The impact of delirium on healthcare utilization and survival after transcatheter aortic valve replacement.

OBJECTIVES: We assessed whether post-operative delirium is associated with healthcare utilization and overall survival after trans-catheter aortic valve replacement. BACKGROUND: Delirium, a common syndrome among hospitalized older adults, is associated with increased morbidity and mortality. METHODS: We reviewed 294 transcatheter aortic valve replacement cases between June 2008 and February 2015 at a tertiary care academic medical center. Post-operative delirium was identified by confusion assessment method screening and clinician diagnosis. RESULTS: Delirium was identified in 61 patients (21%). Non-femoral access for trans-catheter aortic valve replacement was more common in delirious patients than in non-delirious patients (41% vs. 27%, P = 0.04). Delirious patients had diminished overall survival after trans-catheter aortic valve replacement compared to non-delirious patients (1-year survival 59% vs. 84%, log-rank P = 0.002). After adjusting for age, Society of Thoracic Surgeons predicted 30-day mortality, and access type; delirium remained independently associated with diminished overall survival (hazard ratio 2.01, 95% confidence interval 1.21-3.33, P = 0.007). The delirium group had longer mean hospital stay (13.3 ± 9.5 days vs. 6.7 ± 3.8 days, P < 0.001) and a higher rate of discharge to a rehabilitation facility (61% vs. 27%, P < 0.001), but there was no difference in 30-day hospital re-admission rates or 30-day mortality based on delirium status. CONCLUSIONS: Delirium occurs in one out of five patients after trans-catheter aortic valve replacement and is associated with diminished survival and increased healthcare utilization. Further studies are needed to clarify whether strategies aimed at reducing delirium after trans-catheter aortic valve replacement may improve outcomes in this high-risk subset. © 2016 Wiley Periodicals, Inc.

Association of a geriatric emergency department program with healthcare outcomes among veterans.

BACKGROUND: We aim to describe the outcomes of Geriatric Emergency Room Innovations for Veterans (GERI-VET), the first comprehensive Veterans Affairs Geriatric ED program. METHODS: In this prospective observational cohort study at an urban Veterans Affairs Medical Center ED, participants included Veterans aged 65 years and older treated in the ED from January 7, 2017 to February 29, 2020. Veterans with an Identification of Seniors At Risk (ISAR) score >2 were considered eligible for GERI-VET, receiving geriatric screens and care coordination in addition to standard ED treatment. The control group included GERI-VET eligible Veterans who did not receive GERI-VET care. Propensity score matching was used to compare outcomes in the GERI-VET group (N = 725) and a matched control group (n = 725). Key measures included ED resource utilization, outpatient referrals, ED admission, and 30-day admission. RESULTS: In the ED, the GERI-VET group received more consults to pharmacy (315 [43.4%] vs. 195 [26.9%], p < 0.001) and social work (399 [55.0%] vs. 132 [18.2%], p < 0.001). The GERI-VET group had higher referral rates to Geriatrics (64 [17.7%] vs. 18 [5.8%], p < 0.001) and Home Based Primary Care (110 [30.4%] vs. 24 [7.8%], p < 0.001). Key outcome measures included lower rates of ED admission (363 [50.1%] vs. 417 [n = 57.5%], p = 0.003) and 30-day hospital admission (412 [56.8%] vs. 464 [64.0%], p = 0.004) without increasing ED length of stay (5.4 ± 2.2 vs. 5.4 ± 2.6 h, p = 0.85) or 72-h ED revisits (23 [3.2%] vs. 16 [2.2%], p = 0.25) in the GERI-VET group. CONCLUSIONS: A program designed to screen for geriatric syndromes and coordinate care among at-risk older Veterans was associated with increased multidisciplinary resource utilization and reduced ED and 30-day admissions without increasing ED length of stay or re-visitation.

Complications Encountered with Non-adherence to Regular Follow-up in the Long-term Medical Management of Hyperparathyroidism.

Primary hyperparathyroidism is the third most commonly encountered endocrine disorder after diabetes and thyroid diseases. There has been a constant debate between medical and surgical management of the disorder. Guidelines clearly indicate surgical management over medical management in symptomatic patients and asymptomatic patients below 50 years of age. The problem is identification of symptoms can be difficult as there is a large overlap in the presentation of symptomatic and asymptomatic patients. Here, a 74-year-old veteran presented with scrotal edema and a perineal abscess. He had urinary incontinence secondary to urological procedures which were done for nephrolithiasis, which were detected incidentally on imaging. He had multiple vertebral compression fractures and required referral to neurosurgery. He had worsening renal function and cognitive impairment. On review of his medical records he was found to have a long-standing history of medically managed hyperparathyroidism, which was complicated due to non-compliance to follow-up outpatient visits. He constantly declined elective parathyroidectomy but unfortunately had to undergo several other invasive procedures with multiple hospital visits due to the complications of hyperparathyroidism. Safe medical management of hyperparathyroidism requires a religious follow-up and compliance to outpatient visits. He was started on Denosumab which we attribute to be contributory to his skin infections although evidence to support the same is insufficient.

Frailty Status and Outcomes After Transcatheter Aortic Valve Implantation.

Frailty is a syndrome of older adults associated with increased morbidity and mortality. We aimed to assess the impact of frailty status on outcomes after transcatheter aortic valve implantation (TAVI). We reviewed all 191 patients who underwent a modified Fried frailty assessment before TAVI between February 2012 and September 2015 at a single academic medical center, and we assessed the impact of preoperative frailty status on morbidity, mortality, and health care utilization after TAVI. Frailty, pre-frailty, and nonfrailty were present in 33% (n = 64), 37% (n = 70), and 30% (n = 57) of patients, respectively. Slowness (75% vs 54%, p = 0.003) and low physical activity (55% vs 31%, p = 0.001) were more common in women than men. With increasing frailty status, the proportion of women increased (35% nonfrail, 44% pre-frail, and 66% frail, p = 0.002) and stature decreased (1.68 ± 0.11 m nonfrail, 1.66 ± 0.11 m pre-frail, 1.62 ± 0.12 m frail, p = 0.028). There was no difference in post-TAVI 30-day mortality, stroke, major vascular injury, major or life-threatening bleeding, respiratory failure, mean hospital length of stay, 30-day hospital re-admission, or overall survival between groups. The rate of discharge to a rehabilitation facility increased with increasing frailty status (14% nonfrail, 22% pre-frail, and 39% frail, p = 0.005). Frailty was independently associated with discharge to a rehabilitation facility (odds ratio 4.80, 95% confidence interval 1.66 to 13.85, p = 0.004). In conclusion, the safety of TAVI is not affected by frailty status, but patients with frailty are less likely to be discharged directly home after TAVI.

Screening for Fall Risks in the Emergency Department: A Novel Nursing-Driven Program.

INTRODUCTION: Seniors represent the fasting growing population in the U.S., accounting for 20.3 million visits to emergency departments (EDs) annually. The ED visit can provide an opportunity for identifying seniors at high risk of falls. We sought to incorporate the Timed Up & Go Test (TUGT), a commonly used falls screening tool, into the ED encounter to identify seniors at high fall risk and prompt interventions through a geriatric nurse liaison (GNL) model. METHODS: Patients aged 65 and older presenting to an urban ED were evaluated by a team of ED nurses trained in care coordination and geriatric assessment skills. They performed fall risk screening with the TUGT. Patients with abnormal TUGT results could then be referred to physical therapy (PT), social work or home health as determined by the GNL. RESULTS: Gait assessment with the TUGT was performed on 443 elderly patients between 4/1/13 and 5/31/14. A prior fall was reported in 37% of patients in the previous six months. Of those screened with the TUGT, 368 patients experienced a positive result. Interventions for positive results included ED-based PT (n=63, 17.1%), outpatient PT referrals (n=56, 12.2%) and social work consultation (n=162, 44%). CONCLUSION: The ED visit may provide an opportunity for older adults to be screened for fall risk. Our results show ED nurses can conduct the TUGT, a validated and time efficient screen, and place appropriate referrals based on assessment results. Identifying and intervening on high fall risk patients who visit the ED has the potential to improve the trajectory of functional decline in our elderly population.