Peter H. Van Ness

Days of Delirium Are Associated with 1-Year Mortality in an Older Intensive Care Unit Population

RATIONALE Delirium is a frequent occurrence in older intensive care unit (ICU) patients, but the importance of the duration of delirium in contributing to adverse long-term outcomes is unclear. OBJECTIVES To examine the association of the number of days of ICU delirium with mortality in an older patient population. METHODS We performed a prospective cohort study in a 14-bed ICU in an urban acute care hospital. The patient population comprised 304 consecutive admissions 60 years of age and older. MEASUREMENTS AND MAIN RESULTS The main outcome was 1-year mortality after ICU admission. Patients were assessed daily for delirium with the Confusion Assessment Method for the ICU and a validated chart review method. The median duration of ICU delirium was 3 days (range, 1-46 d). During the follow-up period, 153 (50%) patients died. After adjusting for relevant covariates, including age, severity of illness, comorbid conditions, psychoactive medication use, and baseline cognitive and functional status, the number of days of ICU delirium was significantly associated with time to death within 1 year post-ICU admission (hazard ratio, 1.10; 95% confidence interval, 1.02-1.18). CONCLUSIONS Number of days of ICU delirium was associated with higher 1-year mortality after adjustment for relevant covariates in an older ICU population. Investigations should be undertaken to reduce the number of days of ICU delirium and to study the impact of this reduction on important health outcomes, including mortality and functional and cognitive status.

Benzodiazepine and opioid use and the duration of intensive care unit delirium in an older population.

Objective:There is a high prevalence of delirium in older medical intensive care unit (ICU) patients and delirium is associated with adverse outcomes. We need to identify modifiable risk factors for delirium, such as medication use, in the ICU. The objective of this study was to examine the impact of benzodiazepine or opioid use on the duration of ICU delirium in an older medical population. Design:Prospective cohort study. Setting:Fourteen-bed medical intensive care unit in an urban university teaching hospital. Patients:304 consecutive admissions age 60 and older. Interventions:None. Main Outcome Measurements:The main outcome measure was duration of ICU delirium, specifically the first episode of ICU delirium. Patients were assessed daily for delirium with the Confusion Assessment Method for the ICU and a validated chart review method. Our main predictor was receiving benzodiazepines or opioids during ICU stay. A multivariable model was developed using Poisson rate regression. Results:Delirium occurred in 239 of 304 patients (79%). The median duration of ICU delirium was 3 days with a range of 1–33 days. In a multivariable regression model, receipt of a benzodiazepine or opioid (rate ratio [RR] 1.64, 95% confidence interval [CI] 1.27–2.10) was associated with increased delirium duration. Other variables associated with delirium duration in this analysis include preexisting dementia (RR 1.19, 95% CI 1.07–1.33), receipt of haloperidol (RR 1.35, 95% CI 1.21–1.50), and severity of illness (RR 1.01, 95% CI 1.00–1.02). Conclusions:The use of benzodiazepines or opioids in the ICU is associated with longer duration of a first episode of delirium. Receipt of these medications may represent modifiable risk factors for delirium. Clinicians caring for ICU patients should carefully evaluate the need for benzodiazepines, opioids, and haloperidol.

Older Adults Discharged from the Hospital with Delirium: 1‐Year Outcomes

OBJECTIVES: To compare 1‐year institutionalization and mortality rates of patients who were delirious at discharge, patients whose delirium resolved by discharge, and patients who were never delirious in the hospital.

Health Outcome Prioritization as a Tool for Decision Making Among Older Persons With Multiple Chronic Conditions

Older persons with multiple chronic conditions are at substantial risk for unintended adverse outcomes, such as medication adverse events. Less severe adverse events are commonly referred to as “side effects,” implying that they are secondary to disease-specific benefits. However, patients consider these adverse events to be important outcomes in their own right.1 Such findings suggest that all possible benefits and harms resulting from different treatment options be considered as competing outcomes, among which older persons with multiple chronic conditions face trade-offs. When treatments involve trade-offs, the best option depends upon patients’ preferences. The challenge for older persons with multiple conditions is that these trade-offs encompass both many different specific diseases and non disease-specific health domains.2 One approach to this challenge is to consider treatment in terms of its effects on a set of universal, cross-disease outcomes and to use older persons’ prioritization of these outcomes as an assessment of preferences. These outcomes, examples of which include length of life, physical and cognitive function, and symptoms, include basic domains recognized to be the key components of health.3 The goal of this study was to explore the use of a simple to tool to elicit older persons’ health outcome priorities.

Modifiable Risk Factors for Nursing Home-Acquired Pneumonia

BACKGROUND This study sought to identify modifiable risk factors for pneumonia in elderly nursing home residents. METHODS A cohort of 613 elderly residents (age, >65 years) of 5 nursing homes in the New Haven, Connecticut, area was followed-up prospectively from February 2001 through March 2003. The primary outcome was radiographically documented pneumonia within a 12-month surveillance period. Baseline modifiable risk factors were evaluated for their independent association with pneumonia. RESULTS Of 613 elderly nursing home residents, 131 (21%) died, and an additional 112 (18%) developed a radiographically documented case of pneumonia during the 12-month surveillance period. Among the 9 candidate modifiable risk factors that were evaluated individually in Cox proportional hazards models adjusting for covariates (i.e., nursing home facility, age, race, coexisting conditions, and immobility), inadequate oral care (hazard ratio [HR], 1.60; 95% confidence interval [CI], 1.06-2.35; P=.024) and swallowing difficulty (HR, 1.65; 95% CI, 1.04-2.62; P=.033) were associated with pneumonia. When modifiable risk factors were evaluated simultaneously in the same Cox proportional hazards model, inadequate oral care (HR, 1.55; 95% CI, 1.04-2.30; P=.030) and swallowing difficulty (HR, 1.61; 95% CI, 1.02-2.55; P=.043) remained independently associated with pneumonia, adjusting for the same covariates. Calculation of population-based attributable fractions showed that 21% of all cases of pneumonia in our cohort could have been avoided if inadequate oral care and swallowing difficulty were not present. CONCLUSIONS Two biologically plausible and modifiable risk factors increased the risk of pneumonia in elderly nursing home residents. These results provide a framework for the development and testing of a targeted pneumonia prevention strategy.

Inconsistency Over Time in the Preferences of Older Persons with Advanced Illness for Life-Sustaining Treatment

OBJECTIVES: To determine whether preferences for future attempts at life‐sustaining treatment change over time in a consistent and predictable manner.

Burden in caregivers of older adults with advanced illness.

OBJECTIVES: To examine caregiver burden over time in caregivers of patients with advanced chronic disease.

The Ratio of FEV1 to FVC as a Basis for Establishing Chronic Obstructive Pulmonary Disease

RATIONALE The lambda-mu-sigma (LMS) method is a novel approach that defines the lower limit of normal (LLN) for the ratio of FEV1/FVC as the fifth percentile of the distribution of Z scores. The clinical validity of this threshold as a basis for establishing chronic obstructive pulmonary disease is unknown. OBJECTIVE To evaluate the association between the LMS method of determining the LLN for the FEV1/FVC, set at successively higher thresholds, and clinically meaningful outcomes. METHODS Using data from a nationally representative sample of 3,502 white Americans aged 40-80 years, we stratified the FEV1/FVC according to the LMS-LLN, with thresholds set at the 5th, 10th, 15th, 20th, and 25th percentiles (i.e., LMS-LLN5, LMS-LLN10, etc.). We then evaluated whether these thresholds were associated with an increased risk of death or prevalence of respiratory symptoms. Spirometry was not specifically completed after a bronchodilator. MEASUREMENTS AND MAIN RESULTS Relative to an FEV1/FVC greater than or equal to LMS-LLN25 (reference group), the risk of death and the odds of having respiratory symptoms were elevated only in participants who had an FEV1/FVC less than LMS-LLN(5), with an adjusted hazard ratio of 1.68 (95% confidence interval, 1.34-2.12) and an adjusted odds ratio of 2.46 (95% confidence interval, 2.01-3.02), respectively, representing 13.8% of the cohort. Results were similar for persons aged 40-64 years and those aged 65-80 years. CONCLUSIONS In white persons aged 40-80 years, an FEV1/FVC less than LMS-LLN5 identifies persons with an increased risk of death and prevalence of respiratory symptoms. These results support the use of the LMS-LLN5 threshold for establishing chronic obstructive pulmonary disease.

Clinical Features to Identify Urinary Tract Infection in Nursing Home Residents: A Cohort Study

OBJECTIVES: To identify clinical features associated with bacteriuria plus pyuria in noncatheterized nursing home residents with clinically suspected urinary tract infection (UTI).

Identifying Dysglycemic States in Older Adults: Implications of the Emerging Use of Hemoglobin A1c

CONTEXT Hemoglobin A1c (A1c) was recently added to the diagnostic criteria for diabetes and prediabetes. OBJECTIVE Our objective was to examine performance of A1c in comparison with fasting plasma glucose (FPG) in diagnosing dysglycemia in older adults. DESIGN AND SETTING We conducted a cross-sectional analysis of data from the Health, Aging, and Body Composition study at yr 4 (2000-2001) when FPG and standardized A1c measurements were available. PARTICIPANTS Of 3075 persons (aged 70-79 yr, 48% men, 42% Black) at study entry, 1865 participants without known diabetes who had appropriate measures were included. MAIN OUTCOME MEASURES Sensitivity and specificity of A1c-based diagnoses were compared with those based on FPG and the proportion of participants identified with dysglycemia by each measure. RESULTS Of all participants, 2.7 and 3.1% had undiagnosed diabetes by FPG≥126 mg/dl and A1c≥6.5%, respectively. Among the remaining participants, 21.1% had prediabetes by impaired fasting glucose (≥100 mg/dl) and 22.2% by A1c≥5.7%. Roughly one third of individuals with diabetes and prediabetes were identified by either FPG or A1c alone and by both tests simultaneously. Sensitivities and specificities of A1c compared with FPG were 56.9 and 98.4% for diabetes and 47.0 and 84.5% for prediabetes, respectively. Blacks and women were more likely to be identified with dysglycemia by A1c than FPG. CONCLUSIONS In this older population, we found considerable discordance between FPG- and A1c-based diagnosis of diabetes and prediabetes, with differences accentuated by race and gender. Broad implementation of A1c to diagnose dysglycemic states may substantially alter the epidemiology of these conditions in older Americans.