Delirium and Functional Recovery in Patients Discharged to ...

Meaning Study results suggest that delirium on admission to skilled nursing facilities after heart failure hospitalization was associated with ... DeliriumandFunctionalRecoveryinPatientsDischargedtoSkilledNursingFacilitiesAfterHospitalizationforHeartFailure|Cardiology|JAMANetworkOpen|JAMANetwork Ourwebsiteusescookiestoenhanceyourexperience.Bycontinuingtouseoursite,orclicking"Continue,"youareagreeingtoourCookiePolicy | Continue [SkiptoNavigation] fulltexticon FullText contentsicon Contents figureicon Figures/Tables multimediaicon Multimedia attachicon SupplementalContent referencesicon References relatedicon Related commentsicon Comments DownloadPDF Comment TopofArticle KeyPoints Abstract Introduction Methods Results Discussion Conclusions ArticleInformation References Table1. ComparisonofCharacteristicsofSNFResidentsWithandWithoutDeliriumAfterHFHospitalizationViewLargeDownloadTable2. OverallADLOutcomesinSNFResidentsAccordingtoDeliriumClassificationViewLargeDownloadTable3. UnadjustedandAdjustedLinearMixed-EffectsModelsforADLChangeViewLargeDownload Supplement.eTable1.ICD-9CodesandDescriptionsUsedtoIdentifyDementiaeTable2.OverallActivitiesofDailyLiving(ADL)OutcomesinSkilledNursingFacility(SNF)ResidentsAccordingtoDementiaClassificationeFigure1.CohortFlowcharteFigure2.OverallActivitiesofDailyLiving(ADL)OutcomesbyDeliriumStatus 1.Virani  SS,Alonso  A,Benjamin  EJ,  etal;AmericanHeartAssociationCouncilonEpidemiologyandPreventionStatisticsCommitteeandStrokeStatisticsSubcommittee. Heartdiseaseandstrokestatistics,2020update:areportfromtheAmericanHeartAssociation.  Circulation.2020;141(9):e139-e596.doi:10.1161/CIR.0000000000000757PubMedGoogleScholarCrossref2.Allen  LA,Hernandez  AF,Peterson  ED,  etal. Dischargetoaskillednursingfacilityandsubsequentclinicaloutcomesamongolderpatientshospitalizedforheartfailure.  CircHeartFail.2011;4(3):293-300.doi:10.1161/CIRCHEARTFAILURE.110.959171PubMedGoogleScholarCrossref3.Orr  NM,Boxer  RS,Dolansky  MA,Allen  LA,Forman  DE. Skillednursingfacilitycareforpatientswithheartfailure:canwemakeit“heartfailureready?”  JCardFail.2016;22(12):1004-1014.doi:10.1016/j.cardfail.2016.10.009PubMedGoogleScholarCrossref4.Dunlay  SM,Manemann  SM,Chamberlain  AM,  etal. Activitiesofdailylivingandoutcomesinheartfailure.  CircHeartFail.2015;8(2):261-267.doi:10.1161/CIRCHEARTFAILURE.114.001542PubMedGoogleScholarCrossref5.Takabayashi  K,Kitaguchi  S,Iwatsu  K,  etal. Adeclineinactivitiesofdailylivingduetoacuteheartfailureisanindependentriskfactorofhospitalizationforheartfailureandmortality.  JCardiol.2019;73(6):522-529.doi:10.1016/j.jjcc.2018.12.014PubMedGoogleScholarCrossref6.Inouye  SK,Westendorp  RG,Saczynski  JS. Deliriuminelderlypeople.  Lancet.2014;383(9920):911-922.doi:10.1016/S0140-6736(13)60688-1PubMedGoogleScholarCrossref7.Marcantonio  ER,Kiely  DK,Simon  SE, 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 SK. Recognizingdeliriumsuperimposedondementia:assessingnurses’knowledgeusingcasevignettes.  JGerontolNurs.2007;33(2):40-47.doi:10.3928/00989134-20070201-09PubMedGoogleScholarCrossref12.Cannon  JA,McMurray  JJ,Quinn  TJ. ‘Heartsandminds’:association,causationandimplicationofcognitiveimpairmentinheartfailure.  AlzheimersResTher.2015;7(1):22.doi:10.1186/s13195-015-0106-5PubMedGoogleScholarCrossref13.Rudolph  JL,Jones  RN,Levkoff  SE,  etal. Derivationandvalidationofapreoperativepredictionrulefordeliriumaftercardiacsurgery.  Circulation.2009;119(2):229-236.doi:10.1161/CIRCULATIONAHA.108.795260PubMedGoogleScholarCrossref14.vonElm  E,Altman  DG,Egger  M,Pocock  SJ,Gøtzsche  PC,Vandenbroucke  JP;STROBEInitiative. TheStrengtheningtheReportingofObservationalStudiesinEpidemiology(STROBE)statement:guidelinesforreportingobservationalstudies.  AnnInternMed.2007;147(8):573-577.doi:10.7326/0003-4819-147-8-200710160-00010PubMedGoogleScholarCrossref15.Inouye  SK,vanDyck  CH,Alessi  CA,Balkin  S,Siegal 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 V. Deliriumduringpostacutenursinghomeadmissionandriskforadverseoutcomes.  JAmGeriatrSoc.2017;65(7):1470-1475.doi:10.1111/jgs.14823PubMedGoogleScholarCrossref20.Fong  TG,Davis  D,Growdon  ME,Albuquerque  A,Inouye  SK. Theinterfacebetweendeliriumanddementiainelderlyadults.  LancetNeurol.2015;14(8):823-832.doi:10.1016/S1474-4422(15)00101-5PubMedGoogleScholarCrossref21.Garvin  JH,Kim  Y,Gobbel  GT,  etal. Automatingqualitymeasuresforheartfailureusingnaturallanguageprocessing:adescriptivestudyinthedepartmentofVeteransAffairs.  JMIRMedInform.2018;6(1):e5.doi:10.2196/medinform.9150PubMedGoogleScholar22.Yancy  CW,Jessup  M,Bozkurt  B,  etal;WritingCommitteeMembers;AmericanCollegeofCardiologyFoundation/AmericanHeartAssociationTaskForceonPracticeGuidelines. 2013ACCF/AHAguidelineforthemanagementofheartfailure:areportoftheAmericanCollegeofCardiologyFoundation/AmericanHeartAssociationTaskForceonpracticeguidelines.  Circulation.2013;128(16):e240-e327.doi:10.1161/CIR.0b013e31829e8776PubMedGoogleScholar23.Faraone  SV. Interpretingestimatesoftreatmenteffects:implicationsformanagedcare.  PT.2008;33(12):700-711.PubMedGoogleScholar24.Lakens  D. Calculatingandreportingeffectsizestofacilitatecumulativescience:apracticalprimerfort-testsandANOVAs.  FrontPsychol.2013;4:863.doi:10.3389/fpsyg.2013.00863PubMedGoogleScholarCrossref25.Fong  TG,Vasunilashorn  SM,Libermann  T,Marcantonio  ER,Inouye  SK. DeliriumandAlzheimerdisease:aproposedmodelforsharedpathophysiology.  IntJGeriatrPsychiatry.2019;34(6):781-789.doi:10.1002/gps.5088PubMedGoogleScholarCrossref26.Inzitari  D,Pracucci  G,Poggesi  A, 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 etal. AssessmentoftheaccuracyofusingICD-9diagnosiscodestoidentifypneumoniaetiologyinpatientshospitalizedwithpneumonia.  JAMANetwOpen.2020;3(7):e207750.doi:10.1001/jamanetworkopen.2020.7750PubMedGoogleScholar39.Shao  Y,Zeng  QT,Chen  KK,Shutes-David  A,Thielke  SM,Tsuang  DW. Detectionofprobabledementiacasesinundiagnosedpatientsusingstructuredandunstructuredelectronichealthrecords.  BMCMedInformDecisMak.2019;19(1):128.doi:10.1186/s12911-019-0846-4PubMedGoogleScholarCrossref SeeMoreAbout CardiologyHeartFailureGeriatrics SignUpforEmailsBasedonYourInterests SelectYourInterests CustomizeyourJAMANetworkexperiencebyselectingoneormoretopicsfromthelistbelow. 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ThisIssue Views 4,117 Citations 0 ViewMetrics DownloadPDF Twitter Facebook More LinkedIn Cite This Citation MadrigalC,KimJ,JiangL,etal.DeliriumandFunctionalRecoveryinPatientsDischargedtoSkilledNursingFacilitiesAfterHospitalizationforHeartFailure.JAMANetwOpen.2021;4(3):e2037968.doi:10.1001/jamanetworkopen.2020.37968 Downloadcitationfile: Ris(Zotero) EndNote BibTex Medlars ProCite RefWorks ReferenceManager Mendeley ©2021 Permissions OriginalInvestigation Cardiology March 16,2021 DeliriumandFunctionalRecoveryinPatientsDischargedtoSkilledNursingFacilitiesAfterHospitalizationforHeartFailure Caroline Madrigal, PhD,RN1;Jenny Kim1;Lan Jiang, MS1;etal Jacob Lafo, PhD1,2;Melanie Bozzay, PhD3,4;Jennifer Primack, PhD1,2,4;Stephen Correia, PhD1,2,3,5;Sebhat Erqou, MD,PhD1,2;Wen-Chih Wu, MD1,2;JamesL. Rudolph, MD1,2,6 AuthorAffiliations ArticleInformation 1ProvidenceVAMedicalCenter,CenterofInnovationinLongTermServicesandSupports,Providence,RhodeIsland 2DepartmentofMedicine,WarrenAlpertMedicalSchoolofBrownUniversity,Providence,RhodeIsland 3DepartmentofPsychiatry&HumanBehavior,BrownUniversity,Providence,RhodeIsland 4ProvidenceVAMedicalCenter,CenterforNeurorestorationandNeurotechnology,Providence,RhodeIsland 5ButlerHospital,Providence,RhodeIsland 6CenterforGerontology,BrownUniversitySchoolofPublicHealth,Providence,RhodeIsland JAMANetwOpen.2021;4(3):e2037968.doi:10.1001/jamanetworkopen.2020.37968 visualabstracticon VisualAbstract editorialcommenticon EditorialComment relatedarticlesicon RelatedArticles authorinterviewicon Interviews multimediaicon Multimedia KeyPointsQuestion  Isdeliriumassociatedwith30-dayfunctionalrecoveryinpatientsdischargedtoskillednursingfacilitiesafterheartfailurehospitalization?Findings  Inthiscohortstudyof20 495patientsfromtheUSDepartmentofVeteransAffairshealthsystemdischargedtoskillednursingfacilitiesafterheartfailurehospitalization,deliriumwasassociatedwithpoorfunctionalrecovery.ThebaselineActivitiesofDailyLivingscoreonadmissiontoaskillednursingfacilitywassignificantlyworseamongpatientswithdelirium;patientswithdeliriumalsohadsignificantlylowerActivitiesofDailyLivingimprovementfrombaselinetofollow-upassessments.Meaning  Studyresultssuggestthatdeliriumonadmissiontoskillednursingfacilitiesafterheartfailurehospitalizationwasassociatedwithpoorfunctionalrecovery. Abstract Importance  Asubstantialnumberofpatientsdischargedtoskillednursingfacilities(SNFs)afterheartfailure(HF)hospitalizationexperienceregressioninfunctionordonotimprove.Deliriumisoneoffewmodifiableriskfactorsinthispatientpopulation.Therefore,understandingtheroleofdeliriuminfunctionalrecoverymaybeusefulforimprovingoutcomes.Objective  Toassesstheassociationofdeliriumwith30-dayfunctionalimprovementinpatientsdischargedtoSNFsafterHFhospitalization.Design,Setting,andParticipants  ThisretrospectivecohortstudyincludedpatientshospitalizedforHFin129USDepartmentofVeteransAffairshospitalswhoweredischargedtoSNFsfromOctober1,2010,toSeptember30,2015.DatawereanalyzedfromJune14toDecember18,2020.Exposures  Delirium,asdeterminedbytheMinimumDataSet(MDS)3.0ConfusionAssessmentMethod,withdementiaasacovariate,determinedviaInternationalClassificationofDiseases,NinthRevision(ICD-9)coding.MainOutcomesandMeasures  Thedifferencebetweenadmissionand30-dayMDS3.0ActivitiesofDailyLiving(ADL)scores.Results  Atotalof20 495patients(mean[SD]age,78[10.3]years;78.9%White;and97%male)wereincludedintheanalysis.Ofthetotalsample,882patients(4.3%)haddeliriumonanSNFadmission.Themean(SD)baselineADLscoreonadmissiontoSNFwassignificantlyworseamongpatientswithdeliriumthanwithout(18.3[4.7]vs16.1[5.2];P 0),nochangeinfunction(scores=0),andfunctionaldecline(scores<0). AdditionalVariables Dementiawasacovariateinthisstudybecausedeliriumanddementiaoftencoexistinhospitalizedpatients.20PreexistingdementiawasfoundusinginpatientandoutpatientcodingviatheInternationalClassificationofDiseases,NinthRevision(ICD-9)fromtheCentersforMedicare&MedicaidChronicConditionWarehouseatanypointbeforeSNFadmission.eTable1intheSupplementliststhecodesused.VeteransHealthAdministrationelectronichealthrecordswereusedtofinddemographicinformation,includingage,sex,andrace/ethnicity.TheElixhausercomorbidityindexwasusedtoidentifycomorbiditiesviaICD-9codesdrawnfromVAdataintheyearbeforeadmission.TheVAhealthcarecostsintheyearbeforeadmissionwereobtainedfromVAaccountingrecords.UseofVAresources(eg,numberofemergencydepartmentvisits,lengthofstayofhospitalizationimmediatelyprecedingSNFplacement)wascollectedfromVAadministrativerecords.Ejectionfraction(%)wasgatheredfromnaturallanguageprocessingofechocardiographyreportsintheyearprior21andwascategorizedwithclinicalconvention(ie,reduced,borderline,orpreserved).22 StatisticalAnalysis Thebaselinecharacteristicsofthosewithdeliriumwerecomparedwiththosewithoutdeliriumusingttestsforcontinuousvariablesandχ2testsfornoncontinuouscategoricalvariables.Standardizedmeandifferences(Cohend)werecalculatedasthedifferenceinmeansdividedbytheSDoftheentiresample.23Standardizedmeandifferenceshelptocontextualizethesizeofassociationsbetweenvariablesandgroups(eg,veteranswithorwithoutdelirium);effectsizescanbeinterpretedassmall(0.2),medium(0.5),orlarge(0.8).24Alinearmixed-effectsmodelwasusedtomodelthedifferenceinADLfrombaselineassessmenttothepost30-dayassessmentamongthe2groups.Theadjustedmodelincludedcovariatesofage,sex,race/ethnicity,dementia,Elixhausercomorbidityindex,emergencydepartmentadmissions,ejectionfractioncategory,lengthofhospitalstay,costofhealthcareuse,andbaselineADLscores.Allcovariatesweretreatedasfixedeffects. TheVAMedicalCentersfacilitywasincludedasarandomeffecttoaccountforpotentialclusteringwithinthefacility.Ourmodelingusedtheexchangeablecorrelationmatrix,inwhichthediagonalelementsrepresentthevarianceandoff-diagonalelementsrepresentcovarianceorcorrelation.The95%CIswerecalculatedforthelinearmixed-effectsmodels.Outputfromthemodelingisdisplayedastheregressionβcoefficient,whichcanbeinterpretedasthemeanADLchangefrombaselineovertimebetweenthosewithandwithoutdelirium,adjustedforthecovariatesofinterestspecifiedabove.DatawereanalyzedfromJune14toDecember18,2020.A2-sidedP 65yearsofagewithacutedecompensatedheartfailure.  AmJCardiol.2011;108(3):402-408.doi:10.1016/j.amjcard.2011.03.059PubMedGoogleScholarCrossref9.Alosco  ML,Spitznagel  MB,Raz  N,  etal. Obesityinteractswithcerebralhypoperfusiontoexacerbatecognitiveimpairmentinolderadultswithheartfailure.  CerebrovascDisExtra.2012;2(1):88-98.doi:10.1159/000343222PubMedGoogleScholarCrossref10.Apold  S. Deliriumsuperimposedondementia.  JNursePract.2018;14(3):183-189.doi:10.1016/j.nurpra.2017.12.010GoogleScholarCrossref11.Fick  DM,Hodo  DM,Lawrence  F,Inouye  SK. Recognizingdeliriumsuperimposedondementia:assessingnurses’knowledgeusingcasevignettes.  JGerontolNurs.2007;33(2):40-47.doi:10.3928/00989134-20070201-09PubMedGoogleScholarCrossref12.Cannon  JA,McMurray  JJ,Quinn  TJ. ‘Heartsandminds’:association,causationandimplicationofcognitiveimpairmentinheartfailure.  AlzheimersResTher.2015;7(1):22.doi:10.1186/s13195-015-0106-5PubMedGoogleScholarCrossref13.Rudolph  JL,Jones  RN,Levkoff  SE,  etal. Derivationandvalidationofapreoperativepredictionrulefordeliriumaftercardiacsurgery.  Circulation.2009;119(2):229-236.doi:10.1161/CIRCULATIONAHA.108.795260PubMedGoogleScholarCrossref14.vonElm  E,Altman  DG,Egger  M,Pocock  SJ,Gøtzsche  PC,Vandenbroucke  JP;STROBEInitiative. TheStrengtheningtheReportingofObservationalStudiesinEpidemiology(STROBE)statement:guidelinesforreportingobservationalstudies.  AnnInternMed.2007;147(8):573-577.doi:10.7326/0003-4819-147-8-200710160-00010PubMedGoogleScholarCrossref15.Inouye  SK,vanDyck  CH,Alessi  CA,Balkin  S,Siegal  AP,Horwitz  RI. Clarifyingconfusion:theconfusionassessmentmethod:anewmethodfordetectionofdelirium.  AnnInternMed.1990;113(12):941-948.doi:10.7326/0003-4819-113-12-941PubMedGoogleScholarCrossref16.Wei  LA,Fearing  MA,Sternberg  EJ,Inouye  SK. TheConfusionAssessmentMethod:asystematicreviewofcurrentusage.  JAmGeriatrSoc.2008;56(5):823-830.doi:10.1111/j.1532-5415.2008.01674.xPubMedGoogleScholarCrossref17.Saliba  D,Jones  M,Streim  J,Ouslander  J,Berlowitz  D,Buchanan  J. OverviewofsignificantchangesintheMinimumDataSetfornursinghomesversion3.0.  JAmMedDirAssoc.2012;13(7):595-601.doi:10.1016/j.jamda.2012.06.001PubMedGoogleScholarCrossref18.Saliba  D,Buchanan  J.Developmentandvalidationofarevisednursinghomeassessmenttool:MDS3.0.2008.2008.AccessedDecember1,2020.https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/downloads/MDS30FinalReport.pdf19.Kosar  CM,Thomas  KS,Inouye  SK,Mor  V. Deliriumduringpostacutenursinghomeadmissionandriskforadverseoutcomes.  JAmGeriatrSoc.2017;65(7):1470-1475.doi:10.1111/jgs.14823PubMedGoogleScholarCrossref20.Fong  TG,Davis  D,Growdon  ME,Albuquerque  A,Inouye  SK. Theinterfacebetweendeliriumanddementiainelderlyadults.  LancetNeurol.2015;14(8):823-832.doi:10.1016/S1474-4422(15)00101-5PubMedGoogleScholarCrossref21.Garvin  JH,Kim  Y,Gobbel  GT,  etal. Automatingqualitymeasuresforheartfailureusingnaturallanguageprocessing:adescriptivestudyinthedepartmentofVeteransAffairs.  JMIRMedInform.2018;6(1):e5.doi:10.2196/medinform.9150PubMedGoogleScholar22.Yancy  CW,Jessup  M,Bozkurt  B, 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