Publications

Delirium is an acute change in cognition which occurs frequently after coronary artery bypass graft (CABG) surgery. Cerebral microemboli, from plaque, air, or thrombus, have been hypothesized to contribute to delirium and cognitive decline after CABG. The purpose of this study was to determine if there was an association between cerebral microemboli and delirium after cardiac surgery. Non-delirious patients (n=68) were prospectively enrolled and underwent intraoperative monitoring of the middle cerebral arteries with transcranial Doppler (TCD). TCD signals were saved and analyzed postoperatively for microemboli manually, according to established criteria. Postoperatively, patients were assessed for delirium with a standardized battery. Thirty-three patients (48.5%) developed delirium after surgery. Microemboli counts (mean + or - SD) were not significantly different in those with and without delirium (303 + or - 449 vs. 299 + or - 350; p=0.97). While intraoperative microemboli were not associated with delirium after CABG, further investigation into the source and composition of microemboli can further elucidate the long-term clinical impact of microemboli.

BACKGROUND: While delirium has been increasingly recognized as a serious and potentially preventable condition, its long-term implications are not well understood. This study determined the total 1-year health care costs associated with delirium.

METHODS: Hospitalized patients aged 70 years and older who participated in a previous controlled clinical trial of a delirium prevention intervention at an academic medical center between 1995 and 1998 were followed up for 1 year after discharge. Total inflation-adjusted health care costs, calculated as either reimbursed amounts or hospital charges converted to costs, were computed by means of data from Medicare administrative files, hospital billing records, and the Connecticut Long-term Care Registry. Regression models were used to determine costs associated with delirium after adjusting for patient sociodemographic and clinical characteristics.

RESULTS: During the index hospitalization, 109 patients (13.0%) developed delirium while 732 did not. Patients with delirium had significantly higher unadjusted health care costs and survived fewer days. After adjusting for pertinent demographic and clinical characteristics, average costs per day survived among patients with delirium were more than 2(1/2) times the costs among patients without delirium. Total cost estimates attributable to delirium ranged from $16 303 to $64 421 per patient, implying that the national burden of delirium on the health care system ranges from $38 billion to $152 billion each year.

CONCLUSIONS: The economic impact of delirium is substantial, rivaling the health care costs of falls and diabetes mellitus. These results highlight the need for increased efforts to mitigate this clinically significant and costly disorder.

PURPOSE: Service quality deficiencies are common in health care. However, little is known about the relationship between service quality and the occurrence of adverse events and medical errors. We hypothesized that patients who reported poor service quality were at increased risk of experiencing adverse events and medical errors.

SUBJECTS AND METHODS: Patients were interviewed during and after their admissions regarding problems experienced during the hospitalizations. We used this information to identify service quality deficiencies. We then performed a blinded, retrospective chart review to independently identify adverse events and errors. We used multivariable methods to analyze whether patients who reported service quality deficiencies (obtained by patient report) experienced any adverse event, close call, or low risk error (ascertained by chart review).

RESULTS: The 228 participants (mean age 63 years, 37% male) reported 183 service quality deficiencies. Of the 52 incidents identified on chart review, patients experienced 34 adverse events, 11 close calls, and 7 low risk errors. The presence of any service quality deficiency more than doubled the odds of any adverse event, close call, or low risk error (adjusted odds ratio = 2.5; 95% confidence interval = 1.2-5.4). Service quality deficiencies involving poor coordination of care (adjusted odds ratio = 4.4; 95% confidence interval = 1.4-14.0) were associated with the occurrence of adverse events and medical errors.

CONCLUSIONS: Patient-reported service quality deficiencies were associated with adverse events and medical errors. Patients who report service quality incidents may help to identify patient safety hazards.

BACKGROUND: Delirium has been hypothesized to be a central nervous system response to systemic inflammation during a state of blood-brain barrier compromise. The purpose of this study was to compare postoperative changes in groups of inflammatory markers in persons who developed delirium following cardiac surgery and matched controls without delirium.

METHODS: Serum samples were drawn from 42 patients undergoing cardiac surgery preoperatively and postoperatively at 6 hours and postoperative day 4. The serum concentrations of 28 inflammatory markers were determined with a microsphere flow cytometer. A priori, inflammatory markers were assigned to five classes of cytokines. A class z score was calculated by averaging the standardized, normalized levels of the markers in each class. Beginning on postoperative day 2, patients underwent a daily delirium assessment.

RESULTS: Twelve patients with delirium were matched by surgical duration, age, and baseline cognition to 12 patients without delirium. At the 6-hour time point, patients who went on to develop delirium had higher increases of chemokines compared to matched controls (class z score 0.3 +/- 1.0, p <.05). Among the five classes of cytokines, there were no other significant differences between patients with or without delirium at either the 6 hour or postoperative day 4 assessments.

CONCLUSION: After cardiac surgery, chemokine levels were elevated in patients who developed delirium in the early postoperative period. Because chemokines are capable of disrupting blood-brain barrier integrity in vitro, future studies are needed to define the relationship of these inflammatory mediators to delirium pathogenesis.

PURPOSE: We sought to examine the use of preventive health services among older women and to assess how age and illness burden influence care patterns.

METHODS: The charts of 299 women aged > or =80 and 229 women aged 65-79 years who did not have dementia or terminal illness at 1 academic primary care practice in Boston were reviewed between July and December 2005 to determine receipt of screening tests (e.g., mammography), counseling on healthy lifestyle (e.g., exercise), and/or geriatric health issues (e.g., incontinence), and immunizations. Illness burden was quantified using the Charlson Comorbidity Index (CCI).

RESULTS: Women aged > or =80 were more likely than women aged 65-79 to have a CCI of > or =3 (24.0% vs. 16.7%) and were less likely to receive all screening tests. However, receipt of mammography (47.8%) and colon cancer screening (51.2%) was still common among women aged > or =80 and was not targeted to older women in good health. Women aged > or =80 were less likely to be screened for depression (adjusted relative risk [aRR] 0.6; 95% confidence interval [CI], 0.5-0.8), osteoporosis (aRR, 0.6; 95% CI, 0.5-0.9), or counseled about exercise (aRR 0.8; 95% CI, 0.6-0.9) than younger women, but were more likely to receive counseling about falls (aRR 1.9; 95% CI, 1.4-2.6) and/or incontinence (aRR 1.8; 95% CI, 1.2-2.6). However notes documenting discussions about mood (28.6%), exercise (40.0%), falls (28.8%), or incontinence (20.8%) were low among all women.

CONCLUSION: In a comprehensive review of preventive health measures for elderly women, many in poor health were screened for cancer. Meanwhile, many older women were not screened for depression or counseled about exercise, falls, or incontinence. There is a need to improve delivery of preventive health care to older women.

OBJECTIVES: To measure the prevalence of depressive symptoms, cognitive impairment, and delirium in patients with hip fracture and to estimate their effect on functional recovery, institutionalization, and death after surgical repair.

DESIGN: Prospective cohort.

SETTING: Hospital, follow-up to community and nursing home.

PARTICIPANTS: One hundred twenty-six patients aged 65 and older admitted for hip fracture repair.

MEASUREMENTS: Baseline measurements: Mini-Mental State Examination, Blessed Dementia Rating Scale, Geriatric Depression Scale, prefracture activities of daily living (ADLs), ambulatory status. The Confusion Assessment Method was used to diagnose in-hospital delirium. One- and 6-month outcomes were ADL decline, loss of ambulation, and new nursing home placement or death.

RESULTS: Twenty-two percent of patients had one cognitive or mood disorder, 30% had two, and 7% had three. At 1 month, each cognitive or mood disorder was independently associated with one or more adverse outcome. Considered together, each additional cognitive or mood disorder was associated with greater odds of 1 month outcomes (ADL decline: odds ratio (OR)=1.8, 95% confidence interval (CI)=1.1-2.9; decline in ambulation: OR=1.8, 95% CI=1.1-3.0; nursing home placement or death: OR=3.9, 95% CI=1.9-8.1).

CONCLUSION: Cognitive and mood disorders were common in elderly hip fracture patients and were associated with greater risk of poor outcomes, both independently and in combination. Recognition and treatment of these conditions may reduce adverse outcomes in this vulnerable population.

OBJECTIVES: To examine the mediating role between educational attainment and risk for incidence delirium of activity participation and to examine the contribution of participation in specific activities to the development of delirium.

DESIGN: Prospective cohort study.

SETTING: Urban teaching hospital in New Haven, Connecticut.

PARTICIPANTS: Participants were drawn from two prospective cohort studies of 779 newly hospitalized patients aged 70 and older without dementia.

MEASUREMENTS: The main outcome was delirium, measured using the full Confusion Assessment Method (CAM) algorithm, which consisted of acute onset and fluctuating course, inattention, and disorganized thinking or altered level of consciousness, as rated by trained clinical interviewers.

RESULTS: Bivariable results indicated a significant relationship between education and the development of delirium (odds ratio (OR)=0.92, 95% confidence interval (CI)=0.88-0.97) and between activity and delirium (OR= 0.60, 95% CI=0.46-0.79). In multivariable analysis, activity mediated the relationship between education and risk for delirium. Considering each activity separately, multivariable logistic regression analysis showed that regular exercise significantly lowered the risk for developing delirium (OR=0.76, 95% CI=0.60-0.96).

CONCLUSION: In older persons without dementia, activity participation before hospitalization is a mediator between education and incidence of delirium. Specifically, it was found that participation in regular exercise was found to be significantly protective against delirium.

PURPOSE: We sought to determine how women aged 80 years or older value different preventive health measures compared to women aged 65 to 79 years.

DESIGN AND METHODS: We surveyed 107 women aged 80 years or older and 93 women aged 65 to 79 years; we randomly selected all of them from a large academic primary care practice. We measured perceived importance and priority placed on different preventive health measures, including screening tests; counseling on healthy lifestyle and geriatric health issues; immunizations; and recommendations for over-the-counter prevention medications.

RESULTS: Of the 200 women, 28.5% were aged 80 to 84 and 25.0% were aged 85 years or older. The majority of the women were non-Hispanic White (65.5%), had private insurance (82.0%), and were in good health condition (52.0%). Women aged between 65 and 79 were more likely than women aged 80 or older to consider screening tests and exercise counseling essential or very important to maintaining their health. Women aged 80 or older did not value any preventive health measure more highly than did younger women. Women who were 65 to 79 years of age ranked mammography screening as their most valued preventive health measure, with five of their top six measures being screening tests. Women who were 85 years of age or older prioritized flu shots, recommendations for aspirin, and then mammography screening.

IMPLICATIONS: Screening tests and exercise counseling are more highly valued by women aged 65 to 79 years than by women aged 80 years or older. Regardless of age, mammography screening is prioritized over other preventive health measures. Understanding how older women value different preventive health measures may help clinicians improve their preventive health counseling.

OBJECTIVES: To identify barriers and motivators to participation in long-term clinical research by high-risk elderly people and to develop procedures to maximize recruitment and retention.

DESIGN: Quantitative and qualitative survey.

SETTING: Academic primary care medicine and pre-anesthesia testing clinics.

PARTICIPANTS: Fifty patients aged 70 and older, including 25 medical patients at high risk of hospitalization and 25 patients with planned major surgery.

MEASUREMENTS: Fifteen- to 20-minute interviews involved open- and closed-ended questions guided by an in-depth script. Two planned study protocols were presented to each participant. Both involved serial neuropsychological assessments, blood testing, and magnetic resonance brain imaging (MRI); one added lumbar puncture (LP). Participants were asked whether they would be willing to participate in these protocols, rated barriers and incentives to participation, and were probed with open-ended questions.

RESULTS: Of 50 participants (average age 78, 44% male, 40% nonwhite), 32 (64%) expressed willingness to participate in the LP-containing protocol, with LP cited as the strongest disincentive. Thirty-eight (76%) expressed willingness to participate in the protocol without LP, with phlebotomy and long interviews cited as the strongest disincentives. Altruism was a strong motivator for participation, whereas transportation was a major barrier. Study visits at home, flexible appointment times, assessments shorter than 75 minutes, and providing transportation and free parking were strategies developed to maximize study participation.

CONCLUSION: Vulnerable elderly people expressed a high rate of willingness to participate in an 18-month prospective study. Participants identified incentives and barriers that enabled investigators to develop procedures to maximize recruitment and retention.

BACKGROUND: Unplanned hospitalization often represents a costly and hazardous event for the older population.

OBJECTIVES: To develop and validate a predictive model for unplanned medical hospitalization from administrative data.

RESEARCH DESIGN: Model development and validation.

SUBJECTS: A total of 3919 patients aged > or =70 years who were followed for at least 1 year in primary care clinics of an academic medical center.

MEASURES: Risk factor data and the primary outcome of unplanned medical hospitalization were obtained from administrative data.

RESULTS: Of 1932 patients in the development cohort, 299 (15%) were hospitalized during 1 year follow up. Five independent risk factors were identified in the preceding year: Deyo-Charlson comorbidity score > or =2 [adjusted relative risk (RR) = 1.8; 95% confidence interval (CI): 1.4-2.2], any prior hospitalization (RR = 1.8; 95% CI: 1.5-2.3), 6 or more primary care visits (RR = 1.6; 95% CI: 1.3-2.0), age > or =85 years (RR = 1.4; 95% CI: 1.1-1.7), and unmarried status (RR = 1.4; 95% CI: 1.1-1.7). A risk stratification system was created by adding 1 point for each factor present. Rates of hospitalization for the low- (0 factor), intermediate- (1-2 factors), and high-risk (> or =3 factors) groups were 5%, 15%, and 34% (P < 0.0001). The corresponding rates in the validation cohort, where 328/1987 (17%) were hospitalized, were 6%, 16%, and 36% (P < 0.0001).

CONCLUSIONS: A predictive model based on administrative data has been successfully validated for prediction of unplanned hospitalization. This model will identify patients at high risk for hospitalization who may be candidates for preventive interventions.