Browsing by Author "Mulhall, Paula"

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    Anticholinergic Exposure During Rehabilitation: Cognitive and Physical Function Outcomes in Patients with Delirium Superimposed on Dementia
    (Elsevier, 2015-12) Kolanowski, Ann; Mogle, Jacqueline; Fick, Donna M.; Campbell, Noll; Hill, Nikki; Mulhall, Paula; Behrens, Liza; Colancecco, Elise; Boustani, Malaz; Clare, Linda; Department of Medicine, IU School of Medicine
    OBJECTIVES: We examined the association between anticholinergic medication exposure and subsequent cognitive and physical function in patients with delirium superimposed on dementia during rehabilitation. We also examined length of stay and discharge disposition by anticholinergic medication exposure. DESIGN: In this secondary analysis we used control group data from an ongoing randomized clinical trial. SETTING/PARTICIPANTS: Participants with delirium and dementia were enrolled at admission to post-acute care. These 99 participants had a mean age of 86.11 (±6.83) years; 67.6% were women; 98% were Caucasian; and 33% were positive for at least one APOE e4 allele. MEASURES: We obtained daily measures of cognitive and physical function using: Digit Span; memory, orientation and attention items from the Montreal Cognitive Assessment; CLOX; the Confusion Assessment Method; and the Barthel Index. Anticholinergic medication exposure was measured weekly using the Anticholinergic Cognitive Burden Scale. RESULTS: Using multilevel models for time we found that greater use of clinically relevant anticholinergic medications in the previous week reduced cognitive and physical function, as measured by Digit Span Backwards and the Barthel index, in the current week. There was no effect of anticholinergic medication use on delirium severity, and APOE status did not moderate any outcomes. Greater use of clinically relevant anticholinergic medications was related to longer length of stay but not discharge disposition. CONCLUSIONS: For vulnerable older adults, anticholinergic exposure represents a potentially modifiable risk factor for poor attention, working memory, physical function, and greater length of stay during rehabilitation.
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    Effect of Cognitively-Stimulating Activities for the Symptom Management of Delirium Superimposed on Dementia: A Randomized Controlled Trial
    (Wiley, 2016-12) Kolanowski, Ann; Fick, Donna; Litaker, Mark; Mulhall, Paula; Clare, Linda; Hill, Nikki; Mogle, Jacqueline; Boustani, Malaz; Gill, David; Yevchak-Sillner, Andrea; Medicine, School of Medicine
    Background Delirium is common in post-acute care (PAC) patients with dementia; its treatment is not established. We hypothesized that cognitively-stimulating activities would reduce the duration and severity of delirium and improve cognitive and physical function to a greater extent than usual care. Design Single-blind randomized clinical trial. Setting eight PAC facilities. Participants 283 community-dwelling older adults with dementia and delirium. Intervention Cognitively-stimulating activities delivered daily for up to 30 days. Measurements Primary outcomes were delirium duration (Confusion Assessment Method), and delirium severity (Delirium Rating Scale). Secondary outcomes were cognitive function (Digits Forward, Montreal Cognitive Assessment and CLOX) and physical function (Barthel Index). Results Mean percentage of delirium-free days were similar in both groups: 64.8% (95% CI: 59.6–70.1) (intervention) vs. 68.7% (95% CI: 63.9–73.6) (control), p = 0.37, Wilcoxon's rank sums test. Delirium severity was similar in both groups: 10.77 (95% CI: 10.10–11.45) (intervention) vs. 11.15 (95% CI: 10.50–11.80) (control), a difference of 0.37 (95% CI: 0.56–1.31, p= 0.43). Significant differences for secondary outcomes favoring intervention were found: executive function: 6.58 (95% CI: 6.12–7.04) vs. 5.89 (95% CI: 5.45–6.33), a difference of −0.69 (95% CI: 1.33– −0.06, p=0.03); and constructional praxis: 8.84 (95% CI: 8.83–9.34) vs. 7.53 (95% CI: 7.04–8.01), a difference of − 1.31 (95% CI: 2.01– −0.61, p=0.0003). After adjusting for baseline constructional praxis the group comparison was no longer significant. Average length of stay was shorter in intervention (36.09 days vs. 53.13 days, SE = 0.15, p = 0.01, negative binomial regression). Conclusion Cognitively-stimulating activities did not improve delirium but did improve executive function and reduced length of stay. Resolution of delirium may require more intense non-pharmacological management when the patient has dementia.