Biomedical subjects

Nandini Dendukuri

Publications and source records attributed to Nandini Dendukuri.

29 records · Page 2Linked to original sources

PubMed2003

The course of delirium in older medical inpatients: a prospective study.

OBJECTIVES: To describe the clinical course and outcomes of delirium up to 12 months after diagnosis, the relationship between the in-hospital clinical course and post-discharge outcomes, and the role of dementia in both the clinical course and outcomes of delirium. DESIGN: Prospective cohort study. SETTING: Medical wards of a 400-bed, university-affiliated, primary acute care hospital in Montreal. PATIENTS: Cohort of 193 medical inpatients aged 65 and over with delirium diagnosed at admission or during the first week in hospital, who were discharged alive from hospital. MEASUREMENTS AND MAIN RESULTS: Study outcomes included cognitive impairment and activities of daily living (standardized, face-to-face clinical instruments at 1-, 2-, 6-, and 12-month follow-up), and mortality. Dementia, severity of illness, comorbidity, and sociodemographic variables were measured at time of diagnosis. Several measures of the in-hospital course of delirium were constructed. The mean numbers of symptoms of delirium at diagnosis and 12-month follow-up, respectively, were 4.5 and 3.5 in the subgroup of patients with dementia and 3.4 and 2.2 among those without dementia. Inattention, disorientation, and impaired memory were the most persistent symptoms in both subgroups. In multivariate analyses, pre-morbid and admission level of function, nursing home residence, and slower recovery during the initial hospitalization were associated with worse cognitive and functional outcomes but not mortality. CONCLUSIONS: Among patients with and without dementia, symptoms of delirium persist up to 12 months after diagnosis. Quicker in-hospital recovery is associated with better outcomes.

Activities of Daily Living↗

PubMed2003

Does delirium increase hospital stay?

OBJECTIVES: To determine the effects of prevalent and incident delirium on length of hospital stay. DESIGN: Prospective cohort study, comparing (1). length of stay after admission in cases of prevalent delirium versus controls without prevalent delirium with (2). length of stay after diagnosis in cases of incident delirium versus controls matched by day of diagnosis. SETTING: The medical services of a primary, acute care hospital. PARTICIPANTS: Medical admissions of patients aged 65 and older from the emergency department with delirium diagnosed during the first week in hospital. Patients admitted to intensive care or oncology and those with a primary diagnosis of stroke were excluded. A sample of those without delirium was also enrolled. MEASUREMENTS: Delirium was diagnosed using the Confusion Assessment Method. Data on length of stay and diagnosis-related groups (DRGs) were abstracted from administrative data. Measures of covariates included the Informant Questionnaire on Cognitive Decline in the Elderly, the Delirium Index, the instrumental activities of daily living questionnaire from the Older American Resources and Services project, the Charlson Comorbidity Index, the Clinical Severity Scale, and the Acute Physiology Score. RESULTS: The study sample comprised 359 patients: 204 with prevalent delirium, 37 with incident delirium, and 118 without delirium. After controlling for covariates, prevalent delirium was not associated with a significantly longer hospital stay, but incident delirium was associated with an excess stay after diagnosis of 7.78 days (95% confidence interval=3.07, 12.48). Similar results were obtained using log-transformed or DRG-adjusted estimates of length of stay. CONCLUSION: In older medical inpatients, incident but not prevalent delirium is an important predictor of longer hospital stay. Interventions to prevent incident delirium may reduce length of stay.

Aged↗

PubMed2003

Cost-effectiveness of a brief two-stage emergency department intervention for high-risk elders: results of a quasi-randomized controlled trial.

STUDY OBJECTIVE: : We determine the cost-effectiveness of a 2-stage emergency department intervention in addition to usual ED care compared with that of usual care alone. METHODS: The intervention comprises 2 steps: (1) identification of high-risk patients by using a screening tool and (2) a brief standardized nursing assessment to identify unresolved problems, followed by referral to an appropriate community provider. The patient population was composed of individuals aged 65 years and older to be released from the EDs of 4 Montreal hospitals. Patients were randomized by day of ED visit. The perspective of the study is societal, including patients, caregivers, and the formal health care (government-funded) system. Outcomes, measured from randomization to 4 months after randomization, included (1) functional decline, as measured by an activities of daily living instrument, or death, and (2) changes in depressive symptoms. Costs include post-ED care, including hospitalization, physician services, community care, outpatient drugs, and patient and caregiver costs. Cost items were measured with administrative databases and self-reported questionnaires. Unit costs for these items were either province-wide rates or else were estimated directly by using provider data. Cost-effectiveness is assessed in qualitative terms, such that outcomes and costs are compared separately. RESULTS: The intervention was associated with a reduced rate of functional decline (including death) at 4 months. There was no effect of the intervention on change in the patient's depressive symptoms at 4 months relative to baseline. The estimated ratio of overall costs per patient in the intervention versus the control group, adjusted for covariates, was 0.94 (95% credible interval 0.75 to 1.17). Among patients who had visited the ED during the 30 days before the index visit, the ratio was 0.66 (95% credible interval 0.44 to 0.97). CONCLUSION: In this study setting, the intervention is preferred over usual care because beneficial functional outcomes were observed, and overall societal costs were no higher than if usual care only was given.

Activities of Daily Living↗

PubMed2003

Impact of cardiac service availability on case-selection for angiography and survival associated with angiography.

OBJECTIVE: To examine whether availability of cardiac services at the admitting hospital affects case-selection for angiography and one-year survival following angiography, within groups of patients who have similar clinical need for angiography according to published criteria. STUDY SETTING: Elderly Medicare beneficiaries (37,788) discharged with a diagnosis of acute myocardial infarction (AMI) from hospitals in seven U.S. states between February 1994 and July 1995. We focused on patients who were eligible to receive angiography 12 or more hours after symptom onset. DATA COLLECTION: Data were abstracted from patient's medical records, Medicare National Claims Standard Analytic Files, Health Care Financing Administration (HCFA) Provider of Service File and Health Insurance Master File. METHODS: Admitting hospitals were classified as offering no cardiac services, angiography only, or revascularization. Case-selection differences across these three types of hospitals were examined by comparing relative risk of receiving angiography for various patient and hospital characteristics. Relative differences in one-year survival rate, comparing patients who received angiography to those who did not, were estimated within each hospital type and clinical need category (necessary, appropriate, or uncertain) after matching on propensity to receive angiography. PRINCIPAL FINDINGS: Compared to patients for whom angiography was deemed necessary, the relative risk of receiving angiography among those for whom it was deemed of uncertain benefit was 0.58, 0.79, and 0.92 (p-value of homogeneity test < 0.001) at hospitals offering no cardiac services, angiography only, and revascularization, respectively. There was no significant difference in survival following angiography across hospital types, overall as well as within clinical need categories. CONCLUSIONS: Despite increased case selection at hospitals with on-site cardiac services, there was no evidence of increase in the survival rate associated with angiography use at these hospitals.

Aged↗

PubMed2003

Rapid two-stage emergency department intervention for seniors: impact on continuity of care.

OBJECTIVES: A two-stage intervention comprising screening and a brief standardized nursing assessment and referral, for emergency department (ED) patients aged 65 years and over, reduced the rate of functional decline four months after the visit, without increasing societal costs. In this study, the authors investigated the effects of the intervention on the process of care at, and during the month after, the ED visit. METHODS: Patients at four Montreal hospital EDs were randomized by day of visit to the intervention or to usual care. Patients admitted to the hospital were excluded. Measures of process of care included: referrals and visits to the primary physician and to the local community health center, for home care or other services, and return ED visits. Data sources included hospital charts, patient questionnaires, and provincial administrative databases. RESULTS: The study sample included 166 intervention and 179 control group patients ready for discharge from the ED. Intervention group patients were more likely to have a chart-documented referral to their local community health center [adjusted odds ratio (OR) 4.0, 95% confidence interval (95% CI) = 1.7 to 9.5] and their primary physician [adjusted OR 1.9, 95% CI = 1.0 to 3.4], and to have received home care services one month after the ED visit [adjusted OR 2.3, 95% CI = 1.1 to 5.1]. Unexpectedly, they were also more likely to make a return visit to the ED [adjusted OR 1.6, 95% CI = 1.0 to 2.6]. CONCLUSIONS: The beneficial outcomes of the intervention appear to result primarily from the early provision of home care rather than early contact with the primary physician.

Aged↗

PubMed2003

Risk factors for depression among elderly community subjects: a systematic review and meta-analysis.

OBJECTIVE: The goal of this study was to determine risk factors for depression among elderly community subjects. METHOD: MEDLINE and PsycINFO were searched for potentially relevant articles published from January 1966 to June 2001 and from January 1967 to June 2001, respectively. The bibliographies of relevant articles were searched for additional references. Twenty studies met the following six inclusion criteria: original research reported in an English or French publication, study group of community residents, age of subjects 50 years or more, prospective study design, examination of at least one risk factor, and use of an acceptable definition of depression. The validity of studies was assessed according to the four primary criteria for risk factor studies described by the Evidence-Based Medicine Working Group. Information about group size at baseline and follow-up, age, proportion of men, depression criteria, exclusion criteria at baseline, length of follow-up, number of incident cases of depression, and risk factors was abstracted from each report. RESULTS: Follow-up of the inception cohort was incomplete in most studies. In the qualitative meta-analysis, risk factors identified by both univariate and multivariate techniques in at least two studies each were disability, new medical illness, poor health status, prior depression, poor self-perceived health, and bereavement. In the quantitative meta-analysis, bereavement, sleep disturbance, disability, prior depression, and female gender were significant risk factors. CONCLUSIONS: Despite the methodologic limitations of the studies and this meta-analysis, bereavement, sleep disturbance, disability, prior depression, and female gender appear to be important risk factors for depression among elderly community subjects.

Age Factors↗

PubMed2003

An empirical study of different diagnostic criteria for delirium among elderly medical inpatients.

This study compared the sensitivity and specificity of DSM-IV criteria for delirium with the sensitivity and specificity of DSM-III and ICD-10 criteria among elderly medical inpatients with or without dementia. Secondary objectives were to examine the effect of changing the definition of criterion A on sensitivity and specificity and to compare the sensitivity and specificity of different numbers of symptoms of delirium. A total of 322 elderly patients who had been admitted from the emergency department to the medical services were classified into one of four groups using DSM-III-R criteria: delirium and dementia (n = 128), delirium only (n = 40), dementia only (n = 94), and neither (n = 60). The sensitivity and specificity of DSM-IV, DSM-III, and ICD-10 criteria were determined against DSM-III-R criteria using three definitions of criterion A (clouding of consciousness only, clouding of consciousness and inattention, clouding of consciousness or inattention). When criterion A was defined as clouding of consciousness or inattention, the sensitivity and specificity of DSM-IV, DSM-III, and ICD-10 criteria were 100% and 71%, 96% and 91%, and 61% and 91%, respectively. The results were similar among patients with or without dementia. The lower specificity of DSM-IV was accounted for by its inclusion of patients who did not show disorganized thinking. DSM-IV criteria for delirium are the most inclusive criteria to date for elderly medical patients with or without dementia.

Aged↗

PubMed2002

The prevalence and phenomenology of auditory hallucinations among elderly subjects attending an audiology clinic.

BACKGROUND: Studies of auditory hallucinations are scant. METHOD: To determine the prevalence and phenomenology of auditory hallucinations among elderly subjects with hearing impairment. OBJECTIVE: We surveyed 125 men and women aged 65 years and over referred to the Audiology department of a university-affiliated primary acute-care hospital. RESULTS: The prevalence of auditory hallucinations was 32.8% (95% confidence interval (CI) 24.7-41.8). These hallucinations represented a spectrum of phenomenology from elementary personal impressions to complex percepts. The types of auditory hallucinations included humming or buzzing (35.9%), shushing (12.8%), beating or tapping (10.6%), ringing (7.7%), other individual sounds (15.4%), multiple sounds (12.6%), voices (2.5%) or music (2.5%). Subjects with any type of hallucination were younger and had poorer discrimination scores in the left ear and impaired binaural discrimination with lip-reading. Subjects with hallucinations that had more qualities of a true percept heard different types of sounds and had lower reflex thresholds and better air conduction in the right ear. CONCLUSION: Auditory hallucinations are frequent in elderly subjects with hearing impairment and seem to be associated with younger age and asymmetrical hearing impairment.

Aged↗

PubMed2002

Inhaled corticosteroids and the risk of diabetes among the elderly.

AIMS: There is evidence that large doses of inhaled corticosteroids lead to an increased risk of glaucoma, cataracts and other problems associated with oral corticosteroid use. However, no formal investigation so far has been conducted into the relationship between inhaled corticosteroids and diabetes. METHODS: Our nested case-control design studied the association between current use of inhaled corticosteroids and the risk of using antidiabetic medications among a cohort of 21 645 elderly subjects. We also investigated the possibility of a dose-response relationship in users of beclomethasone. Data were obtained from the medical and pharmaceutical databases of the Regie de l'assurance maladie du Québec. RESULTS: Within the cohort, we identified 1494 cases and we selected 14 931 controls using density sampling. The unadjusted rate ratio (and 95% confidence interval, CI) for developing diabetes among current users of inhaled corticosteroids was 1.4 (1.2, 1.5). After adjusting for covariates, the rate ratio (95% CI) decreased to 0.9 (0.8, 1.1). The loss of statistical significance was due in large part to adjusting for the current use of oral corticosteroids. We also did not observe a statistically significant increase in risk among users of high-dose beclomethasone compared to nonusers, after adjusting for covariates. CONCLUSIONS: Our results do not indicate an increased risk of diabetes among current users of inhaled corticosteroids.

Administration, Inhalation↗

PubMed2002

Proxy reporting of quality of life using the EQ-5D.

BACKGROUND: The economic evaluation of health interventions for older people is complicated by the difficulty in obtaining self-reports of quality of life from persons with cognitive impairments, physical impairments, or both. OBJECTIVES: Using the EQ-5D (EuroQoL) measures, to assess: (1) agreement between subjects and proxies on subject's quality of life ratings at different points in time; (2) agreement between subjects and proxies on change of subject's quality of life ratings over time; and (3) subject and proxy characteristics related to agreement. RESEARCH DESIGN: Prospective study of subjects visiting hospital emergency departments (ED). Data were collected at enrollment in the ED and at follow-up, 1 and 4 months after the ED visit. SUBJECTS: The study comprised 231 pairs of cognitively intact patients aged 65 years or older and their primary caregivers. MEASURES: Quality of life was measured using both components of the EQ-5D scale, the index score and the Visual Analogue Scale (VAS). Demographic characteristics and health status (physical and mental) were measured for both subjects and proxies. Subjects and proxies were interviewed either in English or French. RESULTS: There was low to moderate agreement between subjects and proxies at different points in time (intraclass correlation coefficient [ICC] = 0.22 to 0.59), and between subject and proxy change scores over time (ICC = 0-0.50), on both the index score and the VAS. Better agreement between subjects and proxies was found at the 4 months follow-up, when the subject was less depressed, and when the proxy's native language was English. CONCLUSIONS: Proxy EQ-5D responses, either for a specific point in time or for assessing change over time, may not be valid measures of self-reported quality of life among older medically-ill patients.

Aged↗

PubMed2002

Symptoms of delirium among elderly medical inpatients with or without dementia.

This study examined the frequencies of the 10 symptoms of delirium identified in DSM-III-R among patients with delirium (DSM-III-R criteria) who did or did not have dementia. The prevalence of each symptom, the numbers of symptoms, and the combinations of symptoms were determined among 322 elderly medical inpatients classified into one of four groups: delirium and dementia (n=128), delirium only (n=40), dementia only (n=94), or neither (n=60). Symptoms were assessed at the time of diagnosis and independently (by use of a different scale) within 24 hours of diagnosis. Delirium appeared to be phenomenologically similar among patients with and those without dementia, although patients with dementia had more psychomotor agitation at the time of diagnosis and more disorganized thinking and disorientation at the second assessment.

Adult↗