Delirium Associated With Decreased Functional Improvement Among Patients With HF

Delirium on admission to skilled nursing facilities (SNFs) after hospitalization for heart failure (HF) may be associated with poor functional recovery, according to results of a retrospective cohort study published in JAMA Network Open.

Although many patients can return home after hospitalization for HF, nearly 20% of individuals are unable to function independently and are discharged to SNFs to facilitate functional recovery, researchers wrote.

Delirium, defined as “an acute reversible change in mental status characterized by fluctuations in awareness and attention” can result in complications among these patients, including rehospitalization and delayed discharge from SNFs.

As a better understanding of the link between delirium and functional recovery may have implications for improving outcomes for patients with HF, investigators assessed Veterans Health Administration electronic records to explore this association.

Veterans from 129 Veterans Affairs (VA) Medical Centers who were hospitalized with a primary diagnosis of HF and discharged to SNFs outside the VA health system between October 2010 and September 2015 were included in the study (n = 20,495). Any individual who received palliative or hospice care services before, during, or at hospital discharge or who did not have complete data were excluded from the study.

Delirium presence was classified using the Minimum Data Set (MDS) 3.0 Confusion Assessment Method (CAM), a federally mandated standardized assessment administered to residents within 14 days of SNF admission and every 30 days thereafter or at discharge.

To measure patients’ function within an SNF, individuals completed the MDS 3.0 Activities of Daily Living (ADL) assessment. Functional recovery was calculated by subtracting total ADL scores at 30 days from ADL total scores at admission.

Mean (SD) patient age was 78 (10.3) years, and the majority (78.9%) were White and male (97%). Of those included, 6606 (32%) had a diagnosis of dementia before HF admission, and 51% had diabetes, 43% had chronic lung disease, 24% had depression, and 31% had obesity.

“On admission assessment to SNFs, 882 veterans (4.3%) had delirium and 19,613 (95.7%) did not. Veterans with delirium were more likely to be older (mean [SD] age, 81.0 [9.3] vs 77.5 [10.3]; P < .001), with a history of dementia (59.5% vs 31.0%; P < .001) and lower comorbidity burden (Elixhauser comorbidity index, 4.3 vs 4.8) compared with those without delirium,” authors wrote.

Mean left ventricular ejection fraction and length of hospital stay for HF admission were also comparable between veterans presenting with and without delirium.

Additional analyses revealed:

• Mean (SD) baseline ADL score on admission to SNF was significantly worse among patients with delirium than without (18.3 [4.7] vs 16.1 [5.2]; P < .001; d = 0.44).
• Among the veterans with baseline delirium, 21.7% (n = 191) had worse functional performance, 41.3% (n = 364) showed no change, and 37.1% (n = 327) improved in functional performance between their initial baseline and follow-up ADL assessments.
• Among the 19,613 veterans without delirium on admission to SNFs, 14.4% (n = 2821) had worse functional performance, 33.9% (n = 6655) showed no change, and 51.7% (n = 10,137) improved over the same time frame.
• On the 30-day repeated assessment, mean (SD) function (ADL scores) improved for both patients with delirium (0.6 [2.9]) and without delirium (1.8 [3.6]) (P < .001; d = −0.38).
• In the multivariate adjusted model, delirium was associated with statistically significant lower ADL improvement (difference in ADL score, –1.07; 95% CI, –1.31 to –0.83; P < .001).

Although delirium is reversible, results suggest that even in facilities designed to promote functional recovery, patients with delirium were less likely to improve in function compared with those without, researchers wrote. This may be due to the fact that these patients are less likely to participate in self-care education or physical activities. Furthermore, as atherosclerosis affects all arteries, including those in the brain, HF may exacerbate cognitive changes that reduce functional recovery.

“The association between delirium and functional recovery for patients with HF may be a marker of slow long-term functional recovery, if any, which may hold decision-making implications for families and health system implications for insurance payers,” authors explained.

The MDS 3.0 CAM does not capture duration of delirium, marking a limitation to this study. In addition, researchers did not explore the co-occurrence of delirium and dementia.

“Increased emphasis on identifying and treating delirium for patients with HF before discharge and throughout their SNF course may be important for functional recovery, but more research is needed,” authors said.

“To improve functional outcomes of the rapidly growing HF population, future studies may wish to investigate the association between delirium treatment and change in functional recovery in patients with HF during their functional recovery posthospitalization,” they concluded.

Reference

Madrigal C, Kim J, Jiang L, et al. Delirium and functional recovery in patients discharged to skilled nursing facilities after hospitalization for heart failure. JAMA Netw Open. Published online March 16, 2021. doi:10.1001/jamanetworkopen.2020.37968