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No matter what type of cognitive impairment an older hospitalized patient has, the risk of mortality is increased. To describe a hospital-based geriatrics program with a focus on any type of cognitive impairment and to determine whether this program was associated with reduced mortality over time. Retrospective chart review of all patients age 70+ admitted during a 3-year period (2017–2019, N=20,401), to a 500-bed community-based hospital (Level 1 Trauma Center and Stroke Center). A multicomponent geriatrics program was developed and implemented throughout 2018 and included: geriatric consultation, data collection, review of the data with hospital leaders, a geriatrics task force, clinician education and a Delirium Unit. Monthly mortality rates for patients with and without cognitive impairment over the 3-year period. To control for other variables associated with mortality, pre-post implementation analyses were performed (2017 versus 2019). A linear regression analysis showed a significant downward trend in mortality over time for patients with cognitive impairment [R2=0.4, P

Length of hospital stay (LOS) and readmission are important outcomes for older inpatients. The association between functional status on admission and outcomes has not been well investigated in Chinese elderly. To detect the impact of function impairments on LOS and 90-day readmission in a population of Chinese elderly inpatients. This is a prospective cohort study. All new patients over 60 years in geriatrics department of a university hospital in Western China from June to August 2016 were enrolled. Activities of daily living (ADL) and Instrumental ADL (IADL) on admission were evaluated with Barthel Index and Lawton IADL. Outcomes were LOS and 90-day readmission. LOS was calculated as the total days of hospital stay. Readmission was investigated through telephone interviews after discharge. Pearson Chi-square test was used to detect the associations. Binary logistic regression was used to detect the association of function status on admission with LOS and readmission. A total of 225 patients were enrolled. Mean age 82.41 (± 7.316; 63–99), 31.1% were females. Overall, 64.9% of the patients were hospitalized longer than 14 days and 33.30% experienced a 90-day readmission. Following an adjustment for age, gender, marital status, education level, smoking, alcohol, nutrition status, and admission location, the binary logistic regression models showed that both ADL impairment (OR 2.03; 95% CI 1.06–3.87) and IADL impairment (OR 2.54; 95% CI 1.28–5.01) were independent predictors for LOS. ADL impairment was an independent predictor for 90-day readmission (OR 2.26; 95% CI 1.14–4.47), while IADL impairment was not associated with readmission (OR 1.43; 95% CI 0.68–3.02). Functional status on admission is the predictor of LOS and 90-day readmission in Chinese older inpatients from the geriatric department of a university hospital.

PURPOSE: Our purpose was to create a content domain framework for delirium severity to inform item development for a new instrument to measure delirium severity. METHODS: We used an established, multi-stage instrument development process during which expert panelists discussed best approaches to measure delirium severity and identified related content domains. We conducted this work as part of the Better Assessment of ILlness (BASIL) study, a prospective, observational study aimed at developing and testing measures of delirium severity. Our interdisciplinary expert panel consisted of twelve national delirium experts and four expert members of the core research group. Over a one month period, experts participated in two rounds of review. RESULTS: Experts recommended that the construct of delirium severity should reflect both the phenomena and the impact of delirium to create an accurate, patient-centered instrument useful to interdisciplinary clinicians and family caregivers. Final content domains were Cognitive, Level of Consciousness, Inattention, Psychiatric-Behavioral, Psychomotor Features, Emotional Dysregulation, and Functional. Themes debated by experts included reconciling clinical geriatrics and psychiatric content, mapping symptoms to one specific domain, and accurate capture of unclear clinical presentations. CONCLUSIONS: We believe this work represents the first application of instrument development science to delirium. The identified content domains are inclusive of various, wide-ranging domains of delirium severity and are reflective of a consistent framework that relates delirium severity to potential clinical outcomes. Our content domain framework provides a foundation for development of delirium severity instruments that can help improve care and quality of life for patients with delirium.

The development of delirium indicates neurophysiologic disruption and predicts unfavorable outcomes. This relationship between delirium and its outcomes has inspired a generation of studies aimed at identifying, predicting, and preventing both delirium and its associated sequelae. Despite this, evidence on delirium prevention and management remains limited. No medication is approved for the prevention or treatment of delirium or for its associated psychiatric symptoms. This unmet need for effective delirium treatment calls for a refined approach. First, we explain why a one-size-fits-all approach based on a unitary biological model of delirium has contributed to variance in delirium studies and prevents further advance in the field. Next, in parallel with the shift from dementia to "major neurocognitive disorder," we propose a transtheoretical model of "delirium disorder" composed of interactive elements-precipitant, neurophysiology, delirium phenotype, and associated psychiatric symptoms. We explore how these relate both to the biopsychosocial factors that promote healthy cognition ("procognitive factors") and to consequent neuropathologic sequelae. Finally, we outline a preliminary delirium typology of specific neurophysiologic disturbances. Our model of delirium disorder offers several avenues for novel insights and clinical advance: it univocally differentiates delirium disorder from the phenotype of delirium, highlights delirium neurophysiology as a treatment target, separates the core features of delirium from associated psychiatric symptoms, suggests how procognitive factors influence the core elements of delirium disorder, and makes intuitive predictions about how delirium disorder leads to neuropathologic sequelae and cognitive impairment. Ultimately, this model opens several avenues for modern neuroscience to unravel this disease of antiquity.

Procalcitonin (PCT) has predictive value for patients with infectious diseases, but has not been studied in frailty. The purpose of this study was to compare PCT to two other inflammatory biomarkers [interleukin-6 (IL-6)] and C-reactive protein (CRP) in their association with frailty among older hospitalized patients. Retrospective study of inpatients (June–December, 2016), who had all three biomarkers measured within 24 h of admission. Frailty was defined according to the Chinese version of a validated frailty scale. Due to the association of biomarkers with infection, we divided patients into “non-infected” (no pneumonia or other infections) and “pneumonia” (using standard criteria) groups. Of 435 patients (mean age 81.6 ± 8.6 years), 181 (41.6%) were designated the non-infected group and 254 (58.4%) the pneumonia group. Prevalence of frailty in the non-infected group was 32.0% (58/181) and frailty (univariate analysis) was associated with higher PCT and IL-6 levels but not CRP. Prevalence of frailty in the pneumonia group was 40.2% (102/254) and frailty was associated with all three biomarkers. In multivariable analysis adjusting for age, gender, smoking, alcohol use, hemoglobin, albumin, neutrophils and creatinine, PCT (not IL-6 and CRP) was associated with frailty in the non-infected group (OR = 5.244; 95% CI, 1.622–16.947; P = 0.006) and none of the biomarkers were associated with frailty in the pneumonia group. Although the study is limited due to the retrospective methods, PCT but not IL-6 or CRP, was associated with frailty among older inpatients without infection. None of these biomarkers were associated with frailty among patients with pneumonia.

Due to the aging population of China, the need for palliative care will increase. However, one of the barriers to utilization of palliative care is the traditional belief that talking about death and dying is taboo.The aim of this study was to examine to what extent older Chinese patients were willing to answer questions about death and dying by asking them about "fear of death" and their desire to "use advanced life support when dying."Survey questionnaire.Convenience sample (N = 993 hospitalized patients).Only 215 (21.7%; 95% confidence interval [CI] 16.2%-27.1%) and 99 (9.9%; 95% CI 4.1%-15.8%) patients did not answer the questions related to "fear of death" and "use of advanced life support when dying," respectively, while 439 (44.2%; 95% CI 38.7%-49.7%) answered "yes" and 339 (34.1%; 95% CI 28.7%-39.6%) answered "no" for "fear of death" and 382 (38.5%; 95% CI 32.6%-44.3%) answered "yes" and 512 (51.6%; 95% CI 45.7%-57.4%) answered "no" for "use of advanced life support when dying." In multinomial logistic regression analysis, fear of death was associated with younger age, lowest level of function, and desire to use advanced life support.The majority of older patients were willing to answer the two questions about death and dying. About one-third of patients were not afraid of death, and older patients were less likely to be afraid of death. More than 50% of patients answered that they would not choose advanced life support when dying. More research in this area is needed to help advance palliative care in China.

Delirium is an acute change in attention and awareness that preferentially occurs in older patients with acute illness. This review provides an overview for clinicians with descriptions of the presentations (phenotypes), consequences, diagnosis, and screening of delirium. In addition, this review provides guidance for the challenges posed by delirium in a health care system, including implementation of delirium programs, tools to address the diagnosis and differential diagnosis of delirium, and a review of preventive and treatment studies with a goal of improving clinical practice.

Delirium is common in acute, postacute, and long-term care settings, and it can be difficult to recognize, especially without deliberate mental status evaluation. Because delirium typically presents with altered arousal and arousal can be assessed within a matter of seconds, routine assessment of arousal offers an efficient means of delirium screening. Nevertheless, impaired arousal often precludes formal assessment of attention and awareness, the cardinal features of delirium per the current Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Here we debate the relative merits of "ruling in" as delirious noncomatose patients with impaired arousal (inclusive approach) vs reserving delirium diagnosis to patients in whom diagnostic criteria can be elicited (restrictive approach). Inclusivism provides efficiency and may prevent missing or delaying delirium diagnosis. The restrictive approach challenges the utility of ruling such patients in as delirious and advocates for identifying mental states that directly inform clinical care. Both positions, however, firmly emphasize the value of routine clinical assessment of arousal.

Delirium is an acute change in attention and awareness that preferentially occurs in older patients with acute illness. This review provides an overview for clinicians with descriptions of the presentations (phenotypes), consequences, diagnosis, and screening of delirium. In addition, this review provides guidance for the challenges posed by delirium in a health care system, including implementation of delirium programs, tools to address the diagnosis and differential diagnosis of delirium, and a review of preventive and treatment studies with a goal of improving clinical practice.

Importance Postoperative delirium occurs in 10% to 60% of elderly patients having major surgery and is associated with longer hospital stays, increased hospital costs, and 1-year mortality. Emerging literature suggests that dexmedetomidine sedation in critical care units is associated with reduced incidence of delirium. However, intraoperative use of dexmedetomidine for prevention of delirium has not been well studied. Objective To evaluate whether an intraoperative infusion of dexmedetomidine reduces postoperative delirium. Design, Setting, and Participants This study was a multicenter, double-blind, randomized, placebo-controlled trial that randomly assigned patients to dexmedetomidine or saline placebo infused during surgery and for 2 hours in the recovery room. Patients were assessed daily for postoperative delirium (primary outcome) and secondarily for postoperative cognitive decline. Participants were elderly (>68 years) patients undergoing major elective noncardiac surgery. The study dates were February 2008 to May 2014. Interventions Dexmedetomidine infusion (0.5 µg/kg/h) during surgery and up to 2 hours in the recovery room. Main Outcomes and Measures The primary hypothesis tested was that intraoperative dexmedetomidine administration would reduce postoperative delirium. Secondarily, the study examined the correlation between dexmedetomidine use and postoperative cognitive change. Results In total, 404 patients were randomized; 390 completed in-hospital delirium assessments (median [interquartile range] age, 74.0 [71.0-78.0] years; 51.3% [200 of 390] female). There was no difference in postoperative delirium between the dexmedetomidine and placebo groups (12.2% [23 of 189] vs 11.4% [23 of 201],P = .94). After adjustment for age and educational level, there was no difference in the postoperative cognitive performance between treatment groups at 3 months and 6 months. Adverse events were comparably distributed in the treatment groups. Conclusions and Relevance Intraoperative dexmedetomidine does not prevent postoperative delirium. The reduction in delirium previously demonstrated in numerous surgical intensive care unit studies was not observed, which underscores the importance of timing when administering the drug to prevent delirium. Trial Registration clinicaltrials.gov IdentifierNCT00561678

Introduction Delirium is one of the most common complications after cardiac surgery in the elderly. Future studies aimed at preventing postoperative delirium will need an accurate estimate of incidence. However, there are no available systematic reviews on the incidence, and reports of incidence of postoperative delirium after a cardiac operation vary widely with significant heterogeneity. Therefore, we aim to perform a systematic review and meta-analysis to determine the most accurate incidence possible of postoperative delirium in individuals aged >65 years after cardiac surgery. Methods and analyses We will undertake a comprehensive literature search among PubMed, EMBASE, the Cochrane Library, PsycINFO and CINAHL, from their inception to January 2017. Prospective cohort and cross sectional studies that described the incidence of delirium will be eligible for inclusion. The primary outcome will be the incidence of delirium. Risk of bias and methodological quality for the included studies will be assessed using a risk of bias tool for prevalence studies and the Cochrane guidelines. Heterogeneity of the estimates across studies will be assessed. Incidence data will be pooled by selective or emergency surgery. This systematic review will be reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). Ethics and dissemination This proposed systematic review and meta-analysis is based on published data, and thus there is no requirement for ethics approval. The study will provide an up to date and accurate incidence of postoperative delirium among the older population after cardiac surgery, which is necessary for future research in this area. The findings of this study will be presented at conferences and disseminated through publication in a peer reviewed journal. Trial registration number CRD42016047773.

The SARC-F scale is a newly developed tool to diagnose sarcopenia and obviate the need for measurement of muscle mass. SARC-F ≥ 4 is defined as sarcopenia. The questions of SARC-F cover physical functions targeting sarcopenia or initial presentation for sarcopenia. The aim of the study is to explore the application of SARC-F in the Chinese people.Two hundred thirty Chinese people over 65 years old were assessed by the SARC-F scale, PSMS, Lawton IADL and the shortened version of the falls efficacy scale-international(the short FES-I). Hospitalization was investigated. Physical performance and strength were measured. The association of SARC-F with other scales or tests was analyzed.Poor physical performance and grip strength were associated with SARC-F ≥ 4 independently (P0.005). The κ value for agreement of SARC-F ≥ 4 and cutoff points of tests were 0.391 to 0.635. The short FES-I were correlated to SARC-F scores (Spearman's coefficient 0.692). Poor PSMS and Lawton IADL scores were associated with SARC-F ≥ 4(P=0.000) and SARC-F ≥ 4 was associated with hospitalization in the past 2 years (P=0.000).The SARC-F scale can identify old Chinese people with impaired physical function who may suffered from sarcopenia. SARC-F judgment reflects fear of falling, indicates the hospitalization events and is associated with ability of daily life. Thus, SARC-F may be a simple and useful tool for screening individuals with impaired physical function. Further studies on SARC-F in Chinese people would be worthy.

Background The diagnosis of metabolic syndrome indicates a clustering of metabolic imbalances which in sum have been recognized as a major predictor of cardiovascular and all-cause mortality. The aim of this study was to assess the level of under-pharmacy and poly-pharmacy and its prognostic impact in elderly patients with metabolic syndrome.

Objectives: To examine evidence of the efficacy of antipsychotics in the treatment of delirium in older hospitalized adults. Design: Systematic literature review. Setting: Hospital. Participants: Older adults with delirium. Measurements: The MEDLINE (January 1980�December 2010) and Cochrane Databases were searched using the keywords �delirium� and �antipsychotics.� References of review articles were reviewed to identify additional studies. Study selection criteria included prospective design, more than 10 participants (in treatment arms), mean age 60 and older, standardized criteria for diagnosing delirium, and validated delirium rating scales for reporting outcomes. Results: Thirteen articles met selection criteria: six single-agent and seven comparison studies. Of these, eight (62%) had fewer than 25 participants in treatment arms, 10 (77%) recruited participants from psychiatry referrals, and eight (62%) did not clearly describe their screening methods. All single-agent studies were open-label studies. Of the comparison studies, five (71%) used randomization, but only one of these (a placebo-controlled study) used adequate allocation concealment methods, and only one other study (comparing two antipsychotics) described a double-blind method in detail. In the only placebo-controlled study (which was stopped early), no statistically significant differences in mean delirium severity scores were found at individual time points (Days 2, 3, 4, 7, 10). The other 12 studies reported improvements in delirium severity or resolution of delirium based on cutoff scores of the scales, but it is not clear from any of these studies what the natural course of delirium would have been without use of antipsychotics. Conclusion: Because of severe methodological limitations, the studies in this review do not support the use of antipsychotics in the treatment of delirium in older hospitalized adults. Additional well-designed randomized placebo-controlled trials are needed.

Delirium is associated with several negative outcomes and is not always preventable. Current practices for the management of older hospitalized adults with delirium, such as one-on-one sitters, antipsychotic medications, and physical restraints, have limited effectiveness or potential health risks. An alternative management model, called the Delirium Room (DR), is a four-bed patient room (within an Acute Care for Elders (ACE) Unit) that provides 24-hour nursing care, emphasizes nonpharmacological approaches, and is completely free of physical restraints. This article is based on 13 years of experience at two hospitals. The authors have found that a restraint-free environment can be achieved; "tolerate, anticipate, and don't agitate" (the T-A-DA method) are the core principles of the nonpharmacological approach that go beyond the traditional strategies of management (such as reorientation); based on observational data, it appears that negative outcomes associated with delirium, such as loss of function, longer hospital stay, and greater mortality, can be decreased to levels seen in individuals without delirium; and based on limited data, it appears that the rate of falls is at least not higher in the DR than in the ACE unit overall. The limitations of the DR model include lack of randomized controlled trials and the inability to determine which component of the model provides its benefits.

This article reviews the pathophysiology, prevalence, incidence, and consequences of delirium, focusing on the evaluation of delirium, the published models of care for prevention in patients at risk of delirium, and management of patients for whom delirium is not preventable. Evidence on why physical restraints should not be used for patients with delirium is reviewed. Current available evidence on antipyschotics does not support the role for the general use in the treatment of delirium. An example of a restraint-free, nonpharmacologic management approach [called the TADA approach (tolerate, anticipate, and don't agitate)] is presented.

Aims: We examined the individual association between body mass index (BMI) and cognitive function among the very elderly. Methods: The present study analyzed data from a survey that was conducted on all residents aged 90 years or more from a district which had 2,311,709 inhabitants in 2005. The subjects were divided into 4 groups according to quartiles of BMI (21.1), and according to classification criteria of underweight, normal weight, overweight and obesity in BMI (27.5), respectively. Results: The subjects included in the statistical analysis were 211 men and 427 women. Those in the 3rd quartile of BMI (18.9–21.1) had higher cognitive function scores (p < 0.001) and were less likely to present possible dementia (p = 0.016) than the others. However, there was no difference in cognitive function scores (p = 0.350) or prevalence of possible dementia (p = 0.263) among obesity, overweight, normal weight and underweight groups. Conclusions: Concerning longevity in Chinese, there is an association between BMI and cognitive function. BMI of around 20 (18.9–21.1) is associated with the lowest risk of prevalence of possible dementia and the highest cognitive function scores.

The association of cognitive impairment with abnormal levels of serum lipid/lipoprotein in the elderly, in whom there are differences between the old aged 65–84 years and the oldest old aged 85 years or above, has been confirmed by previous studies. However, there are no relevant data from a Chinese oldest old population. In the present study, we observed an association of cognitive impairment with abnormal levels of serum lipid/lipoprotein among very old people using a Chinese cohort aged 90–108 years. The population included 709 unrelated Chinese nonagenarians and centenarians (67.8% women, mean age 93.8 years). The mean score of cognitive function (measured with the 30-item Mini-Mental State Examination, MMSE) was 14.9 (SD 6.0). Comparing abnormal with normal levels of serum lipid/lipoprotein (including triglycerides, total cholesterol, high-density lipoprotein and low-density lipoprotein), in both genders, the odds ratio of cognitive impairment was statistically insignificant. There were no significant differences in levels of lipid/lipoprotein between subjects with and without cognitive impairment. Pearson correlation showed that MMSE scores were not significantly correlated with levels of lipid/lipoprotein. In summary, we found that levels of serum lipid/lipoprotein were not directly correlated with cognitive impairment among Chinese nonagenarians and centenarians.

Among hospitalized older persons, rates of insomnia are alarmingly high, as is evident by the high rates of use of sedative-hypnotic drugs, ranging from 31% to 88%. Insomnia among hospitalized patients may represent undiagnosed sleep disorders, underlying medical problems, and underlying psychiatric problems. Causes of insomnia can be intrinsic or extrinsic. In the intensive care unit, which is one of the most studied areas of the hospital related to insomnia, most studies using polysomnography monitoring have shown that although sleep times seem normal (about 7&8 hours per night), no patients have normal sleep patterns. There is evidence supporting the use of nonpharmacologic interventions, which are preferable to the use of sedating drugs because of the risk associated with their use.

This article examines the changing demographics of China, with particular attention paid to the effect of the one-child policy in relation to long-term care of older people. It also examines the current state of health care for older people. Long-term stays characterize hospital care. Most geriatric syndromes are less common in hospitalized older people (e.g., delirium, falls), but some (e.g., polypharmacy) are more common. A high volume of patients and brief targeted visits characterize outpatient care. Nursing homes exist in China, but relatively fewer than in the most developed countries. Geriatric departments in university-based hospitals primarily have developed out of a need to care for retired government officials and workers. There are no formal geriatric fellowships or national board certifications in geriatrics Health care is primarily based on fee for service. Not all elderly have healthcare insurance. Although costs of health care and medications are less expensive than in the United States, they are relatively high for lower- and middle-class Chinese and have increased more quickly than has the standard of living in the past 20 years. Family and community support for older people is strong in China. Some older people have one-to-one care from a baomu (literally "protection" (bao) "mother" (mu)), a type of live-in maid who also provides care for the older person. Some of the challenges facing China in the care of its aging population are how to increase geriatric research and training, how to care for the uninsured or underinsured, and how to handle the inevitable growth of disabled and frail older people.

No single agent has been shown to truly reverse aging or increase longevity in humans. This article reviews the evidence of efficacy (or lack thereof) for two types of agents touted as antiaging therapies: antioxidants (vitamin E, vitamin C, and carotenoids) and hormones (growth hormone, testosterone, dehydroepiandrosterone, and vitamin D).

Patient and caregiver education and other interventions targeted toward risk factors or types of abuse or neglect play an invaluable role in preventing elder abuse and mistreatment.

New-onset or subsyndromal delirium is one of the most disruptive conditions in nursing home life. As shown in this issue of the Journal, delirium occurs in nearly 1 in 5 nursing home residents who experience an acute illness, and delirium is a major risk factor for a noticeable decline in cognition following the acute episode.1 In 6 Dutch nursing homes, the prevalence of delirium was 8.9%, with an incidence of 20.7 per 100 person-years.2 A Canadian study in long term care residents found a prevalence of 3.4% in persons with a Mini Mental Status Examination (MMSE) of greater than 10 and 33.3% in those with a lower MMSE.3 A large study of 35,721 long term stay residents in the United States using the Minimum Data Assessment 2.0 found that 1.4% had delirium and 30.4% had subsyndromal delirium.4 Other studies have found a higher prevalence of delirium on admission to postacute care ranging from 5.5% to 51.0%.5e8 Many residents remain in a state of subsyndromal delirium over a prolonged period of time. Delirium is often unrecognized.9 One of the most commonly used and best validated screening tools in the United States for delirium is the Confusion Assessment Methodology (CAM).10 The key components of diagnosis are acute onset, fluctuation throughout the day, inattention, disorganized thinking, and abnormal level of consciousness. The new Minimum Data Set, Version 3.0, includes a modification of the CAM screen for delirium.11 Studies have suggested that nurses in nursing homes fail to identify almost half the cases of delirium,12 even though they can differentiate delirium from dementia and depression.13 When the CAM is used, there is a greater reliability of identifying delirium in the nursing home.14 Delirium has been recognized as a serious and underrecognized problem, leading to the suggestion that mental status should be considered the sixth vital sign.15 The Department of Veterans Affairs Delirium Working Group has developed a simple pictorial mental status vital sign to improve recognition of delirium.16 Based on this concept, a modified version of the Richmond Agitation and Sedation Scale (mRASS) was developed. If the mRASS assessments (which take

RANSPORTATION is an essential part of our community infrastructure, which helps people gain access to goods, services, and social contacts that support their daily activities and quality of life. Our reliance on transportation systems has grown over the years as populations have shifted from the city to more remote suburban areas, and remains vital for populations in rural areas. Absence of transportation among any population impairs quality of life by decreasing personal independence, access, choice, and opportunities, which can lead to social isolation. Older adults, for whom quality of life and health are intimately connected (1‐3), are one of the populations who often lack transportation. This is particularly true for the large emerging population of frail elderly adults (4,5). As our health care system continues to struggle to find ways to keep older persons healthy and functional (6,7), the link between transportation services and health care becomes increasingly critical.

The care of older hospitalized patients with delirium can be challenging. Standard practice is limited to the use of 1:1 sitters, antipsychotic medications, and physical restraints. An alternative model of care, called the delirium room (DR), provides 24-h nursing care, emphasizes non-pharmacological approaches, and is completely free of physical restraints. Experience at two different hospitals has found that a restraint-free environment can be achieved; the principles of tolerate, anticipate, and don’t agitate (T-A-DA method) are effective strategies of management. Based on two different sets of data, negative outcomes associated with delirium such as loss of function, longer hospital stay, and increased mortality can be decreased to levels seen in patients without delirium. In-hospital falls are less frequent in the DR compared to typical rooms on the same ward. While limitations exist, a DR is a safe, effective way to manage patients with delirium.

Cognitive impairment creates significant challenges for patients, their families and friends, and clinicians who provide their health care. Early recognition allows for diagnosis and appropriate treatment, education, psychosocial support, and engagement in shared decision-making regarding life planning, health care, involvement in research, and financial matters. An IAGG-GARN consensus panel examined the importance of early recognition of impaired cognitive health. Their major conclusion was that case-finding by physicians and health professionals is an important step toward enhancing brain health for aging populations throughout the world. This conclusion is in keeping with the position of the United States' Centers for Medicare and Medicaid Services that reimburses for detection of cognitive impairment as part the of Medicare Annual Wellness Visit and with the international call for early detection of cognitive impairment as a patient's right. The panel agreed on the following specific findings: (1) validated screening tests are available that take 3 to 7 minutes to administer; (2) a combination of patient- and informant-based screens is the most appropriate approach for identifying early cognitive impairment; (3) early cognitive impairment may have treatable components; and (4) emerging data support a combination of medical and lifestyle interventions as a potential way to delay or reduce cognitive decline.

PURPOSE: To report attitudinal changes of medical students from five medical schools rotating through a home care program, and to determine which of the program characteristics influenced attitudes the most. METHOD: A survey instrument covering four home care domains (general attitudes, home-based therapies, home care training, and time and reimbursement) was designed and validated by the five schools involved. Using pre- and post-rotation scores, analyses were done to evaluate for attitudinal changes within and among schools. The programs had similar basic characteristics (home visits, attending physicians' involvement, didactics), but had differing degrees of these components. RESULTS: Significant improvements in attitude scores were found in three domains: general attitudes, homebased therapies, and home care training. For time and reimbursement, only three schools improved significantly between pre- and post-rotation scores. Among the five schools, there were significant differences in the homebased therapies and home care training domains (p

Methods. A retrospective chart review of 833 discharged older home care patients was performed. These patients were consecutive discharges from a single home care agency who either (a) returned to independent self-care or care of the family (S/F Care group) or (b) were admitted to the hospital (Hospitalized group). Medication assessment within these two groups included total number of medications (prescription and nonprescription); degree of polypharmacy (percentage of patients taking 5 or more, 7 or more, and 10 or more medications); and prevalence for different types of medications, including different types of inappropriate medications. Inappropriate medications were designated according to a list that was previously developed through a modified Delphi consensus technique by a panel of 13 experts in geriatric pharmacology and has been utilized in other studies. Student’s t test was used for continuous variables and chi-square test was used for categorical variables to evaluate for differences between the S/F Care group and the Hospitalized group ( p , .05). For comparisons of types of medications, p , .01 was used for significant differences, because of the high number of comparisons made. Results. Of 833 discharges, 644 (77.3%) returned to self-care or care of the Family (S/F Care group) and 189 (22.7%) were hospitalized. The Hospitalized group, compared with the S/F Care group, was taking a higher number of medications (mean 6 SD : 6.6 6 3.9 vs 5.7 6 3.4, p 5 .004), and had a higher percentage of patients taking 7 or more medications (46% vs 26%, p 5 .002) and 10 or more medications (21% vs 10%, p 5 .005), but not 5 or more medications. Only three types of medications were more commonly used among patients in the Hospitalized group than among patients in the S/F Care group: clonidine (4.2% vs 1.1%, p 5 .004); mineral supplements (23.8% vs 14.8%, p 5 .003); and metoclopramide (5.8% vs 2.0%, p 5 .006). The Hospitalized group had a lower percentage of patients taking inappropriate medications than did the S/F Care group (20% vs 27%, p 5 .040), but none of the types of inappropriate medications was used more often in either group. Conclusions. This study shows a relationship between high levels of polypharmacy and hospitalization. Although it cannot be determined from this study whether a higher number of medications was an indicator of sicker patients at risk for hospitalization, or whether a higher number of medications might have directly led to hospitalization, polypharmacy should still be considered a marker for older home care patients for whom prevention of hospitalization is the goal.

Diabetes mellitus is one of the most common chronic diseases affecting older persons in the United States. It occurs in 18% of persons between 65 and 75 years of age and in as many as 40% of persons over 80 years of age. The prevalence of diabetes mellitus varies considerably by ethnic group and is higher among most minority groups in the United States than among non-Hispanic white persons. Published data also show increased complications and mortality rate from diabetes in the minority groups. In this article, we review the current literature on the prevalence, complications, and mortality-rate effects of diabetes mellitus and the results of interventions in three major minority groups in the United States, namely African Americans, Hispanic Americans, and Native Americans. Recent studies of diabetes mellitus in Mexican seniors also are described. Our review focuses primarily on patients with non-insulin-dependent diabetes mellitus, because by far this is the most prevalent type in older persons.

Acute confusion is associated with significant morbidity and mortality among older persons. Among the common causes of confusion, medications are at the top of the list. Since virtually any drug can cause confusion, it is helpful for the clinician to know which patients are at risk and which medications are risky. At particular risk are patients with dementia and patients whose pharmacokinetics or pharmacodynamics have been impaired by the aging process or diseases. The list of medications that can cause confusion is a long one, yet it can be remembered by the mnemonic ACUTE CHANGE IN MS (mental status). In addition to recognizing the offending agent, it is prudent for clinicians to prevent the chance of drug-induced confusion. One of the safest ways to do this is to avoid too many medications since the risk of adverse drug events rises exponentially with the number of medications prescribed.

OBJECTIVE: To target medically ill older home care patients with symptoms of depression in order to reduce their rate of hospitalization. DESIGN: A case-control study. SETTING: A private, nonprofit home care organization, the Visiting Nurse Association of St. Louis. PARTICIPANTS: Home care patients 65 years of age and older with symptoms of depression who were participants of a Total Quality Management (TQM) intervention (n = 81) were compared with an historical control of home care patients 65 years of age and older with symptoms of depression (n = 69). INTERVENTION: Utilization of TQM principles to develop a plan including: (a) an educational seminar on depression for home care staff involved in the project; (b) letters to physicians introducing the TQM project; (c) use of the Geriatric Depression Scale (GDS) for screening; (d) recommendation to the primary physician of a home social service (SS) consultation for patients with a GDS of 10 to 14; (e) recommendation to the primary physician of three interventions for patients with a GDS ≥ 15: home SS consultation + mental health (MH), or gerontological nurse (GN) consultation + antidepressant medication (a pharmacotherapeutic algorithm sent by facsimile to the primary physician upon request). OUTCOME MEASURES: Hospitalization rates of the control group compared with the TQM intervention group, the degree to which part (e) of the plan was implemented, and the effect this had on hospitalization rates. RESULTS: The TQM intervention patients had a higher mean age than the historical control patients but were not different in percent female, percent white race, percent with a caregiver in the home, functional status, and in 15 of 16 diagnostic categories. Overall, the TQM intervention group had a hospitalization rate of 23.5% (19/81) compared with a rate of 40.6% (28/69) for the historical control group (P = .024). For part (e) of the plan (56/81 patients had a GDS ≥ 15), 29/56 (52%) received the recommended SS consultation, 50/56 (89%) received the recommended MH or GN consultation, and 32/56 (57%) received antidepressant medication. One type of intervention did not seem to lower hospitalization rates more than another although having received the MH or GN visits approached significance (12/50, 24%; P = .052) when compared with the control group. CONCLUSION: Utilization of TQM principles and the development of an intervention such as the one described here can decrease hospitalization rates for medically ill older home care patients with symptoms of depression.

Item does not contain fulltext This article reports the findings of a policy survey designed to establish research priorities to inform future research strategy and advance nursing home practice. The survey was administered in 2 rounds during 2013, and involved a combination of open questions and ranking exercises to move toward consensus on the research priorities. A key finding was the prioritization of research to underpin the care of people with cognitive impairment/dementia and of the management of the behavioral and psychological symptoms of dementia within the nursing home. Other important areas were end-of-life care, nutrition, polypharmacy, and developing new approaches to putting evidence-based practices into routine practice in nursing homes. It explores possible innovative educational approaches, reasons why best practices are difficult to implement, and challenges faced in developing high-quality nursing home research.

Delirium is an acute and common problem often affecting frail and older persons in the acute care hospital, but can develop in any setting. It is associated with serious complications but can also be treatable if diagnosed early and managed properly. Preventive measures should be implemented in high risk patients, such as those with malnutrition, polypharmacy, infections, previous delirium, or dementia. Despite precautions, delirium is unavoidable in some cases and clinicians should be familiar with the typical features and varied presentations of this condition. Diagnosing delirium can be based on the DSM criteria, though multiple useful screening tools exist. Since delirium is almost always triggered by an underlying condition, an aggressive search for the causative insult(s) is essential in order that a targeted intervention be started promptly. Although there is neither any medication approved by the FDA for the treatment of delirium nor any robust evidence supporting the benefit of medications, there is general consensus that drug intervention can be attempted when non-pharmacological interventions have failed.

Objective: The authors investigated the relationship of activities of daily living (ADL) disability with medical diseases and geriatric conditions among nonagenarians and centenarians. Method: Cross-sectional, n = 870 Chinese (age range: 90-108 years). Self-reported medical diseases and geriatric-specific conditions were obtained by face-to-face interviews. Biomedical measurements included systolic/diastolic blood pressure, BMI (body mass index), albumin, fasting glucose, creatinine clearance, hemoglobin, and lipid panel. Results: In bivariate analyses, 4 of 7 geriatric conditions (hearing problems, falls, cognitive impairment, fracture), and 6 of 11 biomedical measurements (fasting glucose, cholesterol, LDL, creatinine clearance, hemoglobin, albumin), but none of 10 medical diseases and no degree of comorbidities, were associated with ADL disability. In four different multivariate logistic regression models, two geriatric conditions (impaired cognition, fracture) were significant in three models, respiratory disease in one model, and fasting glucose in two models. Discussion: This study emphasizes the importance of geriatric conditions and their association with ADL disability among the oldest-old adult population.

BACKGROUND Little is known about mortality among nonagenarians after an earthquake. METHODS Using secondary data analyses from the 2005 study called the Project of Longevity and Aging in Dujiangyan(n = 870), 1-year mortality rates were compared among a pre-earthquake group and a post-earthquake group of nonagenarians. All participants were from Dujiangyan, 50 km from the epicenter of the May 12, 2008 earthquake, in China. The pre-earthquake group was a subset of the 870 Project of Longevity and Aging in Dujiangyan participants, ages 93-95 years at the beginning of "Time Frame 1" (July 2005 through June 2006; n = 228). The post-earthquake group was a different subset of the 870 Project of Longevity and Aging in Dujiangyan participants, ages 93-95 years and alive at the beginning of Time Frame 2 (July 2008 through June 2009; n = 235). Time Frame 2 excluded a 7-week period following the earthquake in order to account for deaths due to trauma. Pre-earthquake health assessment data from the 2005 Project of Longevity and Aging in Dujiangyan study were used to calculate unadjusted/adjusted hazard ratios (HRs) for mortality. RESULTS One-year mortality rates were 8.3% (19/228) and 16.2% (38/235) in the pre-earthquake group and the post-earthquake group, respectively (p =.01). In unadjusted analyses, only "being in the post-earthquake group" was associated with death (HR = 2.04; 95% confidence interval [CI], 1.17-3.53; p = .011). In the multivariable Cox regression model, being in the post-earthquake group continued to be the strongest risk factor associated with mortality (HR = 2.47; 95% CI, 1.39-4.40; p = .002). Other significant risk factors included impaired cognition (HR = 1.97; 95% CI, 1.10-3.53; p = .024), serum albumin (HR = 0.90; 95% CI, 0.82-0.98; p < .015), and serum triglycerides (HR = 1.51; 95% CI, 1.15-1.99; p = .003). CONCLUSION The May 12, 2008 earthquake in Wenchuan, China, was associated with a twofold increase in the 1-year mortality among a group of nonagenarians who lived nearby.

BACKGROUND Patients with delirium, compared with those without, are at increased risk for loss of function, longer hospital stays, and increased mortality. We studied the effect that an Acute Care of the Elderly Unit, which includes a delirium room, has on patients with delirium. METHODS Retrospective observational study. Charts of 148 patients (≥65 years) admitted to an Acute Care of the Elderly Unit with a delirium room during a 4-month period were reviewed. Delirium on admission (prevalence) was based on physician-performed Confusion Assessment Method; delirium during hospital stay (incidence) was based on nurse-performed Confusion Assessment Method. Patients with delirium were compared with those without delirium regarding change in function between admission and discharge (activities of daily living), hospital length of stay, and mortality. RESULTS The prevalence of delirium was 16.2% (24/148), and the incidence was 16.1% (20/124). There were no significant differences between delirious and non-delirious patients in demographics or comorbidity scores. A significant interaction effect (p < .001) indicated improved activities of daily living (mean ± SD; scale 0-12) between admission and discharge among delirious patients (4.1 ± 4.6 and 6.1 ± 3.9) compared with non-delirious patients (7.4 ± 4.7 and 6.9 ± 4.5). There were no differences between delirious and non-delirious patients with reference to mean length of stay (6.4 ± 3.1 vs 5.9 ± 3.6 days, respectively; p = .461) and mortality (2 [4.5%] versus 2 [1.9%], respectively; p = .582). CONCLUSIONS Although this study sample was small, the results suggest that an Acute Care of the Elderly Unit with a delirium room may improve function among delirious patients and may equalize other outcomes compared with non-delirious patients.