AAHPM 2015

AAHPM 2015

Saturday 2/28

ACTION ITEMS

✔️Redefine roles:

MD: symptom assessment

RN: care coordination; follow up all team recommendations; expressive writing and patient needs assessment; educate & empower other RNs

SW: ACP, social services

SC: emotional, spiritual, psychosocial needs

✔️heart failure clinic ACP

How to help patients make valuebased medical decisions: Promoting adaptive coping and prognostic awareness

Prognostic awareness is the patient's capacity to understand the likely disease trajectory and prognosis. With deeper prognostic awareness patients can

–Weigh burdens and benefits of treatment

–Have more meaningful discussions of their goals and values

–Match treatment decisions to goals and values

When goals and values are informed by low prognostic awareness, patients make unrealistic treatment decisions

Patients express varying degrees of prognostic awareness by swinging between hope and realism

The cultivation of prognostic awareness is a process that happens over time

Palliative care helps temper the fear of dying by embracing the joy of living

- our job is to help patients simultaneously acknowledge both realities and manage the ambivalence

- to help patients more easily acknowledge both realities

- When patients can acknowledge both realities, they can better incorporate them into more informed decision making

Cultivating prognostic awareness 

Skills for well times 

1. Assess prognostic awareness 

•"What is your understanding about what to expect with your cancer?" 

•"What discussions have you had about the big picture with your care team or your family?" 

•"What are you hoping for?" 

•"What are you most worried about?"

2. Create a framework to focus on living and tolerate the possibility of dying 

A. Focus on living 

- Manage symptoms; improve QOL

- Develop rapport & trust - makes it easier to have harder conversations

i. Identify and encourage diverse coping behaviors 

- Elicit and reinforce behaviors that the patient is already using 

- Identify areas where the patient may benefit from a new strategy

ii. Respond to and build positive emotions 

–"Are there still moments of happiness and joy even when you are going through such a tough time? Can you tell me about them?" 

–"What are you hoping for?"

iii. Help with practical problem solving 

B. Tolerate the possibility of dying 

i. Milligram strength words 

- Help patient to  tolerate the possibility of  dying by  recognizing  that words  have different milligram  strengths

ii. The box 

- The "box" metaphor  can help powerful emotions feel more manageable  when discussing difficult  topics

iii. Explore what the patient wants to know 

- Patient's ambivalence  about  deepened prognostic awareness is  evident  in changing information  preferences.  We need to  keep asking what  a  patient wants to  know repeatedly.  It  changes. 

iv. Hypothetical questions

Cachexia in Post-Hospital Care Focus on Heart Failure

james_judge@optum.com

Cachexia 

• a  complex metabolic  syndrome  associated with underlying  illness and  characterized by  loss  of muscle  with  or  without  loss  of  fat  mass. 

• The prominent  clinical  feature of  cachexia  is  weight loss in adults  (corrected  for fluid retention)

• Anorexia,  inflammation,  insulin resistance and increased  muscle  protein breakdown  are  frequently associated with  cachexia. 

• Cachexia  is distinct  from  starvation,  age-related  loss of  muscle mass,  primary  depression,  malabsorption and  hyperthyroidism and is  associated  with  increased morbidity".

Dying in America: what is the hospice and palliative care community's role in implementation?

End of life decisions should not be made at end of life.

Beatease.org

Www.iom.com/endoflife for report

Resolutioncare.com

The Polypharmacy Police vs. The Patient Advocate: An Evidence‐Based, Patient‐Tailored Approach to Medication Simplification Strategies for the Palliative Care Patient

⚫️Key Polypharmacy References 

•Scott IA, Gray LC, Martin JH, PillansPI, Mitchell CA. Deciding when to stop: towards evidence‐based deprescribingof drugs in older populations. Evidence Based Medicine 2012:ebmed‐2012‐100930. 

•Hanlon JT, SchmaderKE, SamsaGP, et al. A method for assessing drug therapy appropriateness. Journal of clinical epidemiology 1992;45:1045‐51. 

- Hardy. J  Pharm  Pract Research 2011.

⚫️Deprescribing 

• Process  of  tapering,  withdrawing or  stopping medications  to  reduce  polypharmacy,  adverse drug  effects  and  inappropriate  or  ineffective medication  use  by  re‐evaluating  the  ongoing reasons  for,  and  effectiveness  of  medications

- Engage the original  prescribers  of  the  medications  to  assure patient  /  loved  ones  to  ensure  coordination  amongst  providers and  build  trust.

⚫️Systematic  Review  of  Dementia Practice  Guidelines 

• Vascular  dementia

–Only  one guideline  recommends  cholinesterase inhibitors (CI)  (donepezil);  

- other guidelines  discourage  use.  

- Conflicting recommendations  for  memantine. 

• Dementia  with  Lewy Bodies

–CI  recommended;  rivastigmine agent  of  choice

–No recommendation  for  memantine 

• Frontotemporal dementia

–CI  considered  harmful;  

- memantine not  recommended 

[Ngo,  Age  and Ageing  2015]

Bottom  Line:   Dementia  Drugs 

• Dementia  medications  are  LESS  HELPFUL  and MORE HARMFUL in advanced  disease  (see  adverse effects) 

• NOT indicated  or  provided  with  FAST  7  without clear  and  ongoing  benefit  in  managing  identifiable and  distressing  behaviors. 

• MAY be covered  with FAST  6; discuss goals/outcomes  with  hospice  physician  or pharmacist 

• 2 week tapering  supply  should  be  provided  if medication  discontinued

⚫️Antibiotics  for  Palliation  of  Symptoms 

- Antimicrobials  improved  symptoms  in a majority  of patients  with  urinary  tract  infections, but  less successful  for infections  of the respiratory  tract, mouth/pharynx, skin/subcutaneous  tissue,  or  blood Reinbolt ,  

[JPSM  2005]

⚫️Warfarin vs ASA in AF for stroke prevention

Cochrane  Review  2011 

• 8 randomized  trials,  n=9,598,  1.9  year  followup 

• All  stroke  risk  less  in  warfarin  group  by  30%,  but  higher  incidence  of intracranial  hemorrhage 

• ASA reduced  risk  by  20%  versus  no  therapy 

• All  cause  mortality  the  same

- use 325 mg

State of the Science: Update in Hospice & Palliative Care

Key Issues to Be Considered 

Is the question important? 

What are the results? 

Are the results valid? 

Can I apply the results to my patients?

Neurolytic sympathectomy in the management of cancer pain-time effect: a prospective, randomized multicenter study

AmrYM, MakharitaMY J Pain Symptom Manage. 2014 Nov;48(5):944-956

✔️Early use of neurolyticblocks leads to 5-9 months of better pain control, less opioid consumption, and better quality of life for patients with abdominal and pelvic cancers.  

Randomized controlled trial of expressive writing for patients with renal cell carcinoma

MilburyK, Spelman A, Wood C, MatinS F, TannirN, JonaschE, PistersL, Wei Q, Cohen L J ClinOncol. 2014 Mar 1;32(7):663-70

✔️Renal cancer patients who wrote about their deepest concerns had fewer symptoms and improved function at 10 months. Symptom reduction was partially explained by improved short-term cognitive processing. 

Safety of benzodiazepines and opioids in very severe respiratory disease: national prospective study

EkströmM, Bornefalk-HermanssonA, Abernethy A, CurrowD BMJ. 2014 Jan;348:g445

✔️Opioids in lower doses (≤30 mg oral morphine equivalents/day) are not associated with increased hospital admissions or deaths in patients receiving long term oxygen therapy for COPD, whereas benzodiazepines and opioids in higher doses might increase mortality. Lower dose opioids might be safe for reduction of symptoms in those with severe respiratory disease.

An integrated palliative and respiratory care service for patients with advanced disease and refractory breathlessness: a randomized controlled trial

Higginson I, BauseweinC, Reilly C, Gao W, GyselsM, Dzingina, M, McCroneP, Booth S, Jolley C, MoxhamJ Lancet. 2014 December; 2: 979-87

✔️Compared to usual care, a multi-professional breathlessness support service demonstrated higher breathlessness mastery at 6 weeks and better overall survival without affecting overall costs for patients with refractory breathlessness. There were no differences in severity of breathlessness on exertion in prev. 24 hrs., activity, other measures of respiratory function, QOL, palliative needs, depression, anxiety, and spirometry.     

Inpatient palliative care for patients with acute heart failure:  outcomes from a randomized trial

Sidebottom AC, Jorgenson A, Richards H, KirvenJ, SillahA J PalliatMed. 2015 Feb;18(2):134-142

✔️In patients with heart failure, inpatient palliative care consultation + standard care versus standard care alone is associated with short-term improvement in measures of symptom burden, quality of life and depression.  

Intervention to improve care at life's end in inpatient settings:  the BEACON Trial

Bailey FA, Williams BR, WoodbyLL, Goode PS, Redden DT, Houston TK, GranstaffUS, Johnson TM, PennypackerLC, Haddock KS, Painter JM, Spencer JM, HartneyT, BurgioKL J Gen Intern Med. 2014 Jun;29(6);836-43

✔️A multi-modal intervention improved some care processes for patients dying in inpatients settings, including medications ordered for symptom management, sublingual administration of medications, and documentation of advance directives.  

Association of experience with illness and end-of-life care with advance care planning in older adults

AmjadH, TowleV, Fried T C J Am GeriatrSoc. 2014 Jul;62(7):1304-1309

✔️Older adults with experience with endof-life care of others report greater readiness to participate in advance care planning than those without such experiences.

Friday 2/27

55 Words

⚫️Anne Scheetz, MD, Mary Fry MD. The stories.   JAMA 2000;283:1934.

⚫️Colleen Fogarty, MD, Nancy Gross, MA, Donald McLaren, MD. 55-Word Stories: Small Jewels for Staying Soulful. AAHPM Quarterly; Spring, 2011.

⚫️Marchand, Fleming, Mastrocola, Gasper, Marty.  AAHPM Quarterly. 2014; 15: 7.

Atul Gawande 

Serious illness conversation guide

- serious illness communication trial

Thursday 2/25

TH330 Developing Accountable Payment Models: Key Issues for Hospice and Palliative Care

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Description: Can healthcare spending be reduced without harming patients or providers? Must physician practices and hospice programs merge into large health systems in order to deliver "accountable care?" Harold Miller, a nationally recognized expert on payment and delivery reform, will explain why most current efforts at payment reform, such as shared savings, value-based purchasing, and procedural bundles, do little to overcome the problems in the current payment system and can actually make things worse. Miller will describe how properly-designed payment models can enable providers to remain financially healthy while both improving care for patients and reducing spending for purchasers – a win-win-win. He will also discuss how hospice and palliative care providers can help to design Accountable Care Organizations from the bottom up, rather than the top down approach being used in most communities today.

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Learning Objectives:

1.) Understand the weaknesses in "value based purchasing" and other current approaches to payment reform

2.) Learn how properly designed accountable payment models can reduce spending for Medicare and other payers without harming patients and without financially harming physician practices, hospices, hospitals, or other care providers

3.) Understand how hospice and palliative care providers can encourage implementation of better payment systems and position themselves to succeed in the future

Www.chqpr.org

Www.paymentreform.org

Building a Successful Interdisciplinary Team- Learning to Love Conflict

1. Competing: my way or the highway

2. Collaborative: 2 heads are better than one

3. Compromising: split the difference; seek middle ground

4. Avoiding: leave well enough alone

5. Accommodating: Unassertive & uncooperative 

Individual & Team Expectations 

Goals of dialogue:

- learn

- find truth

- produce results

- strengthening relationships 

Myths re: communication 

- we can make people do things

- people can make us feel things

- if I know what is right with me, I know what is right for you

Team "success"

- completing tasks, reaching goals

- developed social relationship that helps them work well together

All In: How High-Performing Teams Develop a Culture of Collaboration, Belief, and Renewal

Chester Elton

1. Create an emotional connection 

Put the passion in compassion 

2. Creating a team culture:

⚫️being engaged

⚫️being enabled

⚫️being energized

3. Create a customer experience 

How many people will you inspire?

4. Develop agility

Adapt to change

5. The soft stuff is the hard stuff

You create buy-in

Have 10 positive interactions

Show appreciation to your team

Your patient experience will never exceed your team experience 

Ratio of positive to negative feedback should be 5:1

6. Cheer for each other

Do it now

Do it Often

Be Specific

Be Sincere

7. Be specific!

General praise has no impact on people

Appreciate your team's family

Great teams root for each other

People will never forget the way you made them feel

Be good to everybody, everybody is having a tough day

Are you all in?

The Rule of 3's

1. World class

2. No excuses

3. Cheer for each other

People

Mark Corbett tcorbett@wakehealth.edu

Geriatrician & palliative MD

Randomized Study Comparing a Basal Bolus With a Basal Plus Correction Insulin Regimen for the Hospital Management of Medical and Surgical patients With Type 2 Diabetes

Umpierrez et al. Diabetes Care 2013 Feb 22
Journal Watch Summary:

In non–critically ill hospitalized patients, a single daily dose of basal insulin plus corrective short-acting doses was equivalent to basal bolus insulin therapy.

Randomized, controlled trials in patients admitted to general medical and surgical services have shown that a basal bolus insulin regimen results in superior glycemic control and fewer complications than does sliding scale insulin (SSI; JW Hosp Med Apr 4 2011). Accordingly, in a recent consensus guideline, experts recommended that clinicians adopt the basal bolus regimen as the preferred approach in non–critically ill hospitalized patients (JW Hosp Med Apr 4 2011). However, some clinicians have been reluctant to use this approach because of its complexity and their fear of inducing hypoglycemia.

In a U.S. multicenter trial, researchers randomized 375 hospitalized patients with type 2 diabetes to one of three insulin regimens:

1. Basal bolus regimen with glargine given once daily and glulisine given before meals, plus additional corrective glulisine SSI as needed for BS > 140 ( total daily dose (TDD) of 0.5 units/kg divided with half as insulin glargine once daily and half as insulin glulisine be-fore meals)*
2. Basal plus regimen with glargine given once daily, plus corrective glulisine SSI before meals as needed for BS > 140 (0.25 units/kg of glargine plus corrective doses of glulisine before meals)*
3. Regular SSI alone for BS > 140

• The goal of insulin therapy was to maintain fasting and premeal glucose concentrations between 100 and 140 mg/dL
• Insulin protocol available at: http://care.diabetesjournals.org/content/suppl/2013/02/19/dc12-1988.DC1/DC121988SupplementaryData.pdf

* In patients >70 years of age and those with a serum creatinine >2.0 mg/dL, the starting TDD in the basal bolus group was reduced to 0.3 units/kg in the basal bolus, and TDD of glargine reduced to 0.15 units/kg in the basal plus regimen.

The basal plus regimen resulted in glycemic control similar to that with the basal bolus regimen, and both were superior to SSI alone. Hypoglycemia (blood glucose level, <70 mg/dL) occurred in 16%, 13%, and 3% of patients in the basal bolus, basal plus, and SSI groups, respectively. However, rates of severe hypoglycemia (blood glucose level, <40 mg/dL) were <1% in all three groups.

Excluded: history of hyper-glycemic crises, patients with hyperglyce-mia without a known history of diabetes, patients admitted to or expected to re-quire ICU admission, patients undergo-ing cardiac surgery, patients receiving corticosteroid therapy, patients with clinically relevant hepatic disease or impaired renal function (serum creatinine >3.0 mg/dL), patients with a history of diabetic ketoacidosis, pregnancy.

Comment: Although this study was not powered to evaluate hospital complications, it gives the practicing clinician another viable approach for treating type 2 diabetes in non–critically ill hospitalized patients. Clinicians now have the option of "basal plus," which seems to be just as effective as "basal bolus," but is less complex and easier to implement.

What a bloody mess! Which bleeding risk score is best?

Numerous publications have come out regarding the validity and utility of currently available bleeding risk scores. Here are some recent studies that looked at 3 commonly used scores:
1) HAS-BLED
2) HEMMORR2HAGES
3) ATRIA

Scores to Predict Major Bleeding Risk During Oral Anticoagulation Therapy: A Prospective Validation Study
AJM August 2012
Prospective cohort study of 515 adult patients taking oral anticoagulants over a 12-month follow-up period comparing the prognostic performance of 7 clinical prediction scores to the first major bleeding event.

1. OBRI
2. Kuijer
3. Shireman
4. HEMORR2HAGES
5. RIETE
6. HAS-BLED
7. ATRIA 

The performance of 7 clinical scoring systems in predicting major bleeding events in patients receiving oral anticoagulation therapy was poor and not better than physicians' subjective assessments.

RESULTS:

• the proportions of major bleeding ranged from 3.0% to 5.7% for low-risk, 6.7% to 9.9% for intermediate-risk, and 7.4% to 15.4% for high-risk patients. 
• The overall predictive accuracy of the scores was poor, with the C statistic ranging from 0.54 to 0.61 and not significantly different from each other (P = .84). 
• Only the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) score performed slightly better than would be expected by chance (C statistic, 0.61; 95% confidence interval, 0.52-0.70). 
• The performance of the scores was not statistically better than physicians' subjective risk assessments (C statistic, 0.55; P = .94). 

Predictive value of the HAS-BLED and ATRIA bleeding scores for the risk of serious bleeding in a 'real world' anticoagulated atrial fibrillation population.
Chest. 2012 Jun 21.
Prospective cohort study of anticoagulated AF patients from our out-patient anticoagulation clinic with an INR between 2.0-3.0 during the previous 6 months clinic visits. Authors assessed both bleeding risk scores as quantitative variables or as dichotomized variables (low-moderate vs high risk).

The HAS-BLED score shows significantly better prediction accuracy than the weighted (and more complex) ATRIA score. Our findings reinforce the incremental utility of the simple HAS-BLED score over other published bleeding risk scores in anticoagulated AF patients.

 RESULTS:

• The HAS-BLED score had a similar model performance (based on c-statistics) to the ATRIA score as a quantitative variable (c-statistics 0.71 vs. 0.68, p=0.356), but was superior to the ATRIA score when analysed as a dichotomized variable (c-statistics, 0.68 vs. 0.59, p=0.035). 
• The HAS-BLED score more accurately predicted major bleeding episodes than the ATRIA risk score, as reflected in the percentage of events correctly reclassified.

Performance of the HEMORR(2)HAGES, ATRIA, and HAS-BLED bleeding risk-prediction scores in patients with atrial fibrillation undergoing anticoagulation: the AMADEUS (evaluating the use of SR34006 compared to warfarin or acenocoumarol in patients with atrial fibrillation) study.
J Am Coll Cardiol. 2012 Aug 28Dataset from the AMADEUS (Evaluating the Use of SR34006 Compared to Warfarin or Acenocoumarol in Patients With Atrial Fibrillation) trial, a multicenter, randomized, open-label noninferiority study that compared fixed-dose idraparinux with adjustable-dose oral vitamin K antagonist therapy in patients with AF.  

All 3 tested bleeding risk-prediction scores demonstrated only modest performance in predicting any clinically relevant bleeding, although the HAS-BLED score performed better than the HEMORR(2)HAGES and ATRIA scores, as reflected by ROC analysis, reclassification analysis, and decision-curve analysis. Only HAS-BLED demonstrated a significant predictive performance for intracranial hemorrhage. Given its simplicity, the HAS-BLED score may be an attractive method for the estimation of oral anticoagulant-related bleeding risk for use in clinical practice, supporting recommendations in international guidelines.

RESULTS:

• The HAS-BLED score performed best in predicting any clinically relevant bleeding, reflected both in net reclassification improvement (10.3% and 13% improvement compared with HEMORR(2)HAGES and ATRIA, respectively) and receiver-operating characteristic (ROC) analyses (c-indexes: 0.60 vs. 0.55 and 0.50 for HAS-BLED vs. HEMORR(2)AGES and ATRIA, respectively). 
• Using decision-curve analysis, the HAS-BLED score demonstrated superior performance compared with ATRIA and HEMORR(2)HAGES at any threshold probability for clinically relevant bleeding. 
• HAS-BLED was the only score that demonstrated a significant predictive performance for intracranial hemorrhage (c-index: 0.75; p = 0.03). An ATRIA score >3 was not significantly associated with the risk for any clinically relevant bleeding on Cox regression or on ROC analysis (c-index: 0.50; p = 0.87). 

So which one will you choose?

Blood glucose control for ICU patients

NEJM Article (Sept 20, 2012)

Hypoglycemia and Risk of Death in Critically Ill Patients

In critically ill patients, intensive glucose control leads to moderate and severe hypoglycemia, both of which are associated with an increased risk of death. 

Understanding Low Sugar from NICE-SUGAR (Commentary):

Given the current stage of evolution in inpatient insulin therapy, what are the best glucose targets for patients admitted to the ICU? In many hospitals, maintaining blood glucose at levels similar to those in the conventional-control group of the NICE-SUGAR population is safe and similar to other recommendations (140 to 180 mg per deciliter).

Key Points:

• ICU patients were randomized to intensive (target BS 81-108 mg/dL) vs conventional (target BS 180 mg/dL) blood glucose control.
• Mean BS in intensive control gp = 115 mg/dL vs conventional gp = 144 mg/dL
• Intensive control gp had 2.6% absolute increased risk of death in 90d vs conventional gp (NNH = 38). 
• Moderate hypoglycemia (blood glucose level, 41–70 mg/dL) was significantly more common in the intensive-control group than in the conventional control group (74% vs. 16%). 
• Almost all (93%) of the 223 patients who experienced severe hypoglycemia (blood glucose level <40 mg/dL) were in the intensive-control group. 
• Hypoglycemia was associated with longer ICU stay, longer hospital stay, and mortality. 
• Patients with worse outcomes included those who experienced more than one episode of hypoglycemia and those with severe hypoglycemia despite not having received insulin (reflecting that hypoglycemia can result from severe illness). 
• The adjusted hazard ratios for death were 1.41 in patients with moderate hypoglycemia and 2.10 in patients with severe hypoglycemia.

Clearing up the confusion: minimizing postoperative delirium

Lionel Lim, MD, MPH, FACP, FACPM

Postoperative delirium is an under-diagnosed yet common geriatric syndrome that manifests as an acute confusional state, typically within 48 to 72 hours after surgery.  Occurrence of postoperative delirium is variable (15-25% in elective surgery) and its incidence is highest in hip and coronary artery bypass surgeries (>50%).¹  Delirium in elderly patients is associated with increased mortality, hospital length of stay, institutionalization, and dementia.^{2, 3}  Furthermore, functional and cognitive impairment from delirium may persist for months after discharge from hospital.¹  Risk factors for delirium are older age, neurocognitive impairment, multiple comorbidities, functional and sensory impairments, male gender and alcoholism.¹  Patients should be screened for risk factors or cognitive impairment at baseline so that appropriate delirium-preventing interventions can be implemented. 

It is also important to educate the patient and family regarding the etiology, treatment and prognosis of delirium.  Informing family that delirium is not permanent and may take weeks to months to eventually resolve may help to reduce anxiety or frustration.  Having the support and continued presence of family members or caregivers can also help patients during their recovery by providing frequent orientation, reassurance, and avoiding the need to institute unfamiliar “sitters” or physical restraint use during episodes of confusion.  Providers should pay close attention for delirium occurrence in previously affected or high-risk patients by using a validated screening tool like the Confusion Assessment Method (CAM).⁴  Appropriate steps should be taken to avoid the precipitants mentioned above and to correct and treat any underlying infective or metabolic derangements.  

Patients at high risk of post-operative delirium should be followed closely by an interdisciplinary team that is knowledgeable in the prevention, detection and management of delirium.  This team should include a geriatrician or internist working in a setting with established protocols in place to reduce the risk of postoperative delirium.⁵  These protocols would include adequate postoperative pain management, early mobilization, close monitoring of fluid status to avoid dehydration, adequate cognitive stimulation to maintain orientation, maintenance of diurnal rhythm through nonpharmacologic sleep protocols, bowel regimens to avoid constipation, minimizing the use of bladder or vascular catheters, and avoiding deliriogenic medications (benzodiazepines or sedatives and highly anticholinergic medications, e.g. diphenhydramine).  Implementation of the Hospital Elder Life Program (HELP) which targets some of the above risk factors and includes a nonpharmacologic sleep protocol in hospitalized older adults has been shown to reduce the risk of delirium by over a third.⁶  Although haloperidol for postoperative delirium prophylaxis may be a promising agent for use in high risk patients, larger trials are needed before their routine use can be justified in higher-risk patients.^7-9

References

1.            Marcantonio ER. In the clinic. Delirium. Ann Intern Med. Jun 7 2011;154(11):ITC6-1 to 6-16.

2.            Inouye SK. Delirium in older persons. N Engl J Med. Mar 16 2006;354(11):1157-1165.

3.            Witlox J, Eurelings LS, de Jonghe JF, Kalisvaart KJ, Eikelenboom P, van Gool WA. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. Jama. Jul 28 2010;304(4):443-451.

4.            Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. Dec 15 1990;113(12):941-948.

5.            Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc. May 2001;49(5):516-522.

6.            Inouye SK, Bogardus ST, Jr., Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. Mar 4 1999;340(9):669-676.

7.            Girard TD, Pandharipande PP, Carson SS, et al. Feasibility, efficacy, and safety of antipsychotics for intensive care unit delirium: the MIND randomized, placebo-controlled trial. Crit Care Med. Feb 2010;38(2):428-437.

8.            Kalisvaart KJ, de Jonghe JF, Bogaards MJ, et al. Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-controlled study. J Am Geriatr Soc. Oct 2005;53(10):1658-1666.

9.            Wang W, Li HL, Wang DX, et al. Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery: a randomized controlled trial*. Crit Care Med. Mar 2012;40(3):731-739.

How to Decrease Your Risk of Dementia with Cognitive Activities

Daviglus ML, Plassman BL, Pirzada A, et al. Risk Factors and Preventive Interventions for Alzheimer Disease: State of the Science. Arch Neurol. 2011;68(9):1185-1190.

·         Four cohort studies on the association between cognitive engagement and development of AD:

o   In all 4 studies, participants had normal cognition at baseline, and self-reported frequency of involvement in specific activities was assessed

o   All 4 studies showed a somewhat decreased risk of AD associated with greater involvement in cognitive activities.

Study 1

Verghese J, Lipton RB, Katz MJ,  et al.  Leisure activities and the risk of dementia in the elderly.  N Engl J Med. 2003;348(25):2508-2516
PubMed  |  Link to Article

·         Participation in leisure activities is associated with a reduced risk of dementia.

1.       reading,

2.       playing board games,

3.       playing musical instruments, and

4.       dancing.

·         Increased participation in cognitive activities at base line was associated with reduced rates of decline in memory.

Study 2

Akbaraly TN, Portet F, Fustinoni S,  et al.  Leisure activities and the risk of dementia in the elderly: results from the Three-City study.  Neurology. 2009;73(11):854-861
PubMed  |  Link to Article

·         Cognitively stimulating leisure activities may delay the onset of dementia in community-dwelling elders.

·         Cognitive activities in which seeking or processing information plays a central role.

1.       Doing crosswords,

2.       playing cards,

3.       attending organizations,

4.       going to cinema/theater, and

5.       practicing an artistic activity

Study 3

Wilson RS, Mendes De Leon CF, Barnes LL,  et al.  Participation in cognitively stimulating activities and risk of incident Alzheimer disease.  JAMA. 2002;287(6):742-748
PubMed  |  Link to Article

·         Frequent participation in cognitively stimulating activities is associated with reduced risk of Alzheimer’s disease.

·         7 common activities that involve information processing as a central component:

1.       viewing television;

2.       listening to radio;

3.       reading newspapers;

4.       reading magazines;

5.       reading books;

6.       playing games such as cards, checkers, crosswords, or other puzzles; and

7.       going to museums.

Study 4

Wilson RS, Scherr PA, Schneider JA, Tang Y, Bennett DA. Relation of cognitive activity to risk of .developing Alzheimer disease.  Neurology. 2007;69(20):1911-1920
PubMed  |  Link to Article

·         Level of cognitively stimulating activity in old age is related to risk of developing dementia.

·         More frequent participation in cognitive activity was associated with reduced incidence of AD.

·         Frequent cognitive activity was also associated with reduced incidence of mild cognitive impairment and less rapid decline in cognitive function.

·         Common activities in which seeking or processing information played a central role:

1.       reading a newspaper,

2.       playing games like chess or checkers,

3.       visiting a library, or

4.       attending a play