Adverse Outcomes After Hospitalization and Delirium in Persons with Alzheimer DiseaseCharles Wang, PharmD Candidate

Study•Adverse Outcomes After Hospitalization and

Delirium in Persons with Alzheimer Disease▫Fong T, Jones R, et al.▫Annals of Internal Medicine▫Volume 156 Number 12▫June 19, 2012

•Funding▫National Institute on Aging ▫Massachusetts Alzheimer’s Disease Research

Center

Background•Hospitalization can have potentially

catastrophic consequences for patients with AD▫Delirium▫Loss of independence▫Institutionalization▫Death

•Every year, 20% to 40% of patients with AD are hospitalized with an average of 3.7 days per year

Study Objective•To determine risks for institutionalization,

cognitive decline, or death associated with hospitalization and delirium in patients with Alzheimer’s Disease

Design•Enrollment

▫Prospective Cohort enrolled between 1991 and 2006 into the Massachusetts Alzheimer’s Disease Research Center (MADRC) patient registry

•Population▫Persons aged 65 or older with a clinical

diagnosis of Alzheimer's Disease (AD)

Methods•Drew study population from 5,600

patients that have been evaluated by MADRC at the Massachusetts General Hospital, a Harvard affiliated teaching hospital

•Data was merged from MADRC with data from the Medicare Provider Analysis and Review (MEDPAR) database, medical records, the Social Security Death Index database, and the National Death Index (NDI)

Methods•Hospitalizations were determined using the

MEDPAR database and corresponding medical charts

•Hospitalization group were participants hospitalized within 18 months of a MADRC visit

•Non-hospitalization group were participants without an hospitalizations for up to 36 months

•Participants hospitalized between 18 months and 36 months were excluded

Methods•Inclusion criteria

▫≥65 years of age▫Diagnosis of probable or possible AD

according to guidelines from the National Institute of Neurological and Communicative Diseases and Stroke and the Alzheimer’s Disease and Related Disorders Association

▫Were not enrolled in a Medicare HMO▫Had at least 3 MADRC visits during study

interval

Methods•Exclusion Criteria

▫Participants hospitalized after January 1, 2006 1 year follow up would not be complete

within the study time frame▫Participants hospitalized between 18

months and 36 months were excluded

Methods•Baseline was determined by the MADRC

visit prior to hospitalization▫Demographic characteristics▫Medical history▫Neurologic examination▫Cognitive testing

Information-Memory-Concentration subtest of the Blessed Dementia Scale test

Dementia Severity Rating

Outcomes•Institutionalization•Cognitive Decline

▫Loss of 4 or more points from baseline•Death

▫All within 1 year of Hospitalization

Demographics•Total Participants

▫771•Hospitalized patients with Delirium

▫194•Hospitalized patients without Delirium

▫173•Non-hospitalized patients

▫404

Demographics

Demographics

•Chronic Lung disease, CHF, fever, infections, dehydration, renal failure, PVD, psychiatric illness, and DM

Results

Results

Results

Discussion•Poor outcomes is greater among patients

who develop delirium, even after adjusting for cofounders

•Substantial proportion of risk could be attributed to delirium▫Death: 6.2%▫Institutionalization: 15.2%▫Cognitive Decline: 20.6%▫Overall adverse outcomes: 12.4%

Author’s Conclusions•Approximately 1 in 8 hospitalized patient

with AD who develop delirium will have at least 1 adverse outcome, including death, institutionalization, or cognitive decline, associated with delirium

•Delirium prevention may represent an important strategy for reducing adverse outcomes in this population

Strengths•Large scale study examining outcomes of

hospitalization of people with Alzheimer’s Disease

•Even distribution of men and women•Large sample size

Limitations•Population mainly white (95%)•Cognitive outcome was missing from 291

patients•Non-randomized•Patients that were hospitalized with

delirium were most cognitively impaired•All data was obtained from a single site•Data from multiple databases were

combined to create a single cohort

Discussion•Traditionally, observational study cannot

determine causality•Causative or associative?

References•Fong T, Jones R, et al. “Adverse outcomes

after hospitalization and delirium in persons with alzheimer’s disease” Annals of internal medicine 156(2012):848-856.