Patient Outcomes After Delirium Screening and Incident Alzheimer's Disease or Related Dementias in Skilled Nursing Facilities.

BACKGROUND: The extent to which a positive delirium screening and new diagnosis of Alzheimer's disease or related dementias (ADRD) increases the risk for re-hospitalization, long-term nursing home placement, and death remains unknown. OBJECTIVE: To compare long-term outcomes among newly admitted skilled nursing facility (SNF) patients with delirium, incident ADRD, and both conditions. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study of Medicare beneficiaries who entered a SNF from hospital with a minimum 14-day stay (n = 100,832) from 2015 to 2016. MAIN MEASURES: Return to home, hospital readmission, admission to a long-term care facility, or death. KEY RESULTS: Patients with delirium were as likely to be discharged home as patients diagnosed with ADRD (HR: 0.63, 95% CI: 0.59, 0.67; HR: 0.65, 95% CI: 0.64, 0.67). Patients with both delirium and ADRD were less likely to be discharged home (HR: 0.49, 95% CI: 0.47, 0.52) and showed increased risk of death (HR: 1.30, 95% CI: 1.17, 1.45). Patients with ADRD, regardless of delirium screening status, had increased risk for long-term nursing home care transfer (HR: 1.66, 95% CI: 1.63, 1.70; HR: 1.76, 95% CI: 1.69, 1.82). Patients with delirium and no ADRD showed increased risk of transfer to long-term nursing home care (HR: 1.25, 95% CI: 1.18, 1.33). The rate of deaths was higher among patients who screened positive for delirium without ADRD compared to the no delirium and no ADRD groups (HR: 2.35, 95% CI: 2.11, 2.61). CONCLUSION: A positive delirium screening increased risk of death and transfer to long-term care in the first 100 days after admission regardless of incident ADRD diagnosis. Patients with delirium and/or ADRD also are less likely to be discharged home. Our study builds on the evidence base that delirium is important to address in older adults as it is associated with negative outcomes.

Medication cost-reducing behaviors in older adults with atrial fibrillation: The SAGE-AF study.

BACKGROUND: As patient prices for many medications have risen steeply in the United States, patients may engage in cost-reducing behaviors (CRBs) such as asking for generic medications or purchasing medication from the Internet. OBJECTIVE: The objective of this study is to describe patterns of CRB, cost-related medication nonadherence, and spending less on basic needs to afford medications among older adults with atrial fibrillation (AF) and examine participant characteristics associated with CRB. METHODS: Data were from a prospective cohort study of older adults at least 65 years with AF and a high stroke risk (CHA2DS2VASc ≥ 2). CRB, cost-related medication nonadherence, and spending less on basic needs to afford medications were evaluated using validated measures. Chi-square and t tests were used to evaluate differences in characteristics across CRB, and statistically significant characteristics (P < 0.05) were entered into a multivariable logistic regression to examine factors associated with CRB. RESULTS: Among participants (N = 1224; mean age 76 years; 49% female), 69% reported engaging in CRB, 4% reported cost-related medication nonadherence, and 6% reported spending less on basic needs. Participants who were cognitively impaired (adjusted odds ratio 0.69 [95% CI 0.52-0.91]) and those who did not identify as non-Hispanic white (0.66 [0.46-0.95]) were less likely to engage in CRB. Participants who were married (1.88 [1.30-2.72]), had a household income of $20,000-$49,999 (1.52 [1.02-2.27]), had Medicare insurance (1.38 [1.04-1.83]), and had 4-6 comorbidities (1.43 [1.01-2.01]) had significantly higher odds of engaging in CRB. CONCLUSION: Although CRBs were common among older adults with AF, few reported cost-related medication nonadherence and spending less on basic needs. Patients with cognitive impairment may benefit from pharmacist intervention to provide support in CRB and patient assistance programs.

Association Between Perioperative Medication Use and Postoperative Delirium and Cognition in Older Adults Undergoing Elective Noncardiac Surgery.

BACKGROUND: Postoperative delirium is frequent in older adults and is associated with postoperative neurocognitive disorder (PND). Studies evaluating perioperative medication use and delirium have generally evaluated medications in aggregate and been poorly controlled; the association between perioperative medication use and PND remains unclear. We sought to evaluate the association between medication use and postoperative delirium and PND in older adults undergoing major elective surgery. METHODS: This is a secondary analysis of a prospective cohort study of adults ≥70 years without dementia undergoing major elective surgery. Patients were interviewed preoperatively to determine home medication use. Postoperatively, daily hospital use of 7 different medication classes listed in guidelines as risk factors for delirium was collected; administration before delirium was verified. While hospitalized, patients were assessed daily for delirium using the Confusion Assessment Method and a validated chart review method. Cognition was evaluated preoperatively and 1 month after surgery using a neurocognitive battery. The association between prehospital medication use and postoperative delirium was assessed using a generalized linear model with a log link function, controlling for age, sex, type of surgery, Charlson comorbidity index, and baseline cognition. The association between daily postoperative medication use (when class exposure ≥5%) and time to delirium was assessed using time-varying Cox models adjusted for age, sex, surgery type, Charlson comorbidity index, Acute Physiology and Chronic Health Evaluation (APACHE)-II score, and baseline cognition. Mediation analysis was utilized to evaluate the association between medication use, delirium, and cognitive change from baseline to 1 month. RESULTS: Among 560 patients enrolled, 134 (24%) developed delirium during hospitalization. The multivariable analyses revealed no significant association between prehospital benzodiazepine (relative risk [RR], 1.44; 95% confidence interval [CI], 0.85-2.44), beta-blocker (RR, 1.38; 95% CI, 0.94-2.05), NSAID (RR, 1.12; 95% CI, 0.77-1.62), opioid (RR, 1.22; 95% CI, 0.82-1.82), or statin (RR, 1.34; 95% CI, 0.92-1.95) exposure and delirium. Postoperative hospital benzodiazepine use (adjusted hazard ratio [aHR], 3.23; 95% CI, 2.10-4.99) was associated with greater delirium. Neither postoperative hospital antipsychotic (aHR, 1.48; 95% CI, 0.74-2.94) nor opioid (aHR, 0.82; 95% CI, 0.62-1.11) use before delirium was associated with delirium. Antipsychotic use (either presurgery or postsurgery) was associated with a 0.34 point (standard error, 0.16) decrease in general cognitive performance at 1 month through its effect on delirium (P = .03), despite no total effect being observed. CONCLUSIONS: Administration of benzodiazepines to older adults hospitalized after major surgery is associated with increased postoperative delirium. Association between inhospital, postoperative medication use and cognition at 1 month, independent of delirium, was not detected.

Associations of state-level and county-level hate crimes with individual-level cardiovascular risk factors in a prospective cohort study of middle-aged Americans: the National Longitudinal Survey of Youths 1979.

BACKGROUND: There have been long-standing debates about the potential health consequences of hate crimes over and above other types of crimes. Besides the direct consequences for victims, less is known about whether hate crimes have spillover effects onto the health of local residents. METHODS: We drew data on cardiovascular disease risk factors from middle-aged Americans in the National Longitudinal Survey of Youths 1979 and on hate crimes from the FBI's Uniform Crime Reports. Employing multivariable logistic regression, we estimated the associations between changes in state/county-level all and group-specific hate crime rates from 2000 to 2006 and incident individual-level diabetes, hypertension, obesity and depressive symptoms from 2008 to 2016. All models controlled for individual-level sociodemographic factors and financial strain, county-level and state-level changes in the total crime rate, the percentage of non-Hispanic Black and Hispanic/Latino residents, and median household income, as well as state-level changes in the percentage of residents aged 65 years or older and the unemployment rate. RESULTS: 1-SD increases in state-level all and race/ethnicity-based hate crime rates were associated with 20% (OR 1.20, 95% CI 1.05 to 1.35) and 15% higher odds (OR 1.15, 95% CI 1.01 to 1.31) of incident diabetes, respectively. At the county level, a 1-SD increase in the all hate crime rate was linked to 8% higher odds (OR 1.08, 95% CI 1.00 to 1.16) of obesity, while a 1-SD increase in the race/ethnicity-based hate crime rate was associated with 8% higher odds (OR 1.08, 95% CI 1.01 to 1.15) of obesity and 9% higher odds (OR 1.09, 95% CI 1.02 to 1.17) of hypertension. We found no significant associations for depressive symptoms, and no interactions between race/ethnicity-based hate crime rates and individual-level race/ethnicity. CONCLUSION: Living in areas with higher hate crime rates may confer higher odds of hypertension, diabetes and obesity.

Psychoactive medication therapy and delirium screening in skilled nursing facilities.

BACKGROUND: A positive delirium screen at skilled-nursing facility (SNF) admission can trigger a simultaneous diagnosis of Alzheimer's Disease or related dementia (AD/ADRD) and lead to psychoactive medication treatment despite a lack of evidence supporting use. METHODS: This was a nationwide historical cohort study of 849,086 Medicare enrollees from 2011-2013 who were admitted to the SNF from a hospital without a history of dementia. Delirium was determined through positive Confusion Assessment Method screen and incident AD/ADRD through active diagnosis or claims. Cox proportional hazard models predicted the risk of receiving one of three psychoactive medications (i.e., antipsychotics, benzodiazepines, antiepileptics) within 7 days of SNF admission and within the entire SNF stay. RESULTS: Of 849,086 newly-admitted SNF patients (62.6% female, mean age 78), 6.1% had delirium (of which 35.4% received an incident diagnosis of AD/ADRD); 12.6% received antipsychotics, 30.4% benzodiazepines, and 5.8% antiepileptics. Within 7 days of admission, patients with delirium and incident dementia were more likely to receive an antipsychotic (relative risk [RR] 3.09; 95% confidence interval [CI] 2.99 to 3.20), or a benzodiazepine (RR 1.23; 95% CI 1.19 to 1.27) than patients without either condition. By the end of the SNF stay, patients with both delirium and incident dementia were more likely to receive an antipsychotic (RR 3.04; 95% CI 2.95 to 3.14) and benzodiazepine (RR 1.32; 95% CI 1.29 to 1.36) than patients without either condition. CONCLUSION: In this historical cohort, a positive delirium screen was associated with a higher risk of receiving psychoactive medication within 7 days of SNF admission, particularly in patients with an incident AD/ADRD diagnosis. Future research should examine strategies to reduce inappropriate psychoactive medication prescribing in older adults admitted with delirium to SNFs.

Association of Social Isolation of Long-term Care Facilities in the United States With 30-Day Mortality.

Importance: Long-term care (LTC) residents may be susceptible to social isolation if living in facilities located in neighborhoods lacking social connection. Objective: To characterize the social isolation of residents living in LTC facilities in the US. Design, Setting, and Participants: This cross-sectional study included 730 524 LTC residents from 14 224 LTC facilities in 8652 zip code tabulation areas (ZCTAs) in the US in 2011. A nationwide LTC database with ZCTA data was linked to population-level geographic data from the US Census Bureau. Statistical analysis was performed from January 2019 to December 2020. Exposures: The primary variable of interest was the social isolation of LTC neighborhoods defined as the percentage of households in the ZCTA with individuals aged 65 years or older who lived alone and categorized into quartiles of social isolation. Main Outcomes and Measures: Maps were generated to illustrate geographic variation of LTC facilities at the ZCTA level by the quartile of socially isolated neighborhoods. Generalized estimating equations were used to estimate the adjusted likelihood that LTC facilities were located in areas of highest social isolation. We also used multilevel logistic regression models to assess the association between the social isolation of neighborhoods of LTC facilities and 30-day all-cause mortality after LTC admission. Subgroup analyses were conducted by race and ethnicity. Results: Among 33 120 ZCTAs in the US, 8652 (26.1%) had at least 1 LTC facility. Among the 730 524 LTC residents included in the study's 14 224 LTC facilities, 458 136 (62.71%) were female, 610 802 (83.61%) were non-Hispanic White, and 419 654 (57.45%) were aged 80 years or older. Location of LTC facilities was associated with increasing levels of social isolation (quartile 1 = 9.72% [n = 840]; quartile 2 = 18.60% [n = 1607]; quartile 3 = 32.23% [n = 2784]; quartile 4 = 39.45% [n = 3408]; P < .001). In multivariate models, LTC facilities were 8 times more likely to be located in ZCTAs with the highest percentages of older adults residing in single-occupancy households (odds ratio [OR], 8.46; 95% CI, 7.44-9.65; P < .001), compared with ZCTAs with the lowest percentages. This association held across ZCTAs with a majority population of African American and Hispanic individuals, although it was strongest in ZCTAs with a majority population of White individuals. LTC residents entering facilities in neighborhoods with the highest levels of social isolation among older adults had a 17% higher risk of 30-day mortality (OR, 1.17; 95% CI, 1.10-1.25; P < .001) compared with those in neighborhoods with the lowest levels of social isolation among older adults. Conclusions and Relevance: This study found that LTC facilities were often located in socially isolated neighborhoods, suggesting the need for special attention and strategies to keep LTC residents connected to their family and friends for optimal health.

Opioid Use Increases the Risk of Delirium in Critically Ill Adults Independently of Pain.

Rationale: It is unclear whether opioid use increases the risk of ICU delirium. Prior studies have not accounted for confounding, including daily severity of illness, pain, and competing events that may preclude delirium detection.Objectives: To evaluate the association between ICU opioid exposure, opioid dose, and delirium occurrence.Methods: In consecutive adults admitted for more than 24 hours to the ICU, daily mental status was classified as awake without delirium, delirium, or unarousable. A first-order Markov model with multinomial logistic regression analysis considered four possible next-day outcomes (i.e., awake without delirium, delirium, unarousable, and ICU discharge or death) and 11 delirium-related covariables (baseline: admission type, age, sex, Acute Physiology and Chronic Health Evaluation IV score, and Charlson comorbidity score; daily: ICU day, modified Sequential Organ Failure Assessment, ventilation use, benzodiazepine use, and severe pain). This model was used to quantify the association between opioid use, opioid dose, and delirium occurrence the next day.Measurements and Main Results: The 4,075 adults had 26,250 ICU days; an opioid was administered on 57.0% (n = 14,975), severe pain occurred on 7.0% (n = 1,829), and delirium occurred on 23.5% (n = 6,176). Severe pain was inversely associated with a transition to delirium (odds ratio [OR] 0.72; 95% confidence interval [CI], 0.53-0.97). Any opioid administration in awake patients without delirium was associated with an increased risk for delirium the next day [OR, 1.45; 95% CI, 1.24-1.69]. Each daily 10-mg intravenous morphine-equivalent dose was associated with a 2.4% increased risk for delirium the next day.Conclusions: The receipt of an opioid in the ICU increases the odds of transitioning to delirium in a dose-dependent fashion.

Association Between Incident Delirium Treatment With Haloperidol and Mortality in Critically Ill Adults.

OBJECTIVES: Haloperidol is commonly administered in the ICU to reduce the burden of delirium and its related symptoms despite no clear evidence showing haloperidol helps to resolve delirium or improve survival. We evaluated the association between haloperidol, when used to treat incident ICU delirium and its symptoms, and mortality. DESIGN: Post hoc cohort analysis of a randomized, double-blind, placebo-controlled, delirium prevention trial. SETTING: Fourteen Dutch ICUs between July 2013 and December 2016. PATIENTS: One-thousand four-hundred ninety-five critically ill adults free from delirium at ICU admission having an expected ICU stay greater than or equal to 2 days. INTERVENTIONS: Patients received preventive haloperidol or placebo for up to 28 days until delirium occurrence, death, or ICU discharge. If delirium occurred, treatment with open-label IV haloperidol 2 mg tid (up to 5 mg tid per delirium symptoms) was administered at clinician discretion. MEASUREMENTS AND MAIN RESULTS: Patients were evaluated tid for delirium and coma for 28 days. Time-varying Cox hazards models were constructed for 28-day and 90-day mortality, controlling for study-arm, delirium and coma days, age, Acute Physiology and Chronic Health Evaluation-II score, sepsis, mechanical ventilation, and ICU length of stay. Among the 1,495 patients, 542 (36%) developed delirium within 28 days (median [interquartile range] with delirium 4 d [2-7 d]). A total of 477 of 542 (88%) received treatment haloperidol (2.1 mg [1.0-3.8 mg] daily) for 6 days (3-11 d). Each milligram of treatment haloperidol administered daily was associated with decreased mortality at 28 days (hazard ratio, 0.93; 95% CI, 0.91-0.95) and 90 days (hazard ratio, 0.97; 95% CI, 0.96-0.98). Treatment haloperidol administered later in the ICU course was less protective of death. Results were stable by prevention study-arm, predelirium haloperidol exposure, and haloperidol treatment protocol adherence. CONCLUSIONS: Treatment of incident delirium and its symptoms with haloperidol may be associated with a dose-dependent improvement in survival. Future randomized trials need to confirm these results.

Socially-isolated neighborhoods and the risk of all-cause mortality among nursing home residents in the United States: A multilevel study.

The total number of Americans age 65 and older is expected to nearly double by 2060, and the number of Americans admitted to nursing homes is likewise anticipated to escalate. Studies have found living alone to be an important risk factor for mortality. Yet little is known about possible spillover health effects of living in a community where many elderly residents live alone. Even less is known about whether these risks persist after entering nursing homes. Our study population consisted of 874,162 US elderly adults newly admitted to nursing homes in 2011, as identified from the 3.0 Minimum Data Set. Data on these individuals were linked to Medicare claims and 2010 Census data. In this cohort study, we estimated multivariable-adjusted hazard ratios for the associations between the quartiles of county-level percentage of households with those age 65 or older living alone and the individual-level risks of all-cause mortality until December 31, 2013, controlling for county-, nursing home facility-, and individual-level factors. Older adults in counties belonging to the highest quartile of elderly single-occupancy households had a 8% higher risk of dying (HR = 1.08; 95% CI = 1.04-1.12, p < 0.001) after entering nursing homes compared to those in counties belonging to the lowest quartile. There was evidence of a linear trend (p for trend < 0.001). Should these findings be confirmed in future studies, it would suggest that living arrangements in elderly communities may have spillover health effects onto their residents. Programs and interventions that modify such living arrangements may yield more favorable health trajectories among older Americans, who are increasingly aging in place and at growing risk of entering nursing homes.

Affordability of Medical Care Among Medicare Enrollees.

Importance: Cost-sharing requirements can discourage patients from seeking care and impose financial hardship. The Medicare program serves many older and disabled individuals with multimorbidity and limited resources, but little has been known about the affordability of care in this population. Objective: To examine the affordability of medical care among Medicare enrollees, in terms of the prevalence of delaying medical care because of costs and having problems paying medical bills, and risk factors for these outcomes. Design Setting and Participants: Cross-sectional analyses conducted from November 1, 2019, to October 15, 2021, used logistic regression to compare the probability of outcomes by demographic and health characteristics. Data were obtained from the 2017 nationally representative Medicare Current Beneficiary Survey (response rate, 61.7%), with respondents representing 53 million community-dwelling Medicare enrollees. Main Outcomes and Measures: New questions about medical care affordability were included in the 2017 Medicare Current Beneficiary Survey: difficulty paying medical bills, ongoing medical debt, and contact by collection agencies. A companion survey question asked whether individuals had delayed seeking medical care because of worries about costs. Results: Respondents included 10 974 adults aged 65 years or older and 2197 aged 18 to 64 years; 54.2% of all respondents were women. The weighted proportions of Medicare enrollees with annual incomes below $25 000K were 30.7% in the older population and 67.4% in the younger group. Self-reported prevalence of delaying care because of cost was 8.3% (95% CI, 7.4%-9.1%) among enrollees aged 65 years or older, 25.2% (95% CI, 21.8%-28.6%) among enrollees younger than 65 years, and 10.9% (95% CI, 9.9%-11.9%) overall. Similarly, 7.4% (95% CI, 6.6%-8.2%) of older enrollees had problems paying medical bills, compared with 29.8% (95% CI, 25.6%-34.1%) among those younger than 65 years and 10.8% (95% CI, 9.8%-11.9%) overall. Regarding specific payment problems, 7.9% (95% CI, 7.0%-8.9%) of enrollees overall experienced ongoing medical debt, contact by a collection agency, or both. In adjusted analyses, older adults with incomes $15 000 to $25 000 per year had odds of delaying care more than twice as high as those with incomes greater than $50 000 (odds ratio, 2.47; 95% CI, 1.82-3.39), and their odds of problems paying medical bills were more than 3 times as high (odds ratio, 3.37; 95% CI, 2.81-5.21). Older adults with 4 to 10 chronic conditions were more than twice as likely to have problems paying medical bills as those with 0 or 1 condition. Conclusions and Relevance: The findings of this study suggest that unaffordability of medical care is common among Medicare enrollees, especially those with lower incomes, or worse health, or who qualify for Medicare based on disability. Policy reforms, such as caps on patient spending, are needed to reduce Medical cost burdens on the most vulnerable enrollees.

Cost-related Medication Nonadherence and Its Risk Factors Among Medicare Beneficiaries.

BACKGROUND: Unaffordability of medications is a barrier to effective treatment. Cost-related nonadherence (CRN) is a crucial, widely used measure of medications access. OBJECTIVES: Our study examines the current national prevalence of and risk factors for CRN (eg, not filling, skipping or reducing doses) and companion measures in the US Medicare population. RESEARCH DESIGN: Survey-weighted analyses included logistic regression and trends 2006-2016. SUBJECTS: Main analyses used the 2016 Medicare Current Beneficiary Survey. Our study sample of 12,625 represented 56 million community-dwelling beneficiaries. MEASURES: Additional outcome measures were spending less on other necessities in order to pay for medicines and use of drug cost reduction strategies such as requesting generics. RESULTS: In 2016, 34.5% of enrollees under 65 years with disability and 14.4% of those 65 years and older did not take their medications as prescribed due to high costs; 19.4% and 4.7%, respectively, experienced going without other essentials to pay for medicines. Near-poor older beneficiaries with incomes $15-25K had 50% higher odds of CRN (vs. >$50K), but beneficiaries with incomes <$15K, more likely to be eligible for the Part D Low-Income Subsidy, did not have significantly higher risk. Three indicators of worse health (general health status, functional limits, and count of conditions) were all independently associated with higher risk of CRN. CONCLUSIONS: Changes in the risk profile for CRN since Part D reflect the effectiveness of targeted policies. The persistent prevalence of CRN and associated risks for sicker people in Medicare demonstrate the consequences of high cost-sharing for prescription fills.

Approaches to Optimize Medication Data Analysis in Clinical Cohort Studies.

OBJECTIVES: Methods for pharmacoepidemiologic studies of large-scale data repositories are established. Although clinical cohorts of older adults often contain critical information to advance our understanding of medication risk and benefit, the methods best suited to manage medication data in these samples are sometimes unclear and their degree of validation unknown. We sought to provide researchers, in the context of a clinical cohort study of delirium in older adults, with guidance on the methodological tools to use data from clinical cohorts to better understand medication risk factors and outcomes. DESIGN: Prospective cohort study. SETTING: The Successful Aging After Elective Surgery (SAGES) prospective cohort. PARTICIPANTS: A total of 560 older adults (aged ≥70 years) without dementia undergoing elective major surgery. MEASUREMENTS: Using the SAGES clinical cohort, methods used to characterize medications were identified, reviewed, analyzed, and distinguished by appropriateness and degree of validation for characterizing pharmacoepidemiologic data in smaller clinical data sets. RESULTS: Medication coding is essential; the American Hospital Formulary System, most often used in the United States, is not preferred over others. Use of equivalent dosing scales (e.g., morphine equivalents) for a single medication class (e.g., opioids) is preferred over multiclass analgesic equivalency scales. Medication aggregation from the same class (e.g., benzodiazepines) is well established; the optimal prevalence breakout for aggregation remains unclear. Validated scale(s) to combine structurally dissimilar medications (e.g., anticholinergics) should be used with caution; a lack of consensus exists regarding the optimal scale. Directed acyclic graph(s) are an accepted method to conceptualize causative frameworks when identifying potential confounders. Modeling-based strategies should be used with evidence-based, a priori variable-selection strategies. CONCLUSION: As highlighted in the SAGES cohort, the methods used to classify and analyze medication data in clinically rich cohort studies vary in the rigor by which they have been developed and validated.

Association of Positive Delirium Screening with Incident Dementia in Skilled Nursing Facilities.

BACKGROUND AND OBJECTIVE: Early detection of delirium in skilled nursing facilities (SNFs) is a priority. The extent to which delirium screening leads to a potentially inappropriate diagnosis of Alzheimer's disease and related dementia (ADRD) is unknown. DESIGN: Nationwide retrospective cohort study from 2011 to 2013. SETTING: An SNF. PARTICIPANTS: A total of 1,175,550 Medicare enrollees who entered the SNF from a hospital and had no prior diagnosis of dementia. EXPOSURE: A positive screen for delirium using the validated Confusion Assessment Method (CAM), performed as part of the federally mandated Minimum Data Set (MDS) assessment. MEASUREMENTS: Incident all-cause dementia, ascertained through International Classification of Diseases, Ninth Revision (ICD-9), diagnosis in Medicare claims or active diagnoses in MDS. RESULTS: Positive screening for delirium was identified in 7.7% of cases (n = 90,449), and most occurred within the first 7 days of SNF admission (62.5%). The overall incidence of ADRD was 6.3% (n = 73,542). Nearly all new diagnoses of ADRD (93.5%) occurred within the first 30 days of SNF admission. Patients who screened CAM positive for delirium had a nearly threefold increased risk of receiving an incident ADRD diagnosis on the same day (hazard ratio (HR) = 2.63; 95% confidence interval (CI) = 1.50-4.63). Among patients who screened CAM positive for delirium, those who were cognitively intact or had mild cognitive impairments were, on average, six times more likely to receive an incident ADRD diagnosis (HR = 6.64; 95% CI = 1.76-25.0) relative to those testing CAM negative. CONCLUSION AND RELEVANCE: Among older adults not previously diagnosed with dementia, a positive screen for delirium was significantly associated with higher risk of ADRD diagnosis after admission to a SNF. This risk was highest for patients in the first days of their stay and with the least cognitive impairment, suggesting that the ADRD diagnosis was potentially inappropriate.

Does Home Remedy Use Contribute to Medication Nonadherence Among Blacks with Hypertension?

Background: Home remedies (HRs) are described as foods, herbs, and other household products used to manage chronic conditions. The objective of this study was to examine home remedy (HR) use among Blacks with hypertension and to determine if home remedy use is correlated with blood pressure and medication adherence. Methods: Data for this cross-sectional study were obtained from the TRUST study conducted between 2006-2008. Medication adherence was measured using the Morisky Medication Adherence Scale, and HR use was self-reported. Multivariable associations were quantified using ordinal logistic regression. Results: The study sample consisted of 788 Blacks with hypertension living in the southern region of the United States. HR use was associated with higher systolic (HR users 152.79, nonusers 149.53; P=.004) and diastolic blood pressure (HR users 84.10, nonusers 82.14 P=.005). Use of two or more HRs was associated with low adherence (OR: .55, CI: .36-.83, P= .004). Conclusion: The use of HR and the number of HRs used may be associated with medication nonadherence, and higher systolic and diastolic blood pressure among Blacks with hypertension. Medication nonadherence is of critical importance for individuals with hypertension, and it is essential that health care providers be aware of health behaviors that may serve as barriers to medication adherence, such as use of home remedies.

Association between incident delirium and 28- and 90-day mortality in critically ill adults: a secondary analysis.

BACKGROUND: While delirium prevalence and duration are each associated with increased 30-day, 6-month, and 1-year mortality, the association between incident ICU delirium and mortality remains unclear. We evaluated the association between both incident ICU delirium and days spent with delirium in the 28 days after ICU admission and mortality within 28 and 90 days. METHODS: Secondary cohort analysis of a randomized, double-blind, placebo-controlled trial conducted among 1495 delirium-free, critically ill adults in 14 Dutch ICUs with an expected ICU stay ≥2 days where all delirium assessments were completed. In the 28 days after ICU admission, patients were evaluated for delirium and coma 3x daily; each day was coded as a delirium day [≥1 positive Confusion Assessment Method for the ICU (CAM-ICU)], a coma day [no delirium and ≥ 1 Richmond Agitation Sedation Scale (RASS) score ≤ - 4], or neither. Four Cox-regression models were constructed for 28-day mortality and 90-day mortality; each accounted for potential confounders (i.e., age, APACHE-II score, sepsis, use of mechanical ventilation, ICU length of stay, and haloperidol dose) and: 1) delirium occurrence, 2) days spent with delirium, 3) days spent in coma, and 4) days spent with delirium and/or coma. RESULTS: Among the 1495 patients, 28 day mortality was 17% and 90 day mortality was 21%. Neither incident delirium (28 day mortality hazard ratio [HR] = 1.02, 95%CI = 0.75-1.39; 90 day mortality HR = 1.05, 95%CI = 0.79-1.38) nor days spent with delirium (28 day mortality HR = 1.00, 95%CI = 0.95-1.05; 90 day mortality HR = 1.02, 95%CI = 0.98-1.07) were significantly associated with mortality. However, both days spent with coma (28 day mortality HR = 1.05, 95%CI = 1.02-1.08; 90 day mortality HR = 1.05, 95%CI = 1.02-1.08) and days spent with delirium or coma (28 day mortality HR = 1.03, 95%CI = 1.00-1.05; 90 day mortality HR = 1.03, 95%CI = 1.01-1.06) were significantly associated with mortality. CONCLUSIONS: This analysis suggests neither incident delirium nor days spent with delirium are associated with short-term mortality after ICU admission. TRIAL REGISTRATION: ClinicalTrials.gov, Identifier NCT01785290 Registered 7 February 2013.

Nursing homes underreport antipsychotic prescribing.

Objective: Determine the accuracy of nursing home self-reported antipsychotic prescribing before and after implementation of a Medicare campaign to reduce use.Methods: Quasi-experimental study comparing trends in self-reported antipsychotic prescribing relative to claims-based prescribing. Setting is a nationwide sample of 11,912 facilities, 2011-2013. Participants are long-stay nursing home residents (n = 586,281) with prescribing data in Medicare Minimum Data Set 3.0 and Medicare Part D claims database. Verified with a pharmacy dispensing database. Main outcomes are the discrepancies in quarterly prevalence of antipsychotic prescribing between nursing home self-reports and claims data and the characteristics of facilities and residents where discrepancies were identified.Results: Nursing homes underreport their antipsychotic prescribing levels, on average, by 1 percentage point per quarter relative to Medicare Part D claims (0.013, 95% confidence interval (CI), 0.012-0.015; p<.001). After the Medicare campaign, the underreporting gap increased by another half a percentage point (0.004, 95% CI .003-.005; p = .012). Nursing home residents with dementia, Alzheimer's disease or bipolar disorders were at the highest risk for underreported antipsychotic prescribing before the campaign (Adjusted Odds ratio (AOR) 1.385, 95% CI: 1.330-1.444; AOR 1.234, 95% CI: 1.172-1.300; AOR 1.574, 95% CI: 1.444-1.716, respectively) and afterwards. After the launch of the Medicare campaign, underreported antipsychotic prescribing occurred most in for-profit nursing homes (AOR 1.088, 95% CI: 1.005-1.178) and facilities in the US South (AOR 1.262, 95% CI: 1.145-1.391). Agreement was high between claims and dispensing data (99.7%).Conclusion: Nursing homes did not identify up to 6,000 residents per calendar quarter as having received antipsychotics despite these prescriptions being paid by Medicare and dispensed by a pharmacy. Nursing home rates of antipsychotic prescribing from self-reported data may be biased.

An Examination of John Henryism, Trust, and Medication Adherence Among African Americans With Hypertension.

Background. John Henryism is defined as a measure of active coping in response to stressful experiences. John Henryism has been linked with health conditions such as diabetes, prostate cancer, and hypertension, but rarely with health behaviors. Aims. We hypothesized that reporting higher scores on the John Henryism Scale may be associated with poorer medication adherence, and trust in providers may mediate this relationship. Method. We tested this hypothesis using data from the TRUST study. The TRUST study included 787 African Americans with hypertension receiving care at a safety-net hospital. Ordinal logistic regression was used to examine the relationship between John Henryism and medication adherence. Results. Within our sample of African Americans with hypertension, lower John Henryism scores was associated with poorer self-reported adherence (low, 20.62; moderate, 19.19; high, 18.12; p < .001). Higher John Henryism scores were associated with lower trust scores (low John Henryism: 40.1; high John Henryism: 37.9; p < .001). In the adjusted model, each 1-point increase in the John Henryism score decreased the odds of being in a better cumulative medication adherence category by a factor of 4% (odds ratio = 0.96, p = .014, 95% confidence interval = 0.93-0.99). Twenty percent of the association between medication adherence and John Henryism was mediated by trust (standard deviation = 0.205, 95% confidence interval = 0.074-0.335). Discussion. This study provides important insights into the complex relationship between psychological responses and health behaviors. It also contributes to the body of literature examining the construct of John Henryism among African Americans with hypertension. Conclusion. The findings of this study support the need for interventions that promote healthful coping strategies and patient-provider trust.

County-level housing affordability in relation to risk factors for cardiovascular disease among middle-aged adults: The National Longitudinal Survey of Youths 1979.

BACKGROUND: Housing is a fundamental social determinant of health yet housing affordability has diminished over much of the twenty-first century. Research on housing affordability as a determinant of health is limited, but studies to date have shown correlations with mental health. However, few studies have examined the relationship between housing affordability and risk factors for cardiovascular disease, the leading cause of morbidity and mortality among Americans. METHODS: Using a nationally-representative sample of middle-aged adults from the National Longitudinal Survey of Youths 1979 (NLSY79) and exploiting quasi-experimental variation before and after the Great Recession, we estimated the associations between the change in median county-level percentage of household income spent on housing (rent/mortgage) between 2000 and 2008 and individual-level risks of incident hypertension, obesity, diabetes, and depression from 2008 to 2014. We employed conditional fixed effects logistic regression models to reduce bias due to time-invariant confounding. RESULTS: Each percentage point increase in county-level median percentage of household income spent on housing was associated with a 22% increase in the odds of incident hypertension (OR = 1.22, 95% CI = 1.06 to 1.42; p = 0.01), a 37% increased odds of obesity (OR = 1.37, 95% CI = 1.00-1.87; p = 0.049), and a 15% increased odds of depression (OR = 1.15, 95% CI = 1.01-1.31; p = 0.03), controlling for individual- and area-level factors. These associations were stronger among renters than homeowners, and among men compared to women. CONCLUSIONS: Our findings suggest that lower levels of housing affordability contribute to worse risk profiles for cardiovascular disease. Policies that make housing more affordable may help to reduce the population burden of cardiovascular disease.

Approaches to Gradual Dose Reduction of Chronic Off-Label Antipsychotics Used for Behavioral and Psychological Symptoms of Dementia.

OBJECTIVE: Little is known about how to best taper antipsychotics used in patients with dementia. To address this gap, we reviewed published antipsychotic discontinuation trials to summarize what is known about tapering strategies for antipsychotics used with older adults with dementia. We further developed pharmacokinetic-based gradual dose reduction (GDR) protocols based on antipsychotic half-lives. DATA SOURCES: MEDLINE, EMBASE, and International Pharmaceutical Abstracts were searched up to October 2014 to identify intervention studies reporting the behavioral and psychological symptoms of dementia outcomes resulting from discontinued off-label use of antipsychotics in nursing facility populations. Recently published pharmacokinetic reviews and standard pharmacology texts were used to determine antipsychotic drug half-lives for the pharmacokinetic-based GDR protocols. STUDY SELECTION: For the review, studies with an intervention resulting in antipsychotic medication discontinuation or tapering were eligible, including randomized controlled trials and pre- and post-intervention studies. DATA EXTRACTION: When available, we extracted the protocols used for antipsychotic GDR from each study included in the review. DATA SYNTHESIS: We found that clinical trials used different approaches to antipsychotic discontinuation, including abrupt discontinuation, slow tapers (more than two weeks), and mixed strategies based on drug dosage. None of the published trials described an approach based on pharmacokinetic principles. We developed a two-stage GDR protocol for tapering antipsychotic medications based on the log dose-response relationship; each stage was designed to result in a 50% dose reduction prior to discontinuation. This pharmacologically based strategy for patients chronically prescribed antipsychotics resulted in recommendations for slow tapers. CONCLUSION: Our theoretically derived GDR recommendations suggest a different approach than previously published in clinical trials. Further study is needed to evaluate the effect of this approach on patients.