Delirium in Frail Older Adults

Delirium and frailty are prevalent geriatric syndromes and important public health issues among older adults. The prevalence of delirium among hospitalized older adults ranges from 15% to 75%, while that of frailty ranges from 12% to 24%. The exact pathophysiology of these two conditions has not been clearly identified, although several hypotheses have been proposed. However, these conditions are considered to be multifactorial in etiology and are associated with inflammation related to aging, alterations in vascular systems, genetics, and nutritional deficiency. Furthermore, clinically, they are significantly associated with frailty, which increases the risk of delirium by almost two- to three-fold among hospitalized older adults. With their multifactorial etiology and unknown pathophysiology, current evidence supports more practical multicomponent patient-centered approaches to prevent and manage delirium with frailty among hospitalized older adults. These comprehensive and organized bundled approaches can identify high-risk patients with frailty and more effectively manage their delirium

COMPARATIVE ANALYSIS OF EARLY AND LATE TRACHEOSTOMY AMONG PATIENTS WITH ACUTE HEART FAILURE EXACERBATION, TRENDS, CLINICAL AND ECONOMIC OUTCOME ASSESSMENT, FROM 2005 TO 2014 NATIONWIDE

Heart failure is one of the leading causes of high morbidity and mortality. Acute exacerbation of heart failure may result in acute respiratory failure, which requires mechanical ventilator support. Despite supportive management, patients can fail extubation of the endotracheal tube and need a tracheostomy to continue mechanical ventilator support. However, optimal timing of tracheostomy has been controversial. Systemic study to assess the clinical and economic outcome of early tracheostomy among patients with acute heart failure exacerbation is lacking. The purpose of the study was to assess the national trend of tracheostomy among those who are admitted for acute respiratory failure with acute congestive heart failure exacerbation and to compare clinical and economic outcomes between the two groups (early and late tracheostomy) using national discharge data between from 2005 to 2014. We also conducted an economic evaluation comparing early and late tracheostomy among them using average cost and incremental costs with an outcome of length of stay. Among those who are admitted with acute heart failure exacerbation, 0.30% patients underwent the tracheostomy, and among them, 9.69% received early tracheostomy. There was no trend in the percentage of early tracheostomy. The length of stay in the hospital has decreased over time in late tracheostomy group, but it was stable in early tracheostomy group. Median total hospital length of stay (19 days) and total hospital cost ($52,158.23) in early tracheostomy group were significantly lower than late tracheostomy group (25 days and$68,037.40). Patients with coronary artery disease, pneumonia, and liver disease are less likely to receive early tracheostomy (OR 0.79, 0.63 and 0.64 respectively). After propensity score matching, it showed that the two groups did not show a significant difference in inhospital mortality (OR 0.91, p-value 0.676), or decannulation rate (OR 2.01, p-value 0.571). However, early tracheostomy was associated with higher likelihood of having a complication from tracheostomy with OR 2.08 (p-value 0.044) but was also associated with lower total hospital length of stay with coefficient factor -6.50 (p-value 0.000) from the linear regression model. From the economic evaluation, the early tracheostomy dominates the late tracheostomy with the outcome of total hospital length of stay and post-procedural length of stay with lower cost and higher effectiveness. The incremental cost-effectiveness ratio (ICER) is negative, meaning it costs $3,492.65 for each additional day in the hospital for late tracheostomy compared to early tracheostomy. ICER with the outcome of post-procedural length of stay was again negative, showing$2,032.67 per extra day in the hospital after the procedure among late tracheostomy group. Early tracheostomy among patients with acute heart failure exacerbation had no significant difference in mortality but had significant economic benefit with lower cost and less total hospital length of stay

Definition of Polypharmacy in Heart Failure: A Scoping Review of the Literature

Patients with heart failure (HF) have a high prevalence of polypharmacy, which can lead to drug interactions, cognitive impairment, and medication non-compliance. However, the definition of polypharmacy in these patients is still inconsistent. The aim of this scoping review was to find the most common definition of polypharmacy in HF patients. We conducted a scoping review searching Medline, Embase, CINAHL, and Cochrane using terms including polypharmacy, HF and deprescribing, which resulted in 7,949 articles. Articles without a definition of polypharmacy in HF patients and articles which included patients \u3c 18 years of age were excluded; only 59 articles were included. Of the 59 articles, 49% (n = 29) were retrospective, 20% (n = 12) were prospective, 10% (n = 6) were cross-sectional, and 27% (n = 16) were review articles. Twenty percent (n = 12) of the articles focused on HF with reduced ejection fraction, 10% (n = 6) focused on HF with preserved ejection fraction and 69% (n = 41) articles either focused on both diagnoses or did not clarify the specific type of HF. The most common cutoff for polypharmacy in HF was five medications (59%, n = 35). There was no consensus regarding the inclusion or exclusion of over-the-counter medications, supplements, or vitamins. Some newer studies used a cutoff of 10 medications (14%, n = 8), and this may be a more practical and meaningful definition for HF patients

How Do We Define High and Low Dose Intensity of Heart Failure Medications: A Scoping Review

BACKGROUND: Older adults with heart failure often experience adverse drug events with high doses of heart failure medications. Recognizing whether a patient is on a high or low dose intensity heart failure medication can be helpful for daily practice, since it could potentially guide the physician on which symptoms to look for, whether from overdosing or underdosing. However, the current guideline does not provide sufficient information about the dose intensity below the target dose. Furthermore, the definition of high or low-intensity heart failure medication is unclear, and there is no consensus. METHODS: To close the knowledge gap, we conducted a scoping review of the current literature to identify the most frequently used definition of high versus low doses of heart failure medications. We searched Pubmed, Embase, CINAHL, and Cochrane Library using comprehensive search terms that can capture the intensity of heart failure medications. RESULTS: We reviewed 464 articles, including 144 articles that had information about beta-blockers (BB), 179 articles about angiotensin-converting enzyme inhibitors (ACEi), 75 articles about angiotensin receptor blockers (ARB), 80 articles about diuretics, 37 articles about mineralocorticoid receptor antagonists (MRA), and 33 articles about angiotensin receptor-neprilysin inhibitor (ARNI). For hydralazine with isosorbide dinitrate or ivabradine, we could not identify any eligible articles. We identified 40 medications with most frequently used definitions of dose intensity. Four medications (nadolol, pindolol, cilazapril, and torsemide) did not reach consensus in definitions. Most of the BBs, ACEis, or ARBs used the definition of low being \u3c 50% of the target dose and high being ≥ 50% of the target dose from the guideline. However, for lisinopril and losartan, the most commonly used definitions of high or low were from pivotal clinical trials with a pre-defined definition of high or low. CONCLUSION: Our comprehensive scoping review studies identified the most frequently used definition of dose intensity for 40 medications but could not identify the definitions for 4 medications. The results of the current scoping review will be helpful for clinicians to have awareness whether the currently prescribed dose is considered high - requiring close monitoring of side effects, or low - requiring more aggressive up-titration

Removal of Blunt Esophageal Foreign Body Using Foley Catheter in Children

Purpose Foreign body ingestion is a common cause for children to visit the emergency department. Removal of esophageal foreign body was usually done by an endoscopy. After Bigler introduced the Foley catheter technique for esophageal foreign body in 1966, many studies were performed regarding such technique. However, only a few researchers in Korea have attempted to report this technique. This study reports a 10-year experience of the Foley catheter removal method for blunt esophageal foreign body at a single center in Korea. Methods Medical records of patients who were treated as esophageal foreign body with Foley catheters between March 2005 and February 2015 were retrospectively reviewed. Their clinical characteristics and outcomes were evaluated. Results A total of 73 patients were treated as esophageal foreign body impaction using the Foley catheter method. Foreign body removals were successful in 67 (91.8%) cases. Six failed cases were treated with esophagoscopy or endoscopy. The mean age was 3.7 years old. The most common foreign body was a coin (80.8%). Foreign bodies were lodged at the upper esophagus level most frequently (79.5%), followed by the middle esophagus (12.3%) and the lower esophagus (6.8%). During the removal procedure, 43.8% of patients were sedated, and 95.9% were treated with fluoroscopy. There were no positive correlations between the removal success and sedation (P=0.54) or using a fluoroscopy (P=0.23). In 69 cases (94.5%), there were no serious complications. However, in one patient, complications, such as vomiting, fever, and esophageal ulceration were observed. One patient complained fever and esophageal ulceration. In 3 (60%) of the total 5 patients with button battery ingestion, serious complications, such as fever or esophageal ulceration, occurred. Conclusion Removal of blunt esophageal foreign body using a Foley catheter in children is a useful and relatively safe method. However, patients with button battery ingestion need more attention when trying the Foley catheter removal technique

Underutilization of Endovascular Therapy in Black Patients With Ischemic Stroke: An Analysis of State and Nationwide Cohorts

BACKGROUND AND PURPOSE: Endovascular therapy (EVT) is a very effective treatment but relies on specialized capabilities that are not available in every hospital where acute ischemic stroke is treated. Here, we assess whether access to and utilization of this therapy has extended uniformly across racial and ethnic groups. METHODS: We conducted a retrospective, population-based study using the 2019 Texas Inpatient Public Use Data File. Acute ischemic stroke cases and EVT use were identified using the RESULTS: Among 40 814 acute ischemic stroke cases in Texas in 2019, 54% were White, 17% Black, and 21% Hispanic. Black patients had similar admissions to EVT-performing hospitals and greater admissions to comprehensive stroke centers (CSCs) compared with White patients (EVT 62% versus 62%, CONCLUSIONS: We found no evidence of disparity in presentation to EVT-performing hospitals or CSCs; however, lower rates of EVT were observed in Black patients

National Trends in Smoking Cessation Medication Prescriptions for Smokers With Chronic Obstructive Pulmonary Disease in the United States, 2007-2012

Objectives Smoking cessation decreases morbidity and mortality due to chronic obstructive pulmonary disease (COPD). Pharmacotherapy for smoking cessation is highly effective. However, the optimal prescription rate of smoking cessation medications among smokers with COPD has not been systemically studied. The purpose of this study was to estimate the national prescription rates of smoking cessation medications among smokers with COPD and to examine any disparities therein. Methods We conducted a retrospective study using National Ambulatory Medical Care Survey data from 2007 to 2012. We estimated the national prescription rate for any smoking cessation medication (varenicline, bupropion, and nicotine replacement therapy) each year. Multiple survey logistic regression was performed to characterize the effects of demographic variables and comorbidities on prescriptions. Results The average prescription rate of any smoking cessation medication over 5 years was 3.64%. The prescription rate declined each year, except for a slight increase in 2012: 9.91% in 2007, 4.47% in 2008, 2.42% in 2009, 1.88% in 2010, 1.46% in 2011, and 3.67% in 2012. Hispanic race and depression were associated with higher prescription rates (odds ratio [OR], 5.15; 95% confidence interval [CI], 1.59 to 16.67 and OR, 2.64; 95% CI, 1.26 to 5.51, respectively). There were no significant differences according to insurance, location of the physician, or other comorbidities. The high OR among Hispanic population and those with depression was driven by the high prescription rate of bupropion. Conclusions The prescription rate of smoking cessation medications among smokers with COPD remained low throughout the study period. Further studies are necessary to identify barriers and to develop strategies to overcome them

Real-World Safety of Neurohormonal Antagonist Initiation Among Older Adults Following a Heart Failure Hospitalization

AIMS: To optimize guideline-directed medical therapy for heart failure, patients may require the initiation of multiple neurohormonal antagonists (NHAs) during and following hospitalization. The safety of this approach for older adults is not well established. METHODS AND RESULTS: We conducted an observational cohort study of 207 223 Medicare beneficiaries discharged home following a hospitalization for heart failure with reduced ejection fraction (HFrEF) (2008-2015). We performed Cox proportional hazards regression to examine the association between the count of NHAs initiated within 90 days of hospital discharge (as a time-varying exposure) and all-cause mortality, all-cause rehospitalization, and fall-related adverse events over the 90 day period following hospitalization. We calculated inverse probability-weighted hazard ratios (IPW-HRs) with 95% confidence intervals (CIs) comparing initiation of 1, 2, or 3 NHAs vs. 0. The IPW-HRs for mortality were 0.80 [95% CI (0.78-0.83)] for 1 NHA, 0.70 [95% CI (0.66-0.75)] for 2, and 0.94 [95% CI (0.83-1.06)] for 3. The IPW-HRs for readmission were 0.95 [95% CI (0.93-0.96)] for 1 NHA, 0.89 [95% CI (0.86-0.91)] for 2, and 0.96 [95% CI (0.90-1.02)] for 3. The IPW-HRs for fall-related adverse events were 1.13 [95% CI (1.10-1.15)] for 1 NHA, 1.25 [95% CI (1.21-1.30)] for 2, and 1.64 [95% CI (1.54-1.76)] for 3. CONCLUSIONS: Initiating 1-2 NHAs among older adults within 90 days of HFrEF hospitalization was associated with lower mortality and lower readmission. However, initiating 3 NHAs was not associated with reduced mortality or readmission and was associated with a significant risk for fall-related adverse events