Delirium tied to poor HF outcomes in patients discharged to skilled nursing facilities
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Delirium, independent of preexisting dementia, at the time of discharge to a skilled nursing facility after HF hospitalization was associated with increased risk for 30-day and 1-year mortality among veterans, researchers reported.
In results published in ESC Heart Failure, there was no difference in HF outcomes among patients with dementia and no delirium compared with those with neither form of cognitive impairment.
“People hospitalized for heart failure already have one organ system in dysfunction. The big takeaway for us was that the acute change of delirium represents another organ system in dysfunction,” James L. Rudolph, MD, geriatrician and palliative care physician at the Providence VA Medical Center, Center of Innovation in Long Term Services and Supports, and professor of medicine and health services in the department of psychiatry and human behavior at Brown University, told Healio. “While dementia is characterized by an organ system in decline, dementia and heart failure does not have the same impact as the acute insults (organ dysfunction) of delirium and heart failure.”
Utilizing the Veterans Health Administration electronic records, researchers identified veterans hospitalized with a primary diagnosis of HF and discharged to skilled nursing facilities from 2010 to 2015 (n = 21,655; mean age, 77 years; 97% men). Health records were also used to identify those with preexisting dementia, and delirium was determined using the Minimum Data Set 3.0 Confusion Assessment Method algorithm.
Outcomes of interest were mortality at 30 days and 1 year.
Researchers observed greater 30-day and 1-year mortality among patients discharged to skilled nursing facilities with delirium and no dementia compared with those discharged with neither (adjusted HR for 30-day mortality = 2.2; 95% CI, 1.7-3; aHR for 1 year mortality = 1.5; 95% CI, 1.3-1.7).
Hospital readmission after 30 days was also higher among patients discharged to skilled nursing facilities with delirium and no dementia compared with other cognitive impairment combinations (HR = 1.2; 95% CI, 1-1.5).
“Patients with dementia may engage with the health system differently than patients with intact cognitive function,” the researchers wrote. “Our analytic approach of adjustment for comorbidities may not account for shifts in advanced care planning that occurs with chronic illnesses such as dementia and HF.”
In the group with dementia and no delirium, researchers observed similar 30-day mortality (12.8%; HR = 0.7; 95% CI, 0.7-0.8) and readmissions (5.3%; HR = 1; 95% CI, 0.8-1.1) compared with those with neither dementia nor delirium.
“The critical clinical factor is to identify delirium. Based on the delirium prevalence of other studies, we believe that the methods used in our study only identifies 30% to 50% of the delirium that occurs in skilled nursing facilities,” Rudolph told Healio. “This low prevalence does not negate our findings, but does highlight the importance of identifying delirium consistently in those entering skilled nursing facilities.
“One of the unique features of the study was the ability to follow patients from the hospital to the skilled nursing facilities — it was a data juggling act that is possible in only a few health systems, like the VA,” Rudolph said.
For more information:
James L. Rudolph, MD, can be reached at james.rudolph@va.gov.
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