Browsing by Author "Nazir, Arif"
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Item Connecting research discovery with care delivery in dementia: the development of the Indianapolis Discovery Network for Dementia(Dove Press, 2012) Boustani, Malaz A.; Frame, Amie; Munger, Stephanie; Healey, Patrick; Westlund, Jessie; Farlow, Martin; Hake, Ann; Guerriero Austrom, Mary; Shepard, Polly; Bubp, Corby; Azar, Jose; Nazir, Arif; Adams, Nadia; Campbell, Noll L.; Chehresa, Azita; Dexter, Paul; Neurology, School of MedicineBackground: The US Institute of Medicine has recommended an integrated, locally sensitive collaboration among the various members of the community, health care systems, and research organizations to improve dementia care and dementia research. Methods: Using complex adaptive system theory and reflective adaptive process, we developed a professional network called the "Indianapolis Discovery Network for Dementia" (IDND). The IDND facilitates effective and sustainable interactions among a local and diverse group of dementia researchers, clinical providers, and community advocates interested in improving care for dementia patients in Indianapolis, Indiana. Results: The IDND was established in February 2006 and now includes more than 250 members from more than 30 local (central Indiana) organizations representing 20 disciplines. The network uses two types of communication to connect its members. The first is a 2-hour face-to-face bimonthly meeting open to all members. The second is a web-based resource center (http://www.indydiscoverynetwork.org ). To date, the network has: (1) accomplished the development of a network website with an annual average of 12,711 hits per day; (2) produced clinical tools such as the Healthy Aging Brain Care Monitor and the Anticholinergic Cognitive Burden Scale; (3) translated and implemented the collaborative dementia care model into two local health care systems; (4) created web-based tracking software, the Enhanced Medical Record for Aging Brain Care (eMR-ABC), to support care coordination for patients with dementia; (5) received more than USD$24 million in funding for members for dementia-related research studies; and (6) adopted a new group-based problem-solving process called the "IDND consultancy round." Conclusion: A local interdisciplinary "think-tank" network focused on dementia that promotes collaboration in research projects, educational initiatives, and quality improvement efforts that meet the local research, clinical, and community needs relevant to dementia care has been built.Item Delirium in Hospitalized Patients: Implications of Current Evidence on Clinical Practice and Future Avenues for Research—A Systematic Evidence Review(Wiley, 2012) Khan, Babar A.; Zawahiri, Mohammed; Campbell, Noll L.; Fox, George C.; Weinstein, Eric J.; Nazir, Arif; Farber, Mark O.; Buckley, John D.; MacLullich, Alasdair; Boustani, Malaz A.; Medicine, School of MedicineBackground: Despite the significant burden of delirium among hospitalized adults, critical appraisal of systematic data on delirium diagnosis, pathophysiology, treatment, prevention, and outcomes is lacking. Purpose: To provide evidence-based recommendations for delirium care to practitioners, and identify gaps in delirium research. Data sources: Medline, PubMed, the Cochrane Library, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) information systems from January 1966 to April 2011. Study selection: All published systematic evidence reviews (SERs) on delirium were evaluated. Data extraction: Three reviewers independently extracted the data regarding delirium risk factors, diagnosis, prevention, treatment, and outcomes, and critically appraised each SER as good, fair, or poor using the United States Preventive Services Task Force criteria. Data synthesis: Twenty-two SERs graded as good or fair provided the data. Age, cognitive impairment, depression, anticholinergic drugs, and lorazepam use were associated with an increased risk for developing delirium. The Confusion Assessment Method (CAM) is reliable for delirium diagnosis outside of the intensive care unit. Multicomponent nonpharmacological interventions are effective in reducing delirium incidence in elderly medical patients. Low-dose haloperidol has similar efficacy as atypical antipsychotics for treating delirium. Delirium is associated with poor outcomes independent of age, severity of illness, or dementia. Conclusion: Delirium is an acute, preventable medical condition with short- and long-term negative effects on a patient's cognitive and functional states.Item Emergency Medical Service, Nursing, and Physician Providers’ Perspectives on Delirium Identification and Management(Sage, 2017-04) LaMantia, Michael A.; Messina, Frank C.; Jhanji, Shola; Nazir, Arif; Maina, Mungai; McGuire, Siobhan; Hobgood, Cherri D.; Miller, Douglas K.; Medicine, School of MedicinePurpose of the study The study objective was to understand providers’ perceptions regarding identifying and treating older adults with delirium, a common complication of acute illness in persons with dementia, in the pre-hospital and emergency department environments. Design and methods The authors conducted structured focus group interviews with separate groups of emergency medical services staff, emergency nurses, and emergency physicians. Recordings of each session were transcribed, coded, and analyzed for themes with representative supporting quotations identified. Results Providers shared that the busy emergency department environment was the largest challenge to delirium recognition and treatment. When describing delirium, participants frequently detailed hyperactive features of delirium, rather than hypoactive features. Participants shared that they employed no clear diagnostic strategy for identifying the condition and that they used heterogeneous approaches to treat the condition. To improve care for older adults with delirium, emergency nurses identified the need for more training around the management of the condition. Emergency medical services providers identified the need for more support in managing agitated patients when in transport to the hospital and more guidance from emergency physicians on what information to collect from the patient’s home environment. Emergency physicians felt that delirium care would be improved if they could have baseline mental status data on their patients and if they had access to a simple, accurate diagnostic tool for the condition. Implications Emergency medical services providers, emergency nurses, and emergency physicians frequently encounter delirious patients, but do not employ clear diagnostic strategies for identifying the condition and have varying levels of comfort in managing the condition. Clear steps should be taken to improve delirium care in the emergency department including the development of mechanisms to communicate patients’ baseline mental status, the adoption of a systematized approach to recognizing delirium, and the institution of a standardized method to treat the condition when identified.Item The experiences of family members in the nursing home to hospital transfer decision(Springer (Biomed Central Ltd.), 2016-11-15) Abrahamson, Kathleen; Bernard, Brittany; Magnabosco, Lara; Nazir, Arif; Unroe, Kathleen T.; Department of Medicine, School of MedicineBACKGROUND: The objective of this study was to better understand the experiences of family members in the nursing home to hospital transfer decision making process. Semi-structured interviews were conducted with 20 family members who had recently been involved in a nursing home to hospital transfer decision. RESULTS: Family members perceived themselves to play an advocacy role in their resident's care and interview themes clustered within three over-arching categories: Family perception of the nursing home's capacity to provide medical care: Resident and family choices; and issues at 'hand-off' and the hospital. Multiple sub-themes were also identified. CONCLUSIONS: Findings from this study contribute to knowledge surrounding the nursing home transfer decision by illuminating the experiences of family members in the transfer decision process.Item Impact of an Inpatient Geriatric Consultative Service on Outcomes for Cognitively Impaired Patients(John Wiley & Sons, Inc., 2015-05) Nazir, Arif; Khan, Babar; Counsell, Steven; Henderson, Macey; Gao, Sujuan; Boustani, Malaz; Department of Medicine, IU School of MedicineBackground Impact of geriatric consultative services (GCS) on hospital readmission and mortality outcomes for cognitively impaired (CI) patients is not known. Objective Evaluate impact of GCS on hospital readmission and mortality among CI inpatients. Design Secondary data-analysis of a prospective trial of a computerized decision support system between July 1, 2006, and May 30, 2008. Setting Study conducted at XXXXX hospital, a 340-bed, public hospital with over 2,300 yearly admissions of 65 or older. Patients 415 inpatients aged 65 and older with CI were enrolled from July 2006 to March 2008. Measurements 30 day and one year mortality and hospital readmission following the index admission. Cox’s proportional hazard models were used to determine the association between receiving GCS, re-admission or mortality while adjusting for demographics, discharge destination, delirium, Charlson Comorbidity Index, and prior hospitalizations. The propensity score method was used to adjust for the non-random assignment of GCS. Results Patients receiving GCS were older (79; 8.1 SD vs 76; 7.8 SD; p<.001 with higher incidence of delirium (49% vs. 29%; p<.001)). No significant differences were found between the groups for hospital readmission (Hazard Ratio (HR)=1.19; 95% CI = 0.89, 1.59) and mortality at 12 months of index admission (HR=.91 ; 95% CI = 0.59, 1.40). However, a significant increase in readmissions was observed for the GCS group (HR=1.75; 95% CI = 1.06–2.88) at 30 days post-discharge. Conclusion One year post-discharge outcomes of CI patients that received GCS were not different from patients who did not receive the service. New models of care are needed to improve post-discharge readmission and mortality among hospitalized patients with CI.Item Implementation of a Heart Failure Quality Initiative in a Skilled Nursing Facility: Lessons Learned(SLACK, 2015-05) Nazir, Arif; Dennis, M. E.; Unroe, Kathleen T.; Department of Medicine, IU School of MedicineSkilled nursing facilities (SNFs) are organizations that represent complex adaptive systems, offering barriers to the implementation of quality improvement (QI) initiatives. The current article describes the authors’ efforts to use the approach of reflective adaptive process to implement a new model of care (i.e., the Skilled Heart Unit Program) for effective heart failure (HF) care in one SNF. A team of stakeholders from the local hospital system and a local SNF was convened to design and implement this new model. Evaluation of the implementation processes confirmed the value of the implementation approach, which centered on team-based approaches, staff engagement, and flexibility of processes to respect the SNF’s needs and culture. Interviews with facility staff and the administrator revealed their perceptions that the strategy resulted in better HF care, enhanced teamwork between staff and clinicians, and improved staff job satisfaction. This work provides a unique blueprint of strategic QI implementation for patients with HF in the SNF setting.Item Interaction between cognitive impairment and discharge destination and its effect on rehospitalization(Wiley, 2013-11) Nazir, Arif; LaMantia, Michael; Chodosh, Joshua; Khan, Babar; Campbell, Noll; Hui, Siu; Boustani, Malaz; Medicine, School of MedicineOBJECTIVES: To evaluate the effect of cognitive impairment on rehospitalization in older adults. DESIGN: One-year longitudinal study. SETTING: Medical service of an urban, 340-bed public hospital in Indianapolis between July 2006 and March 2008. PARTICIPANTS: Individuals aged 65 and older admitted to the medical service (N = 976). MEASUREMENTS: Rehospitalization was defined as any hospital admission after the index admission. Participant demographics, discharge destination, Charlson Comorbidity Index, Acute Physiology Score, and prior hospitalizations were measured as the confounders. Participants were considered to have cognitive impairment if they had two or more errors on the Short Portable Mental Status Questionnaire. RESULTS: After adjusting for confounders, a significant interaction between cognitive impairment and discharge location was found to predict rehospitalization rate (P = .008) and time to 1-year rehospitalization (P = .03). Participants with cognitive impairment discharged to a facility had a longer time to rehospitalization (median 142 days) than participants with no cognitive impairment (median 98 days) (hazard ratio (HR) = 0.77, 95% confidence interval (CI) = 0.58-1.02, P = .07), whereas participants with cognitive impairment discharged to home had a slightly shorter time to rehospitalization (median 182 days) than those without cognitive impairment (median 224 days) (HR = 1.15, 95% CI = 0.92-1.43, P = .23). These two nonsignificant HRs in opposite directions were significantly different from each other (P = .03). CONCLUSION: Discharge destination modifies the association between cognitive impairment and rehospitalization. Of participants discharged to a facility, those without cognitive impairment had higher rehospitalization rates, whereas the rates were similar between cognitively impaired and intact participants discharged to the community.Item An Interim Analysis of an Advance Care Planning Intervention in the Nursing Home Setting(Wiley, 2016-11) Hickman, Susan E.; Unroe, Kathleen T.; Ersek, Mary T.; Buente, Bryce; Nazir, Arif; Sachs, Greg A.; IU School of NursingObjectives To describe processes and preliminary outcomes from the implementation of a systematic advance care planning (ACP) intervention in the nursing home setting. Design Specially trained project nurses were embedded in 19 nursing homes and engaged in ACP as part of larger demonstration project to reduce potentially avoidable hospitalizations. Setting Nursing homes. Participants Residents enrolled in the demonstration project for a minimum of 30 days between August 2013 and December 2014 (n = 2,709) and residents currently enrolled in March 2015 (n = 1,591). Measurements ACP conversations were conducted with residents, families, and the legal representatives of incapacitated residents using a structured ACP interview guide with the goal of offering ACP to all residents. Project nurses reviewed their roster of currently enrolled residents in March 2015 to capture barriers to engaging in ACP. Results During the initial implementation phase, 27% (731/2,709) of residents had participated in one or more ACP conversations with a project nurse, resulting in a change in documented treatment preferences for 69% (504/731). The most common change (87%) was the generation of a Physician Orders for Scope of Treatment form. The most frequently reported barrier to ACP was lack of time. Conclusion The time- and resource-intensive nature of robust ACP must be anticipated when systematically implementing ACP in the nursing home setting. The fact that these conversations resulted in changes over 2/3 of the time reinforces the importance of deliberate, systematic ACP to ensure that current treatment preferences are known and documented so that these preferences can be honored.Item The Influence of Cognitive Impairment, Special Care Unit Placement, and Nursing Facility Characteristics on Resident Quality of Life(Sage, 2013) Abrahamson, Kathleen; Lewis, Teresa; Perkins, Anthony; Clark, Daniel; Nazir, Arif; Arling, Greg; Medicine, School of MedicineObjective: We examined the (a) influence of nursing facility characteristics on resident quality of life and (b) the impact of cognitive impairment and residence on a dementia special care unit(SCU) on QOL after controlling for resident and facility characteristics. Method: Multilevel models (resident and facility) were estimated for residents with and without cognitive impairment on conventional units and dementia SCU. Data came from the 2007 Minnesota Nursing Home Resident Quality of Life and Consumer Satisfaction Survey (N = 13,983). Results: Level of resident CI was negatively related to QOL, although residing on a dementia SCU was positively related to QOL. Certified Nursing Assistant and activity personnel hours per resident day had a positive relationship with resident QOL. Discussion: Our results highlight the need to ensure adequate levels of paraprofessional direct care staff and the availability of dementia-focused (SCU)s despite current constraints on long-term care funding.