Hospitalization, Delirium Catastrophic in Alzheimer's

Megan Brooks

July 05, 2012

July 5, 2012 — Patients with Alzheimer's disease (AD) who require a hospital stay are at increased risk for further cognitive decline, institutionalization, and death in the year following the hospital stay, a new study shows.

These risks are greatest in those who develop delirium while in the hospital, according to the researchers. In their study, 1 in 16 deaths (6.2%), 1 in 7 institutionalizations (15.2%), and 1 in 5 cases of cognitive decline (20.6%) within 1 year could be attributed to delirium.

"We hope that this study will bring attention to how bad delirium can be for persons with AD," first author Tamara G. Fong, MD, PhD, assistant professor of neurology at Harvard Medical School and staff neurologist at Beth Israel Deaconess Medical Center, Boston, Massachusetts, told Medscape Medical News.

"The next step," she said, "will be to conduct intervention studies that would look at whether avoiding hospitalization (such as Hospital at Home) and/or delirium prevention strategies (such as the Hospital Elder Life Program) can reduce the risk of poor outcomes in patients with AD."

The study was published June 19 in Annals of Internal Medicine.

"True Burden" Revealed

In an interview with Medscape Medical News, Andrew F. Shorr, MD, MPH, FCCP, said this study demonstrates "the true burden of hospitalization in this patient population, not only in terms of the acute event but how hospitalization itself is a marker for future declines in health and resource utilization, and potentially that hospitalization may actually contribute to those declines."

Dr. Shorr is associate chief of the Department of Pulmonary and Critical Care Medicine at the Washington Hospital Center and associate professor of medicine in the Department of Pulmonary and Critical Care Medicine at Georgetown University in Washington, DC. He was not involved in the study.

Patients with AD often require a hospital stay. In a prior study, Dr. Fong and colleagues found that over an average of 3 years, up to two thirds of community-dwelling patients with AD had at least 1 hospitalization, and nearly half were hospitalized 2 or more times.

In a separate study that was reported by Medscape Medical News at that time, the same researchers found that delirium often accelerates cognitive decline in patients with AD.

The aim of their latest study was to see how hospitalization and delirium, alone or in combination, contribute to poor outcomes, specifically institutionalization, cognitive decline, or death.

"We found that hospitalization alone resulted in poor outcomes for patients with AD, but the combination of hospitalization and delirium resulted in an even greater risk for a poor outcome," Dr. Fong told Medscape Medical News.

The research team reviewed the medical records of 771 adults aged 65 years and older with a clinical diagnosis of AD in the Massachusetts Alzheimer's Disease Research Center patient registry. The cohort was relatively high-functioning with few comorbid conditions and only mild stages of AD, the authors note. The median length of follow-up was 2 years.

Among all 771 study patients, 367 (48%) were hospitalized and 194 (25%) developed delirium. During follow-up, at least 1 adverse outcome (institutionalization, cognitive decline, or death) occurred in 32% of the nonhospitalized group, 55% of the hospitalized group without delirium, and 79% of the hospitalized group with delirium. This finding, say the researchers, highlights the "association of hospitalization and the incremental effect of delirium with negative outcomes in this population of patients with AD."

The most common individual outcome in the hospitalized group with delirium was institutionalization, which occurred in 43%, compared with only 4% in the nonhospitalized group. Death occurred in 2% of the nonhospitalized group, compared with 9% of the hospitalized group without delirium and 15% of their counterparts with delirium. As expected, cognitive decline was seen in all groups.

According to the study team, hospitalized patients without delirium had a greater than 4-fold increased risk of dying and a nearly 7-fold increased risk of being institutionalized in the year after their hospital stay. With delirium, these risks were even greater. Hospitalization and delirium also was associated with increased risk for cognitive decline.

Table: Adjusted Relative Risks for Adverse Outcomes

Variable Hospitalized With No Delirium (95% CI) Hospitalized With Delirium (95% CI)
Death 4.7 (1.9 - 11.6) 5.4 (2.3 - 12.5)
Institutionalization 6.9 (4.0 - 11.7) 9.3 (5.5 - 15.7)
Cognitive decline 0.9 (0.6 - 1.4) 1.6 (1.2 - 2.3)
Any adverse outcome 1.7 (1.4 - 2.2) 2.2 (1.8 - 2.7)

CI = confidence interval

Prevention Efforts Needed

"Ultimately, we hope that the findings from this study can teach us how to provide better care for patients with AD," Dr. Fong said. "If we can show that delirium prevention can delay cognitive decline and improve the outcomes for patients with AD, this may be a far more effective treatment than the current drug treatments that are available."

Dr. Shorr said this study also demonstrates "the burden of dementia care in hospitals. We spend vast amounts of money caring for patients with dementia who end up in the intensive care unit, and we as a society have never had a conversation about whether that's the right thing to do or not. This paper may serve as a touchstone for that dialogue to happen," Dr. Shorr said.

He added: "If you have a patient with dementia who's recently been admitted to the hospital, especially if they suffered delirium, you really need to address not only discharge planning but end of life care, future resource needs, and their goals."

The study was funded by the National Institute on Aging and the Massachusetts Alzheimer's Disease Research Center. Disclosures for the study team can be viewed here . Dr. Shorr has disclosed relationships with various pharmaceutical companies, including Astellas Pharma, Inc, Bayer HealthCare Pharmaceuticals, CR Bard Inc, Canyon Pharmaceuticals Inc, Forrest Laboratories Inc, Theravance Inc, Trius Therapeutics, Pfizer Inc, Cubist Pharmaceuticals, BioCritica, and Roche.

Ann Intern Med. Published online June 19, 2012. Abstract

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