Enhancing Care for Hospitalized Older Adults with Cognitive Impairment: A Randomized Controlled Trial
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Approximately 40% of hospitalized older adults have cognitive impairment (CI) and are more prone to hospital-acquired complications. The Institute of Medicine suggests using health information technology to improve the overall safety and quality of the health care system.
Evaluate the efficacy of a clinical decision support system (CDSS) to improve the quality of care for hospitalized older adults with CI.
A randomized controlled clinical trial.
A public hospital in Indianapolis.
A total of 998 hospitalized older adults were screened for CI, and 424 patients (225 intervention, 199 control) with CI were enrolled in the trial with a mean age of 74.8, 59% African Americans, and 68% female.
A CDSS alerts the physicians of the presence of CI, recommends early referral into a geriatric consult, and suggests discontinuation of the use of Foley catheterization, physical restraints, and anticholinergic drugs.
Orders of a geriatric consult and discontinuation orders of Foley catheterization, physical restraints, or anticholinergic drugs.
Using intent-to-treat analyses, there were no differences between the intervention and the control groups in geriatric consult orders (56% vs 49%, P = 0.21); discontinuation orders for Foley catheterization (61.7% vs 64.6%, P = 0.86); physical restraints (4.8% vs 0%, P = 0.86), or anticholinergic drugs (48.9% vs 31.2%, P = 0.11).
A simple screening program for CI followed by a CDSS did not change physician prescribing behaviors or improve the process of care for hospitalized older adults with CI.
- Boustani M, Baker MS, Campbell N, Munger S, Hui SL, Castelluccio P, et al. Impact and recognition of cognitive impairment among hospitalized elders. J Hosp Med. 2010;5:69–75. CrossRef
- Bynum JP, Rabins PV, Weller W, Niefeld M, Anderson GF, Wu AW. The relationship between a dementia diagnosis, chronic illness, medicare expenditures, and hospital use. J Am Geriatr Soc. 2004;52:187–194. CrossRef
- Boustani M, Munger S, Beck R, Campbell N, Weiner M. A gero-informatics tool to enhance the care of hospitalized older adults with cognitive impairment. Clin Interv Aging. 2007;2:1–7. CrossRef
- National Hospital Discharge Survey 2005. Public use data file documentation. U.S. Department of Health and Human Services. Centers for Disease Control and Prevention. National Center for Health Statistics. Division of Health Care Statistics. Hospital Care Statistics Branch. http://www.cdc.gov/nchs/about/major/hdasd/nhds.htm (accessed January 10, 2012).
- DeFrances CJ, Podgornik MN. 2004 National Hospital Discharge Survey. Advance data from vital and health statistics; no 371. Hyattsville, MD: National Center for Health Statistics 2006.
- Inouye SK, Rushing JT, Foreman MD, Palmer RM, Pompei P. Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study. J Gen Intern Med. 1998;13:234–242. CrossRef
- Inouye SK, Schlesinger MJ, Lydon TJ. Delirium: a symptom of how hospital care is failing older persons and a window to improve quality of hospital care. Am J Med. 1999;106:565–573. CrossRef
- Frels C, Williams P, Narayanan S, Gariballa SE. Iatrogenic causes of falls in hospitalised elderly patients: a case-control study. Postgrad Med J. 2002;78:487–489. CrossRef
- Ely EW, Gautam S, Margolin R, et al. The impact of delirium in the intensive care unit on hospital length of stay. Intensive Care Med. 2001;27:1892–1900. CrossRef
- Milbrandt EB, Deppen S, Harrison PL, et al. Costs associated with delirium in mechanically ventilated patients. Crit Care Med. 2004;32(4):955–962. CrossRef
- Saravay SM, Kaplowitz M, Kurek J, et al. How do delirium and dementia increase length of stay of elderly general medical inpatients? Psychosomatics. 2004;45:235–242. CrossRef
- Witlox J, Eurelings LSM, de Jonghe JFM, Kalaisvaart KJ, Eikelenboom P, van Gool WA. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia. a meta-analysis. JAMA. 2010;304(4):443-451.
- Baztan JJ, Suarez-Garcia FM, Lopez-Arrieta J, Rodriguez-Manas L, Rodriguea-Artalejo F. Effectiveness of acute geriatric units on functional decline, living at home, and case fatality among older patients admitted to hospital for acute medical disorders: meta-analysis. BMJ. 2009;338:b50. CrossRef
- Counsell SR, Holder CM, Liebenauer LL, et al. Effects of a multicomponent intervention on functional outcomes and process of care in hospitalized older patients: a randomized controlled trial of Acute Care for Elders (ACE) in a community hospital. J Am Geriatr Soc. 2000;48:1572–1581.
- Cohen HJ, Feussner JR, Weinberger M, et al. A controlled trial of inpatient and outpatient geriatric evaluation and management. N Engl J Med. 2002;346:905–912. CrossRef
- Cole MG, McCusker J, Bellavance F, et al. Systematic detection and multidisciplinary care of delirium in older medical inpatients: a randomized trial. CMAJ. 2002;167:753–759.
- Inouye SK, Bogardus ST Jr, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340:669–676. CrossRef
- Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc. 2001;49:516–522. CrossRef
- Medicine, Institute of. Crossing the Quality Chasm. Washington, DC. Institute of Medicine Press 2001.
- McDonald CJ, Overhage JM, Tierney WM, et al. The Regenstrief Medical Record System: a quarter century experience. Int J Med Inform. 1999;54:225–253. CrossRef
- Tierney WM, Miller ME, Overhage JM, McDonald CJ. Physician inpatient order writing on microcomputer workstations. Effects on resource utilization. JAMA. 1993;269:379–383. CrossRef
- Pfeiffer E. A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc. 1975;23:433–441.
- Erkinjuntti T, Sulkava R, Wikstrom J, Autio L. Short Portable Mental Status Questionnaire as a screening test for dementia and delirium among the elderly. J Am Geriatr Soc. 1987;35:412–416.
- Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113:941–948.
- American Psychiatric Association. Practice guidelines for the treatment of patients with delirium. American Psychiatric Association. Am J Psychiatry. 1999 May;156(5 Suppl):1-20.
- Chow TW, MacLean CH. Quality indicators for dementia in vulnerable community-dwelling and hospitalized elders. Ann Intern Med. 2001;135:668–676.
- Mayo-Smith MF, Beecher LH, Fischer TL, et al. Management of alcohol withdrawal delirium. An evidence-based practice guideline. Arch Intern Med. 2004;164(13):1405–1412. CrossRef
- Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med. 2003;163:2716–2724. CrossRef
- Campbell N, Boustani M, Ayub A, et al. Pharmacological management of delirium in hospitalized adults: a systematic evidence review. J Gen Intern Med. 2009;24:848–853. CrossRef
- Campbell N, Boustani M, Limbil T, et al. The cognitive impact of anticholinergics: a clinical review. Clin Interv Aging. 2009;4:225–233.
- Charlson ME, Sax FL, MacKenzie CR, Fields SD, Braham RL, Douglas RG Jr. Assessing illness severity: does clinical judgment work? J Chronic Dis. 1986;39:439–452. CrossRef
- Osheroff JA, Teich JM, Middleton B, Steen EB, Wright A, Detmer DE. A roadmap for national action on clinical decision support. J Am Med Inform Assoc. 2007;14:141–145. CrossRef
- Chaudry B, Wang J, Wu S, et al. Systematic review: Impact of health information technology on quality, efficiency, and cost of medical care. Ann Int Med. 2006;144:742–749.
- Van der Sijs H, Aarts J, Vulto A, Berg M. Overriding of drug safety alerts in computerized physician order entry. J Am Med Inform Assoc. 2006;13:138–147. CrossRef
- Terrell KM, Perkins AJ, Dexter PR, Hui SL, Callahan CM, Miller DK. Computerized decision support to reduce potentially inappropriate prescribing to older emergency department patients: a randomized, controlled trial. J Am Geriatr Soc. 2009;57(8):1388–1394. CrossRef
- Mattison MLP, Afonso KA, Ngo LH, Mukamal KJ. Preventing potentially inappropriate medication use in hospitalized older patients with a computerized provider order entry warning system. Arch Intern Med. 2010;170(15):1331–1336. doi:10.1001/archinternmed.2010.244. CrossRef
- Landefeld CS, Palmer RM, Kresevic DM, Fortinsky RH, Kowal J. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med. 1995;332:1338–44. CrossRef
- Slaets JP, Kauffmann RH, Duivenvoorden HJ, Pelemans W, Schudel WJ. A randomized trial of geriatric liaison intervention in elderly medical inpatients. Psychosom Med. 1997;59:585–91.
- Stuck AE, Siu AL, Wieland GD, Adams J, Rubenstein LZ. Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet. 1993;342:1032–6. CrossRef
- Reuben DB, Borok GM, Wolde-Tsadik G, et al. A randomized trial of comprehensive geriatric assessment in the care of hospitalized patients. N Engl J Med. 1995;332:1345–50. CrossRef
- Campion EW, Jette A, Berkman B. An interdisciplinary geriatric consultation service: a controlled trial. J Am Geriatr Soc. 1983;31:792–6.
- Becker PM, McVey LJ, Saltz CC, Feussner JR, Cohen HJ. Hospital-acquired complications in a randomized controlled clinical trial of a geriatric consultation team. JAMA. 1987;257:2313–7. CrossRef
- Gayton D, Wood-Dauphinee S, de Lorimer M, Tousignant P, Hanley J. Trial of a geriatric consultation team in an acute care hospital. J Am Geriatr Soc. 1987;35:726–36.
- Rubenstein LZ, Josephson KR, Wieland GD, English PA, Sayre JA, Kane RL. Effectiveness of a geriatric evaluation unit. A randomized clinical trial. N Engl J Med. 1984;311:1664–70. CrossRef
- Burns R, Nichols LO, Graney MJ, Cloar FT. Impact of continued geriatric outpatient management on health outcomes of older veterans. Arch Intern Med. 1995;155:1313–8. CrossRef
- Owens NJ, Sherburne NJ, Silliman RA, Fretwell MD. The Senior Care Study. The optimal use of medications in acutely ill older patients. J Am Geriatr Soc. 1990;38:1082–7.
- Edwards RF, Harrison TM, Davis SM. Potentially inappropriate rescribing for geriatric inpatients: an acute care of the elderly unit compared to a general medicine serice. Consult Pharm. 2003;18(37–42):47–49.
- Dexter PR, Perkins S, Overhage JM, Maharry K, Kohler RB, McDonald CJ. A computerized reminder system to increase the use of preventive care for hospitalized patients. N Engl J Med. 2001;345:965. CrossRef
- Pestotnik SL, Classen DC, Evans RS, Burke JP. Implementing antibiotic practice guidelines through computer-assisted decision support: clinical and financial outcomes. Ann Intern Med. 1996;124:884–90.
- Larsen RA, Evans RS, Burke JP, Pestotnik SL, Gardner RM, Classen DC. Improved perioperative antibiotic use and reduced surgical wound infections through use of computer decision analysis. Infect Control Hosp Epidemiol. 1989;10:316–20. CrossRef
- Overhage JM, Tierney WM, Zhou XH, McDonald CJ. A randomized trial of "corollary orders" to prevent errors of omission. J Am Med Inform Assoc. 1997;4:364–75. CrossRef
- Schneider LS, Tariot PN, Dagerman KS, et al. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer's disease. N Engl J Med. 2006;355:1525–1538. CrossRef
- Sink KM, Holden KF, Yaffe K. Pharmacological treatment of neuropsychiatric symptoms of dementia: a review of the evidence. JAMA. 2005;293:596–608. CrossRef
- Boustani M, Peterson B, Hanson L, Harris R, Lohr KN. US Preventive Services Task Force. Screening for dementia in primary care: a summary of the evidence for the US Preventive Services Task Force. Ann Intern Med. 2003;138(11):927–937.
- Callahan CM, Boustani M, Unverzagt FW, et al. Effectiveness of guideline-level care for older adults with Alzheimer's disease in primary care: a clinical trial. JAMA. 2006;295:2148–2157. CrossRef
- Enhancing Care for Hospitalized Older Adults with Cognitive Impairment: A Randomized Controlled Trial
Journal of General Internal Medicine
Volume 27, Issue 5 , pp 561-567
- Cover Date
- Print ISSN
- Online ISSN
- Additional Links
- cognitive impairment
- clinical trial
- decision support
- hospitalized elders
- Industry Sectors
- Malaz A. Boustani MD, MPH (1) (2) (3)
- Noll L. Campbell PharmD (1) (2) (4) (5)
- Babar A. Khan MD (3)
- Greg Abernathy MD (2)
- Mohammed Zawahiri MD (1) (2)
- Tiffany Campbell BS (1) (2)
- Jason Tricker NP (3)
- Siu L. Hui PhD (1) (2) (3)
- John D. Buckley MD (1) (2) (3)
- Anthony J. Perkins MS (2)
- Mark O. Farber MD (3)
- Christopher M. Callahan MD (1) (2) (3)
- Author Affiliations
- 1. Indiana University Center for Aging Research, Indianapolis, IN, USA
- 2. Regenstrief Institute, Inc, 410 West 10th Street, Suite 2000, Indianapolis, IN, 46202, USA
- 3. Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- 4. Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN, USA
- 5. Department of Pharmacy, Wishard Health Services, Indianapolis, IN, USA