Dataset Information

Delirium and Behavioral Symptoms in Persons With Dementia at Hospital Admission: Mediating Factors.

ABSTRACT:

Background

Hospitalized persons with dementia are at risk of delirium with behavioral symptoms, predisposing them to a higher rate of complications and caregiver distress. The purpose of this study was to examine the relationship between delirium severity in patients with dementia upon admission to the hospital and the manifestation of behavioral symptoms, and to evaluate the mediating effects of cognitive and physical function, pain, medications, and restraints.

Methods

This descriptive study used baseline data from 455 older adults with dementia enrolled in a cluster randomized clinical trial that tested the efficacy of family centered function-focused care. Mediation analyses were conducted to determine the indirect effect of cognitive and physical function, pain, medications (antipsychotics, anxiolytics, sedative/hypnotics, narcotics, and number of medications), and restraints on behavioral symptoms, controlling for age, sex, race, and educational level.

Results

The majority of the 455 participants were female (59.1%), had an average age of 81.5 (SD=8.4), were either white (63.7%) or black (36.3%), and demonstrated one or more behavioral symptoms (93%) and delirium (60%). Hypotheses were partially supported in that physical function, cognitive function, and antipsychotic medication partially mediated the relationship between delirium severity and behavioral symptoms.

Conclusion

This study provides preliminary evidence identifying antipsychotic use, low physical function, and significant cognitive impairment as specific targets for clinical intervention and quality improvement in patients with delirium superimposed on dementia at hospital admission.

SUBMITTER: Boltz M

PROVIDER: S-EPMC10238610 | biostudies-literature | 2023 Apr-Jun 01

REPOSITORIES: biostudies-literature

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Publications

Delirium and Behavioral Symptoms in Persons With Dementia at Hospital Admission: Mediating Factors.

Boltz Marie M Kuzmik Ashley A Resnick Barbara B BeLue Rhonda R Jao Ying-Ling YL Paudel Anju A Behrens Liza L Leslie Doug D Sinvani Liron L Galvin James E JE

Alzheimer disease and associated disorders 20230313 2

<h4>Background</h4>Hospitalized persons with dementia are at risk of delirium with behavioral symptoms, predisposing them to a higher rate of complications and caregiver distress. The purpose of this study was to examine the relationship between delirium severity in patients with dementia upon admission to the hospital and the manifestation of behavioral symptoms, and to evaluate the mediating effects of cognitive and physical function, pain, medications, and restraints.<h4>Methods</h4>This desc ...[more]

PMID: 36897056

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Project description:ImportanceDelirium at admission is associated with increased hospital morbidity and mortality, but it may be missed in up to 70% of cases. Use of a predictive algorithm in an electronic medical record (EMR) system could provide critical information to target assessment of those with delirium at admission.ObjectivesTo develop and assess a prediction rule for delirium using 2 populations of veterans and compare this rule with previously confirmed rules.Design, setting, and participantsIn a diagnostic study, randomly selected EMRs of hospitalized veterans from the Veterans Affairs (VA) External Peer Review Program at 118 VA medical centers with inpatient facilities were reviewed for delirium risk factors associated with the National Institute for Health and Clinical Excellence (NICE) delirium rule in a derivation cohort (October 1, 2012, to September 30, 2013) and a confirmation cohort (October 1, 2013, to March 31, 2014). Delirium within 24 hours of admission was identified using key word terms. A total of 39 377 veterans 65 years or older who were admitted to a VA medical center for congestive heart failure, acute coronary syndrome, community-acquired pneumonia, and chronic obstructive pulmonary disease were included in the study.ExposureThe EMR calculated delirium risk.Main outcomes and measuresDelirium at admission as identified by trained nurse reviewers was the main outcome measure. Random forest methods were used to identify accurate risk factors for prevalent delirium. A prediction rule for prevalent delirium was developed, and its diagnostic accuracy was tested in the confirmation cohort. This consolidated NICE rule was compared with previously confirmed scoring algorithms (electronic NICE and Pendlebury NICE).ResultsA total of 27 625 patients were included in the derivation cohort (28 118 [92.2%] male; mean [SD] age, 75.95 [8.61] years) and 11 752 in the confirmation cohort (11 536 [98.2%] male; mean [SD] age, 75.43 [8.55] years). Delirium at admission was identified in 2343 patients (8.5%) in the derivation cohort and 882 patients (7.0%) in the confirmation cohort. Modeling techniques identified cognitive impairment, infection, sodium level, and age of 80 years or older as the dominant risk factors. The consolidated NICE rule (area under the receiver operating characteristic [AUROC] curve, 0.91; 95% CI, 0.91-0.92; P < .001) had significantly higher discriminatory function than the eNICE rule (AUROC curve, 0.81; 95% CI, 0.80-0.82; P < .001) or Pendlebury NICE rule (AUROC curve, 0.87; 95% CI, 0.86-0.88; P < .001). These findings were confirmed in the confirmation cohort.Conclusions and relevanceThis analysis identified preexisting cognitive impairment, infection, sodium level, and age of 80 years or older as delirium screening targets. Use of this algorithm in an EMR system could direct clinical assessment efforts to patients with delirium at admission.

Project description:BackgroundAlthough disclosing the predictors of different behavioral and psychological symptoms of dementia (BPSD) is the first step in developing person-centered interventions, current understanding is limited, as it considers BPSD as a homogenous construct. This fails to account for their heterogeneity and hinders development of interventions that address the underlying causes of the target BPSD subsyndromes. Moreover, understanding the influence of proximal factors-circadian rhythm-related factors (ie, sleep and activity levels) and physical and psychosocial unmet needs states-on BPSD subsyndromes is limited, due to the challenges of obtaining objective and/or continuous time-varying measures.ObjectiveThe aim of this study was to explore factors associated with BPSD subsyndromes among community-dwelling older adults with dementia, considering sets of background and proximal factors (ie, actigraphy-measured sleep and physical activity levels and diary-based caregiver-perceived symptom triggers), guided by the need-driven dementia-compromised behavior model.MethodsA prospective observational study design was employed. Study participants included 145 older adults with dementia living at home. The mean age at baseline was 81.2 (SD 6.01) years and the sample consisted of 86 (59.3%) women. BPSD were measured with a BPSD diary kept by caregivers and were categorized into seven subsyndromes. Independent variables consisted of background characteristics and proximal factors (ie, sleep and physical activity levels measured using actigraphy and caregiver-reported contributing factors assessed using a BPSD diary). Generalized linear mixed models (GLMMs) were used to examine the factors that predicted the occurrence of BPSD subsyndromes. We compared the models based on the Akaike information criterion, the Bayesian information criterion, and likelihood ratio testing.ResultsCompared to the GLMMs with only background factors, the addition of actigraphy and diary-based data improved model fit for every BPSD subsyndrome. The number of hours of nighttime sleep was a predictor of the next day's sleep and nighttime behaviors (odds ratio [OR] 0.9, 95% CI 0.8-1.0; P=.005), and the amount of energy expenditure was a predictor for euphoria or elation (OR 0.02, 95% CI 0.0-0.5; P=.02). All subsyndromes, except for euphoria or elation, were significantly associated with hunger or thirst and urination or bowel movements, and all BPSD subsyndromes showed an association with environmental change. Age, marital status, premorbid personality, and taking sedatives were predictors of specific BPSD subsyndromes.ConclusionsBPSD are clinically heterogeneous, and their occurrence can be predicted by different contributing factors. Our results for various BPSD suggest a critical window for timely intervention and care planning. Findings from this study will help devise symptom-targeted and individualized interventions to prevent and manage BPSD and facilitate personalized dementia care.

Project description:BackgroundDelivering hospital-level care with comprehensive geriatric assessment (CGA) in the home is one approach to deal with the increased demand for bed-based hospital care, but clinical effectiveness is uncertain.ObjectiveTo assess the clinical effectiveness of admission avoidance hospital at home (HAH) with CGA for older persons.DesignMultisite randomized trial. (ISRCTN registry number: ISRCTN60477865).Setting9 hospital and community sites in the United Kingdom.Patients1055 older persons who were medically unwell, were physiologically stable, and were referred for a hospital admission.InterventionAdmission avoidance HAH with CGA versus hospital admission with CGA when available using 2:1 randomization.MeasurementsThe primary outcome of living at home was measured at 6 months. Secondary outcomes were new admission to long-term residential care, death, health status, delirium, and patient satisfaction.ResultsParticipants had a mean age of 83.3 years (SD, 7.0). At 6-month follow-up, 528 of 672 (78.6%) participants in the CGA HAH group versus 247 of 328 (75.3%) participants in the hospital group were living at home (relative risk [RR], 1.05 [95% CI, 0.95 to 1.15]; P = 0.36); 114 of 673 (16.9%) versus 58 of 328 (17.7%) had died (RR, 0.98 [CI, 0.65 to 1.47]; P = 0.92); and 37 of 646 (5.7%) versus 27 of 311 (8.7%) were in long-term residential care (RR, 0.58 [CI, 0.45 to 0.76]; P < 0.001).LimitationThe findings are most applicable to older persons referred from a hospital short-stay acute medical assessment unit; episodes of delirium may have been undetected.ConclusionAdmission avoidance HAH with CGA led to similar outcomes as hospital admission in the proportion of older persons living at home as well as a decrease in admissions to long-term residential care at 6 months. This type of service can provide an alternative to hospitalization for selected older persons.Primary funding sourceThe National Institute for Health Research Health Services and Delivery Research Programme (12/209/66).

Project description:BackgroundClinical features of dementia (cognition, function, and behavioral/psychological symptoms [BPSD]) may differentially affect Medicare expenditures/health care utilization.MethodsWe linked cross-sectional data from the Aging, Demographics, and Memory Study to Medicare data to evaluate the association between dementia clinical features among those with dementia and Medicare expenditures/health care utilization (n = 234). Cognition was evaluated using the Mini-Mental State Examination (MMSE). Function was evaluated as the number of functional limitations (0-10). BPSD was evaluated as the number of symptoms (0-12). Expenditures were estimated with a generalized linear model (log-link and gamma distribution). Number of hospitalizations, institutional outpatient visits, and physician visits were estimated with a negative binomial regression. Medicare covered skilled nursing days were estimated with a zero-inflated negative binomial model.ResultsCognition and BPSD were not associated with expenditures. Among individuals with less than seven functional limitations, one additional limitation was associated with $123 (95% confidence interval: $19-$227) additional monthly Medicare spending. Better cognition and poorer function were associated with more hospitalizations among those with an MMSE less than three and less than six functional limitations, respectively. BPSD had no effect on hospitalizations. Poorer function and fewer BPSD were associated with more skilled nursing among individuals with one to seven functional limitations and more than four symptoms, respectively. Cognition had no effect on skilled nursing care. No clinical feature was associated with institutional outpatient care. Of individuals with an MMSE less than 15, poorer cognition was associated with fewer physician visits. Among those with more than six functional limitations, poorer function was associated with fewer physician visits.ConclusionsPoorer function, not cognition or BPSD, was associated with higher Medicare expenditures.

Dataset Information

Delirium and Behavioral Symptoms in Persons With Dementia at Hospital Admission: Mediating Factors.

Background

Methods

Results

Conclusion

Publications

Delirium and Behavioral Symptoms in Persons With Dementia at Hospital Admission: Mediating Factors.

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