Hospital complications among older adults: Better processes could reduce the risk of delirium

Moura, Valdery; Westover, M. Brandon; Li, Feng; Kimchi, Eyal Y.; Kennedy, Maura; Benson, Nicole M.; Moura, Lidia M.V.R.; Hsu, John

doi:10.1177/09514848211028707

Cited by 12 publications

(8 citation statements)

References 28 publications

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“…Data are contingent upon evaluations and documentation by clinicians, mainly in bedside encounters; thus, ascertainment is neither systematic nor random 39. Not all staff from hospital floors documented observed delirium symptoms, calculated CAM scores or even screened high-risk patients (ie, older adults with acute ischemic stroke) 13. Not all physicians screened for or documented cognitive changes in the medical record; in fact, hypoactive delirium cases could be frequently undiagnosed 9.…”

Section: Discussionmentioning

confidence: 99%

“…Because delirium disproportionately affects older adults, its associated morbidity, mortality, and costs are projected to increase with population aging 10. However, informed policy and population health management are contingent upon the reliable ascertainment of disease status and health care utilization for persons with delirium 11–13…”

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confidence: 99%

“…10 However, informed policy and population health management are contingent upon the reliable ascertainment of disease status and health care utilization for persons with delirium. [11][12][13] Understanding the prevalence of delirium and its relationship to national health care spending would be necessary to assess the effectiveness of public policies to prevent or reduce the delirium burden. Studies attempting to examine such questions generally require large administrative databases, for example, Medicare administrative and insurance claims data, which would rely heavily on diagnosis codes.…”

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confidence: 99%

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Identifying Medicare Beneficiaries With Delirium

Moura¹,

Zafar²,

Benson

et al. 2022

Medical Care

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Background: Each year, thousands of older adults develop delirium, a serious, preventable condition. At present, there is no well-validated method to identify patients with delirium when using Medicare claims data or other large datasets. We developed and assessed the performance of classification algorithms based on longitudinal Medicare administrative data that included International Classification of Diseases, 10th Edition diagnostic codes. Methods: Using a linked electronic health record (EHR)-Medicare claims dataset, 2 neurologists and 2 psychiatrists performed a standardized review of EHR records between 2016 and 2018 for a stratified random sample of 1002 patients among 40,690 eligible subjects. Reviewers adjudicated delirium status (reference standard) during this 3-year window using a structured protocol. We calculated the probability that each patient had delirium as a function of classification algorithms based on longitudinal Medicare claims data. We compared the performance of various algorithms against the reference standard, computing calibration-in-the-large, calibration slope, and the area-under-receiver-operating-curve using 10-fold cross-validation (CV). Results: Beneficiaries had a mean age of 75 years, were predominately female (59%), and non-Hispanic Whites (93%); a review of the EHR indicated that 6% of patients had delirium during the 3 years. Although several classification algorithms performed well, a relatively simple model containing counts of delirium-related diagnoses combined with patient age, dementia status, and receipt of antipsychotic medications had the best overall performance [CV– calibration-in-the-large <0.001, CV-slope 0.94, and CV–area under the receiver operating characteristic curve (0.88 95% confidence interval: 0.84–0.91)]. Conclusions: A delirium classification model using Medicare administrative data and International Classification of Diseases, 10th Edition diagnosis codes can identify beneficiaries with delirium in large datasets.

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

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confidence: 99%

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Identifying Medicare Beneficiaries With Delirium

Moura¹,

Zafar²,

Benson

et al. 2022

Medical Care

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“…The ED itself may be a culprit in precipitating delirium. ED lengths of stay exceeding 10 hours are associated with incident delirium among hospitalized older adults, 24 and patients with neurologic emergencies arriving to the ED on a day of high boarding are more likely to develop delirium 25 . Another observational study demonstrated that the absence of mobilization during the whole ED length of stay was independently associated with a 3‐fold odds of incident delirium 26 …”

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confidence: 99%

“…ED lengths of stay exceeding 10 hours are associated with incident delirium among hospitalized older adults, 24 and patients with neurologic emergencies arriving to the ED on a day of high boarding are more likely to develop delirium. 25 Another observational study demonstrated that the absence of mobilization during the whole ED length of stay was independently associated with a 3-fold odds of incident delirium. 26 With ED boarding at crisis levels in this country and no indication of abatement, 27 we cannot continue pushing off delirium and mobility initiatives to the inpatient setting.…”

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confidence: 99%

It's time to mobilize: Moving mobility interventions for delirium from inpatient units to the emergency department

Kennedy

2023

JACEP Open

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Delirium occurs in 10%-15% of all older emergency department (ED) patients and accounts for 1.5 million ED visits annually, yet emergency clinicians miss this diagnosis one third of the time. [1][2][3] For this reason, ED-based delirium research has predominantly focused on improving delirium identification. However, delirium identification alone without a concerted effort to improve management is insufficient to ameliorate the detrimental effects of delirium. One third of hospitalized older adults and up to 80% of critically ill patients have delirium. 4,5 Delirium is associated with higher mortality, future cognitive decline, greater institutionalization, longer hospital lengths of stay, and greater costs of care. 5,6 Accordingly, it is critical that we implement evidence-based interventions to decrease incident delirium and delirium duration. Non-pharmacologic delirium prevention programs in inpatient wards, which include early mobility, have been shownto prevent approximately half of incident delirium and may decrease inpatient falls, hospital lengths of stay, and costs of care. 7,8 Delirium prevention bundles in inpatient wards and ICUs, which also address mobility, have been demonstrated to reduce mortality and decrease delirium duration. 9,10 However, there is limited research investigating delirium prevention and no research into delirium treatment initiated in the ED. 11 In this issue of JACEP Open, Jordano et al examined the impact of physical therapy (PT) and/or occupational therapy (OT) on delirium duration among ED patients admitted to the hospital. This was a secondary analysis of the prospective cohort study by Han et al funded by the National Institute on Aging, which enrolled a total of 228 patients, of which 105 had delirium, 47 had subsyndrome delirium, and 76 were not delirious in the ED. 12 This secondary analysis was restricted to 130 patients who received PT/OT during their hospitalization. The authors report that the time spent with PT/OT relative to hospital length of stay, termed "PT/OT intensity," was associated with a significant reduction in delirium duration (adjusted odds ratio [OR] = 0.39; 95% confidence interval [CI]: 0.21, 0.73). However, time to initiation of PT/OT was not associated with delirium duration (adjusted OR = 1.02; 95% CI: 0.82, 1.27). What makes this study particularly noteworthy is the inclusion of patients diagnosed with delirium in the ED-to the best of our knowledge presently, this is the only study to examine the effect of PT/OT as a treatment for delirium in ED patients who were hospitalized.Several key limitations of the Jordano et al study merit scrutiny. The

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