Cognitive decline after hospitalization in a community population of older persons

Rush Alzheimer’s Disease Center, Chicago, IL, USA.
Neurology (Impact Factor: 8.29). 03/2012; 78(13):950-6. DOI: 10.1212/WNL.0b013e31824d5894
Source: PubMed


To test the hypothesis that hospitalization in old age is associated with subsequent cognitive decline.
As part of a longitudinal population-based cohort study, 1,870 older residents of an urban community were interviewed at 3-year intervals for up to 12 years. The interview included a set of brief cognitive tests from which measures of global cognition, episodic memory, and executive function were derived. Information about hospitalization during the observation period was obtained from Medicare records.
During a mean of 9.3 years, 1,335 of 1,870 persons (71.4%) were hospitalized at least once. In a mixed-effects model adjusted for age, sex, race, and education, the global cognitive score declined a mean of 0.031 unit per year before the first hospitalization compared with 0.075 unit per year thereafter, a more than 2.4-fold increase. The posthospital acceleration in cognitive decline was also evident on measures of episodic memory (3.3-fold increase) and executive function (1.7-fold increase). The rate of cognitive decline after hospitalization was not related to the level of cognitive function at study entry (r = 0.01, p = 0.88) but was moderately correlated with rate of cognitive decline before hospitalization (r = 0.55, p = 0.021). More severe illness, longer hospital stay, and older age were each associated with faster cognitive decline after hospitalization but did not eliminate the effect of hospitalization.
In old age, cognitive functioning tends to decline substantially after hospitalization even after controlling for illness severity and prehospital cognitive decline.

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    • "Indeed, any examination of the utility of a delirium definition should incorporate criterion validity tests for future dementia. In prospective community cohort studies, hospitalization predicts adverse cognitive outcomes [8-10], though none has been able to specify if delirium is a key determinant. Delirium is also associated with increased mortality [11], and this should be another criterion by which any definition of delirium should be validated. "
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    ABSTRACT: Background In the general population, the epidemiological relationships between delirium and adverse outcomes are not well defined. The aims of this study were to: (1) construct an algorithm for the diagnosis of delirium using the Geriatric Mental State (GMS) examination; (2) test the criterion validity of this algorithm against mortality and dementia risk; (3) report the age-specific prevalence of delirium as determined by this algorithm. Methods Participant and informant data in a randomly weighted subsample of the Cognitive Function and Ageing Study were taken from a standardized assessment battery. The algorithmic definition of delirium was based on the DSM-IV classification. Outcomes were: proportional hazard ratios for death; odds ratios of dementia at 2-year follow-up. Results Data from 2197 persons (representative of 13,004) were used, median age 77 years, 64% women. Study-defined delirium was associated with a new dementia diagnosis at two years (OR 8.82, 95% CI 2.76 to 28.2) and death (HR 1.28, 95% CI 1.03 to 1.60), even after adjustment for acute illness severity. Similar associations were seen for study-defined subsyndromal delirium. Age-specific prevalence as determined by the algorithm increased with age from 1.8% in the 65-69 year age group to 10.1% in the ≥85 age group (p < 0.01 for trend). For study-defined subsyndromal delirium, age-specific period prevalence ranged from 8.2% (65-69 years) to 36.1% (≥85 years). Conclusions These results demonstrate the possibility of constructing an algorithmic diagnosis for study-defined delirium using data from the GMS schedule, with predictive criterion validity for mortality and dementia risk. These are the first population-based analyses able to account prospectively for both illness severity and an earlier study diagnosis of dementia.
    BMC Geriatrics 07/2014; 14(1):87. DOI:10.1186/1471-2318-14-87 · 1.68 Impact Factor
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    • "Population-based studies show that nursing home residents are frequently admitted to hospital for acute care; however, annual rates vary greatly in the range 16%–62 % [1] [2] [3] [4] [5]. Under the assumptions that hospitalizations of frail nursing home residents represent an unfavourable discontinuity of care [6] [7] [8] [9] [10] [11] [12] and that up to 40% of them are considered potentially avoidable, high rates of hospitalizations may represent a quality concern [13] [14] [15]. "
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    ABSTRACT: Background: The geriatric nursing home population is frail and vulnerable to sudden changes in their health condition. Very often, these incidents lead to hospitalization, in which many cases represent an unfavourable discontinuity of care. Analysis of variation in hospitalization rates among nursing homes where similar rates are expected may identify factors associated with unwarranted variation. Objectives: To 1) quantify the overall and diagnosis specific variation in hospitalization rates among nursing homes in a well-defined area over a two-year period, and 2) estimate the associations between the hospitalization rates and characteristics of the nursing homes. Method: The acute hospital admissions from 38 nursing homes to two hospitals were identified through ambulance records and linked to hospital patient journals (n = 2451). Overall variation in hospitalization rates for 2 consecutive years was tested using chi-square and diagnosis-specific variation using Systematic Component of Variation. Associations between rates and nursing home characteristics were tested using multiple regression and ANOVA. Results: Annual hospitalization rates varied significantly between 0.16 and 1.49 per nursing home. Diagnoses at discharge varied significantly between the nursing homes. The annual hospitalization rates correlated significantly with size (r = -0.38) and percentage short-term beds (r = 0.41), explaining 32% of the variation observed (R(2) = 0.319). No association was found for ownership status (r = 0.05) or location of the nursing home (p = 0.52). Conclusion: A more than nine-fold variation in annual hospitalization rates among the nursing homes in one municipality suggests the presence of unwarranted variation. This finding demands for political action to improve the premises for a more uniform practice in nursing homes.
    Scandinavian Journal of Public Health 04/2013; 41(4). DOI:10.1177/1403494813482200 · 1.83 Impact Factor
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