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Background: Delirium is characterized by disturbances in circadian rhythm. Melatonin regulates our circadian rhythm. Our aim was to compare preoperative cerebrospinal fluid (CSF) melatonin levels in patients with and without postoperative delirium. Methods: Prospective cohort study with hip fracture patients ≥ 65 years who were acutely admitted to the hospital for surgical treatment and received spinal anaesthesia. CSF was collected after cannulation, before administering anaesthetics. Melatonin was measured by radioimmunoassay (RIA). Data on delirium was obtained from medical and nursing records. Nurses screened every shift for delirium using the Delirium Observation Screening Scale (DOSS). If the DOSS was ≥3, a psychiatrist was consulted to diagnose possible delirium using the DSM-IV criteria. At admission, demographic data, medical history, and information on functional and cognitive status was obtained. Results: Seventy-six patients met the inclusion criteria. Sixty patients were included in the analysis. Main reasons for exclusion were technical difficulties, insufficient CSF or exogenous melatonin use. Thirteen patients (21.7%) experienced delirium during hospitalisation. Baseline characteristics did not differ between patients with and without postoperative delirium. In patients with and without postoperative delirium melatonin levels were 12.88 pg/ml (SD 6.3) and 11.72 pg/ml (SD 4.5) respectively, p-value 0.47. No differences between patients with and without delirium were found in mean melatonin levels in analyses stratified for cognitive impairment or age. Conclusion: Preoperative CSF melatonin levels did not differ between patients with and without postoperative delirium. This suggests that, if disturbances in melatonin secretion occur, these might occur after surgery due to postoperative inflammation. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To investigate long-term cognitive, functional, and quality-of-life outcomes in very elderly survivors at least 1 year after planned or unplanned surgery or medical intensive care treatment. DESIGN: Retrospective cohort study. SETTING: General, 1,024-bed, tertiary university teaching hospital in the Netherlands. PARTICIPANTS: Two hundred four survivors of a cohort of 578 patients admitted to the medical–surgical intensive care unit (ICU) between January 1997 and December 2002 and alive in December 2003. The majority of survivors underwent elective surgery. MEASUREMENTS: From December 2003 until February 2004, data were collected from 190 patients and 169 relatives. The measures were: Informant Questionnaire on Cognitive Decline short form (IQCODE-SF) (cognition), modified Katz index of activities of daily living (ADLs) (functional status), and EuroQol (EQ-5D) (health-related quality of life). The patients themselves completed the modified Katz ADL index and EQ-5D forms; their caregivers completed the ADL caregiver version and IQCODE-SF. RESULTS: The mean age at admission±standard deviation was 81.7±2.4, and the median time after discharge was 3.7 years (range 1–5.9 years). Of the ICU patients who had planned surgery, 57% survived, compared with 11% of the unplanned surgical admissions and 10% of the medical patients. Three-quarters (74.3%) of the patients who lived at home before ICU admission remained at home at follow-up. Eighty-three percent had no severe cognitive impairment, and 76% had no severe physical limitations (33% had moderate, 40% had mild, and 3% had no limitations). The perceived quality of life was similar to that of an age-matched general population. CONCLUSION: Long-term survivors of ICU treatment received at the age of 80 and older showed fair-to-good cognitive and physical functioning and quality of life, although few patients who underwent unplanned surgery or who were admitted to the ICU for medical reasons survived. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Association Between Acute Care and Critical Illness Hospitalization and Cognitive Function in Older Adults," by William J. Ehlenbach and colleagues in a 2010 issue.

Objectives To examine changes in motor subtype profile in individuals with delirium. Design Observational, longitudinal study; substudy of a multicenter, randomized controlled trial. Setting Departments of surgery and orthopedics, Academic Medical Center and Tergooi Hospital, the Netherlands. Participants Elderly adults acutely admitted for hip fracture surgery who developed delirium according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, for 2 days or longer (n = 76, aged 86.4 ± 6.1, 68.4% female). Measurements Delirium Motor Subtype Scale ( DMSS), Delirium Rating Scale R98 ( DRS-R98), comorbidity, and function. Results Median delirium duration was 3 days (interquartile range 2.0 days). At first assessment, the hyperactive motor subtype was most common (44.7%), followed by hypoactive motor subtype (28.9%), mixed motor subtype (19.7%), and no motor subtype (6.6%). Participants with no motor subtype had lower DRS-R98 scores than those with the other subtypes ( P < .001). The DMSS-defined motor subtype of 47 (61.8%) participants changed over time. Katz Index of Activities of Daily Living, Charlson Comorbidity Index, cognitive impairment, age, sex, and delirium duration or severity were not associated with change in motor subtype. Conclusion Motor subtype profile was variable in the majority of participants, although changes that occurred were often related to changes from or to no motor subtype, suggesting evolving or resolving delirium. Changes appeared not be associated with demographic or clinical characteristics, suggesting that evidence from cross-sectional studies of motor subtypes could be applied to many individuals with delirium. Further longitudinal studies should be performed to clarify the stability of motor subtypes in different clinical populations. [ABSTRACT FROM AUTHOR]

Objective: To describe the effect of implementation of a rapid response system on the composite endpoint of cardiopulmonary arrest, unplanned ICU admission, or death.Design: Pragmatic prospective Dutch multicenter before-after trial, Cost and Outcomes analysis of Medical Emergency Teams trial.Setting: Twelve hospitals participated, each including two surgical and two nonsurgical wards between April 2009 and November 2011. The Modified Early Warning Score and Situation-Background-Assessment-Recommendation instruments were implemented over 7 months. The rapid response team was then implemented during the following 17 months. The effects of implementing the rapid response team were measured in the last 5 months of this period.Patients: All patients 18 years old and older admitted to the study wards were included.Measurements and Main Results: In total, 166,569 patients were included in the study representing 1,031,172 hospital admission days. No differences were observed in patient demographics between periods. The composite endpoint of cardiopulmonary arrest, unplanned ICU admission, or death per 1,000 admissions was significantly reduced in the rapid response team versus the before phase (adjusted odds ratio, 0.847; 95% CI, 0.725-0.989; p = 0.036). Cardiopulmonary arrests and in-hospital mortality were also significantly reduced (odds ratio, 0.607; 95% CI, 0.393-0.937; p = 0.018 and odds ratio, 0.802; 95% CI, 0.644-1.0; p = 0.05, respectively). Unplanned ICU admissions showed a declining trend (odds ratio, 0.878; 95% CI, 0.755-1.021; p = 0.092), whereas severity of illness at the moment of ICU admission was not different between periods.Conclusions: In this study, introduction of nationwide implementation of rapid response systems was associated with a decrease in the composite endpoint of cardiopulmonary arrests, unplanned ICU admissions, and mortality in patients in general hospital wards. These findings support the implementation of rapid response systems in hospitals to reduce severe adverse events. [ABSTRACT FROM AUTHOR]

Context Delirium often presents difficult management challenges in the context of goals of care in palliative care settings. Objectives The aim was to formulate an analytical framework for further research on delirium in palliative care settings, prioritize the associated research questions, discuss the inherent methodological challenges associated with relevant studies, and outline the next steps in a program of delirium research. Methods We combined multidisciplinary input from delirium researchers and knowledge users at an international delirium study planning meeting, relevant literature searches, focused input of epidemiologic expertise, and a meeting participant and coauthor survey to formulate a conceptual research framework and prioritize research questions. Results Our proposed framework incorporates three main groups of research questions: the first was predominantly epidemiologic, such as delirium occurrence rates, risk factor evaluation, screening, and diagnosis; the second covers pragmatic management questions; and the third relates to the development of predictive models for delirium outcomes. Based on aggregated survey responses to each research question or domain, the combined modal ratings of "very" or "extremely" important confirmed their priority. Conclusion Using an analytical framework to represent the full clinical care pathway of delirium in palliative care settings, we identified multiple knowledge gaps in relation to the occurrence rates, assessment, management, and outcome prediction of delirium in this population. The knowledge synthesis generated from adequately powered, multicenter studies to answer the framework's research questions will inform decision making and policy development regarding delirium detection and management and thus help to achieve better outcomes for patients in palliative care settings. [ABSTRACT FROM AUTHOR]

Background: Recent studies have shown that an increased bleeding tendency can be caused by Selective Serotonin Reuptake Inhibitors (SSRI) use. We aimed to investigate the occurrence and risk of blood transfusion in SSRI users compared to non-SSRI users in a cohort of patients admitted for hip-surgery. Methods: We conducted a retrospective cohort study of patients who underwent planned or emergency hip surgery from 1996 to 2011 in the Academic Medical Center in Amsterdam. Primary outcome measure was risk of blood transfusion. Secondary outcome measures were pre- and postoperative hemoglobin level. Multivariate logistic regression was used to adjust for potential confounders. Results: One-hundred and fourteen SSRI users were compared to 1773 non-SSRI users. Risk of blood transfusion during admission was increased for SSRI users in multivariate analyses (OR 1.7 [95% CI 1.1–2.5]). Also, pre-operative hemoglobin levels were lower in SSRI users (7.8±1.0 mmol/L) compared to non-SSRI users (8.0±1.0 mmol/L) (p = 0.042)), as were postoperative hemoglobin levels (6.2±1.0 mmol/L vs. 6.4±1.0 mmol/L respectively) (p = 0.017)). Conclusions: SSRI users undergoing hip surgery have an increased risk for blood transfusion during admission, potentially explained by a lower hemoglobin level before surgery. SSRI use should be considered as a potential risk indicator for increased blood loss in patients admitted for hip surgery. These results need to be confirmed in a prospective study. [ABSTRACT FROM AUTHOR]

Background: Elderly patients are at a 4-fold higher risk of adverse drug events (ADEs) and drug-related hospitalization. Hospitalization of an elderly patient is often preceded by geriatric syndromes, like falls or delirium. Objectives: The primary aim of this study was to investigate whether geriatric syndromes were associated with ADEs in acutely admitted elderly patients. Methods: Consecutive medical patients, aged 65 years or more, who were acutely admitted, were enrolled. An initial multidisciplinary evaluation was completed and baseline characteristics were collected. A fall before admission was retrieved from medical charts. Delirium was determined by the Confusion Assessment Method. Results: A total of 641 patients were included. Over 25% had an ADE present at admission, 26% presented with delirium and 12% with a fall. Delirium was associated with the use of antidepressants, antipsychotics and antiepileptics. In all ADEs (n= 167), ADEs were associated with a fall, with non-steroidal anti-inflammatory drugs or diuretics, but not with pre-existing functioning, delirium or older age. For ADEs involving psychoactive medication (n = 35), an association was found between delirium, falls, opioids and antipsychotics in bivariate analyses. A fall just before hospitalization (odds ratio [OR] 3.69 [95% CI 1.41, 9.67]), antipsychotics (OR 3.70 [95% CI 1.19, 11.60]) and opioids (OR 14.57 [95% CI 2.02, 105.30]) remained independently associated with an ADE involving psychoactive medication. Conclusion: This prospective study demonstrated that, in a cohort of elderly hospital patients, a fall before admission and prevalent delirium are associated with several pharmacological groups and/or with ADE-related hospital admission. [ABSTRACT FROM AUTHOR]

Background: The diagnostic approach to dizzy, older patients is not straightforward as many organ systems can be involved and evidence for diagnostic strategies is lacking. A first differentiation in diagnostic subtypes or profiles may guide the diagnostic process of dizziness and can serve as a classification system in future research. In the literature this has been done, but based on pathophysiological reasoning only. Objective: To establish a classification of diagnostic profiles of dizziness based on empirical data. Design: Cross-sectional study. Participants and Setting: 417 consecutive patients of 65 years and older presenting with dizziness to 45 primary care physicians in the Netherlands from July 2006 to January 2008. Methods: We performed tests, including patient history, and physical and additional examination, previously selected by an international expert panel and based on an earlier systematic review. We used the results of these tests in a principal component analysis for exploration, data-reduction and finally differentiation into diagnostic dizziness profiles. Results: Demographic data and the results of the tests yielded 221 variables, of which 49 contributed to the classification of dizziness into six diagnostic profiles, that may be named as follows: ''frailty'', ''psychological'', ''cardiovascular'', ''presyncope'', ''non-specific dizziness'' and ''ENT''. These explained 32% of the variance. Conclusions: Empirically identified components classify dizziness into six profiles. This classification takes into account the heterogeneity and multicausality of dizziness and may serve as starting point for research on diagnostic strategies and can be a first step in an evidence based diagnostic approach of dizzy older patients. [ABSTRACT FROM AUTHOR]

The article presents a letter to the editor in response to the diet modification of elderly renal disease patients.