Publications

BACKGROUND: Delirium is common among hospitalized elders and may persist for months. The adverse impact of delirium on independence may increasingly occur in the postacute care (PAC) setting. The purpose of this study is to examine the association between delirium resolution and functional recovery in skilled nursing facilities specializing in PAC.

METHODS: Patients were screened for delirium on admission after an acute hospitalization at PAC facilities. Only patients with "Confusion Assessment Method"-defined delirium were enrolled. Delirium and activities of daily living were assessed prehospital, at PAC admission, and at four (2-week, and 1-, 3-, and 6-month) follow-up assessments to measure functional ability. Four distinct delirium resolution groups were created ranging from resolution within 2 weeks without recurrence to no resolution over 6 months. Repeated-measures analysis of covariance was used to determine if functional performance differed over time by delirium resolution status.

RESULTS: Among the 393 PAC patients, functional recovery differed significantly (p <.0001) by delirium resolution status. Patients who resolved their delirium by 2 weeks without recurrence regained 100% of their prehospital functional level, whereas patients who never resolved their delirium retained less than 50% of their prehospital functional level. Patients with slower resolving delirium and recurrent delirium had intermediate functional outcomes.

CONCLUSIONS: Resolution of delirium among PAC patients appears to be a prerequisite for functional recovery. Delirium resolution within 2 weeks without recurrence is associated with excellent functional recovery. Effective strategies to resolve delirium promptly and prevent its recurrence in the PAC setting will likely benefit patient rehabilitation and functional recovery.

OBJECTIVES: To compare the national prevalence of reported receipt of clinician exercise counseling across four age groups of women (50-64, 65-74, 75-84, and > or =85) and to determine whether age or health are barriers to reported receipt of exercise counseling.

DESIGN: 2000 National Health Interview Survey (NHIS).

SETTING: United States.

PARTICIPANTS: Six thousand three hundred eighty-five women aged 50 and older who responded to the 2000 NHIS, representing an estimated 34.5 million noninstitutionalized women nationally.

MEASUREMENTS: Exercise counseling, disease burden, functional dependency, and physical inactivity were assessed by questionnaire.

RESULTS: Of the 6,385 women, 52.2% were aged 50 to 64, 24.8% were aged 65 to 74, 18.0% were age 75 to 84, and 5.1% were aged 85 and older. Overall, 28.3% reported that a clinician had recommended that they begin or continue to perform any type of exercise or physical activity during the previous year: 31.4% of women aged 50 to 64, 29.2% of women aged 65 to 74, 21.6% of women aged 75 to 84, and 14.4% of women aged 85 and older. Women aged 75 to 84 (adjusted odds ratio (AOR)=0.8, 95% confidence interval (CI)=0.6-1.0) and women aged 85 and older (AOR=0.6, 95% CI=0.4-0.9) were substantially less likely to report clinician counseling about exercise, before and after adjustment. Further adjustment for illness burden and functional dependency did not attenuate the effect of receipt of exercise counseling.

CONCLUSION: Reported receipt of exercise counseling by older women is low nationally. Despite known benefits of late-life exercise, women aged 75 and older are less likely to report receiving exercise counseling from their clinicians than women aged 50 to 64. Interventions should be aimed at increasing clinician counseling about exercise, especially to older women.

OBJECTIVES: To obtain information from decision makers about attitudes toward hospitalization and the factors that influence their decisions to hospitalize nursing home residents.

DESIGN: Cross-sectional survey.

SETTING: Four hundred forty-eight nursing homes, 76% of which were nonprofit, from 25 states.

PARTICIPANTS: Medical directors and directors of nursing (DONs).

MEASUREMENTS: Participants were surveyed about resource availability, determinants of hospitalization, causes of overhospitalization, and nursing home practice.

RESULTS: The survey response rate was 81%, with at least one survey from 93% of the facilities. Medical directors and DONs agreed that resident preference was the most important determinant in the decision to hospitalize, followed by quality of life. Although both groups ranked on-site doctor/nurse practitioner evaluation within 4 hours as the least accessible resource, they did not rank doctors not being quickly available as an important cause of overhospitalization. Rather, medical directors perceived the lack of information and support to residents and families around end-of-life care and the lack of familiarity with residents by covering doctors as the most important causes of overhospitalization. DONs agreed but reversed the order. Medical directors and DONs expressed confidence in provider and staff ability, although DONs were significantly more positive.

CONCLUSION: Medical directors and DONs agree about most factors that influence decisions to hospitalize nursing home residents. Patient-centered factors play the largest roles, and the most important causes of overhospitalization are potentially modifiable.

BACKGROUND: It has been recognized that neurocognitive decline (NCD) often occurs as a complication in cardiac surgery. The early inflammatory response and C-reactive protein (CRP) was examined in relation to NCD and to a marker of axonal central nervous system (CNS) injury after cardiopulmonary bypass.

METHODS: A cohort of patients undergoing coronary artery bypass grafting and/or valve procedures using cardiopulmonary bypass were administered a neurocognitive battery preoperatively and postoperatively at 6 hours and day 4. CRP, interleukin 1 beta, and interleukin 10 were quantified from serum. Increase of serum tau protein after surgery was used as a marker of axonal CNS damage.

RESULTS: The rate of NCD was found to be 40.5% in this group. Surprisingly, known predictors of NCD did not differ significantly between patients with/without NCD. Patients with NCD had an early increase of CRP of a significantly higher magnitude than those without NCD (38.01 +/- 11.4 vs 16.49 +/- 3.5 mg/L, P = .042), interleukin 1ss (2.35 +/- 0.3 vs 1.20 +/- 0.2 pg/mL, P = .002), and interleukin 10 (29.77 +/- 4.7 vs 12.94 +/- 2.2 pg/mL, P < .001). Increase in serum Tau protein was significantly correlated to NCD (r = 0.50, P = .02).

CONCLUSION: Perioperative increases in CRP and inflammatory cytokines are associated with NCD in patients after cardiopulmonary bypass. Thus, it appears that inflammation plays a key role in NCD pathophysiology, likely via axonal CNS injury, and could become a target for prevention.

OBJECTIVES: To determine the extent to which preoperative performance on tests of executive function and memory was associated with delirium after coronary artery bypass graft (CABG) surgery.

DESIGN: Prospective observational cohort study.

SETTING: Two academic medical centers and one Department of Veterans Affairs medical center in Massachusetts.

PARTICIPANTS: Eighty subjects without preoperative delirium undergoing CABG or CABG-valve surgery completed baseline neuropsychological assessments with validated measures of memory and executive function.

MEASUREMENTS: Beginning on postoperative Day 2, a battery to diagnose delirium was administered daily. Confirmatory factor analysis (CFA) was used to define two cognitive domain composites (memory and executive function). The loading pattern of neuropsychological measures onto the latent cognitive domains was determined a priori. Poisson regression was used to model the association between neuropsychological performance and cognitive domain composite scores and risk of postoperative delirium. The association was expressed as the difference between impaired (0.5 standard deviations (SDs) below mean) and nonimpaired (0.5 SDs above mean) performers.

RESULTS: Forty subjects (50%) developed delirium. Measures of memory function were not significantly related to delirium. Of the executive function measures, verbal fluency, category fluency, Hopkins Verbal Learning Test learning, and backward recounting of days and months were significantly related to delirium. Preoperative mental status was a strong predictor of postoperative delirium. After controlling for age, sex, education, medical comorbidity, mental status, and the other cognitive domain, CFA cognitive domain composites suggest that risk for delirium is specific for executive functioning impairment (relative risk (RR) = 2.77, 95% confidence interval (CI) = 1.12-6.87) but not for memory impairment (RR = 0.49, 95% CI = 0.19-1.25).

CONCLUSION: Worse preoperative performance in executive function was independently associated with greater risk of developing delirium after CABG.

OBJECTIVE: To determine intensive care unit (ICU) admission characteristics predictive of mortality among older nursing home residents.

DESIGN: Retrospective cohort study.

SETTING: A 725-bed teaching nursing home and two teaching-hospital ICUs.

PATIENTS: One hundred twenty-three nursing home residents > or =75 yrs admitted to the ICU between July 1, 1999, and September 30, 2003.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: Characteristics of nursing home residents admitted to the ICU were identified by medical record review at the nursing home and the hospital. Additionally, the minimum data set was used to calculate preadmission functional status using the Activities of Daily Living-Long Form (ADL-L) and cognitive status with the Cognitive Performance Scale (CPS). Our primary outcomes were hospital mortality and mortality within 90 days of ICU admission. The nursing home residents admitted to the ICU were old (87.7 +/- 5.4 yrs) with impaired cognition (CPS 2.8 +/- 1.7, range 0-6, where 6 = most impaired) and moderately dependent function (ADL-L 14.5 +/- 9.4, range 0-28, where 28 = total dependence). Of the 123 patients, 33 (27%) died in the hospital, whereas 90 (73%) survived to hospital discharge. Acute Physiology and Chronic Health Evaluation (APACHE) III score was independently associated with significantly increased odds of hospital mortality (adjusted odds ratio 1.04; 95% confidence interval 1.02, 1.07). Among the 90 patients who survived to return to the nursing home, 34 (37.8%) died within 90 days. Cox regression demonstrated that higher APACHE III score (adjusted risk ratio 1.02; 95% confidence interval 1.01, 1.04) and increasing functional dependency before ICU admission (adjusted risk ratio 1.6; 95% confidence interval 1.05, 2.57, per ADL-L quartile) were independently associated with increased mortality rate within 90 days.

CONCLUSIONS: Among vulnerable elderly nursing home residents, higher APACHE III score is independently associated with increased hospital mortality rate and mortality within 90 days. Among hospital survivors, impaired functional status is independently associated with increased mortality rate within 90 days.

BACKGROUND: Despite uncertain benefit, many women over age 80 (oldest-old) receive screening mammography.

OBJECTIVE: To explore decision-making and physician counseling of oldest-old women around mammography screening.

DESIGN: Qualitative research using in-depth semi-structured interviews.

PARTICIPANTS: Twenty-three women aged 80 or older who received care at a large academic primary care practice (13 had undergone mammography screening in the past 2 years) and 16 physicians at the same center.

APPROACH: We asked patients and physicians to describe factors influencing mammography screening decisions of oldest-old women. We asked physicians to describe their counseling about screening to the oldest-old.

RESULTS: Patients and/or physicians identified the importance of physician influence, patient preferences, system factors, and social influences on screening decisions. Although physicians felt that patient's health affected screening decisions, few patients felt that health mattered. Three types of elderly patients were identified: (1) women enthusiastic about screening mammography; (2) women opposed to screening mammography; and (3) women without a preference who followed their physician's recommendation. However, physician counseling about mammography screening to elderly women varies; some individualize discussions; others encourage screening; few discourage screening. Physicians report that discussions about stopping screening can be uncomfortable and time consuming. Physicians suggest that more data could facilitate these discussions.

CONCLUSIONS: Some oldest-old women have strong opinions about screening mammography while others are influenced by physicians. Discussions about stopping screening are challenging for physicians. More data about the benefits and risks of mammography screening for women aged 80 or older could inform patients and improve provider counseling to lead to more rational use of mammography.

OBJECTIVE: To evaluate the interrater reliability of a structured delirium assessment method for nonclinician interviewers in elderly patients newly admitted for postacute care.

DESIGN: Prospective assessment using dyads of nonclinician raters.

SETTING: Postacute (Medicare) units at 6 skilled nursing facilities.

PARTICIPANTS: Forty elderly patients newly admitted for postacute care from medical or surgical units at acute care hospitals.

MEASUREMENTS: Subjects underwent dual delirium assessments within 5 days of admission. The standardized delirium assessment included the Mini-Mental Status Exam and Digit Span to assess overall cognitive function, the Delirium Symptom Interview to elicit specific delirium symptoms, the Memorial Delirium Assessment Scale to measure the severity of delirium, and the Confusion Assessment Method (CAM) to make the diagnosis of delirium. A coding protocol that linked observations to specific coding was used to improve reliability.

RESULTS: The structured delirium assessment process produced very high interobserver agreement for all instruments. Kappa for agreement on delirium diagnosis was 0.95.

CONCLUSIONS: Nonclinician interviewers using a structured delirium assessment achieved reliability that rivaled or exceeded that of trained clinical assessors in other studies. Nonclinicians may offer an effective alternative for the assessment of delirium among postacute patients in skilled nursing facilities.

BACKGROUND: While acute illness and hospitalization represent pivotal events for older persons, their contribution to recoverable cognitive dysfunction (RCD) has not been well examined.

OBJECTIVE: Our goals were to estimate the frequency and degree of RCD in an older hospitalized cohort; to examine the relationship of RCD with delirium and dementia; and to determine 1-year cognitive outcomes.

DESIGN: Prospective cohort study.

PARTICIPANTS: Four hundred and sixty patients aged > or =70 years drawn from consecutive admissions to an academic hospital.

MEASUREMENTS: Patients underwent interviews daily during hospitalization and at 1 year. The primary outcome was RCD, defined as an admission Mini-Mental State Examination (MMSE) score that improved by 3 or more points by discharge.

RESULTS: Recoverable cognitive dysfunction occurred in 179 of 460 (39%) patients, with MMSE impairment at baseline ranging from 3 to 13 points (median=5.0 points). The majority of cases were not characteristic of either delirium or dementia, as 144 of 179 (80%) cases did not meet criteria for delirium, and 133 of 164 (81%) cases did not meet criteria for dementia at baseline. In multivariable analysis controlling for baseline MMSE level, 3 factors were predictive of RCD: higher educational level, preadmission functional impairment, and higher illness severity. At 1 year, further improvement in MMSE score occurred in 38 of 92 (41%) patients with RCD. Recoverable cognitive dysfunction was independently predictive of 1-year mortality with an adjusted odds ratio of 1.82 (95% confidence interval [95% CI] 1.03 to 3.20).

CONCLUSIONS: Acute illness is accompanied by a high rate of RCD that is neither characteristic of delirium or dementia. Our observations underscore the reversible nature of this cognitive dysfunction with continued improvement over the ensuing year, and highlight the potential clinical implications of this under-recognized phenomenon.

OBJECTIVE: To derive and confirm scales measuring medical director's attitudes about hospitalization of nursing home residents.

METHOD: The authors surveyed nursing facility medical directors about the necessity of hospitalizing residents for eight clinical conditions and compared the ratings to those obtained from an expert panel to derive a relative hospitalization score. They also asked about factors that might influence hospitalization decisions. They performed a factor analysis to derive scales that measure attitudinal determinants of hospitalization and used the relative hospitalization score to confirm the scales.

RESULTS: The survey had a 79% response rate. The relative hospitalization score demonstrated that medical directors were slightly less likely to recommend hospitalization than expert panel physicians. Factor analyses yielded 10 scales focusing on nursing home functioning, economics, resident specific considerations, and physician attitudes. Eight of the 10 scales had significant bivariable associations with the relative hospitalization score, and 6 had significant multivariable associations.

DISCUSSION: Medical directors identify multiple determinants of hospitalization for nursing facility residents across several domains. Hospitalization decisions for nursing facility residents are complex and involve clinical and nonclinical factors.