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  • 1
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    The Role of Inflammation after Surgery for Elders (RISE) study: Study design, procedures, and cohort profile
    Wiley ; 2019
    In:  Alzheimer's & Dementia: Diagnosis, Assessment & Disease Monitoring Vol. 11, No. 1 ( 2019-12), p. 752-762
    Details
    In: Alzheimer's & Dementia: Diagnosis, Assessment & Disease Monitoring, Wiley, Vol. 11, No. 1 ( 2019-12), p. 752-762
    Abstract: The Role of Inflammation after Surgery for Elders study correlates novel inflammatory markers measured in blood, cerebrospinal fluid (CSF) assays, and [ 11 C]‐PBR28 positron‐emission tomography imaging. Methods This study involved a prospective cohort design with patients who underwent elective hip and knee arthroplasty under spinal anesthesia. Sixty‐five adults participated with their family members. Inflammatory biomarker assays were measured preoperatively on day 1 and postoperatively at one month. Results On average, participants were 75 years old, and 72% were female. 54% underwent total knee arthroplasty, and 46% underwent total hip arthroplasty. The mean Modified Mini‐Mental State (3MS) Examination score was 89.3; four patients (6%) scored ≤77 points. Plasma assays were completed in 63 (97%) participants, cerebrospinal fluid assays in 61 (94%), and PET imaging in 44 (68%). Discussion This complex study presents an innovative effort to correlate peripheral and central inflammatory biomarkers before and after major surgery in older adults. Strengths include collecting concurrent blood, cerebrospinal fluid, and positron‐emission tomography with detailed clinical characterization of delirium, cognition, and functional status.
    Type of Medium: Online Resource
    ISSN: 2352-8729 , 2352-8729
    URL: Article
    DOI: 10.1016/j.dadm.2019.09.004
    Language: English
    Publisher: Wiley
    Publication Date: 2019
    detail.hit.zdb_id: 2832898-X
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  • 2
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    Atherosclerosis Is Associated with Delirium After Coronary Artery Bypass Graft Surgery : ATHEROSCLEROSIS AND DELIRIUM AFTER CABG
    Wiley ; 2005
    In:  Journal of the American Geriatrics Society Vol. 53, No. 3 ( 2005-03), p. 462-466
    Details
    In: Journal of the American Geriatrics Society, Wiley, Vol. 53, No. 3 ( 2005-03), p. 462-466
    Type of Medium: Online Resource
    ISSN: 0002-8614 , 1532-5415
    URL: Issue
    URL: Article
    DOI: 10.1111/jgs.2005.53.issue-3
    DOI: 10.1111/j.1532-5415.2005.53165.x
    Language: English
    Publisher: Wiley
    Publication Date: 2005
    detail.hit.zdb_id: 2040494-3
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  • 3
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    Antipsychotic Use in Hospitalized Adults: Rates, Indications, and Predictors
    Wiley ; 2016
    In:  Journal of the American Geriatrics Society Vol. 64, No. 2 ( 2016-02), p. 299-305
    Details
    In: Journal of the American Geriatrics Society, Wiley, Vol. 64, No. 2 ( 2016-02), p. 299-305
    Abstract: To investigate patterns and predictors of use of antipsychotics in hospitalized adults. Design Retrospective cohort study. Setting Academic medical center. Participants Individuals aged 18 and older hospitalized from August 2012 to August 2013, excluding those admitted to obstetrics and gynecology or psychiatry or with a psychotic disorder. Measurements Use was ascertained from pharmacy charges. Potentially excessive dosing was defined using guidelines for long‐term care facilities. A review of 100 records was performed to determine reasons for use. Results The cohort included 17,775 admissions with a median age 64; individuals could have been admitted more than once during the study period. Antipsychotics were used in 9%, 55% of which were initiations. The most common reasons for initiation were delirium (53%) and probable delirium (12%). Potentially excessive dosing occurred in 16% of admissions exposed to an antipsychotic. Of admissions with antipsychotic initiation, 26% were discharged on these medications. Characteristics associated with initiation included age 75 and older (relative risk ( RR ) = 1.4, 95% confidence interval ( CI ) = 1.2–1.7), male sex ( RR  = 1.2, 95% CI  = 1.1–1.4), black race ( RR  = 0.8, 95% CI  = 0.6–0.96), delirium ( RR  = 4.8, 95% CI  = 4.2–5.7), dementia ( RR  = 2.1, 95% CI  = 1.7–2.6), admission to a medical service ( RR  = 1.2, 95% CI  = 1.1–1.4), intensive care unit stay ( RR  = 2.1, 95% CI  = 1.8–2.4), and mechanical ventilation ( RR  = 2.0, 95% CI  = 1.7–2.4). In individuals who were initiated on an antipsychotic, characteristics associated with discharge on antipsychotics were age 75 and older ( RR  = 0.6, 95% CI  = 0.4–0.7), discharge to any location other than home ( RR  = 2.5, 95% CI  = 1.8–3.3), and class of in‐hospital antipsychotic exposure ( RR  = 1.6, 95% CI  = 1.1–2.3 for atypical vs typical; RR  = 2.7, 95% CI  = 1.9–3.8 for both vs typical). Conclusion Antipsychotic initiation and use were common during hospitalization, most often for delirium, and individuals were frequently discharged on these medications. Several predictors of use on discharge were identified, suggesting potential targets for decision support tools that would be used to prompt consideration of ongoing necessity.
    Type of Medium: Online Resource
    ISSN: 0002-8614 , 1532-5415
    URL: Issue
    URL: Article
    DOI: 10.1111/jgs.2016.64.issue-2
    DOI: 10.1111/jgs.13943
    Language: English
    Publisher: Wiley
    Publication Date: 2016
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  • 4
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    Antipsychotic medication utilization in nonpsychiatric hospitalizations
    Wiley ; 2016
    In:  Journal of Hospital Medicine Vol. 11, No. 8 ( 2016-08), p. 543-549
    Details
    In: Journal of Hospital Medicine, Wiley, Vol. 11, No. 8 ( 2016-08), p. 543-549
    Abstract: Although antipsychotics are used for treatment of delirium/agitation in hospitalized patients, their scope of use has not been investigated in a large, multicenter cohort. OBJECTIVE To determine rates of use and hospital variation in use of antipsychotics in nonpsychiatric admissions. DESIGN, SETTING, PATIENTS Cohort study of adult, nonpsychiatric admissions to 300 US hospitals contributing data to the Premier database, from July 1, 2009 to June 30, 2010. MEASUREMENTS Antipsychotic exposure defined using pharmacy charges. Potentially excessive dosing defined using guidelines for long‐term care facilities. RESULTS Our cohort included 2,695,081 admissions (median age, 63 years; 56% female). Antipsychotic exposure occurred in 160,773 (6%) admissions; 102,148 (64%) received atypical antipsychotics, 76,979 (48%) received typical, and 18,354 (11%) received both. Among exposed admissions, 47% received ≥1 potentially excessive daily dose. Among the variables we analyzed, the strongest predictors of antipsychotic receipt were delirium (relative risk [RR]: 2.93, 95% CI: 2.88‐2.98) and dementia (RR: 2.78, 95% CI: 2.72‐2.83). After adjustment for patient characteristics, patients admitted to hospitals in the highest antipsychotic prescribing quintile were more than twice as likely to be exposed compared to patients admitted to hospitals in the lowest prescribing quintile (RR: 2.56, 95% CI: 2.50‐2.61). This relationship was similar across subgroups of admissions with delirium and dementia. CONCLUSIONS Antipsychotic medication exposure is common in nonpsychiatric admissions to US hospitals. The observed variation in antipsychotic prescribing was not fully explained by measured patient characteristics, suggesting the possibility of differing hospital prescribing cultures. Additional research and guidelines are necessary to define appropriate use of these potentially harmful medications in the hospital setting. Journal of Hospital Medicine 2016;11:543–549. © 2016 Society of Hospital Medicine
    Type of Medium: Online Resource
    ISSN: 1553-5592 , 1553-5606
    URL: Issue
    URL: Article
    DOI: 10.1002/jhm.v11.8
    DOI: 10.1002/jhm.2596
    Language: English
    Publisher: Wiley
    Publication Date: 2016
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  • 5
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    Does Alzheimer's Disease and Related Dementias Modify Delirium Severity and Hospital Outcomes?
    Wiley ; 2020
    In:  Journal of the American Geriatrics Society Vol. 68, No. 8 ( 2020-08), p. 1722-1730
    Details
    In: Journal of the American Geriatrics Society, Wiley, Vol. 68, No. 8 ( 2020-08), p. 1722-1730
    Abstract: We examined the association between delirium severity and outcomes of delirium among persons with and without Alzheimer's disease and related dementias (ADRD). DESIGN Prospective cohort study. SETTING Academic tertiary medical center. PARTICIPANTS A total of 352 medical and surgical patients. MEASUREMENTS Delirium incidence and severity were rated daily using the Confusion Assessment Method (CAM) and CAM‐Severity (CAM‐S) score during hospitalization. Severe delirium was defined as a CAM‐S Short Form score in the highest tertile (3‐7 points out of 7). ADRD status was determined by a clinical consensus process. Clinical outcomes included prolonged length of stay ( 〉 6 d), discharge to post‐acute nursing facility, any decline in activities of daily living (ADLs) at 1 month from prehospital baseline, ongoing nursing facility stay, and mortality. RESULTS Patients with ADRD (n = 85 [24%]) had a significantly higher relative risk (RR) for incident delirium (RR = 2.31; 95% confidence interval [CI] = 1.64‐3.28) and higher peak CAM‐S scores (mean difference = 1.24 points; CI = .83‐1.65; P   〈  .001). Among patients with ADRD, severe delirium significantly increased the RR for nursing facility stay (RR = 2.22; CI = 1.05‐4.69; P = .04) and increased the RR for mortality (RR = 2.10; CI = .89‐4.98; P = .09). Among patients without ADRD, severe delirium was associated with a significantly increased risk for all poor outcomes except mortality including prolonged length of stay in the hospital (RR = 1.47; CI = 1.18‐1.82) and discharge to a post‐acute nursing facility (RR = 2.17; CI = 1.58‐2.98) plus decline in ADLs (RR = 1.30; CI = 1.05‐1.60) and nursing facility stay at 1 month (RR = 1.93; CI = 1.31‐2.83). CONCLUSION Severe delirium is associated with increased risk for poor clinical outcomes in patients with and without ADRD. In both groups, severe delirium increased risk of nursing home placement. In patients with ADRD, delirium was more severe and associated with a trend toward increased mortality at 1 month. Although the increased risk remains substantial by RR, the study had limited power to examine the rarer outcome of death. J Am Geriatr Soc 68:1722‐1730, 2020.
    Type of Medium: Online Resource
    ISSN: 0002-8614 , 1532-5415
    URL: Issue
    URL: Article
    DOI: 10.1111/jgs.v68.8
    DOI: 10.1111/jgs.16420
    Language: English
    Publisher: Wiley
    Publication Date: 2020
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  • 6
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    Delirium Incidence and Functional Outcomes After Transcatheter and Surgical Aortic Valve Replacement
    Wiley ; 2019
    In:  Journal of the American Geriatrics Society Vol. 67, No. 7 ( 2019-07), p. 1393-1401
    Details
    In: Journal of the American Geriatrics Society, Wiley, Vol. 67, No. 7 ( 2019-07), p. 1393-1401
    Abstract: Transcatheter aortic valve replacement (TAVR) may be associated with less delirium and allow faster recovery than surgical aortic valve replacement (SAVR). Objective To examine the association of delirium and its severity with clinical and functional outcomes after SAVR and TAVR. Design Prospective cohort study. Setting An academic medical center. Participants A total of 187 patients, aged 70 years and older, undergoing SAVR (N = 77) and TAVR (N = 110) in 2014 to 2016. Measurements Delirium was assessed daily using the Confusion Assessment Method (CAM), with severity measured by the CAM‐Severity (CAM‐S) score (range = 0‐19). Outcomes were prolonged hospitalization (9 days or more); institutional discharge; and functional status, measured by ability to perform 22 daily activities and physical tasks over 12 months. Results SAVR patients had a higher incidence of delirium than TAVR patients (50.7% vs 25.5%; P   〈  .001), despite younger mean age (77.9 vs 83.7 years) and higher baseline Mini‐Mental State Examination score (26.9 vs 24.7). SAVR patients with delirium had a shorter duration (2.2 vs 3.4 days; P  = .04) with a lower mean CAM‐S score (4.5 vs 5.7; P  = .01) than TAVR patients with delirium. The risk of prolonged hospitalization in no, mild, and severe delirium was 18.4%, 30.8%, and 61.5% after SAVR ( P for trend = .009) and 26.8%, 38.5%, and 73.3% after TAVR ( P for trend = .001), respectively. The risk of institutional discharge was 42.1%, 58.3%, and 84.6% after SAVR ( P for trend = .01) and 32.5%, 69.2%, and 80.0% after TAVR ( P for trend 〈 .001), respectively. Severe delirium was associated with delayed functional recovery after SAVR and persistent functional impairment after TAVR at 12 months. Conclusion Less invasive TAVR was associated with lower incidence of delirium than SAVR. Once delirium developed, TAVR patients had more severe delirium and worse functional status trajectory than SAVR patients did. Registration NCT01845207.
    Type of Medium: Online Resource
    ISSN: 0002-8614 , 1532-5415
    URL: Issue
    URL: Article
    DOI: 10.1111/jgs.2019.67.issue-7
    DOI: 10.1111/jgs.15867
    Language: English
    Publisher: Wiley
    Publication Date: 2019
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  • 7
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    Reducing Delirium After Hip Fracture: A Randomized Trial
    Wiley ; 2001
    In:  Journal of the American Geriatrics Society Vol. 49, No. 5 ( 2001-05), p. 516-522
    Details
    In: Journal of the American Geriatrics Society, Wiley, Vol. 49, No. 5 ( 2001-05), p. 516-522
    Abstract: DESIGN: Prospective, randomized, blinded. SETTING: Inpatient academic tertiary medical center. PARTICIPANTS: 126 consenting patients 65 and older (mean age 79 ± 8 years, 79% women) admitted emergently for surgical repair of hip fracture. MEASUREMENTS: Detailed assessment through interviews with patients and designated proxies and review of medical records was performed at enrollment to ascertain prefracture status. Subjects were then randomized to proactive geriatrics consultation, which began preoperatively or within 24 hours of surgery, or “usual care.” A geriatrician made daily visits for the duration of the hospitalization and made targeted recommendations based on a structured protocol. To ascertain study outcomes, all subjects underwent daily, blinded interviews for the duration of their hospitalization, including the Mini‐Mental State Examination (MMSE), the Delirium Symptom Interview (DSI), and the Memorial Delirium Assessment Scale (MDAS). Delirium was diagnosed using the Confusion Assessment Method (CAM) algorithm. RESULTS: The 62 patients randomized to geriatrics consultation were not significantly different ( P 〉 .1) from the 64 usual‐care patients in terms of age, gender, prefracture dementia, comorbidity, type of hip fracture, or type of surgical repair. Sixty‐one percent of geriatrics consultation patients were seen preoperatively and all were seen within 24 hours postoperatively. A mean of 10 recommendations were made throughout the duration of the hospitalization, with 77% adherence by the orthopedics team. Delirium occurred in 20  /62 (32%) intervention patients, versus 32  /  64 (50%) usual‐care patients ( P = .04), representing a relative risk of 0.64 (95% confidence interval (CI) = 0.37–0.98) for the consultation group. One case of delirium was prevented for every 5.6 patients in the geriatrics consultation group. There was an even greater reduction in cases of severe delirium, occurring in 7/ 60 (12%) of intervention patients and 18  / 62 (29%) of usual‐care patients, with a relative risk of 0.40 (95% CI = 0.18–0.89). Despite this reduction in delirium, length of stay did not significantly differ between intervention and usual‐care groups (median ± interquartile range = 5 ± 2 days in both groups), likely because protocols and pathways predetermined length of stay. In subgroup analyses, geriatrics consultation was most effective in reducing delirium in patients without prefracture dementia or activities of daily living (ADL) functional impairment. CONCLUSIONS: Proactive geriatrics consultation was successfully implemented with good adherence after hip‐fracture repair. Geriatrics consultation reduced delirium by over one‐third, and reduced severe delirium by over one‐half. Our trial provides strong preliminary evidence that proactive geriatrics consultation may play an important role in the acute hospital management of hip‐fracture patients.
    Type of Medium: Online Resource
    ISSN: 0002-8614 , 1532-5415
    URL: Article
    DOI: 10.1046/j.1532-5415.2001.49108.x
    Language: English
    Publisher: Wiley
    Publication Date: 2001
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  • 8
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    Neuropsychological Profiles of an Elderly Cohort Undergoing Elective Surgery and the Relationship Between Cognitive Performance and Delirium
    Wiley ; 2015
    In:  Journal of the American Geriatrics Society Vol. 63, No. 5 ( 2015-05), p. 977-982
    Details
    In: Journal of the American Geriatrics Society, Wiley, Vol. 63, No. 5 ( 2015-05), p. 977-982
    Abstract: To examine baseline (preoperative) neuropsychological test performance in a cohort of elderly individuals undergoing elective surgery and the association between specific neuropsychological domains and postoperative delirium. Design Ongoing prospective cohort study. Setting Successful Aging after Elective Surgery Study. Participants Elderly adults (N = 300) scheduled for elective (noncardiac) surgery. Measurements Neuropsychological testing, including standardized assessments of memory, divided and sustained attention, speed of mental processing, verbal fluency, working memory, language, and an overall measure of premorbid cognitive functioning, was performed 2 to 4 weeks before surgery. The relationship between the individual neuropsychological tests and delirium status was examined using linear regression, adjusting for age, sex, and education. Results Study participants were generally highly educated (mean years of education 15.0 ± 2.9), with minimal or no cognitive impairment (mean Modified Mini‐Mental State Examination score 93.2 out of 100). After adjustment, participants who developed postoperative delirium had performed significantly lower preoperatively on measures of speed of mental processing and divided attention (Trail‐Making Test Part B, mean difference 17.55, P  = .02), category fluency (animal naming, mean difference −1.94, P  = .01), sustained visual attention (Visual Search and Attention, mean difference −3.19, P   〈  .001), and working memory with new learning and recall (Hopkins Verbal Learning Test—Revised Total mean difference −0.53 to −0.79, P   〈  .01). Conclusion Individuals who later develop delirium have lower scores on tests evaluating the areas of complex attention, executive functioning, and rapid access to verbal knowledge or semantic networks at baseline. Future studies to better understand how the cognitive profiles identified may predispose individuals to developing delirium may help pave the way to greater understanding of the mechanisms of delirium.
    Type of Medium: Online Resource
    ISSN: 0002-8614 , 1532-5415
    URL: Issue
    URL: Article
    DOI: 10.1111/jgs.2015.63.issue-5
    DOI: 10.1111/jgs.13383
    Language: English
    Publisher: Wiley
    Publication Date: 2015
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  • 9
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    A Tale of Two Methods: Chart and Interview Methods for Identifying Delirium
    Wiley ; 2014
    In:  Journal of the American Geriatrics Society Vol. 62, No. 3 ( 2014-03), p. 518-524
    Details
    In: Journal of the American Geriatrics Society, Wiley, Vol. 62, No. 3 ( 2014-03), p. 518-524
    Abstract: To compare chart‐ and interview‐based methods for identification of delirium. Design Prospective cohort study. Setting Two academic medical centers. Participants Individuals aged 70 and older undergoing major elective surgery (N = 300) (majority orthopedic surgery). Measurements Participants were interviewed daily during hospitalization for delirium using the C onfusion A ssessment M ethod ( CAM ; interview‐based method), and their medical charts were reviewed for delirium using a validated chart‐review method (chart‐based method). Rate of agreement of the two methods and characteristics of those identified using each approach were examined. Predictive validity for clinical outcomes (length of stay, postoperative complications, discharge disposition) was compared. In the absence of a criterion standard, predictive value could not be calculated. Results The cumulative incidence of delirium was 23% (n = 68) according to the interview‐based method, 12% (n = 35) according to the chart‐based method, and 27% (n = 82) according to the combined approach. Overall agreement was 80%; kappa was 0.30. The methods differed in detection of psychomotor features and time of onset. The chart‐based method missed delirium in individuals that the CAM identified who were lacking features of psychomotor agitation or inappropriate behavior. The CAM ‐based method missed chart‐identified cases occurring during the night shift. The combined method had high predictive validity for all clinical outcomes. Conclusions Interview‐ and chart‐based methods have specific strengths for identification of delirium. A combined approach captures the largest number and broadest range of delirium cases.
    Type of Medium: Online Resource
    ISSN: 0002-8614 , 1532-5415
    URL: Issue
    URL: Article
    DOI: 10.1111/jgs.2014.62.issue-3
    DOI: 10.1111/jgs.12684
    Language: English
    Publisher: Wiley
    Publication Date: 2014
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  • 10
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    Improving appropriateness of acid-suppressive medication use via computerized clinical decision support : Reducing Inappropriate Acid Suppressives
    Wiley ; 2015
    In:  Journal of Hospital Medicine Vol. 10, No. 1 ( 2015-01), p. 41-45
    Details
    In: Journal of Hospital Medicine, Wiley, Vol. 10, No. 1 ( 2015-01), p. 41-45
    Type of Medium: Online Resource
    ISSN: 1553-5592
    URL: Article
    DOI: 10.1002/jhm.2260
    Language: English
    Publisher: Wiley
    Publication Date: 2015
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