Adverse Outcomes After Hospitalization and Delirium in Persons With Alzheimer Disease

Transcription

1 Adverse Outcomes After Hospitalization and Delirium in Persons With Alzheimer Disease J. Sukanya 05.Jul.2012

2 Outline Background Methods Results Discussion Appraisal

3 Background Common outcomes in hospitalized patients with Alzheimer disease Delirium Loss of independence Institutionalization Death Economic burden

4 Background Persons with Alzheimer disease Increased risk for hospitalization 3-fold Hospitalized percent Average 3.7 days per person-year

5 Background Community-dwelling patients with Alzheimer disease Cohort study 3-year-duration 66% at least 1 hospitalization 47% 2 or more hospitalization 3 days per person-year

6 Background Episode of delirium increase the rate of cognitive decline Neurology May 5;72(18):

7 Background Patients with Alzheimer disease High risk for hospitalization Substantial effect of delirium on cognitive decline Hospitalization and delirium VS poor outcomes??? Expands on previous work Patients with Alzheimer disease Delirium is associated with poor outcomes

8 Background Outcomes Associated with hospitalization and delirium Examined by using a clinical epidemiologic cohort

9 Background Clinical epidemiologic cohort Massachusetts Alzheimer s Disease Research Center (MADRC) Medicare Provider Analysis and Review (MEDPAR) database Medical records The Social Security Death Index database The National Death Index (NDI)

10 Specific aims Hospitalization/Delirium/Community-dwelling patients Identify 1-year outcomes Death Institutionalization Cognitive decline Overall composite of these outcomes

11 Specific aims Hospitalization/Delirium/Community-dwelling patients Adjusted risks Outcomes for the hospitalized group With and without delirium Attributable risks Hospitalization and delirium VS Outcomes

12 Hypothesis Hospitalization and delirium Contribute incrementally to negative outcomes Confirming Important roles : Hospitalization and delirium Adverse outcomes Influence care and management of patients with Alzheimer disease

13 Methods Setting and participants Data collection Outcomes Statistical analysis Role of the Funding source

14 Setting and participants Participants Nested within the MADRC cohort MADRC patient registry Prospective cohort Between 1 January June 2006 Longitudinal study of hospitalization in AD MADRC Persons with memory loss Massachusettes General Hospital (MGH)

15 Setting and participants Patients aged 65 years or older probable or possible Alzheimer disease The National Institute of Neurological and Communicative Diseases and Stroke and the Alzheimer s Disease and Related Disorders Association At least 3 MADRC visits Informed consent

16 Setting and participants Hospitalizations Review The MEDPAR database/medical charts Hospitalized group Within 18 months of an MADRC visit Non-hospitalized group Up to 36 months after an MADRC visit

17 Data Collection Baseline MADRC visit Visit before hospitalization Demographic characteristics Medical history Neurologic examination Cognitive testing The Information-Memory-Concentration (IMC) subtest of the Blessed Dementia Scale test Range: 0-37

18 Data Collection Dementia severity MGH Dementia Severity Rating (DSR) scale Range: 0 5 Correlates with the Clinical Dementia Rating scale Others Family history of Alzheimer disease Clinical course Calculate the Charlson Deyo comorbidity score Range: 0-37

19 Data Collection Follow-up MADRC assessments Approximately every 6 months Standardized protocol Update history Physical examination Cognitive testing Balance the observation period Non-hospitalized VS Hospitalized group

20 Data Collection Index hospitalization Trained clinical chart abstractors (2 physicians and 2 nurses) Reviewed the medical record Delirium Chart review:?key terms The Confusion Assessment Method

21 Diagnostic Criteria: CAM The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1. Acute onset and fluctuating course Feature 2. Inattention Feature 3. Disorganized thinking Feature 4. Altered level of consciousness The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4 The Supplementary Appendix of N Engl J Med 2006;354:

22 Outcomes Institutionalization Chart review or MADRC records Death NDI database NDI plus MADRC/Social Security Death Index data Clinical adjudication Cognitive decline Loss of 4 or more points from baseline The Blessed IMC test score

23 Outcomes Any adverse outcome Increase efficiency Decrease the effect of missing data Resolve arbitrary choices among multiple important outcomes

24 Statistical Analysis 1-way analysis of variance Continuous variables Chi-square test groups Categorical variables Outcome rates across the study Poisson regression Missing data Relative risks Prediction models

25 Statistical Analysis Population attributable risk Measuring the potential proportion Reduced incidence of outcomes Elimination hospitalization or delirium Attributable risk Risk for adverse outcome

26 Role of the Funding Source The MADRC and the National Institute on Aging Involved Collection of data, specifically patient demographic characteristics, medical history, neurologic examination, and cognitive testing Not involved Study design, analysis, or interpretation of data or in the preparation or submission of the manuscript for publication

27 Results Table 1 Figure 1 Table 2 Table 3 Table 4 Figure 2

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37 Discussion Patients with Alzheimer s disease Hospitalization and delirium Prevention strategies Attributable risk of hospitalized patients Deaths 6.2% Institutionalization 15.2% Cognitive decline 20.6% Any adverse outcomes 12.4%

38 Discussion Previous studies Examine poor outcomes associated with hospitalization Lack of measurement of delirium This study Examine the association of both hospitalization and delirium Unique, large-scale epidemiologic examination Real-world epidemiologic cohort!!!!! Causality?/generalizability?

39 Discussion Describing the magnitude of statistical associations Maximizing the validity of associations Controlling for baseline differences in the cohorts Multiple sensitivity analyses testing different assumptions Verifying temporal precedence confirming that delirium occurs before the outcomes Establishing biological plausibility Delirium VS adverse outcomes

40 Discussion Attributable risk Interpreted with caution May not reflect causal effects of delirium on outcomes Potential Residual confounding Differential measurement error Informative censoring Adjust known risk factors & sensitivity analyses

41 Discussion Nonrandomized nature Different in baseline cognitive function Most impaired in hospitalized group with delirium Covariate adjustment & stratified analyses Delirium independently contributed to the poor outcomes

42 Discussion Real-world clinical cohort Minimize missing data and bias Effect of missing data Sensitivity analyses assigning extreme values Best case VS Worst case to missing data Confident Internal validity of findings Conclusions

43 ? Are the results of the study valid? Critical Appraisal Skills Programme

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