Are antidementia drugs associated with reduced mortality after a hospital emergency admission in the population with dementia aged 65 years and older?

Introduction: People with dementia experience poor outcomes after hospital admission, with mortality being particularly high. There is no cure for dementia; antidementia medications have been shown to improve cognition and function, but their effect on mortality in real-world settings is little known. This study examines associations between treatment with antidementia medication and mortality in older people with dementia after an emergency admission. Methods: The design is a retrospective cohort study of people aged 65 years, with a diagnosis of dementia and an emergency hospital admission between 01/01/2010 and 31/12/2016. Two classes of antidementia medication were considered: the acetylcholinesterase inhibitors and memantine. Mortality was examined using a Cox proportional hazards model with time-varying covariates for the prescribing of antidementia medication before or on admission and during one-year follow-up, adjusted for demographics, comorbidity, and community prescribing including anticholinergic burden. Propensity score analysis was examined for treatment selection bias. Results: There were 9142 patients with known dementia included in this study, of which 45.0% (n 5 4110) received an antidementia medication before or on admission; 31.3% (n 5 2864) were prescribed one of the acetylcholinesterase inhibitors, 8.7% (n 5 798) memantine, and 4.9% (n 5 448) both. 32.9% (n 5 1352) of these patients died in the year after admission, compared to 42.7% (n 5 2148) of those with no antidementia medication on admission. The Cox model showed a significant reduction in mortality in patients treated with acetylcholinesterase inhibitors (hazard ratio [HR] 5 0.78, 95% CI 0.72-0.85) or memantine (HR 5 0.75, 95% CI 0.66-0.86) or both (HR 5 0.76, 95% CI 0.68-0.94). Sensitivity analysis by propensity score matching confirmed the associations between antidementia prescribing and reduced mortality. Discussion: Treatment with antidementia medication is associated with a reduction in risk of death in the year after an emergency hospital admission. Further research is required to determine if there is a causal relationship between treatment and mortality, and whether "symptomatic" therapy for demen-tia does have a disease-modifying effect

Comorbidity and polypharmacy in people with dementia:insights from a large, population-based cross-sectional analysis of primary care data

Background: The care of older people with dementia is often complicated by physical comorbidity and polypharmacy, but the extent and patterns of these have not been well described. This paper reports analysis of these factors within a large, cross-sectional Methods: Data were extracted for 291,169 people aged 65 years or older registered with 314 general practices in the UK, of whom 10,258 had an electronically recorded dementia diagnosis. Differences in the number and type of 32 physical conditions and the number of repeat prescriptions in those with and without dementia were examined. Age–gender standardised rates were used to calculate odds ratios (ORs) of physical comorbidity and polypharmacy. Results: People with dementia, after controlling for age and sex, had on average more physical conditions than controls (mean number of conditions 2.9 versus 2.4; P < 0.001) and were on more repeat medication (mean number of repeats 5.4 versus 4.2; P < 0.001). Those with dementia were more likely to have 5 or more physical conditions (age–sex standardised OR [sOR] 1.42, 95% confidence interval (CI) 1.35–1.50; P < 0.001) and were also more likely to be on 5 or more (sOR 1.46; 95% CI 1.40–1.52; P < 0.001) or 10 or more repeat prescriptions (sOR 2.01; 95% CI 1.90–2.12; P < 0.001). Conculsions: People with dementia have a higher burden of comorbid physical disease and polypharmacy than those without dementia, even after accounting for age and sex differences. Such complex needs require an integrated response from general health professionals and multidisciplinary dementia specialists

Expert opinion on the management of pain in hospitalised older patients with cognitive impairment: A mixed methods analysis of a national survey

Background: Hospitalised older patients are complex. Comorbidity and polypharmacy complicate frailty. Significant numbers have dementia and/or cognitive impairment. Pain is highly prevalent. The evidence base for pain management in cognitively impaired individuals is sparse due to methodological issues. A wealth of expert opinion is recognised potentially providing a useful evidence base for guiding clinical practice. The study aimed to gather expert opinion on pain management in cognitively impaired hospitalised older people. Methods: Consultant Geriatricians listed as dementia leads in the National Dementia Audit were contacted electronically and invited to respond. The questionnaire sought information on their role, confidence and approach to pain management in cognitively impaired hospitalised patients. Responses were analysed using a mixed methods approach. Results: Respondents considered themselves very confident in the clinical field. Awareness of potential to do harm was highly evident. Unequivocally responses suggested paracetamol is safe and should be first choice analgesic, newer opiates should be used preferentially in renal impairment and nefopam is unsafe. A grading of the safety profile of specific medications became apparent, prompting requirement for further evaluation and holistic assessment. Conclusion: The lack of consensus reached highlights the complexity of this clinical field. The use of paracetamol first line, newer opiates in renal impairment and avoidance of nefopam are immediately transferrable to clinical practice. Further review, evaluation and comparison of the risks associated with other specific analgesics are necessary before a comprehensive clinical guideline can be produced

Mortality in people with dementia, delirium and unspecified cognitive impairment in the general hospital:prospective cohort study of 6724 patients with two years follow-up

Purpose: Cognitive impairment is common in older people admitted to hospital, but the outcomes are generally poorly understood, and previous research has shown inconsistent associations with mortality depending on the type of cognitive impairment examined and duration of follow-up. This study examines mortality in older people with any cognitive impairment during acute hospital admission. Patients and methods: Prospective cohort of 6,724 people aged ≥65 years with a structured cognitive assessment on acute admission were included in this study. Cognitive spectrum disorder (CSD) was defined as delirium alone, known dementia alone, delirium superimposed on known dementia, or unspecified cognitive impairment. Mortality associated with different types of CSD was examined using a non-proportional hazards model with 2-year follow-up. Results: On admission, 35.4% of patients had CSD, of which 52.6% died within 2 years. After adjustment for demographics and comorbidity, delirium alone was associated with increased mortality in the 6 months post-admission (HR =1.45, 95% CI 1.28–1.65) and again after 1 year (HR =1.44, 95% CI 1.17–1.77). Patients with known dementia (alone or with superimposed delirium) had increased mortality only after 3 months from admission (HR =1.85, 95% CI 1.56–2.18 and HR =1.80, 95% CI 1.52–2.14) compared with patients with unspecified cognitive impairment after 6 months (HR =1.55, 95% CI 1.21–1.99). Similar but partially attenuated associations were seen after adjustment for functional ability. Conclusion: Mortality post-admission is high in older people with CSD. Immediate risk is highest in those with delirium, while dementia or unspecified cognitive impairment is associated with medium- to long-term risk. These findings suggest that individuals without dementia who develop delirium are more seriously ill (have required a larger acute insult in order to precipitate delirium) than those with pre-existing brain pathology (dementia). Further research to explain the mortality patterns observed is required in order to translate the findings into clinical care

Indentifying published studies of care home research: an international survey of researchers

Collating the published research around institutional, long term care is confounded by the differing terminologies used to describe this health-care setting. We aimed to collate the descriptors used by researchers to inform the future development of a ‘search filter’ (a collection of search terms to help identify relevant records from electronic literature databases). We surveyed international researchers via the Nursing Home Research International Working Group, European Geriatric Medicine Society and published reviewers, achieving at 38% response rate across 21 countries. Our findings identified variation in terminology used by researchers to describe long-term care settings in their country of practice. Nursing home was the most accepted term (96%). ‘Homes for the Aged’ was selected by 48% of respondents. A range of terms are likely to be necessary to identify all relevant research and these may not be intuitive. We will use these data to help inform development of a search filter

Differential impact of two risk communications on antipsychotic prescribing to people with dementia in Scotland: segmented regression time series analysis 2001-2011

The two risk communications were associated with reductions in antipsychotic use, in ways which were compatible with marked differences in their content and dissemination. Further research is needed to ensure that the content and dissemination of regulatory risk communications is optimal, and to track their impact on intended and unintended outcomes. Although rates are falling, antipsychotic prescribing in dementia in Scotland remains unacceptably hig

Living at home after emergency hospital admission:prospective cohort study in older adults with and without cognitive spectrum disorder

Background: Cognitive spectrum disorders (CSDs) are common in hospitalised older adults and associated with adverse outcomes. Their association with the maintenance of independent living has not been established. The aim was to establish the role of CSDs on the likelihood of living at home 30 days after discharge or being newly admitted to a care home. Methods: A prospective cohort study with routine data linkage was conducted based on admissions data from the acute medical unit of a district general hospital in Scotland. 5570 people aged ≥ 65 years admitted from a private residence who survived to discharge and received the Older Persons Routine Acute Assessment (OPRAA) during an incident emergency medical admission were included. The outcome measures were living at home, defined as a private residential address, 30 days after discharge and new care home admission at hospital discharge. Outcomes were ascertained through linkage to routine data sources. Results: Of the 5570 individuals admitted from a private residence who survived to discharge, those without a CSD were more likely to be living at home at 30 days than those with a CSD (93.4% versus 81.7%; difference 11.7%, 95%CI 9.7–13.8%). New discharge to a care home affected 236 (4.2%) of the cohort, 181 (76.7%) of whom had a CSD. Logistic regression modelling identified that all four CSD categories were associated with a reduced likelihood of living at home and an increased likelihood of discharge to a care home. Those with delirium superimposed on dementia were the least likely to be living at home (OR 0.25), followed by those with dementia (OR 0.43), then unspecified cognitive impairment (OR 0.55) and finally delirium (OR 0.57). Conclusions: Individuals with a CSD are at significantly increased risk of not returning home after hospitalisation, and those with CSDs account for the majority of new admissions to care homes on discharge. Individuals with delirium superimposed on dementia are the most affected. We need to understand how to configure and deliver healthcare services to enable older people to remain as independent as possible for as long as possible and to ensure transitions of care are managed supportively

Improving recognition of delirium in clinical practice: a call for action

The purpose of this correspondence article is to report opinion amongst experts in the delirium field as to why, despite on-going training for all health professionals, delirium continues to be under recognised. Consensus was obtained by means of two conference workshops and an online survey of members of the European Delirium Association. Major barriers to recognition at an individual level include ignorance about the benefit of treating delirium. At an organisational level, reflecting socio-cultural attitudes, barriers include a low strategic and financial priority and the fact that delirium is an orphan condition falling between specialties

Identifying care-home residents in routine healthcare datasets:a diagnostic test accuracy study of five methods

Background: there is no established method to identify care-home residents in routine healthcare datasets. Methods matching patient’s addresses to known care-home addresses have been proposed in the UK, but few have been formally evaluated. Study design: prospective diagnostic test accuracy study. Methods: four independent samples of 5,000 addresses from Community Health Index (CHI) population registers were sampled for two NHS Scotland Health Boards on 1 April 2017, with one sample of adults aged ≥65 years and one of all residents. To derive the reference standard, all 20,000 addresses were manually adjudicated as ‘care-home address’ or not. The performance of five methods (NHS Scotland assigned CHI Institution Flag, exact address matching, postcode matching, Phonics and Markov) was evaluated compared to the reference standard. Results: the CHI Institution Flag had a high PPV 97–99% in all four test sets, but poorer sensitivity 55–89%. Exact address matching failed in every case. Postcode matching had higher sensitivity than the CHI flag 78–90%, but worse PPV 77–85%. Area under the receiver operating curve values for Phonics and Markov scores were 0.86–0.95 and 0.93–0.98, respectively. Phonics score with cut-off ≥13 had PPV 92–97% with sensitivity 72–87%. Markov PPVs were 90–95% with sensitivity 69–90% with cut-off ≥29.6. Conclusions: more complex address matching methods greatly improve identification compared to the existing NHS Scotland flag or postcode matching, although no method achieved both sensitivity and positive predictive value > 95%. Choice of method and cut-offs will be determined by the specific needs of researchers and practitioners

Epidemiology and outcomes of people with dementia, delirium and unspecified cognitive impairment in the general hospital: prospective cohort study of 10,014 admissions

Background  Cognitive impairment of various kinds is common in older people admitted to hospital, but previous research has usually focused on single conditions in highly-selected groups and has rarely examined associations with outcomes. This study examined prevalence and outcomes of cognitive impairment in a large unselected cohort of people aged 65+ with an emergency medical admission.  Methods  Between January 1, 2012, and June 30, 2013, admissions to a single general hospital acute medical unit aged 65+ underwent a structured specialist nurse assessment (n = 10,014). We defined ‘cognitive spectrum disorder’ (CSD) as any combination of delirium, known dementia, or Abbreviated Mental Test (AMT) score < 8/10. Routine data for length of stay (LOS), mortality, and readmission were linked to examine associations with outcomes.  Results  A CSD was present in 38.5% of all patients admitted aged over 65, and in more than half of those aged over 85. Overall, 16.7% of older people admitted had delirium alone, 7.9% delirium superimposed on known dementia, 9.4% known dementia alone, and 4.5% unspecified cognitive impairment (AMT score < 8/10, no delirium, no known dementia). Of those with known dementia, 45.8% had delirium superimposed. Outcomes were worse in those with CSD compared to those without – LOS 25.0 vs. 11.8 days, 30-day mortality 13.6% vs. 9.0%, 1-year mortality 40.0% vs. 26.0%, 1-year death or readmission 62.4% vs. 51.5% (allP < 0.01). There was relatively little difference by CSD type, although people with delirium superimposed on dementia had the longest LOS, and people with dementia the worst mortality at 1 year.  Conclusions  CSD is common in older inpatients and associated with considerably worse outcomes, with little variation between different types of CSD. Healthcare systems should systematically identify and develop care pathways for older people with CSD admitted as medical emergencies, and avoid only focusing on condition-specific pathways such as those for dementia or delirium alone