Adverse Outcomes After Hospitalization and Delirium in Persons with Alzheimer Disease Charles 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

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

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):