Dementia and delirium are highly prevalent conditions in heart failure (HF) and are independently associated with increased risks for hospitalizations, readmissions, and mortality, according to published data. “Delirium is the most common hospital complication in older patients, affecting 1 in 4 hospitalized older adults,” explains James L. Rudolph, MD. “However, past studies suggest that healthcare professionals do not detect or document two-thirds of delirium cases.” Importantly, nearly 25% of Medicare beneficiaries are discharged to skilled nursing facilities (SNFs) after acute hospitalization for HF, he notes. However, patients with HF discharged to SNFs have a higher mortality than those discharged home.

Determining Influence of Delirium & Dementia on HF

Little is known about the associations between dementia and delirium in patients with HF discharged to SNFs after hospitalization. To address this knowledge gap, Dr. Rudolph and colleagues published a study in ESC Heart Failure that examined the effects of dementia and delirium on mortality and hospital readmission risk in veterans discharged to SNFs following an HF hospitalization. “Our goal was to determine if delirium influences clinical outcomes well beyond hospitalizations among people with and without dementia,” Dr. Rudolph says.

The study included more than 21,000 older veterans who were hospitalized with a primary diagnosis of HF and discharged to SNFs between 2010 and 2015. Patients were categorized into 4 groups based on the presence (+) or absence (−) of dementia and delirium:

1.                                                                                                          3.
Dementia−/delirium−                                                                    Dementia+/delirium−
2.                                                                                                          4.
Dementia−/delirium+                                                                    Dementia+/delirium+

Delirium Is a Critical Factor in HF Outcomes

When compared with the dementia−/delirium− cohort (the reference group), patients in the dementia−/delirium+ group had significantly higher 30- and 365-day mortality (Table). Risks for readmission were highest in patients in the dementia−/delirium+ group after 30 days. However, in the group with dementia (delirium−/ dementia+), the 30-day mortality rate and readmission rate were not different when compared with the reference group.

Overall, the study group observed that 59% of patients with HF were readmitted and 40% died within 1 year following discharge to SNFs. Mortality and readmissions within 30 days after being discharged to SNFs were highest among patients with delirium only. Conversely, the presence of dementia alone was not associated with higher mortality risks when compared with patients without either dementia or delirium.

“Our findings were a little surprising,” says Dr. Rudolph. “People living with dementia were as likely as those without it to be readmitted or die within 30 days until we factored in delirium. Patients who developed delirium—particularly without prior dementia—were much more likely to die within the 30 days after hospitalization and in the year after hospitalization.”

Brain Function Is Critical to Avoid Death Post-Hospitalization

The study results suggest that delirium is deserving of extra attention in acute hospitalizations and discharge planning for patients with HF. “Our study highlights the importance of delirium screening, prevention, and management,” Dr. Rudolph says. “The brain is the most important organ for patients’ return to living in their environment after hospitalization. Even in patients hospitalized for HF, brain function is critical to avoid death. We have a parallel study demonstrating that people with delirium did not recover function as well in the 30 days after admission. Small investments in preventing delirium can pay big dividends for patients in terms of their ability to return home.”

Collecting data on baseline cognitive and functional status during acute hospitalizations may improve how patients with HF are evaluated. These data can help characterize pre-existing cognitive impairment, the extent of cognitive changes from baseline, and the course of symptoms.

“We’re still trying to establish why hospital physicians have challenges when it comes to identifying delirium,” says Dr. Rudolph. “Part of the reason may be due to Medicare not providing reimbursement for managing delirium and there are no medications specifically indicated to ‘treat’ delirium. Fundamentally, delirium alters a patient’s life trajectory. Hospital-based delirium prevention strategies, such as cognitive stimulation, ambulation, sleep hygiene, and sensory improvement, may be effective approaches to help patients continue to be functional and live in the community.”