RESUMEN
Importance: Older adults who are hospitalized for COVID-19 are at risk of delirium. Little is known about the association of in-hospital delirium with functional and cognitive outcomes among older adults who have survived a COVID-19 hospitalization. Objective: To evaluate the association of delirium with functional disability and cognitive impairment over the 6 months after discharge among older adults hospitalized with COVID-19. Design, Setting, and Participants: This prospective cohort study involved patients aged 60 years or older who were hospitalized with COVID-19 between June 18, 2020, and June 30, 2021, at 5 hospitals in a major tertiary care system in the US. Follow-up occurred through January 11, 2022. Data analysis was performed from December 2022 to February 2024. Exposure: Delirium during the COVID-19 hospitalization was assessed using the Chart-based Delirium Identification Instrument (CHART-DEL) and CHART-DEL-ICU. Main Outcomes and Measures: Primary outcomes were disability in 15 functional activities and the presence of cognitive impairment (defined as Montreal Cognitive Assessment score <22) at 1, 3, and 6 months after hospital discharge. The associations of in-hospital delirium with functional disability and cognitive impairment were evaluated using zero-inflated negative binominal and logistic regression models, respectively, with adjustment for age, month of follow-up, and baseline (before COVID-19) measures of the respective outcome. Results: The cohort included 311 older adults (mean [SD] age, 71.3 [8.5] years; 163 female [52.4%]) who survived COVID-19 hospitalization. In the functional disability sample of 311 participants, 49 participants (15.8%) experienced in-hospital delirium. In the cognition sample of 271 participants, 31 (11.4%) experienced in-hospital delirium. In-hospital delirium was associated with both increased functional disability (rate ratio, 1.32; 95% CI, 1.05-1.66) and increased cognitive impairment (odds ratio, 2.48; 95% CI, 1.38-4.82) over the 6 months after discharge from the COVID-19 hospitalization. Conclusions and Relevance: In this cohort study of 311 hospitalized older adults with COVID-19, in-hospital delirium was associated with increased functional disability and cognitive impairment over the 6 months following discharge. Older survivors of a COVID-19 hospitalization who experience in-hospital delirium should be assessed for disability and cognitive impairment during postdischarge follow-up.
Asunto(s)
COVID-19 , Disfunción Cognitiva , Delirio , Hospitalización , SARS-CoV-2 , Humanos , COVID-19/complicaciones , COVID-19/psicología , COVID-19/epidemiología , Delirio/epidemiología , Delirio/etiología , Femenino , Masculino , Anciano , Disfunción Cognitiva/epidemiología , Disfunción Cognitiva/etiología , Estudios Prospectivos , Hospitalización/estadística & datos numéricos , Anciano de 80 o más Años , Persona de Mediana EdadRESUMEN
Importance: Guidelines recommend that adult patients receive screening for alcohol and drug use during primary care visits, but the adoption of screening in routine practice remains low. Clinics frequently struggle to choose a screening approach that is best suited to their resources, workflows, and patient populations. Objective: To evaluate how to best implement electronic health record (EHR)-integrated screening for substance use by comparing commonly used screening methods and examining their association with implementation outcomes. Design, Setting, and Participants: This article presents the outcomes of phases 3 and 4 of a 4-phase quality improvement, implementation feasibility study in which researchers worked with stakeholders at 6 primary care clinics in 2 large urban academic health care systems to define and implement their optimal screening approach. Site A was located in New York City and comprised 2 clinics, and site B was located in Boston, Massachusetts, and comprised 4 clinics. Clinics initiated screening between January 2017 and October 2018, and 93â¯114 patients were eligible for screening for alcohol and drug use. Data used in the analysis were collected between January 2017 and October 2019, and analysis was performed from July 13, 2018, to March 23, 2021. Interventions: Clinics integrated validated screening questions and a brief counseling script into the EHR, with implementation supported by the use of clinical champions (ie, clinicians who advocate for change, motivate others, and use their expertise to facilitate the adoption of an intervention) and the training of clinic staff. Clinics varied in their screening approaches, including the type of visit targeted for screening (any visit vs annual examinations only), the mode of administration (staff-administered vs self-administered by the patient), and the extent to which they used practice facilitation and EHR usability testing. Main Outcomes and Measures: Data from the EHRs were extracted quarterly for 12 months to measure implementation outcomes. The primary outcome was screening rate for alcohol and drug use. Secondary outcomes were the prevalence of unhealthy alcohol and drug use detected via screening, and clinician adoption of a brief counseling script. Results: Patients of the 6 clinics had a mean (SD) age ranging from 48.9 (17.3) years at clinic B2 to 59.1 (16.7) years at clinic B3, were predominantly female (52.4% at clinic A1 to 64.6% at clinic A2), and were English speaking. Racial diversity varied by location. Of the 93,114 patients with primary care visits, 71.8% received screening for alcohol use, and 70.5% received screening for drug use. Screening at any visit (implemented at site A) in comparison with screening at annual examinations only (implemented at site B) was associated with higher screening rates for alcohol use (90.3%-94.7% vs 24.2%-72.0%, respectively) and drug use (89.6%-93.9% vs 24.6%-69.8%). The 5 clinics that used a self-administered screening approach had a higher detection rate for moderate- to high-risk alcohol use (14.7%-36.6%) compared with the 1 clinic that used a staff-administered screening approach (1.6%). The detection of moderate- to high-risk drug use was low across all clinics (0.5%-1.0%). Clinics with more robust practice facilitation and EHR usability testing had somewhat greater adoption of the counseling script for patients with moderate-high risk alcohol or drug use (1.4%-12.5% vs 0.1%-1.1%). Conclusions and Relevance: In this quality improvement study, EHR-integrated screening was feasible to implement in all clinics and unhealthy alcohol use was detected more frequently when self-administered screening was used at any primary care visit. The detection of drug use was low at all clinics, as was clinician adoption of counseling. These findings can be used to inform the decision-making of health care systems that are seeking to implement screening for substance use. Trial Registration: ClinicalTrials.gov Identifier: NCT02963948.
Asunto(s)
Alcoholismo/diagnóstico , Tamizaje Masivo/métodos , Tamizaje Masivo/normas , Guías de Práctica Clínica como Asunto , Atención Primaria de Salud/métodos , Atención Primaria de Salud/normas , Trastornos Relacionados con Sustancias/diagnóstico , Adulto , Anciano , Boston , Femenino , Humanos , Masculino , Persona de Mediana Edad , Ciudad de Nueva YorkRESUMEN
OBJECTIVES: Pediatric and young adult patients frequently present to medical inpatient (MIP) units for treatment of substance use disorder (SUD). Given the risk of lifelong dependence and related complications in early life substance use (SU), a review of the literature is warranted. METHODS: We conducted a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) systematic review of literature published through April, 62,020, which examined incidence, screening, and complications of pediatric and young adult SU in the MIP setting. RESULTS: 8843 articles were screened, and 28 articles were included for final qualitative synthesis. The overall prevalence of SU-related discharge diagnoses ranged from 1.3% to 5% for patients aged 0 to 26 years. When compared to adult patients, nearly double the rate of co-morbid psychopathology was observed. Three studies utilized systematic screening tools, with the remainder relying on biologic screens and admission or discharge diagnoses. CONCLUSIONS: The results of our review indicate that current screening practices for SU in the MIP clinical setting are subpar and likely result in an underestimation of incidence and morbidity due to limited use of systematic screening tools. Despite this, incidence of SU hospitalizations and related medical and psychiatric complications continue to rise.
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Trastornos Relacionados con Sustancias , Adolescente , Niño , Comorbilidad , Hospitalización , Humanos , Incidencia , Tamizaje Masivo , Trastornos Relacionados con Sustancias/diagnóstico , Trastornos Relacionados con Sustancias/epidemiología , Trastornos Relacionados con Sustancias/terapia , Adulto JovenRESUMEN
BACKGROUND AND OBJECTIVES: The aim of this study was to investigate the social context of nonmedical use of prescription stimulants (NMUPS) among college students who endorsed NMUPS with co-occurring substance use disorders (SUD) compared with those without co-occurring SUDs. METHODS: Presented here are new analyses based on data previously collected from college students aged 18 to 28 years derived from the Boston metropolitan area who endorsed NMUPS (N = 100) at least once in their lifetime. Differences between those with lifetime history of SUD (N = 46) and without a history of SUD (N = 54) on the Massachusetts General Hospital ADHD Medication Misuse and Diversion Assessment were analyzed using the Student t test, the Pearson χ2 test, and the Wilcoxon rank-sum test. RESULTS: College students who endorsed NMUPS with co-occurring SUD were more likely than those without SUD to have bought or traded stimulants, bought or traded in their car, used at parties with drugs/alcohol, or used intranasally (all P < .05). Intranasal administration was common (38% of all students endorsing NMUPS) and was associated with misuse at a party and simultaneous use with cocaine (P = .04), marijuana (P < .001), and alcohol (P < .001), compared with only oral use. DISCUSSION AND CONCLUSIONS: Notable characteristics were identified among individuals who engaged in NMUPS in the type, amount, cost, and ascertainment of stimulants. SCIENTIFIC SIGNIFICANCE: The concurrence of SUD and/or intranasal administration appear to represent a more severe phenotype of NMUPS that should be considered in the implementation of future prevention and intervention protocols on college campuses. (Am J Addict 2020;29:476-484).
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Estimulantes del Sistema Nervioso Central , Mal Uso de Medicamentos de Venta con Receta/psicología , Medio Social , Estudiantes/psicología , Trastornos Relacionados con Sustancias/psicología , Adolescente , Adulto , Estudios de Casos y Controles , Estudios Transversales , Femenino , Humanos , Masculino , Autoinforme , Universidades , Adulto JovenRESUMEN
PURPOSE OF REVIEW: Extensive research has been conducted on attention-deficit/hyperactivity disorder (ADHD) in children and adults; however, less is known about ADHD during the transition from childhood to adulthood. Transitional aged youth (TAY) with ADHD represents a particularly vulnerable population as their newfound independence and responsibility often coincides with the development of comorbid disorders. The purpose of this review is to provide an update on the evaluation, diagnosis, and treatment of TAY-ADHD. RECENT FINDINGS: Recent studies discovering ADHD symptoms emerging in TAY call the classification of ADHD as a disorder necessarily developing in childhood into question. TAY-ADHD are also shown to be vulnerable to academic and social impairments, increased risky behavior, and comorbid psychiatric disorders. Due to the risk of stimulant diversion in TAY, providers are advised to take precaution when prescribing medication to this population. Recent studies demonstrating the efficacy of psychotherapy in conjunction with non-stimulant or extended release stimulant medication provide a feasible alternative. This review highlights research on the course and evaluation of ADHD, impairments and comorbidities specific to TAY, and treatments tailored to address the unique challenges associated with TAY-ADHD.