Dementia patients with azotemia or anemia may be at increased risk for medical deterioration, new research suggests.
Presented here at the American Association for Geriatric Psychiatry (AAGP) 2012 Annual Meeting, results of a cohort study of elderly inpatients at a stand-alone psychiatric hospital showed that a significantly higher proportion of those diagnosed at entry with dementia and behavioral disturbance had azotemia (26.5% vs 3.9%, respectively) as well as higher rates of anemia (40% vs 16.3%).
In addition, more than 61% of the patients with both dementia and azotemia and more than 61% of those with both dementia and anemia had such serious deterioration that they required emergency transfer to a general hospital.
“Although patients with dementia often have multiple comorbid conditions, the risk factors for medical deteriorations during hospitalizations haven’t really been looked at before,” lead author Eugene Grudnikoff, MD, resident in general psychiatry at North Shore–Long Island Jewish Health System in New York, told Medscape Medical News.
“This is a particular problem in freestanding centers where you can’t just send patients downstairs to x-ray, etc. And our most interesting finding was that at admission, certain baseline laboratory values, such as anemia (low levels of hemoglobin in the blood), predicted future deteriorations — even though the patients had been deemed ‘medically cleared’ to be in a psychiatric hospital,” said Dr. Grudnikoff.
He added that the results illustrate the need for increasing the basic level of monitoring for these patients.
“These are deteriorations that can be prevented. Things such as falls prevention, more frequent blood pressure monitoring, more frequent vital signs monitoring, and just more frequent checks overall are very cheap and effective preventive measures.”
Interrupted Psychiatric Care
Dr. Grudnikoff said that patients with dementia are more vulnerable, more fragile, and generally more elderly.
“For this study, we wanted to look at ways to predict who will essentially have a medical emergency requiring calling an ambulance, transferring to a hospital room, and resulting in interruptions to their psychiatric care,” he explained.
The investigators evaluated data on 1000 elderly patients admitted to a psychiatric hospital in New York City in 2010. All participants, as part of hospital policy, received a full medical evaluation on day of admission. The evaluation included history and physical examination as well as laboratory testing, such as a complete blood count, a comprehensive medical panel, and assessment of thyroid-stimulating hormone level.
“Patients are ‘medically cleared’ for admission if they are clinically stable and do not require intravenous drugs or fluids,” report the researchers.
For this study, azotemia was defined as a blood urea nitrogen level > 24 mg/dL; anemia was defined as a hemoglobin concentration < 12 g/dL; and hypoalbuminemia was defined as an albumin level < 3.7 gm/dL.
“Significant medical deterioration” was determined by transfer from the inpatient psychiatric unit to a general medical center.
Need for Better Monitoring
Of the 1000 patients included in this study, 71 were diagnosed with dementia with behavioral disturbance. Of these, 42.3% (n = 30) had significant medical deterioration vs 12.3% (n = 114) of the patients without dementia (P< .0001).
The most common reasons for these transfers of the dementia patients were fever and falls (27% each), hypoxia, hypotension, chest pain, and deep venous thrombosis.
In addition, the patients with dementia had significantly higher rates of anemia, azotemia, and hypoalbuminemia at admission than did those without dementia (P < .0001 for all 3 measures).
The “positive predictive values” for deterioration were 61.1% and 61.5% for the dementia patients who also had azotemia or anemia, respectively. However, the predictive value for those with dementia and hypoalbuminemia was only 30.0%.
The investigators write that these findings show that patients with dementia who also have azotemia or anemia at admission “should receive enhanced medication evaluation, monitoring, and management to decrease preventable interruptions in care and burdensome transitions.”
Dr. Grudnikoff reported that the participants with anemia but without dementia did not have significant deterioration.
“It appears there is something specific about dementia patients with these baseline abnormalities that puts them at increased risk. It’s not necessarily across-the-board all about anemia only.”
He noted that the investigators did not assess whether using interventions upon admittance would decrease the risk for emergency transfers.
“It’s generally not the standard of practice to do some intervention right at the time these lab values were discovered for these patients during the evaluation process. But perhaps there’s something that could be done throughout their behavioral admission to prevent medical deterioration. That would be interesting to look at,” said Dr. Grudnikoff.
“Anemia is a sign that something is going wrong; but it is a nonspecific sign,” George Alexpoulos, MD, professor of psychiatry and director of the Weill-Cornell Institute of Geriatric Psychiatry in White Plains, New York, toldMedscape Medical News.
“Still, although this study was small, I think it is worth following up to see whether this really can be used as a risk factor and what the effect size is. If it turns out that it is a significant predictor of these outcomes, these are really cheap measures. Blood count is already measured in every patient at admission, so you’re not adding a test. You’re just examining what’s already been given,” he added.
Dr. Alexpoulos, who was not involved with this study, was the designated discussant during the poster’s presentation.
He noted that “the beauty of the study” was that psychiatric inpatients were used.
“These are the sickest patients and most likely to have the outcomes of interest, as opposed to outpatients who are generally healthier. However, unfortunately, inpatients are often excluded in research,” said Dr. Alexpoulos.
Dr. Grudnikoff and 3 of the other 5 study authors have disclosed no relevant financial relationships. The remaining authors report having been a consultant and/or advisor to or having received honoraria from Actelion, Astra-Zeneca, Bristol-Myers Squibb, Cephalon, Eli Lily, GSK, Janssen Pharmaceuticals, Johnson and Johnson, Lundbeck, Merck, Novartis, Ortho-McNeill, Otsuka, Pfizer, PgXHealth, Proteus, Sepracor/Sunovion, Vanda, and Wyeth; on the speaker’s bureau of Astra-Zeneca, Bristol-Myers Squibb/Otsuka, and Eli Lily; and a current shareholder of MedAvante. Dr. Alexpoulos has disclosed no relevant financial relationships.
American Association for Geriatric Psychiatry (AAGP) 2012 Annual Meeting. Abstract EI-28. Presented March 17, 2012.
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