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Illness Trajectories Among Nursing Home Residents (TH318-D)
342
Schedule With Abstracts
Vol. 49 No. 2 February 2015
Setting/Participants. Data on the last seven days of
Methods. Data for 324,435 residents of the Veterans
life were abstracted from the medical records of 5,476 decedents from six Veterans Administration Medical Centers (VAMCs) in the southeast United States and from VA administrative databases. Methods. Based on literature and expert clinical opinion, we prospectively identified potential risk factors for restraint use at the time of death from among all variables collected during the trial. Factors included location of death, medications given, nasogastric tube, intravenous (IV) fluids infusing, family presence at time of death, and receipt of a palliative care consultation. Generalized estimating equations, which account for correlation among patients within a site, were used to assess the relationship between each predictor and physical restraint use. Results. Physical restraint use at time of death was documented in 890 decedents (16.3%). Restrained patients were more likely to have a nasogastric tube (OR, 2.30; p<.0001); and be receiving IV fluids (OR, 2.15, p<.0001), benzodiazepines (OR, 1.75; p<.0001), or antipsychotics (OR, 2.36; p<.0001). Use of restraints varied by location of death, with a higher risk associated with patients in intensive settings compared with decedents on medicine or surgery wards (OR, 1.7; p¼0.006). Conclusions. Factors associated with restraint use include therapies that may be disrupted by an agitated patient, care in intensive settings, and medications commonly used for delirium. Implications for Research, Policy, or Practice. Further study should focus on interventions to reduce restraint use in dying patients.
Administration’s (VA’s) Community Living Centers (CLC) were extracted and analyzed within the VA Informatics and Computing Infrastructure. Data included diagnoses from 1,617,693 inpatient records; 145,575,072 outpatient visits; and 1,901,354 functional status evaluations given as the Minimum Dataset (MDS). The Barthel Index was constructed from MDS Data using nine ADLs (stair climbing was excluded). Diagnoses originally present as ICD-9 codes were converted to Charlson Comorbidity Categories (Deyo version). Results. A total of 144 trajectories were analyzed for combinations of Charlson comorbidities and Barthel Index items. Daily likelihood ratios (probabilities) of ADL impairments were calculated for the 5-year period preceding MDS evaluation to form trajectories of decline over that period. Four general patterns of trajectories were identified: 1. Steady declinedMI, dementia, renal failure, diabetes, peptic ulcer 2. Accelerated declinedobserved in a unique trajectory for AIDS 3. Stable functiondCOPD, CVD, CHF, PVD 4. Overall decline with periods of recoverydmetastatic cancer, rheumatologic disorders, liver disease, stroke Conclusions. Trajectories of illness prior to death in this cohort of nursing home residents occurred in patterns distinct from those observed in other populations. Implications for Research, Policy, or Practice. Given the lack of change in functional impairment prior to death for many common comorbid conditions, reliance on functional measures to aid in prognostication may not be sufficient.
Illness Trajectories Among Nursing Home Residents (TH318-D) Cari Levy, MD, University of Colorado, Denver, CO. Janusz Wojtusiak, PhD, George Mason University, Fairfax, VA. Objectives Understand trajectories of illness among nursing home residents and how these differ from traditional trajectories in general populations. Understand how trajectories different comorbid conditions, independent of age. Original Research Background. By 2020, 40% of all deaths in the United States are expected to occur in nursing homes. Trajectories of illness prior to death have traditionally been defined using four general patterns to include (a) sudden death, (b) a short period of decline, (c) long-term limitations with intermittent serious episodes, and (d) prolonged dwindling. Research Objectives. The purpose of this study was to determine if these trajectories are observed among a cohort of nursing home residents.
Concurrent Sessions ‘‘Are You My Mentor?’’ A Panel Discussion Featuring an All-Star Cast of AAHPM and HPNA Mentors and Mentees (TH319) Rebecca Aslakson, MD PhD, Johns Hopkins Hospital, Baltimore, MD. Arif Kamal, MD, Duke Cancer Institute, Durham, NC. Laura Gelfman, MD, Mount Sinai Hospital, New York, NY. Polly Mazanec, PhD ACNPBC FPCN, Cleveland Veterans Affairs Medical Center, Cleveland, OH. R. Sean Morrison, MD FAAHPM, Icahn School of Medicine at Mount Sinai, New York, NY. Betty Ferrell, PhD RN MA FAAN FPCN CHPN, City of Hope Medical Center, Duarte, CA. Joann N. Bodurtha, MD MPH FAAP FACMG, Johns Hopkins University, Baltimore, MD. Amy Abernethy, MD FAAHPM, Duke University Medical Center, Durham,
Schedule With Abstracts
Vol. 49 No. 2 February 2015
Setting/Participants. Data on the last seven days of
Methods. Data for 324,435 residents of the Veterans
life were abstracted from the medical records of 5,476 decedents from six Veterans Administration Medical Centers (VAMCs) in the southeast United States and from VA administrative databases. Methods. Based on literature and expert clinical opinion, we prospectively identified potential risk factors for restraint use at the time of death from among all variables collected during the trial. Factors included location of death, medications given, nasogastric tube, intravenous (IV) fluids infusing, family presence at time of death, and receipt of a palliative care consultation. Generalized estimating equations, which account for correlation among patients within a site, were used to assess the relationship between each predictor and physical restraint use. Results. Physical restraint use at time of death was documented in 890 decedents (16.3%). Restrained patients were more likely to have a nasogastric tube (OR, 2.30; p<.0001); and be receiving IV fluids (OR, 2.15, p<.0001), benzodiazepines (OR, 1.75; p<.0001), or antipsychotics (OR, 2.36; p<.0001). Use of restraints varied by location of death, with a higher risk associated with patients in intensive settings compared with decedents on medicine or surgery wards (OR, 1.7; p¼0.006). Conclusions. Factors associated with restraint use include therapies that may be disrupted by an agitated patient, care in intensive settings, and medications commonly used for delirium. Implications for Research, Policy, or Practice. Further study should focus on interventions to reduce restraint use in dying patients.
Administration’s (VA’s) Community Living Centers (CLC) were extracted and analyzed within the VA Informatics and Computing Infrastructure. Data included diagnoses from 1,617,693 inpatient records; 145,575,072 outpatient visits; and 1,901,354 functional status evaluations given as the Minimum Dataset (MDS). The Barthel Index was constructed from MDS Data using nine ADLs (stair climbing was excluded). Diagnoses originally present as ICD-9 codes were converted to Charlson Comorbidity Categories (Deyo version). Results. A total of 144 trajectories were analyzed for combinations of Charlson comorbidities and Barthel Index items. Daily likelihood ratios (probabilities) of ADL impairments were calculated for the 5-year period preceding MDS evaluation to form trajectories of decline over that period. Four general patterns of trajectories were identified: 1. Steady declinedMI, dementia, renal failure, diabetes, peptic ulcer 2. Accelerated declinedobserved in a unique trajectory for AIDS 3. Stable functiondCOPD, CVD, CHF, PVD 4. Overall decline with periods of recoverydmetastatic cancer, rheumatologic disorders, liver disease, stroke Conclusions. Trajectories of illness prior to death in this cohort of nursing home residents occurred in patterns distinct from those observed in other populations. Implications for Research, Policy, or Practice. Given the lack of change in functional impairment prior to death for many common comorbid conditions, reliance on functional measures to aid in prognostication may not be sufficient.
Illness Trajectories Among Nursing Home Residents (TH318-D) Cari Levy, MD, University of Colorado, Denver, CO. Janusz Wojtusiak, PhD, George Mason University, Fairfax, VA. Objectives Understand trajectories of illness among nursing home residents and how these differ from traditional trajectories in general populations. Understand how trajectories different comorbid conditions, independent of age. Original Research Background. By 2020, 40% of all deaths in the United States are expected to occur in nursing homes. Trajectories of illness prior to death have traditionally been defined using four general patterns to include (a) sudden death, (b) a short period of decline, (c) long-term limitations with intermittent serious episodes, and (d) prolonged dwindling. Research Objectives. The purpose of this study was to determine if these trajectories are observed among a cohort of nursing home residents.
Concurrent Sessions ‘‘Are You My Mentor?’’ A Panel Discussion Featuring an All-Star Cast of AAHPM and HPNA Mentors and Mentees (TH319) Rebecca Aslakson, MD PhD, Johns Hopkins Hospital, Baltimore, MD. Arif Kamal, MD, Duke Cancer Institute, Durham, NC. Laura Gelfman, MD, Mount Sinai Hospital, New York, NY. Polly Mazanec, PhD ACNPBC FPCN, Cleveland Veterans Affairs Medical Center, Cleveland, OH. R. Sean Morrison, MD FAAHPM, Icahn School of Medicine at Mount Sinai, New York, NY. Betty Ferrell, PhD RN MA FAAN FPCN CHPN, City of Hope Medical Center, Duarte, CA. Joann N. Bodurtha, MD MPH FAAP FACMG, Johns Hopkins University, Baltimore, MD. Amy Abernethy, MD FAAHPM, Duke University Medical Center, Durham,