Date June 25, 2016
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Delirium at nursing home admission a risky sign for seniors

A large Brown University study finds patients who exhibited delirium at the time they entered a nursing home were significantly more likely to die or return to the hospital within 30 days and were less likely to recover fully if they returned home.

PROVIDENCE, R.I. [Brown University] — Brown University public health researchers who analyzed the medical records of more than 5.5 million seniors admitted to nursing homes between 2011 and 2014 found that approximately 240,000 had delirium. Those patients faced serious additional health risks compared to those without the condition.

“Upon admission to post-acute care, there are at least 4 percent of patients who have delirium,” said Cyrus Kosar, a graduate student who led the research and presented the results June 25 at the AcademyHealth Annual Research Meeting in Boston. “We should make an effort to improve care for these specific patients since they are high risk.”

The research was selected as one of the best student abstracts in AcademyHealth’s Long Term Services and Supports Interest Group. The honor includes a $550 award as well as a one year AcademyHealth student membership. 

Delirium is sometimes misunderstood, even among health care providers. Often observed among hospitalized patients – particularly older ones – it’s an acute decline in cognitive functioning that may appear to come and go, sometimes within matters of hours. It’s not chronic, which is a key distinction from dementia, a long-term, progressive, terminal degeneration of brain function.

Delirium may result from severe illnesses such as lingering infections, dehydration, sedation, or an improper blending or administration of medications.

“Delirium essentially is a good signal of a sicker patient or for a patient who is not getting the care that they need,” said Kosar, who worked with Vince Mor and Kali Thomas professor and research assistant professor respectively of health services, policy and practice in the School of Public Health.

Other researchers have found that health outcomes among patients with delirium are worse while they are in the hospital than for people without delirium. In this case, Kosar and Thomas wanted to look into the impact of delirium on post-acute care outcomes, which has rarely been studied.

“There is a good chance that the patients who are admitted to post-acute care with delirium came from acute care with delirium, so we might be capturing a group of patients with unresolved delirium,” Kosar said.

Kosar, Thomas and Mor performed their analysis by looking in the Minimum Data Set 3.0, a national dataset of nursing home care that recently began requiring structured assessments of delirium. To compile the records, nursing home personnel measured a variety of demographic and health characteristics in incoming patients, including delirium using the standard Confusion Assessment Method. In all, their sample included 5.58 million patients aged 65 or older admitted to nursing homes for post-acute care.

Of all the patients, more than 1.1 million had dementia, but even after a statistical accounting for that form of cognitive decline and other health problems (as well as age, gender and other factors) the patients with delirium faced greater health risks.

The mortality rate after 30 days was 16 percent among those with delirium compared to 6 percent (a statistically adjusted 2.3 times greater risk). The risk of readmission to the hospital within a month was also higher: 21 percent for seniors with delirium vs. 15 percent among those without (a 1.4 times risk). Among those delirium patients who went home after the nursing home admission, their rate of functional recovery (a decrease in dependency for daily living activities as measured by a standard scale) was lower: 49 percent vs. 60 percent (a statistically adjusted 17 percent lower chance).

The results can help nursing home care providers become aware that a significant number of their patients likely arrive with delirium and that the stakes for those patients are especially high, the researchers said. Identifying and addressing it could save lives and spare patients (and their insurers) from unnecessary readmissions to the hospital.

“I do believe there are patients we can target to address their delirium more effectively,” Kosar said. “There are going to be times when we can address the issues.”

Other Brown research at the conference

Kosar’s presentation is one of many by Brown University researchers during the conference. Several other talks and posters air additional recent findings involving post-acute care, skilled nursing facilities and the problem of hospital readmissions. 

In a presentation on June 26, for example, Brown researchers present findings that insertion of feeding tubes in elderly patients with dementia has been declining, after years of research questioning the benefits of the tubes. In another presentation, researchers will discuss the relationship between a skilled nursing facility’s historical rehospitalization rate and the likelihood that a patient will be rehospitalized within 30 days of admission.

The conference runs through Tuesday June 28.