Person:

Jones, Richard Norman

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 >=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 >=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 >=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 (>=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.

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.

OBJECTIVES: To examine the association between persistent delirium and 1-year mortality in newly admitted post-acute care (PAC) facility patients with delirium who were followed regardless of residence.

DESIGN: Observational cohort study.

SETTING: Eight greater-Boston skilled nursing facilities specializing in PAC.

PARTICIPANTS: Four hundred twelve PAC patients with delirium at admission after an acute hospitalization.

MEASUREMENTS: Assessments were done at baseline and four follow-up times: 2, 4, 12, and 26 weeks. Delirium, defined using the Confusion Assessment Method, was assessed, as were factors used as covariates in analyses: age, sex, comorbidity, functional status, and dementia. The outcome was 1-year mortality determined according to the National Death Index and corroborated using medical record and proxy telephone interview.

RESULTS: Nearly one-third of subjects remained delirious at 6 months. Cumulative 1-year mortality was 39%. Independent of age, sex, comorbidity, functional status, and dementia, subjects with persistent delirium were 2.9 (95% confidence interval=1.9–4.4) times as likely to die during the 1-year follow-up as subjects whose delirium resolved. This association remained strong and significant in groups with and without dementia. Additionally, when delirium resolved, the risk of death diminished thereafter.

CONCLUSION: In patients who were delirious at the time of PAC admission, persistent delirium was a significant independent predictor of 1-year mortality.

Background— Delirium is a common outcome after cardiac surgery. Delirium prediction rules identify patients at risk for delirium who may benefit from targeted prevention strategies, early identification, and treatment of underlying causes. The purpose of the present prospective study was to develop a prediction rule for delirium in a cardiac surgery cohort and to validate it in an independent cohort.

Methods and Results— Prospectively, cardiac surgery patients ≥60 years of age were enrolled in a derivation sample (n=122) and then a validation sample (n=109). Beginning on the second postoperative day, patients underwent a standardized daily delirium assessment, and delirium was diagnosed according to the confusion assessment method. Delirium occurred in 63 (52%) of the derivation cohort patients. Multivariable analysis identified 4 variables independently associated with delirium: prior stroke or transient ischemic attack, Mini Mental State Examination score, abnormal serum albumin, and the Geriatric Depression Scale. Points were assigned to each variable: Mini Mental State Examination ≤23 received 2 points, and Mini Mental State Examination score of 24 to 27 received 1 point; Geriatric Depression Scale >4, prior stroke/transient ischemic attack, and abnormal albumin received 1 point each. In the derivation sample, the cumulative incidence of delirium for point levels of 0, 1, 2, and ≥3 was 19%, 47%, 63%, and 86%, respectively (C statistic, 0.74). The corresponding incidence of delirium in the validation sample was 18%, 43%, 60%, and 87%, respectively (C statistic, 0.75).

Conclusions— Delirium occurs frequently after cardiac surgery. Using 4 preoperative characteristics, clinicians can determine cardiac surgery patients’ risk for delirium. Patients at higher delirium risk could be candidates for close postoperative monitoring and interventions to prevent delirium.

OBJECTIVES: To measure the prevalence, predictors, and posthospitalization outcomes associated with the overlap syndrome of coexisting depression and incident delirium in older hospitalized patients.

DESIGN: Secondary analysis of prospective cohort data from the control group of the Delirium Prevention Trial.

SETTING: General medical service of an academic medical center. Follow-up interviews at 1 month and 1 year post-hospital discharge.

PARTICIPANTS: Four hundred fifty-nine patients aged 70 and older who were not delirious at hospital admission.

MEASUREMENTS: Depressive symptoms assessed at hospital admission using the 15-item Geriatric Depression Scale (cutoff score of 6 used to define depression), daily assessments of incident delirium from admission to discharge using the Confusion Assessment Method, activities of daily living at admission and 1 month postdischarge, and new nursing home placement and mortality determined at 1 year.

RESULTS: Of 459 participants, 23 (5.0%) had the overlap syndrome, 39 (8.5%) delirium alone, 121 (26.3%) depression alone, and 276 (60.1%) neither condition. In adjusted analysis, patients with the overlap syndrome had higher odds of new nursing home placement or death at 1 year (adjusted odds ratio (AOR)=5.38, 95% confidence interval (CI)=1.57–18.38) and 1-month functional decline (AOR=3.30, 95% CI=1.14–9.56) than patients with neither condition.

CONCLUSION: The overlap syndrome of depression and delirium is associated with significant risk of functional decline, institutionalization, and death. Efforts to identify, prevent, and treat this condition may reduce the risk of adverse outcomes in older hospitalized patients.

Background Brief cognitive screening measures are valuable tools for both research and clinical applications. The most widely used instrument, the Mini-Mental State Examination (MMSE), is limited in that it must be administered face-to-face, cannot be used in participants with visual or motor impairments, and is protected by copyright. Screening instruments such as the Telephone Interview for Cognitive Status (TICS) were developed to provide a valid alternative, with comparable cut-point scores to rate global cognitive function.

Methods The MMSE, TICS-30, and TICS-40 scores from 746 community-dwelling elders who participated in the Aging, Demographics, and Memory Study (ADAMS) were analyzed with equipercentile equating, a statistical process of determining comparable scores based on percentile equivalents for different forms of an examination.

Results Scores from the MMSE and TICS-30 and TICS-40 corresponded well, and clinically relevant cut-point scores were determined. For example, an MMSE score of 23 is equivalent to 17 and 20 on the TICS-30 and TICS-40, respectively.

Conclusions These findings indicate that TICS and MMSE scores can be linked directly. Clinically relevant and important MMSE cut points and the respective ADAMS TICS-30 and TICS-40 cut-point scores are included, to identify the degree of cognitive impairment among respondents with any type of cognitive disorder. These results will help in the widespread application of TICS in both research and clinical practice.