Clinical Decision Support System and Incidence of Delirium in Cognitively Impaired Older Adults Transferred to Intensive Care

Khan, Babar; Calvo-Ayala, Enrique; Campbell, Noll L.; Perkins, Anthony J.; Ionescu, Ruxandra; Campbell, Tiffany; Zawahiri, Mohammed; Buckley, John D.; Farber, Mark O.; Boustani, Malaz

doi:10.4037/ajcc2013447

Cited by 11 publications

(18 citation statements)

References 29 publications

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“…However, a recently published randomised controlled clinical trial of a multifaceted CCDSS intervention in hospitalised older adults with cognitive impairment demonstrated no improvement in the process of care; the intervention involved a CCDSS that alerted physicians on the presence of cognitive impairment, recommended referral to a geriatric consult and suggested discontinuation of catheterisation, physical restraints and anticholinergic medications . A sub‐analysis of this study, found that patients transferred to intensive care for delirium also did not see a change in prescribing patterns or decreasing incidence of delirium with the intervention . The main difference between these studies and others is that the CCDSS intervention did not involve a previously validated anticholinergic scale.…”

Section: Interventions To Reduce Anticholinergic Burden In Older Adultsmentioning

confidence: 65%

Anticholinergic burden: considerations for older adults

O’Donnell

Gnjidic

Nahas

et al. 2016

Pharmacy Practice and Res

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Anticholinergic medications are frequently used in older adults to manage a wide range of chronic diseases. Anticholinergic burden associated with the use of multiple medications with anticholinergic effects is cumulative within an individual, and older adults are particularly susceptible to the adverse effects of these medications. These include dry mouth resulting in poor oral health, constipation, urinary retention and confusion. Use of anticholinergic medications has been associated with impaired cognitive and physical function, increased risk of falls, vascular events and hospitalisation. Consideration of anticholinergic burden is an important component of medication management for older adults. Several measures have been developed and validated to quantify anticholinergic burden, such as the Anticholinergic Drug Scale, Anticholinergic Risk Scale and the Anticholinergic Cognitive Burden scale. However, the evidence for translation of these measures into clinical practice is limited. This narrative review provides a brief clinical overview of the pharmacology of anticholinergic medications in the context of older adults, summarises approaches to measure anticholinergic burden, reviews recent evidence of the clinical impact of anticholinergic medications and discusses deprescribing strategies to manage anticholinergic burden for older adults in clinical practice.

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Section: Interventions To Reduce Anticholinergic Burden In Older Adultsmentioning

confidence: 65%

Anticholinergic burden: considerations for older adults

O’Donnell

Gnjidic

Nahas

et al. 2016

Pharmacy Practice and Res

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“…Another CDSS intervention was described in 2 articles: 1 article evaluated the implementation at the initial site, and 1 article evaluated the implementation at 4 sites [ 28 , 29 ]. Finally, 1 CDSS intervention was linked in 2 articles: 1 article described a subgroup analysis of the earlier RCT [ 30 , 31 ].…”

Section: Resultsmentioning

confidence: 99%

Effect of Interventions With a Clinical Decision Support System for Hospitalized Older Patients: Systematic Review Mapping Implementation and Design Factors

Damoiseaux-Volman¹,

Velde²,

Ruige³

et al. 2021

JMIR Med Inform

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Background Clinical decision support systems (CDSSs) form an implementation strategy that can facilitate and support health care professionals in the care of older hospitalized patients. Objective Our study aims to systematically review the effects of CDSS interventions in older hospitalized patients. As a secondary aim, we aim to summarize the implementation and design factors described in effective and ineffective interventions and identify gaps in the current literature. Methods We conducted a systematic review with a search strategy combining the categories older patients, geriatric topic, hospital, CDSS, and intervention in the databases MEDLINE, Embase, and SCOPUS. We included controlled studies, extracted data of all reported outcomes, and potentially beneficial design and implementation factors. We structured these factors using the Grol and Wensing Implementation of Change model, the GUIDES (Guideline Implementation with Decision Support) checklist, and the two-stream model. The risk of bias of the included studies was assessed using the Cochrane Collaboration’s Effective Practice and Organisation of Care risk of bias approach. Results Our systematic review included 18 interventions, of which 13 (72%) were effective in improving care. Among these interventions, 8 (6 effective) focused on medication review, 8 (6 effective) on delirium, 7 (4 effective) on falls, 5 (4 effective) on functional decline, 4 (3 effective) on discharge or aftercare, and 2 (0 effective) on pressure ulcers. In 77% (10/13) effective interventions, the effect was based on process-related outcomes, in 15% (2/13) interventions on both process- and patient-related outcomes, and in 8% (1/13) interventions on patient-related outcomes. The following implementation and design factors were potentially associated with effectiveness: a priori problem or performance analyses (described in 9/13, 69% effective vs 0/5, 0% ineffective interventions), multifaceted interventions (8/13, 62% vs 1/5, 20%), and consideration of the workflow (9/13, 69% vs 1/5, 20%). Conclusions CDSS interventions can improve the hospital care of older patients, mostly on process-related outcomes. We identified 2 implementation factors and 1 design factor that were reported more frequently in articles on effective interventions. More studies with strong designs are needed to measure the effect of CDSS on relevant patient-related outcomes, investigate personalized (data-driven) interventions, and quantify the impact of implementation and design factors on CDSS effectiveness. Trial Registration PROSPERO (International Prospective Register of Systematic Reviews): CRD42019124470; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=124470.

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“…[24–28] A characteristic feature of all the studies is a significant representation of the African-American community with up to 50% of study subjects representing the minority race. In 2009, Indiana University Delirium working group consisting of IUCAR and the Pulmonary/ Critical Care division of Indiana University started a randomized, clinical trial known as the “Pharmacological Management of Delirium (PMD)” study.…”

Section: Methodsmentioning

confidence: 99%

Relationship Between African-American Race and Delirium in the ICU

Khan

Perkins

Hui

et al. 2016

Critical Care Medicine

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Objective Delirium is a highly prevalent syndrome of acute brain dysfunction among critically ill patients that has been linked to multiple risk factors such as age, pre-existing cognitive impairment, and use of sedatives; but to date the relationship between race and delirium is unclear. We conducted this study to identify whether African-American race is a risk factor for developing ICU delirium. Design A prospective cohort study. Setting Medical and Surgical ICUs of a university affiliated, safety-net hospital in Indianapolis, Indiana. Patients 2087 consecutive admissions with 1008 African-Americans admitted to the ICU services from May 2009 to August 2012. Interventions None Measurements and Main Results Incident delirium defined as first positive Confusion Assessment Method for the ICU (CAM-ICU) result after an initial negative CAM-ICU; and prevalent delirium defined as positive CAM-ICU on first CAM-ICU assessment. The overall incident delirium rate in African-Americans was 8.7% compared to 10.4% in Caucasians (P: 0.26). The prevalent delirium rate was 14% in both African-Americans and Caucasians (P: 0.95). Significant age and race interactions were detected for incident delirium (P: 0.02), but not for prevalent delirium (P: 0.3). The hazard ratio for incident delirium for African-Americans in the 18–49 years age group compared to Caucasians of similar age was 0.4 (0.1– 0.9). The hazard and odds ratios for incident and prevalent delirium in other groups were not different. Conclusions African-American race does not confer any additional risk for developing incident or prevalent delirium in the ICU. Instead younger African-Americans tend to have lower rates of incident delirium compared to similar age Caucasians.

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Clinical Decision Support System and Incidence of Delirium in Cognitively Impaired Older Adults Transferred to Intensive Care

Cited by 11 publications

References 29 publications

Anticholinergic burden: considerations for older adults

Anticholinergic burden: considerations for older adults

Effect of Interventions With a Clinical Decision Support System for Hospitalized Older Patients: Systematic Review Mapping Implementation and Design Factors

Relationship Between African-American Race and Delirium in the ICU

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