundation Trust, Oxford, UK
- NIHR Oxford Health Biomedical Research Centre, Oxford, UK
| | - Adam Pill
- Research Informatics Team, Research and Development Department, Oxford Health NHS Foundation Trust, Oxford, UK
| | - Kinga Varnai
- Research and Development Clinical Informatics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Kerrie Woods
- Research and Development Clinical Informatics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - David Walliker
- Research and Development Clinical Informatics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Aubretia McColl
- Department of Acute Medicine, Royal Berkshire NHS Foundation Trust, Reading, UK
- Department of Elderly Care Medicine, Royal Berkshire NHS Hospital Foundation Trust, Reading, UK
| | - Sasha Shepperd
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sarah Pendlebury
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Department of Acute General (Internal) Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Department of Geratology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Gordon EH, Ward DD, Xiong H, Berkovsky S, Hubbard RE. Delirium and incident dementia in hospital patients in New South Wales, Australia: retrospective cohort study. BMJ 2024; 384:e077634. [PMID: 38537951 PMCID: PMC10966895 DOI: 10.1136/bmj-2023-077634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/22/2024] [Indexed: 04/06/2024]
Abstract
OBJECTIVES To determine the strength and nature of the association between delirium and incident dementia in a population of older adult patients without dementia at baseline. DESIGN Retrospective cohort study using large scale hospital administrative data. SETTING Public and private hospitals in New South Wales, Australia between July 2001 and March 2020. PARTICIPANTS Data were extracted for 650 590 hospital patients aged ≥65 years. Diagnoses of dementia and delirium were identified from ICD-10 (international classification of diseases, 10th revision) codes. Patients with dementia at baseline were excluded. Delirium-no delirium pairs were identified by matching personal and clinical characteristics, and were followed for more than five years. MAIN OUTCOME MEASURES Cox proportional hazards models and Fine-Gray hazard models were used to estimate the associations of delirium with death and incident dementia, respectively. Delirium-outcome dose-response associations were quantified, all analyses were performed in men and women separately, and sensitivity analyses were conducted. RESULTS The study included 55 211 matched pairs (48% men, mean age 83.4 years, standard deviation 6.5 years). Collectively, 58% (n=63 929) of patients died and 17% (n=19 117) had a newly reported dementia diagnosis during 5.25 years of follow-up. Patients with delirium had 39% higher risk of death (hazard ratio 1.39, 95% confidence interval 1.37 to 1.41) and three times higher risk of incident dementia (subdistribution hazard ratio 3.00, 95% confidence interval 2.91 to 3.10) than patients without delirium. The association with dementia was stronger in men (P=0.004). Each additional episode of delirium was associated with a 20% increased risk of dementia (subdistribution hazard ratio 1.20, 95% confidence interval 1.18 to 1.23). CONCLUSIONS The study findings suggest delirium was a strong risk factor for death and incident dementia among older adult patients. The data support a causal interpretation of the association between delirium and dementia. The clinical implications of delirium as a potentially modifiable risk factor for dementia are substantial.
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Affiliation(s)
- Emily H Gordon
- Centre for Health Services Research, The University of Queensland, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
- Australian Frailty Network, The University of Queensland, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - David D Ward
- Centre for Health Services Research, The University of Queensland, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
- Australian Frailty Network, The University of Queensland, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Hao Xiong
- Centre for Health Informatics, Macquarie University, North Ryde, NSW, Australia
| | - Shlomo Berkovsky
- Centre for Health Informatics, Macquarie University, North Ryde, NSW, Australia
| | - Ruth E Hubbard
- Centre for Health Services Research, The University of Queensland, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
- Australian Frailty Network, The University of Queensland, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
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Filiatreault S, Kreindler SA, Grimshaw JM, Chochinov A, Doupe MB. Developing a set of emergency department performance measures to evaluate delirium care quality for older adults: a modified e-Delphi study. BMC Emerg Med 2024; 24:28. [PMID: 38360551 PMCID: PMC10868025 DOI: 10.1186/s12873-024-00947-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 02/05/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Older adults are at high risk of developing delirium in the emergency department (ED); however, it is under-recognized in routine clinical care. Lack of detection and treatment is associated with poor outcomes, such as mortality. Performance measures (PMs) are needed to identify variations in quality care to help guide improvement strategies. The purpose of this study is to gain consensus on a set of quality statements and PMs that can be used to evaluate delirium care quality for older ED patients. METHODS A 3-round modified e-Delphi study was conducted with ED clinical experts. In each round, participants rated quality statements according to the concepts of importance and actionability, then their associated PMs according to the concept of necessity (1-9 Likert scales), with the ability to comment on each. Consensus and stability were evaluated using a priori criteria using descriptive statistics. Qualitative data was examined to identify themes within and across quality statements and PMs, which went through a participant validation exercise in the final round. RESULTS Twenty-two experts participated, 95.5% were from west or central Canada. From 10 quality statements and 24 PMs, consensus was achieved for six quality statements and 22 PMs. Qualitative data supported justification for including three quality statements and one PM that achieved consensus slightly below a priori criteria. Three overarching themes emerged from the qualitative data related to quality statement actionability. Nine quality statements, nine structure PMs, and 14 process PMs are included in the final set, addressing four areas of delirium care: screening, diagnosis, risk reduction and management. CONCLUSION Results provide a set of quality statements and PMs that are important, actionable, and necessary to a diverse group of clinical experts. To our knowledge, this is the first known study to develop a de novo set of guideline-based quality statements and PMs to evaluate the quality of delirium care older adults receive in the ED setting.
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Affiliation(s)
- Sarah Filiatreault
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada.
| | - Sara A Kreindler
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, K1H8L6, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, K1H 8M5, Canada
| | - Alecs Chochinov
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
- Department of Emergency Medicine, Rady Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
| | - Malcolm B Doupe
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
- Department of Emergency Medicine, Rady Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
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Pendlebury ST, Luengo-Fernandez R, Seeley A, Downer MB, McColl A, Rothwell PM. Infection, delirium, and risk of dementia in patients with and without white matter disease on previous brain imaging: a population-based study. THE LANCET. HEALTHY LONGEVITY 2024; 5:e131-e140. [PMID: 38310893 DOI: 10.1016/s2666-7568(23)00266-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 12/01/2023] [Accepted: 12/04/2023] [Indexed: 02/06/2024] Open
Abstract
BACKGROUND The increased risk of dementia after delirium and infection might be influenced by cerebral white matter disease (WMD). In patients with transient ischaemic attack (TIA) and minor stroke, we assessed associations between hospital admissions with delirium and 5-year dementia risk and between admissions with infection and dementia risk, stratified by WMD severity (moderate or severe vs absent or mild) on baseline brain imaging. METHODS We included patients with TIA and minor stroke (National Institutes of Health Stroke Score <3) from the Oxford Vascular Study (OXVASC), a longitudinal population-based study of the incidence and outcomes of acute vascular events in a population of 94 567 individuals, with no age restrictions, attending eight general practices in Oxfordshire, UK. Hospitalisation data were obtained through linkage to the Oxford Cognitive Comorbidity, Frailty, and Ageing Research Database-Electronic Patient Records (ORCHARD-EPR). Brain imaging was done using CT and MRI, and WMD was prospectively graded according to the age-related white matter changes (ARWMC) scale and categorised into absent, mild, moderate, or severe WMD. Delirium and infection were defined by ICD-10 coding supplemented by hand-searching of hospital records. Dementia was diagnosed using clinical or cognitive assessment, medical records, and death certificates. Associations between hospitalisation with delirium and hospitalisation with infection, and post-event dementia were assessed using time-varying Cox analysis with multivariable adjustment, and all models were stratified by WMD severity. FINDINGS From April 1, 2002, to March 31, 2012, 1369 individuals were prospectively recruited into the study. Of 1369 patients (655 with TIA and 714 with minor stroke, mean age 72 [SD 13] years, 674 female and 695 male, and 364 with moderate or severe WMD), 209 (15%) developed dementia. Hospitalisation during follow-up occurred in 891 (65%) patients of whom 103 (12%) had at least one delirium episode and 236 (26%) had at least one infection episode. Hospitalisation without delirium or infection did not predict subsequent dementia (HR 1·01, 95% CI 0·86-1·20). In contrast, hospitalisation with delirium predicted subsequent dementia independently of infection in patients with and without WMD (2·64, 1·47-4·74; p=0·0013 vs 3·41, 1·91-6·09; p<0·0001) especially in those with unimpaired baseline cognition (cognitive test score above cutoff; 4·01, 2·23-7·19 vs 3·94, 1·95-7·93; both p≤0·0001). However, hospitalisation with infection only predicted dementia in those with moderate or severe WMD (1·75, 1·04-2·94 vs 0·68, 0·39-1·20; pdiff=0·023). INTERPRETATION The increased risk of dementia after delirium is unrelated to the presence of WMD, whereas infection increases risk only in patients with WMD, suggesting differences in underlying mechanisms and in potential preventive strategies. FUNDING National Institute for Health and Care Research and Wellcome Trust.
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Affiliation(s)
- Sarah T Pendlebury
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Departments of Acute General Internal Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Ramon Luengo-Fernandez
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Anna Seeley
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK; Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Matthew B Downer
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Aubretia McColl
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Peter M Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Milosevich E, Demeyere N, Pendlebury ST. Infection, Inflammation, and Poststroke Cognitive Impairment. J Am Heart Assoc 2024; 13:e9130. [PMID: 38214255 PMCID: PMC10926823 DOI: 10.1161/jaha.123.033015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 11/22/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Infection and inflammation are dementia risk factors in population-based cohorts; however, studies in stroke are scarce. We determined the prevalence of infection after stroke and routinely measured inflammatory biomarkers during hospitalization and their associations with acute and 6-month cognitive impairment. METHODS AND RESULTS A prospective stroke cohort completed the Oxford Cognitive Screen at ≤2 weeks and 6 months after stroke. Infection, inflammatory markers (C-reactive protein, white cell count, and neutrophil/lymphocyte ratio), and systemic inflammatory response syndrome were ascertained throughout admission with electronic patient records supplemented by hand searches. Associations with acute and 6-month global and domain-specific cognitive impairment were analyzed using multivariable regression, adjusting for demographic/vascular factors and stroke severity. Among 255 patients (mean age, 73.9 [SD, 12.6] years; 46.3% women; mean education, 12.6 [SD, 3.7] years; median National Institutes of Health Stroke Scale score 5 [range, minimum-maximum, 0-30]), infection was present in 90 patients (35.3%) at mean 4.4 (SD, 6.9) days after stroke, consisting predominantly of pneumonia (47/90; 52%) and urinary tract infection (39/90; 43%). Admission white cell count was elevated in 25.1% (n=64; mean, 9.5×109/L [SD, 3.2×109/L]), C-reactive protein in 41.2% (n=105; mean, 27.5 [SD, 50.9 mg/L]), neutrophil/lymphocyte ratio in 55.7% (n=97; mean, 5.5 [SD, 4.5]), and systemic inflammatory response syndrome in 26.6% (n=53 [45.2%] positive during hospitalization). Infection was associated with acute and 6-month poststroke cognitive impairment (P<0.05adj) with stronger associations acutely for severe infection (infection+systemic inflammatory response syndrome; P=0.03adj). Acute language, executive function and attention domain impairments, and 6-month number processing impairment were associated with infection (P<0.05adj). No significant relationships were found for any biomarker and cognitive impairment. CONCLUSIONS Infection and elevations in routinely measured inflammatory biomarkers are common following stroke; however, only infection is associated with poststroke cognitive impairment, suggesting that increases in these biomarkers may be nonspecific. Infection may present a tractable target for reducing poststroke cognitive impairment.
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Affiliation(s)
- Elise Milosevich
- Department of Experimental PsychologyUniversity of OxfordOxfordUK
| | - Nele Demeyere
- Department of Experimental PsychologyUniversity of OxfordOxfordUK
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical NeurosciencesUniversity of OxfordOxfordUK
| | - Sarah T. Pendlebury
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical NeurosciencesUniversity of OxfordOxfordUK
- NIHR Oxford Biomedical Research Centre and Departments of General Medicine and GeratologyJohn Radcliffe HospitalOxfordUK
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Elias TCN, Jacklin C, Bowen J, Lasserson DS, Pendlebury ST. Care pathways in older patients seen in a multidisciplinary same day emergency care (SDEC) unit. Age Ageing 2024; 53:afad257. [PMID: 38275098 PMCID: PMC10811520 DOI: 10.1093/ageing/afad257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Same day emergency care (SDEC) services are being advocated in the UK for frail, older patients in whom hospitalisation may be associated with harm but there are few data on the 'ambulatory pathway'. We therefore determined the patient pathways pre- and post-first assessment in a SDEC unit focussed on older people. METHODS In consecutive patients, we prospectively recorded follow-up SDEC service reviews (face-to-face, telephone, Hospital-at-Home domiciliary visits), outpatient referrals (e.g. to specialist clinics, imaging, and community/voluntary/social services), and hospital admissions <30 days. In the first 67 patients, we also recorded healthcare interactions (except GP attendances) in the 180 days pre- and post-first assessment. RESULTS Among 533 patients (mean/SD age = 75.0/17.5 years, 246, 46% deemed frail) assessed in an SDEC unit, 210 were admitted within 30 days (152 immediately). In the 381(71%) remaining initially ambulatory, there were 587 SDEC follow-up reviews and 747 other outpatient referrals (mean = 3.5 per patient) with only 34 (9%) patients being discharged with no further follow-up. In the subset (n = 67), the number of 'healthcare days' was greater in the 180 days post- versus pre-SDEC assessment (mean/SD = 26/27 versus 13/22 days, P = 0.003) even after excluding hospital admission days, with greater healthcare days in frail versus non-frail patients. DISCUSSION AND CONCLUSION SDEC assessment in older, frail patients was associated with a 2-fold increase in frequency of healthcare interactions with complex care pathways involving multiple services. Our findings have implications for the development of admission-avoidance models including cost-effectiveness and optimal delivery of the multi-dimensional aspects of acute geriatric care in the ambulatory setting.
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Affiliation(s)
- Tania C N Elias
- Departments of Acute Internal Medicine and Older Persons' Services, Great Western Hospital NHS Foundation Trust, Swindon SN3 6BB, UK
| | - Chloe Jacklin
- Departments of Care of the Elderly and Stroke Medicine, North Middlesex University Hospital NHS Trust, Sterling Way, London N18 1QX, UK
| | - Jordan Bowen
- Department of Acute Internal Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Daniel S Lasserson
- Department of Acute Internal Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK
- NIHR Applied Research Collaboration (ARC) West Midlands, Warwick Medical School, University of Warwick, Coventry, Warwickshire CV4 3AL, UK
- Department of Acute Medicine, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham B18 7QH, UK
| | - Sarah T Pendlebury
- Department of Acute Internal Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK
- Nuffield Department of Clinical Neurosciences, Wolfson Centre for Prevention of Stroke and Dementia, John Radcliffe Hospital, and the University of Oxford, Oxford, UK
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Gan JM, Riley J, Basting R, Demeyere N, Pendlebury ST. Decision-making capacity in older medical in-patients: frequency of assessment and rates of incapacity by decision-type and underlying brain/mind impairment. Age Ageing 2023; 52:afad171. [PMID: 37725974 PMCID: PMC10508978 DOI: 10.1093/ageing/afad171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 06/10/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Hospital clinicians find mental capacity assessment challenging and may lack the necessary skills. Given high rates of cognitive impairment, data on mental capacity assessment in real-world hospital cohorts are required to inform the need for staff training and workforce planning. OBJECTIVES In unselected medical inpatients, we determined the rate and outcome of mental capacity assessment by decision type and underlying brain/mind disorder, and recorded the discipline of the assessor. METHODS We included consecutive patients (October-November 2018; November-December 2019) admitted to the complex medicine unit providing acute multidisciplinary care for multi-morbid patients (age ≥ 16 years, average age > 80 years). Audit data were collected at ward multidisciplinary meetings and extracted from electronic patient records. RESULTS Among 892 patients (mean/SD age = 82.8/8.6, 465 male), 140 (16%) required mental capacity assessment (40/140 (29%) had ≥2 assessments) with 203 assessments in total of which 162 (80%) were done by doctors. Capacity was deemed lacking in 124 (61%) assessments, most commonly in delirium with/without other co-morbid conditions (94/114, 82%) or dementia (9/12, 75%) with lower rates in other disorders (15/27, 56%), and no formal diagnosis of brain/mind disorder (6/50, 12%). Cognitive test scores were overall lower in those lacking capacity (mean/SD abbreviated-mental-test-score = 5.2/2.6, range = 0-10 versus 6.8/2.8, P = 0.001, range = 1-10). Decisions involving discharge planning were most often assessed (48%) followed by treatment (29%), discharge against medical advice (12%) and others (11%). CONCLUSION Mental capacity assessments were performed frequently and often repeated, justifying the need for robust training in the practical application of the principles of capacity assessment for staff managing complex older patients.
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Affiliation(s)
- Jasmine M Gan
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Josie Riley
- Departments of Acute General Medicine and Geratology, John Radcliffe Hospital, Oxford, UK
| | - Romina Basting
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Nele Demeyere
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Sarah T Pendlebury
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Ibitoye T, Jackson TA, Davis D, MacLullich AMJ. Trends in delirium coding rates in older hospital inpatients in England and Scotland: full population data comprising 7.7M patients per year show substantial increases between 2012 and 2020. DELIRIUM COMMUNICATIONS 2023; 2023:84051. [PMID: 37654785 PMCID: PMC7614999 DOI: 10.56392/001c.84051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Background Little information is available on change in delirium coding rates over time in major healthcare systems. We examined trends in delirium discharge coding rates in older patients in hospital admissions to the National Health Service (NHS) in England and Scotland between 2012 and 2020. Methods Hospital administrative coding data were sourced from NHS Digital England and Public Health Scotland. We examined rates of delirium (F05 from ICD-10) in patients aged ≥70 years in 5 year and ≥90 age bands. Results There were approximately 7,000,000 discharges/year in England and 700,000/year in Scotland. Substantially increased delirium coding was observed for all age bands between 2012/2013 and 2019/2020 (p<0.001, Mann Kendall's tau). In the ≥90 age band, there was a 4-fold increase between 2012 and 2020. Conclusion Delirium coding rates have shown large increases in the NHS in England and Scotland, likely reflecting several factors including policy initiatives, detection tool implementation and education.
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Affiliation(s)
- Temi Ibitoye
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, The University of Edinburgh
| | | | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing, University College London
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh
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Casamento A, Neto AS, Lawrence M, Chudleigh L, Browne E, Taplin C, Eastwood GM, Bellomo R. Delirium in ventilated patients receiving fentanyl and morphine for Analgosedation: Findings from the ANALGESIC trial. J Crit Care 2023; 77:154343. [PMID: 37235918 DOI: 10.1016/j.jcrc.2023.154343] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 04/30/2023] [Accepted: 05/14/2023] [Indexed: 05/28/2023]
Abstract
PURPOSE The differential effect of fentanyl vs. morphine analgosedation on the development of hospital inpatient delirium in patients receiving mechanical ventilation is unknown. We aimed to compare the incidence of coding for delirium and antipsychotic medication use in patients treated with fentanyl vs. morphine in the ANALGESIC trial. MATERIALS AND METHODS We obtained data from a cluster randomized, cluster crossover trial of fentanyl vs. morphine for analgosedation on antipsychotic use and coding diagnosis of delirium and compared these outcomes according to treatment allocation. We assessed the relationship between opioid choice and dose, hospital inpatient delirium, and outcomes. RESULTS Among 681 patients enrolled in the ANALGESIC trial, 160/344 (46.5%) in the fentanyl group vs. 132/337 (39.1%) in the morphine group (absolute difference 7.34% [95% CI -0.9 to 14.78]; RR: 1.19 [95%CI 1.00 to 1.41]; p = 0.053) developed hospital inpatient delirium. Antipsychotic use was linearly related to opioid dose. Antipsychotic use was not associated with increased mortality. CONCLUSIONS Fentanyl is associated with a higher incidence of hospital inpatient delirium when used for analgosedation compared with morphine, and the dose of opioid is linearly related to the need for antipsychotic medication administration. The role of analgosedation in promoting delirium requires further investigation.
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Affiliation(s)
- Andrew Casamento
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Department of Intensive Care, Northern Hospital, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia.
| | - Ary Serpa Neto
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Data Analytics Research & Evaluation (DARE) Center, University of Melbourne and Austin Hospital, Melbourne, Australia; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil.
| | - Mervin Lawrence
- Department of Intensive Care, Northern Hospital, Melbourne, Australia.
| | - Laura Chudleigh
- Department of Intensive Care, Northern Hospital, Melbourne, Australia
| | - Emma Browne
- Department of Intensive Care, Northern Hospital, Melbourne, Australia.
| | - Christina Taplin
- Department of Intensive Care, Northern Hospital, Melbourne, Australia.
| | - Glenn M Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Data Analytics Research & Evaluation (DARE) Center, University of Melbourne and Austin Hospital, Melbourne, Australia.
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10
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Boucher EL, Gan JM, Rothwell PM, Shepperd S, Pendlebury ST. Prevalence and outcomes of frailty in unplanned hospital admissions: a systematic review and meta-analysis of hospital-wide and general (internal) medicine cohorts. EClinicalMedicine 2023; 59:101947. [PMID: 37138587 PMCID: PMC10149337 DOI: 10.1016/j.eclinm.2023.101947] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/17/2023] [Accepted: 03/21/2023] [Indexed: 05/05/2023] Open
Abstract
Background Guidelines recommend routine frailty screening for all hospitalised older adults to inform care decisions, based mainly on studies in elective or speciality-specific settings. However, most hospital bed days are accounted for by acute non-elective admissions, in which the prevalence and prognostic value of frailty might differ, and uptake of screening is limited. We therefore did a systematic review and meta-analysis of frailty prevalence and outcomes in unplanned hospital admissions. Methods We searched MEDLINE, EMBASE and CINAHL up to 31/01/2023 and included observational studies using validated frailty measures in adult hospital-wide or general medicine admissions. Summary data on the prevalence of frailty and associated outcomes, measurement tools, study setting (hospital-wide vs general medicine), and design (prospective vs retrospective) were extracted and risk of bias assessed (modified Joanna Briggs Institute checklists). Unadjusted relative risks (RR; moderate/severe frailty vs no/mild) for mortality (within one year), length of stay (LOS), discharge destination and readmission were calculated and pooled, where appropriate, using random-effects models. PROSPERO CRD42021235663. Findings Among 45 cohorts (median/SD age = 80/5 years; n = 39,041,266 admissions, n = 22 measurement tools) moderate/severe frailty ranged from 14.3% to 79.6% overall (and in the 26 cohorts with low-moderate risk of bias) with considerable heterogeneity between studies (phet < 0.001) preventing pooling of results but with rates <25% in only 3 cohorts. Moderate/severe vs no/mild frailty was associated with increased mortality (n = 19 cohorts; RR range = 1.08-3.70), more consistently among cohorts using clinically administered tools (n = 11; RR range = 1.63-3.70; phet = 0.08; pooled RR = 2.53, 95% CI = 2.15-2.97) vs cohorts using (retrospective) administrative coding data (n = 8; RR range = 1.08-3.02; phet < 0.001). Clinically administered tools also predicted increasing mortality across the full range of frailty severity in each of the six cohorts that allowed ordinal analysis (all p < 0.05). Moderate/severe vs no/mild frailty was also associated with a LOS >8 days (RR range = 2.14-3.04; n = 6) and discharge to a location other than home (RR range = 1.97-2.82; n = 4) but was inconsistently related to 30-day readmission (RR range = 0.83-1.94; n = 12). Associations remained clinically significant after adjustment for age, sex and comorbidity where reported. Interpretation Frailty is common in older patients with acute, non-elective hospital admission and remains predictive of mortality, LOS and discharge home with more severe frailty associated with greater risk, justifying more widespread implementation of screening using clinically administered tools. Funding None.
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Affiliation(s)
- Emily L. Boucher
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Jasmine M. Gan
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Peter M. Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Sasha Shepperd
- Nuffield Department of Population Health, University of Oxford, UK
| | - Sarah T. Pendlebury
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, University of Oxford, UK
- NIHR Oxford Biomedical Research Centre and Departments of Acute General (Internal) Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, UK
- Corresponding author. Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, John Radcliffe Hospital, Oxford, OX3 9DU, UK.
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11
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Bauernfreund Y, Launders N, Favarato G, Hayes JF, Osborn D, Sampson EL. Incidence and associations of hospital delirium diagnoses in 85,979 people with severe mental illness: A data linkage study. Acta Psychiatr Scand 2023; 147:516-526. [PMID: 35869544 PMCID: PMC10952251 DOI: 10.1111/acps.13480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/12/2022] [Accepted: 07/18/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Delirium is an acute neuro-psychiatric disturbance precipitated by a range of physical stressors, with high morbidity and mortality. Little is known about its relationship with severe mental illness (SMI). METHODS We conducted a retrospective cohort study using linked data analyses of the UK Clinical Practice Research Datalink (CPRD) and Hospital Episodes Statistics (HES) databases. We ascertained yearly hospital delirium incidence from 2000 to 2017 and used logistic regression to identify associations with delirium diagnosis in a population with SMI. RESULTS The cohort included 249,047 people with SMI with median follow-up time in CPRD of 6.4 years. A total of 85,979 patients were eligible for linkage to HES. Delirium incidence increased from 0.04 (95% CI 0.02-0.07) delirium associated admissions per 100 person-years in 2000 to 1.05 (95% CI 0.93-1.17) per 100 person-years in 2017, increasing most notably from 2010 onwards. Delirium was associated with older age at study entry (OR 1.05 per year, 95% CI 1.05-1.06), SMI diagnosis of bipolar affective disorder (OR 1.66, 95% CI 1.44-1.93) or other psychosis (OR 1.56, 95% CI 1.35-1.80) relative to schizophrenia, and more physical comorbidities (OR 1.08 per additional comorbidity of the Charlson Comorbidity Index, 95% CI 1.02-1.14). Patients with delirium received more antipsychotic medication during follow-up (1-2 antipsychotics OR 1.65, 95% CI 1.44-1.90; >2 antipsychotics OR 2.49, 95% CI 2.12-2.92). CONCLUSIONS The incidence of recorded delirium diagnoses in people with SMI has increased in recent years. Older people prescribed more antipsychotics and with more comorbidities have a higher incidence. Linked electronic health records are feasible for exploring hospital diagnoses such as delirium in SMI.
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Affiliation(s)
- Yehudit Bauernfreund
- Division of PsychiatryUniversity College LondonLondonUK
- Camden & Islington NHS Foundation TrustLondonUK
| | | | | | - Joseph F. Hayes
- Division of PsychiatryUniversity College LondonLondonUK
- Camden & Islington NHS Foundation TrustLondonUK
| | - David Osborn
- Division of PsychiatryUniversity College LondonLondonUK
- Camden & Islington NHS Foundation TrustLondonUK
| | - Elizabeth L. Sampson
- Division of PsychiatryUniversity College LondonLondonUK
- Department of Psychological MedicineEast London NHS Foundation Trust, Royal London HospitalLondonUK
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12
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Reeves D, Holland F, Morbey H, Hann M, Ahmed F, Davies L, Keady J, Leroi I, Reilly S. Retrospective study of more than 5 million emergency admissions to hospitals in England: Epidemiology and outcomes for people with dementia. PLoS One 2023; 18:e0281158. [PMID: 36888666 PMCID: PMC9994676 DOI: 10.1371/journal.pone.0281158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 01/13/2023] [Indexed: 03/09/2023] Open
Abstract
INTRODUCTION People living with dementia (PwD) admitted in emergency to an acute hospital may be at higher risk of inappropriate care and poorer outcomes including longer hospitalisations and higher risk of emergency re-admission or death. Since 2009 numerous national and local initiatives in England have sought to improve hospital care for PwD. We compared outcomes of emergency admissions for cohorts of patients aged 65+ with and without dementia at three points in time. METHODS We analysed emergency admissions (EAs) from the Hospital Episodes Statistics datasets for England 2010/11, 2012/13 and 2016/17. Dementia upon admission was based on a diagnosis in the patient's hospital records within the last five years. Outcomes were length of hospital stays (LoS), long stays (> = 15 days), emergency re-admissions (ERAs) and death in hospital or within 30 days post-discharge. A wide range of covariates were taken into account, including patient demographics, pre-existing health and reasons for admission. Hierarchical multivariable regression analysis, applied separately for males and females, estimated group differences adjusted for covariates. RESULTS We included 178 acute hospitals and 5,580,106 EAs, of which 356,992 (13.9%) were male PwD and 561,349 (18.6%) female PwD. Uncontrolled differences in outcomes between the patient groups were substantial but were considerably reduced after control for covariates. Covariate-adjusted differences in LoS were similar at all time-points and in 2016/17 were 17% (95%CI 15%-18%) and 12% (10%-14%) longer for male and female PwD respectively compared to patients without dementia. Adjusted excess risk of an ERA for PwD reduced over time to 17% (15%-18%) for males and 17% (16%-19%) for females, but principally due to increased ERA rates amongst patients without dementia. Adjusted overall mortality was 30% to 40% higher for PwD of both sexes throughout the time-period; however, adjusted in-hospital rates of mortality differed only slightly between the patient groups, whereas PwD had around double the risk of dying within 30 days of being discharged. CONCLUSION Over the six-year period, covariate-adjusted hospital LoS, ERA rates and in-hospital mortality rates for PwD were only slightly elevated compared to similar patients without dementia and remaining differences potentially reflect uncontrolled confounding. PwD however, were around twice as likely to die shortly after discharge, the reasons for which require further investigation. Despite being widely used for service evaluation, LoS, ERA and mortality may lack sensitivity to changes in hospital care and support to PwD.
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Affiliation(s)
- David Reeves
- National Institute for Health Research School for Primary Care Research, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Centre for Biostatistics, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- * E-mail:
| | - Fiona Holland
- National Institute for Health Research School for Primary Care Research, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Centre for Biostatistics, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Hazel Morbey
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, United Kingdom
| | - Mark Hann
- National Institute for Health Research School for Primary Care Research, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Centre for Biostatistics, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Faraz Ahmed
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, United Kingdom
| | - Linda Davies
- National Institute for Health Research School for Primary Care Research, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - John Keady
- National Institute for Health Research School for Social Care Research, Division of Nursing, Midwifery & Social Work, University of Manchester, Manchester, United Kingdom
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, United Kingdom
| | - Iracema Leroi
- Department of Psychiatry St James’ Hospital, Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland
| | - Siobhan Reilly
- Centre for Applied Dementia Studies, Faculty of Health Studies, University of Bradford, Bradford, United Kingdom
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13
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Proposing a Scientific and Technological Approach to the Summaries of Clinical Issues of Inpatient Elderly with Delirium: A Viewpoint. Healthcare (Basel) 2022; 10:healthcare10081534. [PMID: 36011191 PMCID: PMC9408148 DOI: 10.3390/healthcare10081534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 07/13/2022] [Accepted: 08/08/2022] [Indexed: 12/02/2022] Open
Abstract
Background/rationale: Despite mounting evidence about delirium, this complex geriatric syndrome is still not well managed in clinical contexts. The aging population creates a very demanding area for innovation and technology in healthcare. For instance, an outline of an aging-friendly healthcare environment and clear guidance for technology-supported improvements for people at delirium risk are lacking. Objective: We aimed to foster debate about the importance of technical support in optimizing healthcare professional practice and improving the outcomes for inpatients’ at delirium risk. We focused on critical clinical points in the field of delirium worthy of being addressed by a multidisciplinary approach. Methods: Starting from a consensus workshop sponsored by the Management Perfectioning Course based at the Marco Biagi Foundation (Modena, Italy) about clinical issues related to delirium management still not addressed in our healthcare organizations, we developed a requirements’ analysis among the representatives of different disciplines and tried to formulate how technology could support the summaries of the clinical issues. We analyzed the national and international panorama by a PubMed consultation of articles with the following keywords in advanced research: “delirium”, “delirium management”, “technology in healthcare”, and “elderly population”. Results: Despite international recommendations, delirium remains underdiagnosed, underdetected, underreported, and mismanaged in the acute hospital, increasing healthcare costs, healthcare professionals’ job distress, and poor clinical outcomes. Discussion: Although all healthcare professionals recognize delirium as a severe and potentially preventable source of morbidity and mortality for hospitalized older people, it receives insufficient attention in resource allocation and multidisciplinary research. We synthesized how tech-based tools could offer potential solutions to the critical clinical points in delirium management.
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14
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Cunningham E. Longest and largest cohort study of delirium to date reinforces association while causation remains elusive. J Neurol Neurosurg Psychiatry 2022; 93:jnnp-2022-329266. [PMID: 35697500 DOI: 10.1136/jnnp-2022-329266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 05/26/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Emma Cunningham
- Centre for Public Health, Queen's University Belfast Faculty of Medicine Health and Life Sciences, Belfast, UK
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15
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Karalapillai D, Weinberg L, Neto AS, Peyton PJ, Ellard L, Hu R, Pearce B, Tan C, Story D, O'Donnell M, Hamilton P, Oughton C, Galtieri J, Appu S, Wilson A, Eastwood G, Bellomo R, Jones DA. Intraoperative low tidal volume ventilation and the risk of ICD-10 coded delirium and the use for antipsychotic medications. BMC Anesthesiol 2022; 22:149. [PMID: 35578170 PMCID: PMC9109306 DOI: 10.1186/s12871-022-01689-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 05/05/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Low tidal volume (VT) ventilation and its associated increase in arterial carbon dioxide (PaCO2) may affect postoperative neurologic function. We aimed to test the hypothesis that intraoperative low VT ventilation affect the incidence of postoperative ICD-10 coded delirium and/or the need for antipsychotic medications. METHODS This is a post-hoc analysis of a large randomized controlled trial evaluating low vs. conventional VT ventilation during major non-cardiothoracic, non-intracranial surgery. The primary outcome was the incidence of ICD-10 delirium and/or the use of antipsychotic medications during hospital stay, and the absolute difference with its 95% confidence interval (CI) was calculated. RESULTS We studied 1206 patients (median age of 64 [55-72] years, 59.0% males, median ARISCAT of 26 [19-37], and 47.6% of ASA 3). ICD-10 coded delirium and /or antipsychotic medication use was diagnosed in 11.2% with similar incidence between low and conventional VT ventilation (11.1% vs. 11.3%; absolute difference, -0.24 [95%CI, -3.82 to 3.32]; p = 0.894). There was no interaction between allocation group and type of surgery. CONCLUSION In adult patients undergoing major surgery, low VT ventilation was not associated with increased risk of ICD-10 delirium and/or the use of antipsychotic medications during hospital stay. TRIAL REGISTRATION ANZCTR Identifier: ACTRN12614000790640 .
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Affiliation(s)
- Dharshi Karalapillai
- Department of Anaesthesia, Austin Hospital, Melbourne, VIC, Australia. .,Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia. .,Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia.
| | - Laurence Weinberg
- Department of Anaesthesia, Austin Hospital, Melbourne, VIC, Australia.,Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
| | - Ary Serpa Neto
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Data Analytics Research and Evaluation (DARE) Centre, University of Melbourne, Melbourne, VIC, Australia.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Philip J Peyton
- Department of Anaesthesia, Austin Hospital, Melbourne, VIC, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
| | - Louise Ellard
- Department of Anaesthesia, Austin Hospital, Melbourne, VIC, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia.,Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
| | - Raymond Hu
- Department of Anaesthesia, Austin Hospital, Melbourne, VIC, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia.,Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
| | - Brett Pearce
- Department of Anaesthesia, Austin Hospital, Melbourne, VIC, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia.,Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
| | - Chong Tan
- Department of Anaesthesia, Austin Hospital, Melbourne, VIC, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia.,Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
| | - David Story
- Department of Anaesthesia, Austin Hospital, Melbourne, VIC, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
| | - Mark O'Donnell
- Department of Anaesthesia, Austin Hospital, Melbourne, VIC, Australia
| | - Patrick Hamilton
- Department of Anaesthesia, Austin Hospital, Melbourne, VIC, Australia
| | - Chad Oughton
- Department of Anaesthesia, Austin Hospital, Melbourne, VIC, Australia
| | - Jonathan Galtieri
- Department of Anaesthesia, Austin Hospital, Melbourne, VIC, Australia
| | - Sree Appu
- Department of Surgery, Austin Hospital, Melbourne, VIC, Australia
| | - Anthony Wilson
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Glenn Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Data Analytics Research and Evaluation (DARE) Centre, University of Melbourne, Melbourne, VIC, Australia
| | - Daryl A Jones
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia.,Department of Surgery, University of Melbourne, Melbourne, VIC, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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16
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Ritchie C, Walters RW, Ramaswamy S, Alla VM. Impact of delirium on mortality in patients hospitalized for heart failure. Int J Psychiatry Med 2022; 57:212-225. [PMID: 34176306 DOI: 10.1177/00912174211028019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Heart Failure (HF) is one of the leading causes of hospitalization in the United States accounting for ≈800,000 hospital discharges and $11 billion in annual costs. Delirium occurs in approximately 30% of elderly hospitalized patients and its incidence is significantly higher among those admitted to the critical care units. Despite this, there has been limited exploration of the clinical and economic impact of delirium in patients hospitalized with acute HF. We hypothesized that delirium in HF is associated with excess mortality and hospital costs. METHODS We queried the 2001-2014 Nationwide Inpatient Sample to identify hospitalizations that included a primary discharge diagnosis of HF (ICD-9-CM: 428.xx) and stratified them by presence or absence of delirium (ICD-9-CM: 239.0, 290.41, 293.0, 293.1, 348.31). Differences in in-hospital mortality, length of stay (LOS), and hospital costs were assessed using propensity-score matched cohorts. RESULTS Major predictors of delirium included advanced age, Caucasian race, underlying dementia or psychiatric diagnoses, higher Elixhauser Comorbidity Index, renal failure, cardiogenic shock, and coronary artery bypass surgery. In the propensity-score matched analysis of 76,411 hospitalization with delirium compared to 76,612 without delirium, in-hospital mortality (odds ratio: 1.67, 95% CI: 1.51-1.77), LOS (rate ratio [RR]: 1.47, 95% CI: 1.45-1.51), and hospital costs (RR: 1.44, 95% CI: 1.41-1.48) were all statistically higher in the presence of delirium (all p < 0.001). CONCLUSION In patients hospitalized with HF, delirium is an independent predictor of increased in-hospital mortality, longer LOS, and excess hospital costs despite adjustment for baseline characteristics.
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Affiliation(s)
| | - Ryan W Walters
- Division of Clinical Research and Evaluative Sciences, 12282Creighton University School of Medicine, Department of Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | - Sriram Ramaswamy
- Department of Psychiatry, Creighton University School of Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | - Venkata M Alla
- Division of Cardiology, Department of Medicine, Creighton University School of Medicine, Omaha, NE, USA
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17
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Halliday A, Sneade M, Björck M, Pendlebury ST, Bulbulia R, Parish S, Llewellyn-Bennett R, Pan H, Whiteley W, Pan H, Gottsäter A. Editor's Choice - Effect of Carotid Endarterectomy on 20 Year Incidence of Recorded Dementia: A Randomised Trial. Eur J Vasc Endovasc Surg 2022; 63:535-545. [PMID: 35272949 DOI: 10.1016/j.ejvs.2021.12.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 12/12/2021] [Accepted: 12/29/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Stroke and carotid atherosclerosis are associated with dementia. Carotid endarterectomy (CEA) reduces stroke risk, although its effect on later dementia is uncertain. Participants in the Asymptomatic Carotid Surgery Trial (ACST-1), randomly allocated to immediate vs. deferral of CEA (i.e., no intervention unless or until triggered by ipsilateral transient ischaemic attack or stroke), were followed, to study effects on dementia. METHODS From 1993 to 2003, ACST-1 included 3 120 participants with asymptomatic tight carotid stenosis. All UK and Swedish patients (n = 1 601; 796 immediate vs. 805 deferral) were followed with trial records, national electronic health record linkage, and (UK only) by post and telephone. Cumulative incidence and competing risk analyses were used to measure the effects of risk factors and CEA on dementia risk. Intention to treat analyses yielded hazard ratios (HRs; immediate vs. deferral) of dementia. RESULTS The median follow up was 19.4 years (interquartile range 16.9 - 21.7). Dementia was recorded in 107 immediate CEA patients and 115 allocated delayed surgery; 1 290 patients died (1 091 [538 vs. 536] before any dementia diagnosis). Dementia incidence rose with age and with female sex (men: 8.3% aged < 70 years at trial entry vs. 15.1% aged ≥ 70; women: 15.1% aged < 70 years at trial entry vs. 22.4% aged ≥ 70 years) and was higher in those with pre-existing cerebral infarction (silent or with prior symptoms; 20.2% vs. 13.6%). Dementia risk was similar in both randomised groups: 6.7% vs. 6.6% at 10 years and 14.3% vs. 15.5% at 20 years, respectively. The dementia HR was 0.98 (95% confidence interval [CI] 0.75 - 1.28; p = .89), with no heterogeneity in the neutral effect of immediate CEA on dementia related to age, carotid stenosis, blood pressure, diabetes, country of residence, or medical treatments at trial entry (heterogeneity values p > .05). CONCLUSION CEA was not associated with significant reductions in the long term hazards of dementia, but the CI did not exclude a proportional benefit or hazard of about 25%.
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Affiliation(s)
- Alison Halliday
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.
| | - Mary Sneade
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Martin Björck
- Department of Surgical Sciences, University of Uppsala, Uppsala, Sweden
| | - Sarah T Pendlebury
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Richard Bulbulia
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sarah Parish
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Holly Pan
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - William Whiteley
- Nuffield Department of Population Health, University of Oxford, Oxford, UK; Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Hongchao Pan
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
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18
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Chuen VL, Chan ACH, Ma J, Alibhai SMH, Chau V. Assessing the Accuracy of International Classification of Diseases (ICD) Coding for Delirium. J Appl Gerontol 2022; 41:1485-1490. [PMID: 35176883 PMCID: PMC9024024 DOI: 10.1177/07334648211067526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE We assessed the accuracy of the ICD-10 code for delirium (F05) and its relationship with delirium discharge summary documentation. METHODS We performed a retrospective chart review at three academic hospitals. The Chart-based Delirium Identification Instrument (CHART-DEL) was used to identify 108 hospitalized patients aged ≥65 years with delirium, and 758 patients without delirium as controls. We assessed the proportion of patients who received the F05 code and calculated the sensitivity and specificity. We compared the rates of F05 code received between patients with and without "delirium" documented in the discharge summary. RESULTS Among delirious patients, 46.3% received a F05 code, which has a sensitivity of 46.3% and specificity of 99.6% for delirium. Of charts with "delirium" in the discharge summary (n = 67), 67.2% were appropriately coded. CONCLUSIONS Current ICD-10 data inadequately capture delirium. Delirium documentation in the discharge summary is associated with improved delirium coding.
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Affiliation(s)
- Victoria L Chuen
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Faculty of Medicine, 3710McMaster University, Hamilton, ON, Canada
| | - Adrian C H Chan
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Faculty of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Jin Ma
- Biostatistics Research Unit, 7989University Health Network, Toronto, ON, Canada
| | - Shabbir M H Alibhai
- Division of General Internal Medicine and Geriatrics, Department of Medicine, 7989University Health Network, Toronto, ON, Canada.,Division of General Internal Medicine and Geriatrics, Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Vicky Chau
- Division of General Internal Medicine and Geriatrics, Department of Medicine, 7989University Health Network, Toronto, ON, Canada.,Division of General Internal Medicine and Geriatrics, Department of Medicine, Sinai Health System, Toronto, ON, Canada
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Eagles D, Cheung WJ, Avlijas T, Yadav K, Ohle R, Taljaard M, Molnar F, Stiell IG. Barriers and facilitators to nursing delirium screening in older emergency patients: a qualitative study using the theoretical domains framework. Age Ageing 2022; 51:6509750. [PMID: 35061872 DOI: 10.1093/ageing/afab256] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND delirium is common in older emergency department (ED) patients, but vastly under-recognised, in part due to lack of standardised screening processes. Understanding local context and barriers to delirium screening are integral for successful implementation of a delirium screening protocol. OBJECTIVES we sought to identify barriers and facilitators to delirium screening by nurses in older ED patients. METHODS we conducted 15 semi-structured, face-to-face interviews based on the Theoretical Domains Framework with bedside nurses, nurse educators and managers at two academic EDs in 2017. Two research assistants independently coded transcripts. Relevant domains and themes were identified. RESULTS a total of 717 utterances were coded into 14 domains. Three dominant themes emerged: (i) lack of clinical prioritisation because of competing demands, lack of time and heavy workload; (ii) discordance between perceived capabilities and knowledge and (iii) hospital culture. CONCLUSION this qualitative study explored nursing barriers and facilitators to delirium screening in older ED patients. We found that delirium was recognised as an important clinical problem; however, it was not clinically prioritised; there was a false self-perception of knowledge and ability to recognise delirium and hospital culture was a strong influencer of behaviour. Successful adoption of a delirium screening protocol will only be realised if these issues are addressed.
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Affiliation(s)
- Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Warren J Cheung
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Tanja Avlijas
- Department of Emergency Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Robert Ohle
- Department of Emergency Medicine, Health Science North Research Institute, Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Monica Taljaard
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Frank Molnar
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Division of Geriatric Medicine, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Bruyere Research Institute, Ottawa, ON, Canada
| | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Pendlebury ST, Thomson RJ, Welch SJV, Kuker W, Rothwell PM. Utility of white matter disease and atrophy on routinely acquired brain imaging for prediction of long-term delirium risk: population-based cohort study. Age Ageing 2022; 51:6427231. [PMID: 34793588 PMCID: PMC8753040 DOI: 10.1093/ageing/afab200] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 07/04/2021] [Indexed: 12/15/2022] Open
Abstract
Background brain imaging done as part of standard care may have clinical utility beyond its immediate indication. Using delirium as an exemplar, we determined the predictive value of baseline brain imaging variables [white matter changes (WMC) and atrophy] for delirium risk on long-term follow-up after transient ischemic attack (TIA)/stroke in a population-based cohort study. Methods surviving TIA/stroke participants in the Oxford Vascular Study (OXVASC) were assessed prospectively for delirium during all hospitalisations over 6 months (2013–14). Using logistic regression, independent associations were determined between baseline OXVASC computed tomography or magnetic resonance brain imaging measures of WMC and cerebral atrophy (none/mild versus moderate/severe) and delirium adjusted for age, sex, baseline stroke severity, depression, illness severity and pre-admission cognition. Results among 1,565 TIA/stroke survivors with 194 hospital admissions (158 patients, mean/standard deviation age at admission = 79.2/11.5 years), delirium occurred in 59 (37%). WMC and atrophy on baseline imaging were associated with delirium [odds ratio (OR) = 3.41, 1.21–5.85, P = 0.001 and OR = 2.50, 1.23–5.08, P = 0.01 (unadjusted) and OR = 2.67, 1.21–5.85, P = 0.02 and OR = 2.18, 1.00–4.73, P = 0.05 (adjusted age and sex)]. Associations were strengthened when analyses were restricted to patients hospitalised within 5 years of baseline brain imaging [OR = 6.04, 2.39–15.24, P < 0.0001 and OR = 4.64, 1.46–14.82, P = 0.009 (unadjusted)] but only WMC remained significant after adjustment for all covariates including pre-admission cognition (OR = 4.83, 1.29–18.13, P = 0.02 for Mini-Mental State Examination and OR = 5.15, 1.26–21.09, P = 0.02 for Montreal Cognitive Assessment). Conclusions WMC and atrophy on brain imaging done up to 5 years earlier predicted delirium and may have clinical utility in risk stratification. Associations with WMC but not atrophy were independent of pre-admission cognitive impairment.
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Affiliation(s)
- Sarah T Pendlebury
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital and the University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Departments of General (Internal) Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ross J Thomson
- Department of Cardiology, Royal Free Hospital, London, UK
| | - Sarah J V Welch
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital and the University of Oxford, Oxford, UK
| | - Wilhelm Kuker
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital and the University of Oxford, Oxford, UK
| | - Peter M Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital and the University of Oxford, Oxford, UK
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Pendlebury ST, Thomson RJ, Welch SJV, Rothwell PM. Cognitive Predictors of Delirium on Long-Term Follow-Up after TIA and Stroke: Population-Based Cohort Study. Cerebrovasc Dis 2021; 51:288-295. [PMID: 34844242 DOI: 10.1159/000519900] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 09/16/2021] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION TIA and stroke cause cognitive impairment with a typical "vascular" pattern, including prominent frontal/executive deficits. Cognitive impairment is associated with increased delirium risk and the few available data suggest that executive dysfunction is important. We therefore determined the predictive value of both severity and pattern of cognitive deficits for delirium on long-term follow-up after TIA/stroke. METHODS Surviving TIA/stroke participants on October 1, 2013, in the Oxford Vascular Study (OXVASC) were assessed prospectively for delirium during all hospitalizations over the subsequent 6 months. Associations between OXVASC pre-admission mini-mental state examination (MMSE) and Montreal Cognitive Assessment (MoCA) scores, and delirium during hospitalizations on follow-up were determined using logistic regression adjusted for covariates, including demographic factors, history of depression, baseline stroke severity, and admission illness severity. RESULTS Among 1,565 TIA/stroke survivors, 158 patients (mean/SD age = 79.2/11.5 years) had ≥1 admission and 59 (37%) had ≥1 delirium episode. Mean/SD time between baseline TIA/stroke and admission was 4.7/3.6 years and between most recent OXVASC cognitive testing and admission was 1.7/1.8 years. MMSE and MoCA scores were associated with delirium: odds ratio (OR) = 1.16 (95% CI 1.07-1.27, p < 0.0001 per point decrease in MMSE) and OR = 1.20 (1.11-1.30, p < 0.0001 MoCA) and associations were robust to adjustment for all covariates, including stroke severity: OR = 1.11 (1.01-1.22, p = 0.03, MMSE) and OR = 1.15 (1.05-1.25, p = 0.003, MoCA). All 10 subtests on the MoCA and 4/11 on the MMSE were significantly associated with delirium with highest predictive value for frontal/executive and recall domains. CONCLUSIONS Cognitive impairment of increasing severity after TIA/stroke predisposed to delirium particularly deficits in frontal/executive domains and recall. Long-term risk of delirium should be considered as part of the overall cerebrovascular disease burden.
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Affiliation(s)
- Sarah T Pendlebury
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Departments of General (Internal) Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ross J Thomson
- Department of Cardiology, Royal Free Hospital, London, UK
| | - Sarah J V Welch
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - Peter M Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
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Pendlebury ST. Direct Oral Anticoagulants and Prevention of Dementia in Nonvalvular Atrial Fibrillation. Stroke 2021; 52:3469-3471. [PMID: 34496623 DOI: 10.1161/strokeaha.121.035664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sarah T Pendlebury
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom. NIHR Biomedical Research Centre, Departments of Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, United Kingdom
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Elias TCN, Bowen J, Hassanzadeh R, Lasserson DS, Pendlebury ST. Factors associated with admission to bed-based care: observational prospective cohort study in a multidisciplinary same day emergency care unit (SDEC). BMC Geriatr 2021; 21:8. [PMID: 33407210 PMCID: PMC7788859 DOI: 10.1186/s12877-020-01942-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 12/01/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The development of ambulatory emergency care services, now called 'Same Day Emergency Care' (SDEC) has been advocated to provide sustainable high quality healthcare in an ageing population. However, there are few data on SDEC and the factors associated with successful ambulatory care in frail older people. We therefore undertook a prospective observational study to determine i) the clinical characteristics and frailty burden of a cohort in an SDEC designed around the needs of older patients and ii) the factors associated with hospital admission within 30-days after initial assessment. METHODS The study setting was the multidisciplinary Abingdon Emergency Medical Unit (EMU) located in a community hospital and led by a senior interface physician (geriatrician or general practitioner). Consecutive patients from August-December 2015 were assessed using a structured paper proforma including cognitive/delirium screen, comorbidities, functional, social, and nutritional status. Physiologic parameters were recorded. Illness severity was quantified using the Systemic Inflammatory Response Syndrome (SIRS> 1). Factors associated with hospitalization within 30-days were determined using multivariable logistic regression. RESULTS Among 533 patients (median (IQR) age = 81 (68-87), 315 (59%) female), 453 (86%) were living at home but 283 (54%) required some form of care and 299 (56%) had Barthel< 20. Falls, urinary incontinence and dementia affected 81/189 (43%), 50 (26%) and 40 (21%) of those aged > 85 years." Severe illness was present in 148 (28%) with broadly similar rates across age groups. Overall, 210 (39%) patients had a hospital admission within 30-days with higher rates in older patients: 96 (87%) of < 65 years remained on an ambulatory pathway versus only 91 (48%) of ≥ 85 years (p < 0.0001). Factors independently associated with hospital admission were severe illness (SIRS/point, OR = 1.46,95% CI = 1.15-1.87, p = 0.002) and markers of frailty: delirium (OR = 11.28,3.07-41.44, p < 0.0001), increased care needs (OR = 3.08,1.55-6.12, p = 0.001), transport requirement (OR = 1.92,1.13-3.27), and poor nutrition (OR = 1.13-3.79, p = 0.02). CONCLUSIONS Even in an SDEC with a multidisciplinary approach, rates of hospital admission in those with severe illness and frailty were high. Further studies are required to understand the key components of hospital bed-based care that need to be replicated by models delivering acute frailty care closer to home, and the feasibility, cost-effectiveness and patient/carer acceptability of such models.
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Affiliation(s)
- Tania C N Elias
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, and the University of Oxford, Wolfson Building, Oxford, OX3 9DU, England.,Departments of Acute Internal Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU, England
| | - Jordan Bowen
- Departments of Acute Internal Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU, England
| | - Royah Hassanzadeh
- Departments of Acute Internal Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU, England
| | - Daniel S Lasserson
- PIONEER Health Data Research Hub, Institute for Applied Health Research, University of Birmingham, Birmingham, B15 2TT, England.,Department of Acute Medicine, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, B18 7QH, England
| | - Sarah T Pendlebury
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, and the University of Oxford, Wolfson Building, Oxford, OX3 9DU, England. .,Departments of Acute Internal Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU, England. .,NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, OX3 9DU, England.
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Affiliation(s)
- Sarah T Pendlebury
- Departments of Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust and NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital and Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, UK., Professor Sarah Pendlebury is supported by the NIHR Oxford Biomedical Research Centre
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