Hospital Elder Life Program: Systematic Review and Meta-analysis of Effectiveness

Re-evaluating the Morse Fall Scale in obstetrics and gynecology wards and determining optimal cut-off scores for enhanced risk assessment: A retrospective survey

OBJECTIVE

This study aims to examine the validity of the MFS by analyzing the electronic medical records on fall risk in obstetrics and gynecology wards and determine the optimal cut-off score of the Morse Fall Scale.

DESIGN

A retrospective survey.

METHODS

The research was conducted in an Obstetrics and Gynecology Hospital and a general hospital. The sample included 136 fall inpatients and 120 no-fall inpatients recruited from January 1st, 2020, to July 10th, 2022. The Morse Fall Scale was analyzed using the gold standard of patients who fell while hospitalized, assessing the area under the Receiver Operating Characteristic curve, sensitivity, specificity, accuracy, positive predictive value, negative predictive value, and Kappa.

RESULTS

At cut-off scores of 40, 45,50, and 55, the area under the Receiver Operating Characteristic curve was 0.772, 0.761, 0.749, and 0.763, respectively. The Youden index was 0.543, 0.521, 0.498, and 0.525, while Kappa values were 0.540, 0.518, 0.490, and 0.515. Sensitivity was 0.735, 0.713, 0.640, and 0.625; specificity was 0.808, 0.808, 0.858, and 0.900. The positive predictive values were 0.813, 0.808, 0.837, and 0.876, and the negative predictive values were 0.729, 0.713, 0.678, and 0.679. Accuracy were 0.770, 0.758, 0.742, and 0.754.

CONCLUSIONS

The Morse Fall Scale demonstrates good predictive performance for assessing fall risk in gynecology and obstetrics wards. The optimal cut-off score is 40.

Matters We Metric Vs. Metrics that Matter

Introduction

Geriatric fracture is a pressing global health issue, marked by elevated mortality and morbidity rates and escalating health care costs. The evolving health care system from fee-for-service to quality-based reimbursement has led to externally driven reward and reimbursement systems that may not account for the complexity of caring for older adults with fracture.

Significance

The aim of this review is to highlight the need for a shift towards meaningful metrics that impact geriatric fracture care and to issue a call to action for all medical societies to advocate for national reimbursement and ranking systems that focus on metrics that truly matter.

Results

Traditional metrics, while easier to capture, may not necessarily represent high quality care and may even have unintentional adverse consequences. For example, the focus on reducing length of stay may lead to older patients being discharged too early, without adequately addressing pain, constipation, or delirium. In addition, a focus on mortality may miss the opportunity to deliver compassionate end-of-life care. Existing geriatric fracture care metrics have expanded beyond traditional metrics to include assessment by geriatricians, fracture prevention, and delirium assessments. However, there is a need to further consider and develop patient-focused metrics. The Age-Friendly Health Initiative (4 Ms), which includes Mobility, Medication, Mentation, and what Matters is an evidence-based framework for assessing and acting on critical issues in the care of older adults. Additional metrics that should be considered include an assessment of nutrition and secondary fracture prevention.

Conclusion

In the realm of geriatric fracture care, the metrics currently employed often revolve around adherence to established guidelines and are heavily influenced by financial considerations. It is crucial to shift the paradigm towards metrics that truly matter for geriatric fracture patients, recognizing the multifaceted nature of their care and the profound impact these fractures have on their lives.

Effect of the nurse-led Hospital Elder Life Program on delirium reduction among delirious patients with COVID-19: A randomized clinical trial

BACKGROUND

Infectious diseases, such as COVID-19, are high-risk factors for delirium. However, the implementation of nonpharmacological interventions faces major challenges during an infectious disease pandemic.

AIMS

To evaluate the effect of the nurse-led Hospital Elder Life Program (NL-HELP) on delirium reduction among delirious patients with COVID-19.

DESIGN

A single-blind randomized clinical trial.

METHODS

This study recruited 122 delirious patients with COVID-19 from internal medicine wards at West China Hospital in China between January 30 and March 31, 2023. Participants were randomized to the NL-HELP group (n = 62) or the usual care group (n = 60). Patients in the intervention group received the NL-HELP protocol three times daily for 7 days. Patients in the control group received usual care. The primary outcome was the absence/presence of delirium during the intervention period measured by the 3-min Diagnostic Confusion Assessment Method.

RESULTS

Fewer patients remained delirious in the NL-HELP group than in the control group. There were significantly more delirium-free days in the NL-HELP group than in the usual care group. There were no statistically significant differences between the two groups in terms of delirium severity, length of hospital stay, delirium at 30 days after discharge, 30-day readmission, 30-day mortality, physical function or quality of life.

CONCLUSIONS

This study demonstrated that NL-HELP could reduce the presence of delirium in delirious patients. No effect was observed in terms of shortening the length of hospital stay, reducing 30-day mortality, or improving quality of life.

IMPACT

NL-HELP may be effective in reducing the presence of delirium in delirious patients. Further research is needed to determine whether the NL-HELP can improve patient outcomes (e.g. mortality and quality of life) in a larger study.

PATIENT OR PUBLIC CONTRIBUTION

Caregivers of delirious patients were invited to provide intervention strategies to prevent or abate delirium, including environmental management, orientation communications and identification of alert signs.

TRIAL REGISTRATION

This study was prospectively registered at the Chinese Clinical Trial Registry (https://www.chictr.org.cn/) Identifier: ChiCTR2300067874.

Impact of a Delirium Protocol on Deliriogenic Medication Use in Hospitalized Older Veterans

Background The Southern Arizona VA Health Care System (SAVAHCS) implemented a delirium prevention and treatment protocol in 2019. Objective The primary objective of this study was to determine if the implementation of a delirium protocol influenced deliriogenic medication use in hospitalized geriatric veterans. The secondary objectives were to compare the rates of delirium diagnosis, hospital length-of-stay, and rates of newly started deliriogenic medications during admission pre- and post-protocol. Methods This study was a retrospective, secondary data analysis study. Veterans 65 years of age and older who were admitted to an inpatient medical ward at the SAVAHCS for 24 hours or more between January 1, 2018 and December 31, 2018 (pre-protocol) or January 1, 2021 and December 31, 2021 (post-protocol) were included. Patients were excluded if they had a diagnosis of alcohol or benzodiazepine withdrawal upon admission. Results A total of 5491 patients were included in this study; 2940 (53.5%) in the pre-protocol group and 2551 (46.5%) in the post-protocol group. Patients received at least one deliriogenic medication during their admission in the post-protocol group (36.2%) compared with the pre-protocol group (34.1%), but there was no statistically significant difference (P = 0.098). There were also no significant differences in the rates of documentation of delirium as a diagnosis at discharge, hospital length-of-stay, or the rates of newly started deliriogenic medications during admission between the groups. Conclusion Implementation of a delirium prevention and treatment protocol at the SAVAHCS did not significantly impact the use of deliriogenic medications in hospitalized geriatric veterans.

Delirium prevalence and delirium literacy across Italian hospital wards: a secondary analysis of data from the World Delirium Awareness Day 2023

PURPOSE

Delirium, a common medical emergency among hospitalized patients, requires effective detection and management protocols. This study aims to evaluate the delirium point prevalence and its management across Italian hospitals, categorized by delirium literacy levels. Additionally, it seeks to identify prevailing barriers and future priorities in delirium practice and research.

METHODS

We analyzed data from World Delirium Awareness Day (WDAD) on March 15th, 2023, collected by participating clinicians in Italian hospitals. High delirium literacy (HL) was determined based on the use of validated delirium assessment tools and the presence of a written protocol for delirium management. Conversely, low delirium literacy (LL) was determined by meeting only one or neither of these criteria.

RESULTS

Fifty-eight hospital wards participated in the survey, with 25 (43.1%) classified as HL. The overall reported point prevalence of delirium was found to be approximately 10%. Notably, the reported prevalence was twice as high in the HL group compared to the LL group. Despite minimal differences compared to the other group, the HL group demonstrated greater adherence to appropriate delirium management strategies, encompassing both non-pharmacological and pharmacological strategies. Critical gaps in delirium care emerged, including suboptimal management practices, barriers to implementing evidence-based strategies, and insufficient awareness and training among professionals.

CONCLUSION

The study highlights the suboptimal identification and management of delirium among Italian hospitals, emphasizing the necessity of enhancing awareness and implementing evidence-based strategies. Addressing these shortcomings is crucial for optimizing delirium care, improving patient outcomes, and mitigating the burden of delirium in hospital settings.

Retinal imaging with hand-held optical coherence tomography in older people with or without postoperative delirium after hip fracture surgery: A feasibility study

INTRODUCTION

Postoperative delirium in older people may result from the interaction between intrinsic brain vulnerability (e.g. neurodegeneration) and precipitating factors (e.g. surgery induced cytokines). Intrinsic brain vulnerability may be overt (e.g. Alzheimer's disease) or preclinical. In cognitively intact older people presenting for surgery, identification of preclinical neurodegeneration using bedside tools could aid postoperative delirium risk stratification. Thinning of the circumpapillary retinal nerve fibre layer thickness is associated with neurodegenerative disorders e.g. Alzheimer's disease. We propose that thinning of the retinal nerve fibre layer may be present some older people with postoperative delirium due to preclinical neurodegeneration, albeit to a lesser extent than in overt dementia.

OBJECTIVES

The primary objective: Feasibility of acquiring usable retinal images with the hand-held optical coherence device, at the bedside of older, hip fracture surgery patients. Secondary objective: Comparison of the circumpapillary retinal nerve fibre layer thickness between people who did/did not have postoperative delirium. Proportion of exclusions due to retinal pathology.

METHOD

Feasibility study involving 30, cognitively intact, older people recovering from hip fracture surgery. Retinal images were obtained using the hand-held optical coherence tomography device at the participants' bedside. Imaging was deferred in participants who had postoperative delirium.

RESULTS

Retinal images that could be assessed for circumpapillary retinal nerve fibre layer thickness were obtained in 26 participants (22 no postoperative delirium, 4 postoperative delirium). The mean circumpapillary retinal nerve fibre layer thickness was lower in the participants who had postoperative delirium compared to those who did not experience postoperative delirium (Mean (95% CI) of 76.50 (62.60-90.40) vs 89.19 (85.41-92.97) respectively).

CONCLUSION

Retinal imaging at the patient's bedside, using hand-held OCT is feasible. Our data suggests that the circumpapillary retinal nerve fibre layer may be thinner in older people who experience postoperative delirium compared to those who do not. Further studies are required.

Digital education about delirium for health care professional students: a mixed methods systematic review

BACKGROUND

Competence in delirium care begins with pre-registration education for health care professionals. Although a common complication for hospitalised patients, delirium is avoidable and reversible. Delirium requires early recognition in person-centred care. Students need to learn how to identify and effectively care for 'at risk' patients.

AIM

To identify and examine literature on how pre-registration health care professional students are prepared to recognise, assess, and deliver interventions to prevent delirium in practice, using digital/web based educational interventions.

METHOD

Mixed methods systematic review with narrative synthesis. A protocol was registered with PROSPERO. The review questions and search strategy were guided by the Population, Phenomena of Interest, Context (PICo) framework. The PRISMA framework guided the screening, data extraction and analysis. Database searches (MEDLINE, Web of Science, Embase, CINAHL, Cochrane Central Register of Controlled Trials, PsycINFO & Scopus) were undertaken in April 2023 for publications from 2012 to 2023. Covidence software [30] was used to extract and manage the data. Quality appraisal was guided by the Crowe Critical Appraisal Tool (CCAT) [31].

FINDINGS

Ten papers were included: mixed methods (2), qualitative (1) and quantitative (7). Medical students were the most studied group (n = 5), followed by student nurses (n = 4) and mixed nursing and medical students (n = 1). Length of learning experience varied from 12 min virtual reality (VR) to a two-week 'geriatrics' elective. Learning was enhanced by player autonomy, engagement, safety, applicability, choices, multiple perspectives and moral reasoning opportunities.

DISCUSSION

Digital programmes should be visually appealing, interactive with opportunities for practice and timely appropriate feedback.

Experiences of healthcare staff caring for hospitalised people with delirium: a qualitative systematic review

BACKGROUND

Inpatient delirium is common and associated with poor outcomes. Although most organisations have evidence-based guidelines to improve delirium prevention and management, delirium rates and outcomes have remained relatively unchanged over time. A lack of understanding of healthcare providers' experience of caring for people with delirium and its integration into existing guidance may explain some of the slow progress in improving delirium care.

OBJECTIVE

To review and synthesise existing qualitative evidence on healthcare providers' experience of caring for inpatients with delirium within and across disciplines.

METHODS

We systematically searched OVID Medline, CINAHL, Embase, Emcare, PsychINFO, AMED and Web of Science databases for articles published between January 1990 and November 2022. Article inclusion and study quality were assessed by two independent reviewers. Both thematic synthesis and content analysis were then conducted to synthesise findings from included studies.

RESULTS

Within the 25 included studies, the experience of nurses was the most commonly studied perspective, followed by medical and allied health. Nursing, medical and allied health staff all reported that their experience of caring for people with delirium was challenging, highlighting difficulties in delirium recognition and that they felt unsupported at organisational and local levels. Attitudes towards older people and the importance of delirium influenced identification and prioritisation.

CONCLUSIONS

Healthcare providers often find caring for hospitalised patients with delirium challenging and complex. Although good communication within multidisciplinary teams was deemed helpful, more work is required to understand how to achieve this, recognising the unique perspectives of individual disciplines.

Screening for Delirium During Pediatric Brain Injury Rehabilitation

OBJECTIVE

To assess feasibility of routine delirium screening using the Cornell Assessment of Pediatric Delirium (CAPD) in children admitted for rehabilitation with acquired brain injury (ABI), report on the prevalence of positive delirium screens in this population, and explore longitudinal trends in CAPD scores and their association with rehabilitation outcomes.

DESIGN

Retrospective study.

SETTING

Pediatric inpatient rehabilitation unit.

PARTICIPANTS

144 children (median 10.8 years) with ABI (N=144).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Percent compliance with twice daily delirium screening; prevalence of positive delirium screens; trajectories in CAPD scores and their relation with FIM for Children (WeeFIM) scores.

RESULTS

Screening was feasible (mean 75% compliance for each of 144 children). Of 16,136 delirium screens, 29% were positive. 62% of children had ≥1 positive screen. Four primary patterns of CAPD trajectories were identified: Static Encephalopathy (10%), Episodic Delirium (10%), Improving (32%), and No Delirium (48%). Validity of these trajectories was demonstrated through association with WeeFIM and CALS outcomes. Younger age at admission was associated with positive delirium screens, and rehabilitation length of stay was significantly longer for the Improving group.

CONCLUSIONS

Delirium occurs frequently in children with ABI during inpatient rehabilitation. Routine delirium screening provides clinically relevant information including the potential to facilitate early detection and intervention for medical complications. Longitudinal ratings of delirium symptoms may also have a role in developing a standardized definition for Post Traumatic Confusional State (PTCS) stage of recovery in children.

Delirium in the United States: Results From the 2023 Cross-Sectional World Delirium Awareness Day Prevalence Study

BACKGROUND

Delirium is an acute brain dysfunction associated with an increased risk of mortality and future dementia.

OBJECTIVES

To describe the prevalence of clinically documented delirium in the United States on World Delirium Awareness Day 2023.

METHODS

This is a sub-analysis of a prospective, cross-sectional, online, international survey. All health care settings were eligible, with the exception of operating rooms and outpatient clinics. Health care clinicians, administrators, and researchers completed the survey. The primary outcome was the prevalence of clinically documented delirium at 8:00 a.m. and 8:00 p.m. on March 15, 2023. Secondary outcomes were related to health care delivery. Descriptive statistics are reported. Differences between unit types (non-intensive care unit vs intensive care unit) were examined for all outcomes.

RESULTS

Ninety-one hospital units reported on 1318/1213 patients. The prevalence of clinically documented delirium was 16.4% (n = 216/1318) at 8:00 a.m. and 17.9% (n = 217/1213) at 8:00 p.m. (P = 0.316) and significantly differed between age groups, reported discipline, unit, and hospital types. Significant differences were identified between non-intensive care unit and intensive care unit settings in the use of delirium-related protocols, nonpharmacologic and pharmacologic management, educational processes, and barriers to evidence-based delirium care.

CONCLUSIONS

To our knowledge, this is the first epidemiologic survey of clinically documented delirium across two time points in the United States. Delirium remains a significant burden and challenge for health care systems. The high percentage of units using delirium management protocols suggests administrator and clinician awareness of evidence-based strategies for its detection and mitigation. We provide recommendations for future studies and quality improvement projects to improve clinical recognition and management of delirium.

Improving Safety and Satisfaction in the Safety Monitoring Unit

ABSTRACT

BACKGROUND: The safety monitoring unit (SMU) is a 4-bed unit designated for patients who require continual observation. Most experience some form of dementia, and agitation and aggression are not uncommon. When deescalation techniques do not work, request for help may be necessary. Referred to as Security Alert: Behavioral Assist (SABA), this system-wide message requires response from designated personnel. An increase in SABA events prompted this quality improvement project. METHODS: A survey sent to all unit staff members identified a need for specialized training on the care and management of SMU patients. Education on dementia care and deescalation techniques was provided by a certified dementia specialist and a psychiatry advanced practice registered nurse. Staff expressed a need for defined SMU admission criteria and the establishment of patient care guidelines. Patient care guidelines were developed. A structured schedule was implemented, and dedicated staff were hired to provide familiarity for patients. RESULTS: A postproject survey indicated a nonsignificant increase in staff satisfaction. Security Alert: Behavioral Assist events in the SMU decreased from an average of 3.6 to 1.75 episodes per month. CONCLUSION: Caring for SMU patients creates unique challenges to staff. Staff confidence and satisfaction were higher after implementing new SABA policies. This project could be replicated on similar units with ongoing leadership support and staff education.

Hospital Associated Disability among Older Adults with Plasma Cell Disorders Receiving Autologous Stem Cell Transplant

Increasing number of older adults with Plasma Cell Disorders (PCDs) are receiving autologous stem cell transplant (ASCT) in the US. Hospital associated disability (HAD) is a common complication associated with acute care hospitalization among older adults. To estimate the prevalence and prognostic significance of HAD among older adults with MM undergoing ASCT. This retrospective cohort study used consecutive adults ≥ 18 y with PCD receiving ASCT at a single institution between 1/2013 and 5/2023. Trained nursing staff assessed Katz Activities of Daily Living (ADL) at admission and every 3 days thereafter under our Virtual Acute Care for Elders program. The primary outcome was development of HAD defined as ≥1 point decline on the Katz Activities of Daily Living (ADL) scale from hospital admission to discharge. We examined the association between putative risk factors such as age, Karnofsky performance status (KPS), baseline ADL score, Hematopoietic Cell Transplantation-specific Comorbidity Index (HCT-CI) and HAD using modified Poisson regression models with robust variance estimators. Subsequently, we studied the impact of HAD on downstream adverse events including 30-day readmission rates and long term survival. We included 778 adults with a median age of 62 y (QR 56-68 y), with 56% males and 55% non-Hispanic Whites. In the overall population, 112 (14.4%) developed HAD, with much higher incidence among older adults ≥ 65 y compared to those <65 y at ASCT (22% vs. 9%, P value < .01). In multivariable analysis, increasing age (RR 1.56; 95% CI 1.25-1.94, per 10 y increase), female sex (RR 1.79; 95% CI 1.27-2.53) and KPS ≤ 70 (RR 2.55; 95% CI 1.32-4.94) were associated with an increased risk of developing HAD. As compared to those without, patients with HAD had a two-fold higher risk of 30-day readmission (95% CI 1.16-3.39) and a 3.7-fold increased risk of all-cause mortality (95% CI 2.15-6.22). Nearly one in 4 older adults ≥ 65 y developed HAD while undergoing ASCT which was associated with a two-fold increased risk of 30-day readmission. Interventions to prevent HAD and its downstream consequences are critically needed.

Interventions to prevent and treat delirium: An umbrella review of randomized controlled trials

Delirium is a common condition across different settings and populations. The interventions for preventing and managing this condition are still poorly known. The aim of this umbrella review is to synthesize and grade all preventative and therapeutic interventions for delirium. We searched five databases from database inception up to March 15th, 2023 and we included meta-analyses of randomized controlled trials (RCTs) to decrease the risk of/the severity of delirium. From 1959 records after deduplication, we included 59 systematic reviews with meta-analyses, providing 110 meta-analytic estimates across populations, interventions, outcomes, settings, and age groups (485 unique RCTs, 172,045 participants). In surgery setting, for preventing delirium, high GRADE evidence supported dexmedetomidine (RR=0.53; 95%CI: 0.46-0.67, k=13, N=3988) and comprehensive geriatric assessment (OR=0.46; 95%CI=0.32-0.67, k=3, N=496) in older adults, dexmedetomidine in adults (RR=0.33, 95%CI=0.24-0.45, k=7, N=1974), A2-adrenergic agonists after induction of anesthesia (OR= 0.28, 95%CI= 0.19-0.40, k=10, N=669) in children. High certainty evidence did not support melatonergic agents in older adults for delirium prevention. Moderate certainty supported the effect of dexmedetomidine in adults and children (k=4), various non-pharmacological interventions in adults and older people (k=4), second-generation antipsychotics in adults and mixed age groups (k=3), EEG-guided anesthesia in adults (k=2), mixed pharmacological interventions (k=1), five other specific pharmacological interventions in children (k=1 each). In conclusion, our work indicates that effective treatments to prevent delirium differ across populations, settings, and age groups. Results inform future guidelines to prevent or treat delirium, accounting for safety and costs of interventions. More research is needed in non-surgical settings.

Requesting That Delirium Achieve Parity With Acute Encephalopathy in the MS-DRG System

Since 2007, the Medicare Severity Diagnosis Related Groups classification system has favored billing codes for acute encephalopathy over delirium codes in determining hospital reimbursement and several quality-of-care value metrics, despite broad overlap between these sets of diagnostic codes. Toxic and metabolic encephalopathy codes are designated as major complication or comorbidity, whereas causally specified delirium codes are designated as complication or comorbidity and thus associated with a lower reimbursement and lesser impact on value metrics. The authors led a submission to the U.S. Centers for Medicare and Medicaid Services requesting that causally specified delirium be designated major complication or comorbidity alongside toxic and metabolic encephalopathy. Delirium warrants reclassification because it satisfies U.S. Centers for Medicare and Medicaid Services' guiding principles for re-evaluating Medicare Severity Diagnosis Related Group severity levels. Delirium: (1) has a bidirectional relationship with the permanent condition of dementia (major neurocognitive disorder per DSM-5-TR), (2) indexes vulnerability across populations, (3) impacts healthcare systems across levels of care, (4) complicates postoperative recovery, (5) consigns patients to higher levels of care, (6) impedes patient engagement in care, (7) has several recent treatment guidelines, (8) often indicates neuronal/brain injury, and (9) represents a common expression of terminal illness. The proposal's impact was explored using the 2019 National Inpatient Sample, which suggested that increasing delirium's complexity designation would lead to an upcoding of less than 1% of eligible discharges. Parity for delirium is essential to enhancing awareness of delirium's clinical and economic costs. Appreciating delirium's impact would encourage delirium prevention and screening efforts, thereby mitigating its dire outcomes for patients, families, and healthcare systems.

Introducing a machine learning algorithm for delirium prediction-the Supporting SURgery with GEriatric Co-Management and AI project (SURGE-Ahead)

INTRODUCTION

Post-operative delirium (POD) is a common complication in older patients, with an incidence of 14-56%. To implement preventative procedures, it is necessary to identify patients at risk for POD. In the present study, we aimed to develop a machine learning (ML) model for POD prediction in older patients, in close cooperation with the PAWEL (patient safety, cost-effectiveness and quality of life in elective surgery) project.

METHODS

The model was trained on the PAWEL study's dataset of 878 patients (no intervention, age ≥ 70, 209 with POD). Presence of POD was determined by the Confusion Assessment Method and a chart review. We selected 15 features based on domain knowledge, ethical considerations and a recursive feature elimination. A logistic regression and a linear support vector machine (SVM) were trained, and evaluated using receiver operator characteristics (ROC).

RESULTS

The selected features were American Society of Anesthesiologists score, multimorbidity, cut-to-suture time, estimated glomerular filtration rate, polypharmacy, use of cardio-pulmonary bypass, the Montreal cognitive assessment subscores 'memory', 'orientation' and 'verbal fluency', pre-existing dementia, clinical frailty scale, age, recent falls, post-operative isolation and pre-operative benzodiazepines. The linear SVM performed best, with an ROC area under the curve of 0.82 [95% CI 0.78-0.85] in the training set, 0.81 [95% CI 0.71-0.88] in the test set and 0.76 [95% CI 0.71-0.79] in a cross-centre validation.

CONCLUSION

We present a clinically useful and explainable ML model for POD prediction. The model will be deployed in the Supporting SURgery with GEriatric Co-Management and AI project.

Dementia Prevention and Treatment: A Narrative Review

Importance

Dementia affects 10% of those 65 years or older and 35% of those 90 years or older, often with profound cognitive, behavioral, and functional consequences. As the baby boomers and subsequent generations age, effective preventive and treatment strategies will assume increasing importance.

Observations

Preventive measures are aimed at modifiable risk factors, many of which have been identified. To date, no randomized clinical trial data conclusively confirm that interventions of any kind can prevent dementia. Nevertheless, addressing risk factors may have other health benefits and should be considered. Alzheimer disease can be treated with cholinesterase inhibitors, memantine, and antiamyloid immunomodulators, with the last modestly slowing cognitive and functional decline in people with mild cognitive impairment or mild dementia due to Alzheimer disease. Cholinesterase inhibitors and memantine may benefit persons with other types of dementia, including dementia with Lewy bodies, Parkinson disease dementia, vascular dementia, and dementia due to traumatic brain injury. Behavioral and psychological symptoms of dementia are best treated with nonpharmacologic management, including identifying and mitigating the underlying causes and individually tailored behavioral approaches. Psychotropic medications have minimal evidence of efficacy for treating these symptoms and are associated with increased mortality and clinically meaningful risks of falls and cognitive decline. Several emerging prevention and treatment strategies hold promise to improve dementia care in the future.

Conclusions and Relevance

Although current prevention and treatment approaches to dementia have been less than optimally successful, substantial investments in dementia research will undoubtedly provide new answers to reducing the burden of dementia worldwide.

The research progress of perioperative non-pharmacological interventions on postoperative cognitive dysfunction: a narrative review

Postoperative cognitive dysfunction (POCD) is a common neurological complication in elderly patients after surgery and general anesthesia. The occurrence of POCD seriously affects the postoperative recovery of patients, and leads to prolonged hospital stay, reduced quality of life, increased medical costs, and even higher mortality. There is no definite and effective drug treatment for POCD. More evidence shows that perioperative non-pharmacological intervention can improve postoperative cognitive function and reduce the incidence of POCD. Therefore, our studies summarize the current non-pharmacological interventions of POCD from the aspects of cognitive training, physical activity, transcutaneous electrical acupoint stimulation, noninvasive brain stimulation, non-pharmacological sleep improvement, music therapy, environment, and multimodal combination Interventions, to provide more data for clinical application and research.

Effect of thoracic paravertebral nerve block on delirium in patients after video-assisted thoracoscopic surgery: a systematic review and meta-analysis of randomized controlled trials

Background

Nerve blocks are widely used in various surgeries to alleviate postoperative pain and promote recovery. However, the impact of nerve block on delirium remains contentious. This study aims to systematically evaluate the influence of Thoracic Paravertebral Nerve Block (TPVB) on the incidence of delirium in patients post Video-Assisted Thoracoscopic Surgery (VATS).

Methods

We conducted a systematic search of PubMed, Embase, Web of Science, Cochrane Library, and Scopus databases in June 2023. The search strategy combined free-text and Medical Subject Headings (MeSH) terms, including perioperative cognitive dysfunction, delirium, postoperative cognitive dysfunction, paravertebral nerve block, thoracic surgery, lung surgery, pulmonary surgery, and esophageal/esophagus surgery. We utilized a random effects model for the analysis and synthesis of effect sizes.

Results

We included a total of 9 RCTs involving 1,123 participants in our study. In VATS, TPVB significantly reduced the incidence of delirium on postoperative day three (log(OR): -0.62, 95% CI [-1.05, -0.18], p = 0.01, I2 = 0.00%) and postoperative day seven (log(OR): -0.94, 95% CI [-1.39, -0.49], p < 0.001, I2 = 0.00%). Additionally, our study indicates the effectiveness of TPVB in postoperative pain relief (g: -0.82, 95% CI [-1.15, -0.49], p < 0.001, I2 = 72.60%).

Conclusion

The comprehensive results suggest that in patients undergoing VATS, TPVB significantly reduces the incidence of delirium and notably diminishes pain scores.

Systematic review registration

CRD42023435528. https://www.crd.york.ac.uk/PROSPERO.

TAVR in Older Adults: Moving Toward a Comprehensive Geriatric Assessment and Away From Chronological Age: JACC Family Series

Calcific aortic stenosis can be considered a model for geriatric cardiovascular conditions due to a confluence of factors. The remarkable technological development of transcatheter aortic valve replacement was studied initially on older adult populations with prohibitive or high-risk for surgical valve replacement. Through these trials, the cardiovascular community has recognized that stratification of these chronologically older adults can be improved incrementally by invoking the concept of frailty and other geriatric risks. Given the complexity of the aging process, stratification by chronological age should only be the initial step but is no longer sufficient to optimally quantify cardiovascular and noncardiovascular risk. In this review, we employ a geriatric cardiology lens to focus on the diagnosis and the comprehensive management of aortic stenosis in older adults to enhance shared decision-making with patients and their families and optimize patient-centered outcomes. Finally, we highlight knowledge gaps that are critical for future areas of study.

Validation of a viable delirium detection test performed by nurses and physicians during routine patient care

BACKGROUND

Delirium is a frequent mental impairment in geriatric patients hospitalized in acute care facilities. It carries a high risk of complications and is often the first symptom of acute illness. It is clearly important to identify the development of delirium at an early stage, and several short and effective diagnostic tests have been developed and validated for this purpose. Despite this, patients on hospital wards are seldom monitored for signs of emergent delirium, suggesting that compliance with guidelines would be improved by introducing a simpler and more user-friendly test.

METHODS

We recently implemented a simple delirium assessment tool, called RMA that can be introduced into the daily routine of ward staff without significantly adding to their workload. The nurses noted their impression of the patient's cognitive state in the electronic medical record, and during the morning round the ward physician administered a short attention test to any patients suspected of new cognitive impairment. In this study, we compared RMA test against the widely used and well validated 4AT.

RESULTS

RMA performed daily by the ward staff was found to be non-inferior to 4AT performed by an experienced rater. Compared to 4AT, R&M had a sensitivity of 93.9% and a specificity of 98.3%. An Altman-Bland plot indicated that both tests can be used interchangeably.

CONCLUSIONS

The RMA test is reliable, easy to administer, likely to boost compliance with guidelines, and is expected to raise awareness of delirium among the nurses and physicians directly involved in the diagnostic process.

Delirium and incident dementia in hospital patients in New South Wales, Australia: retrospective cohort study

OBJECTIVES

To determine the strength and nature of the association between delirium and incident dementia in a population of older adult patients without dementia at baseline.

DESIGN

Retrospective cohort study using large scale hospital administrative data.

SETTING

Public and private hospitals in New South Wales, Australia between July 2001 and March 2020.

PARTICIPANTS

Data were extracted for 650 590 hospital patients aged ≥65 years. Diagnoses of dementia and delirium were identified from ICD-10 (international classification of diseases, 10th revision) codes. Patients with dementia at baseline were excluded. Delirium-no delirium pairs were identified by matching personal and clinical characteristics, and were followed for more than five years.

MAIN OUTCOME MEASURES

Cox proportional hazards models and Fine-Gray hazard models were used to estimate the associations of delirium with death and incident dementia, respectively. Delirium-outcome dose-response associations were quantified, all analyses were performed in men and women separately, and sensitivity analyses were conducted.

RESULTS

The study included 55 211 matched pairs (48% men, mean age 83.4 years, standard deviation 6.5 years). Collectively, 58% (n=63 929) of patients died and 17% (n=19 117) had a newly reported dementia diagnosis during 5.25 years of follow-up. Patients with delirium had 39% higher risk of death (hazard ratio 1.39, 95% confidence interval 1.37 to 1.41) and three times higher risk of incident dementia (subdistribution hazard ratio 3.00, 95% confidence interval 2.91 to 3.10) than patients without delirium. The association with dementia was stronger in men (P=0.004). Each additional episode of delirium was associated with a 20% increased risk of dementia (subdistribution hazard ratio 1.20, 95% confidence interval 1.18 to 1.23).

CONCLUSIONS

The study findings suggest delirium was a strong risk factor for death and incident dementia among older adult patients. The data support a causal interpretation of the association between delirium and dementia. The clinical implications of delirium as a potentially modifiable risk factor for dementia are substantial.

Effect of hospital elder life program on the incidence of delirium: A systematic review and meta-analysis of clinical trials

OBJECTIVE

This meta-analysis aims to investigate the effect of the Hospital Elder Life Program (HELP) on the incidence of delirium, delirium scores, length of hospital stay, and incidence of falls.

METHODS

Four databases (PubMed, Embase, Cochrane Library, and Web of Science) were searched from inception until January 18, 2024. The search specifically targeted randomized controlled trials (RCTs). Two independent researchers conducted literature screening, quality assessment, and data extraction. The meta-analysis was performed using Review Manager 5.4.1 and Stata 15.1 software.

RESULTS

The final analysis included a total of 9 RCTs with 2583 patients. The findings from the meta-analysis indicated that HELP was found to considerably reduce the incidence of delirium and the length of hospital stay when compared to the control group. Nevertheless, no statistically significant differences were observed between the two groups in terms of delirium scores and fall rates.

CONCLUSION

In this meta-analysis, HELP can effectively reduce the incidence of delirium and lead to a shorter hospital stay.

Does Comprehensive Geriatric Assessment Reduce the Incidence of Postoperative Delirium? A Quasi-experimental Study in Older Adults Undergoing Transcatheter Aortic Valve Implantation

Purpose

Postoperative delirium (POD) after transcatheter aortic valve implantation (TAVI) is frequent in older adults and associated with multiple negative outcomes including a higher mortality. We aimed to investigate whether a comprehensive geriatric assessment (CGA) prior to TAVI reduces the odds of POD and results in a positive change in self-care ability, intended to lay a foundation for future geriatric comanagement.

Patients and methods

We used a retrospective, single-center study with a quasi-experimental design enrolling patients aged 70 years and older undergoing CGA before elective TAVI, and a nonrandomized comparison group without preoperative CGA. Data on POD occurrence during the first 5 days after TAVI (primary outcome) and change in self-care ability index (SPI) between admission and discharge (secondary outcome) were collected from electronic health records and CGA data (exposure) by clinical assessment. To explore associations between (1) CGA and POD, and (2) CGA and SPI, multivariate logistic regression and linear regression models were applied adjusting for age, sex, BMI, and number of medications.

Results

Among 435 patients (mean age 81.0 ± 5.6 years, 43.6% women, median [IQR] SPI at baseline 40 [39, 40] points), POD incidence was 14.3% in the CGA group vs 18.8% in the non-CGA group (P 0.219). Undergoing CGA before TAVI was not associated with the odds for POD (OR: 1.15; 95%CI: 0.65-2.04) or improved SPI (P 0.073).

Conclusion

We observed no association of CGA prior to TAVI with POD incidence or postoperative self-care, highlighting the need for additional studies investigating the effect of POD preventive measures in older TAVI patients integrated into a comprehensive geriatric comanagement program.

Night-Time Noise and Sleep Quality in an Internal Medicine Ward in Portugal: An Observational Study

INTRODUCTION

Hospitals should provide a quiet environment to promote patient healing and well-being. However, published data indicates that World Health Organization's guidelines are frequently not met. The aim of the present study was to quantify night-time noise levels in an internal medicine ward and evaluate sleep quality, as well as the use of sedative drugs.

MATERIAL AND METHODS

Prospective observational study in an acute internal medicine ward. Between April 2021 and January 2022, on random days, noise was recorded using a smartphone app (Apple® iOS, Decibel X). Night-time noise was recorded from 10 p.m. to 8 a.m. During the same period, hospitalized patients were invited to respond to a questionnaire regarding their sleep quality.

RESULTS

A total of 59 nights were recorded. The average noise level recorded was 55 dB with a minimum of 30 dB and a maximum of 97 dB. Fifty-four patients were included. An intermediate score for night-time sleep quality (35.45 out of 60) and noise perception (5.26 out of 10) was reported. The main reasons for poor sleep were related to the presence of other patients (new admission, acute decompensation, delirium, and snoring), followed by equipment, staff noise and surrounding light. Nineteen patients (35%) were previous users of sedatives, and during hospitalization 41 patients (76%) were prescribed sedatives.

CONCLUSION

The noise levels detected in the internal medicine ward were higher than the levels recommended by the World Health Organization. Most patients were prescribed sedatives during hospitalization.

Development of a decision-support framework to support professionals and promote comfort among older hospital inpatients living with dementia

BACKGROUND

Acute hospital wards can be difficult places for many people living with dementia. Promoting comfort and wellbeing can be challenging in this environment. There is little evidence-based support for professionals working on acute care wards on how to respond to distress and maximise comfort and wellbeing among patients living with dementia.

OBJECTIVES

Our overall aim was to codesign an evidence-based easy-to-use heuristic decision-support framework, which was acceptable and practical but acknowledges the complex and acute nature of caring for patients with dementia in the hospital. This paper presents the development process and resulting framework.

METHODS

A codesign study was informed by data from (1) a literature review of the care and management of people living with dementia in acute hospitals; (2) a cohort study of comfort and discomfort in people with dementia in acute hospitals; and (3) interviews with family carers and health care professionals. We synthesised evidence from these data sources and presented to key stakeholders through codesign meetings and workshops to produce our decision-support framework.

RESULTS

The framework consists of a series of flowcharts and operates using a three-stage process of: (1) assess comfort/discomfort; (2) consider causes of discomfort; and (3) address patient needs to manage the discomfort.

CONCLUSION

Working with key stakeholders, synthesising diverse quantitative and qualitative evidence to build a clinical framework is a feasible approach to help address the needs of patients living with dementia in an acute hospital setting. The result is a framework which is now ready for evaluation and implementation.

PATIENT AND PUBLIC CONTRIBUTION

We worked closely with people living with dementia and family carers throughout this study, including the development of the study protocol with input on study development and design, through to inclusion in stakeholder workshops and codesign of the decision support framework.

Development and evaluation of a concise nurse-driven non-pharmacological delirium reduction workflow for hospitalized patients: An interrupted time series study

We created a concise nurse-driven delirium reduction workflow with the aim of reducing delirium rates and length of stay for hospitalized adults. Our nurse-driven workflow included five evidence-based daytime "sunrise" interventions (patient room lights on, blinds up, mobilization/out-of-bed, water within patient's reach and patient awake) and five nighttime "turndown" interventions (patient room lights off, blinds down, television off, noise reduction and pre-set bedtime). Interventions were also chosen because fidelity could be quickly monitored twice daily without patient interruption from outside the room. To evaluate the workflow, we used an interrupted time series study design between 06/01/17 and 05/30/22 to determine if the workflow significantly reduced the unit's delirium rate and average length of stay. Our workflow is feasible to implement and monitor and initially significantly reduced delirium rates but not length of stay. However, the reduction in delirium rates were not sustained following the emergence of the COVID-19 pandemic.

Optimizing delirium care in the era of Age-Friendly Health System

Delirium is a significant geriatric condition associated with adverse clinical and economic outcomes. The cause of delirium is usually multifactorial, and person-centered multicomponent approaches for proper delirium management are required. In 2017, the John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI) launched a national initiative, Age-Friendly Health System (AFHS), promoting the use of a framework called 4Ms (what matters, medication, mentation, and mobility). The 4Ms framework's primary goal is to provide comprehensive and practical person-centered care for older adults and it aligns with the core concepts of optimal delirium management. In this special article, we demonstrate how a traditional delirium prevention and management model can be assessed from the perspective of AFHS. An example is the crosswalk with the Hospital Elder Life Program (HELP) Core Interventions and the 4MS, which demonstrates alignment in delirium management. We also introduce useful tools to create an AFHS environment in delirium management. Although much has been written about delirium management, there is a need to identify the critical steps in advancing the overall delirium care in the context of the AFHS. In this article, we suggest future directions, including the need for more prospective and comprehensive research to assess the impact of AFHS on delirium care, the need for more innovative and sustainable education platforms, fundamental changes in the healthcare payment system for proper adoption of AFHS in any healthcare setting, and application of AFHS in the community for continuity of care for older adults with delirium.

Risk factors, preventive interventions, overlapping symptoms, and clinical measures of delirium in elderly patients

Delirium is an acute reversible neuropsychiatric syndrome caused by multiple factors. It is associated with many adverse clinical outcomes including cognitive impairment, functional decline, prolonged hospitalization, and increased nursing service. The prevalence of delirium was high in department of cardiology, geriatric, and intensive care unit of hospital. With the increase in the aged population, further increases in delirium seem likely. However, it remains poorly recognized in the clinical practice. This article comprehensively discusses the latest research perspectives on the epidemiological data, risk factors, preventive interventions, overlapping symptoms, and clinical measures of delirium, including specific measures to manage delirium in clinical real-world situations. This article helps readers improve their knowledge and understanding of delirium and helps clinicians quickly identify and implement timely therapeutic measures to address various delirium subtypes that occur in the clinical settings to ensure patients are treated as aggressively as possible.

The frail patient undergoing cardiac surgery: lessons learned and future perspectives

Frailty is a geriatric condition characterized by the reduction of the individual's homeostatic reserves. It determines an increased vulnerability to endogenous and exogenous stressors and can lead to poor outcomes. It is an emerging concept in perioperative medicine, since an increasing number of patients undergoing surgical interventions are older and the traditional models of care seem to be inadequate to satisfy these patients' emerging clinical needs. Nowadays, the progressive technical and clinical improvements allow to offer cardiac operations to an older, sicker and frail population. For these reasons, a multidisciplinary team involving cardiac surgeons, clinical cardiologists, anesthesiologists, and geriatricians, is often needed to assess, select and provide tailored care to these high-risk frail patients to optimize clinical outcomes. There is unanimous agreement that frailty assessment may capture the individual's biological decline and the heterogeneity in risk profile for poor health-related outcomes among people of the same age. However, since commonly used preoperative scores for cardiac surgery fail to capture frailty, a specific preoperative assessment with dedicated tools is warranted to correctly recognize, measure and quantify frailty in these patients. On the contrary, pre-operative and post-operative interventions can reduce the risk of complications and support patient recovery promoting surgical resilience. Minimally invasive cardiac procedures aim to reduce surgical trauma and may be associated with better clinical outcome in this specific sub-group of high-risk patients. Among postoperative adverse events, the occurrence of delirium represents a risk factor for several unfavorable outcomes including mortality and subsequent cognitive decline. Its presence should be carefully recognized, triggering an adequate, evidence based, treatment. There is evidence, from several cross-section and longitudinal studies, that frailty and delirium may frequently overlap, with frailty serving both as a predisposing factor and as an outcome of delirium and delirium being a marker of a latent condition of frailty. In conclusion, frail patients are at increased risk to experience poor outcome after cardiac surgery. A multidisciplinary approach aimed to recognize more vulnerable individuals, optimize pre-operative conditions, reduce surgical invasivity and improve post-operative recovery is required to obtain optimal long-term outcome.

Risk factors for delirium among hospitalized adults with COVID-19: A systematic review and meta-analysis of cohort studies

OBJECTIVES

This study aims to systematically assess the risk factors, the overall strength of association, and evidence quality related to delirium among adults hospitalized with COVID-19.

METHODS

A comprehensive search was conducted in thirteen databases from inception to February 10, 2023. The included databases were thoroughly searched, including PubMed, Web of Science, Proquest, Ovid MEDLINE, CINAHL, Scopus, the Cochrane Library, FMRS, Wanfang Database, Chinese Biomedical Database (CBM), China Knowledge Resource Integrated Database (CNKI), Weipu Database (VIP), and Embase. The search was limited to articles published in English and Chinese. The selected studies were screened, data were extracted, and the quality was evaluated using the Newcastle-Ottawa Scale. Meta-analysis was performed using RevMan 5.4 software. The certainty of the evidence was assessed using the GRADE criteria.

RESULTS

A total of 22 cohort studies with a sample size of 11,957 individuals were included in the analysis. Among these studies, 20 were of high quality, while the remaining 2 were of moderate quality. The risk factors that showed the strongest association with delirium were prior cognitive impairment (including dementia), mechanical ventilation, and ICU admission. Age, frailty (Clinical Frailty Scale score > 5), antipsychotic use, benzodiazepine use, neutrophil-to-lymphocyte ratio, and vasopressor use were identified as moderate risk factors for delirium. According to the GRADE evaluation, ICU admission, benzodiazepine use, neutrophil-to-lymphocyte ratio, and vasopressor use had a high-quality body of evidence, while antipsychotic usage had an intermediate-quality body of evidence. All other risk factors had a low-quality body of evidence.

CONCLUSIONS

This systematic review and meta-analysis identified several medium- to high-intensity risk factors for delirium in hospitalized adults with COVID-19. ICU admission, benzodiazepine usage, neutrophil-to-lymphocyte ratio, antipsychotic use, and vasopressor use were associated with delirium and were supported by medium- to high-quality evidence. These findings provide healthcare professionals with an evidence-based basis for managing and treating delirium in hospitalized adults with COVID-19.

Delirium in older adults after percutaneous coronary intervention: Prevalence, risks, and clinical phenotypes

INTRODUCTION

In-hospital delirium is more common among older adults and is associated with increased mortality and adverse health-related outcomes. We aim to establish the contemporary prevalence of delirium among older adults undergoing percutaneous coronary intervention (PCI) and the impact of delirium on in-hospital complications.

METHODS

We identified older adults aged ≥75 years in the National Inpatient Sample who underwent inpatient PCI for any reason from 2016 to 2020 and stratified them into those with and without delirium. The primary outcome was in-hospital mortality, and secondary outcomes encompassed post-procedural complications.

RESULTS

Delirium occurred in 14,130 (2.6 %) hospitalizations in which PCI was performed. Patients who developed delirium were older and had more comorbidities. Patients with in-hospital delirium had higher odds of in-hospital mortality (adjusted odds ratio [aOR] 1.27, p = 0.002) and non-home discharge (aOR 3.17, p < 0.001). Delirium was also associated with higher odds of intracranial hemorrhage (aOR 2.49, p < 0.001), gastrointestinal hemorrhage (aOR 1.25, p = 0.030), need for blood transfusion (aOR 1.52, p < 0.001), acute kidney injury (aOR 1.62, p < 0.001), and fall in hospital (aOR 1.97, p < 0.001).

CONCLUSION

Delirium among older adults undergoing PCI is relatively common and associated with higher odds of in-hospital mortality and adverse events. This highlights the importance of vigilant delirium prevention and early recognition in the peri-procedural setting, especially for older adults.

Non-pharmacological interventions to prevent and treat delirium in older people: An overview of systematic reviews

BACKGROUND

As advanced age is a major risk factor for confusion status, delirium has become prevalent in the older population, contributing to longer hospital stays, cognitive impairment, and higher risks of complications and mortality. Compared with pharmacological methods, non-pharmacological interventions are preferred and are recommended by the National Institute for Health and Care Excellence for the prevention of delirium. Numerous systematic reviews and meta-analyses have been carried out to investigate the effects of non-pharmacological interventions. However, the outcomes were diverse and the quality varied widely, making it challenging to draw firm conclusions from the evidence.

OBJECTIVE

To summarize the contents and evaluate the effects of non-pharmacological interventions to prevent and treat delirium among older people.

DESIGN

Overview of systematic reviews.

METHODS

A comprehensive literature search was conducted in Medline, Cochrane Library, EMBASE, CINAHL, PsycINFO, JBI EBP Database, China's SinoMed, CNKI, and Wangfang databases from inception to 2nd December 2022. Two reviewers performed the study selection, quality appraisal, and data extraction independently. The AMSTAR 2 tool was used to appraise the methodological quality of eligible reviews. The results were presented in narrative synthesis based on types of intervention, including multicomponent and single-component interventions.

RESULTS

Twenty-four systematic reviews were included in this overview, of which four reviews were of high quality. Multicomponent interventions were the most widely disseminated non-pharmacological strategy, which were effective in preventing delirium with 27 %-54 % reduction in delirium incidence. Additionally, the multicomponent strategy also reduced the incidence of falls and pressure ulcers, and showed trends toward shortening the length of stay and improving cognitive function. Among single-component interventions, physical training, geriatric risk assessment, and reorientation protocol revealed positive effects in delirium prevention. However, the effectiveness of non-pharmacological interventions for treating delirium was limited, and while multicomponent methods had inconsistent impacts on the duration and severity of delirium, single-component methods showed no significant impact.

CONCLUSION

Non-pharmacological interventions are effective in reducing the incidence of delirium and improving other health outcomes among older patients. However, the effects on the duration and severity of delirium need more evidence to confirm.

REGISTRATION NUMBER

CRD42022376651 in PROSPERO.

Optimizing the Care of Persons Living with Dementia in the Emergency Department

Emergency department (ED) care for persons living with dementia (PLWD) involves the identification of dementia or cognitive impairment, ED care which is sensitive to the specific needs of PLWD, effective communication with PLWD, their care partners, and outpatient clinicians who the patient and care-partner know and trust, and care-transitions from the emergency department to other health care settings. The recommendations in this article made based on wide-ranging heterogeneous studies of various interventions which have been studied primarily in single-site studies. Future research should work to incorporate promising findings from interventions such as hospital at home, or ED to home Care Transitions Intervention.

Association between the Neutrophil-to-Lymphocyte Ratio and Inpatient Mortality in Hospitalized Older Veterans with COVID-19 Infection

OBJECTIVES

Determine the association of high neutrophil-to-lymphocyte ratio (NLR) values with inpatient mortality and other outcomes in older veterans hospitalized with coronavirus disease 2019 (COVID-19).

METHODS

This was a retrospective, multicenter, cohort study of hospitalized adults, with laboratory-confirmed COVID-19 infection who were studied for 1 year after discharge or until death. The NLR was categorized into tertiles, and we determined frailty status with the 31-item Veterans Affairs Frailty Index. Multivariate logistic regression and adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were performed to assess the association between NLR and clinical outcomes.

RESULTS

The study included 615 hospitalized adult veterans, mean age 66.12 (standard deviation 14.79) years, 93.82% (n = 577) male, 57.56% (n = 354) White, 81.0% (n = 498) non-Hispanic, median body mass index of 30.70 (interquartile range 25.64-34.99, standard deviation 7.13), and median length of stay of 8 days (interquartile range 3-15). Individuals in the middle and upper tertile groups had higher inpatient mortality (8.37%, n = 17 and 18.36%, n = 38, respectively) as compared with the lower tertile (2.93%, n = 6, P < 0.001). Compared with the lowest tertile, the middle and upper tertiles had a higher risk of inpatient mortality (aOR 3.75, 95% CI 1.38-10.21, P = 0.01, and aOR 8.13, 95% CI 3.18-20.84, P < 0.001, respectively). The highest tertile had a higher odds of intensive care unit admission (aOR 4.47, 95% CI 2.33-8.58, P < 0.001) and intensive care unit transfer (aOR 3.54, 95% CI 1.84-6.81, P < 0.001).

CONCLUSIONS

The NLR score is a clinically useful tool to predict in-hospital mortality in older patients with COVID-19.

In defence of falling: the onomastics and ethics of "therapeutic" falls in rehabilitation

Aim: Despite efforts towards a more just culture, rehabilitation providers still experience shame and trauma when their patients fall. This paper proposes a shift in philosophy in how we classify, communicate and learn from falls, and joins the growing literature in which falls in rehab are not seen as something to be avoided at all costs, but rather as part of the recovery journey for some patients.Methods: Patients who understand and are willing to take on the risks of falling are more likely to collaborate with their care team to practice higher-risk activities, such as walking to the bathroom independently at night, as part of their recovery. If a fall takes place in this context, we argue that it should be considered a "therapeutic" fall.Results: This paper details some of the clinical and ethical approaches to supporting a care environment where values-and potential conflicts-about the benefits and challenges of risk-taking are recognized. An expanded concept of a therapeutic fall may help patients and providers take a more balanced and nuanced approach to promoting safety while maximising independence.Conclusion: The goal of this work is to offer rehabilitation patients greater opportunities to make autonomous decisions about their mobility, and lay the groundwork for a more successful transition home.IMPLICATIONS FOR REHABILITATIONDespite best efforts, patients are often less active than they or their rehabilitation team might wish them to be.An expanded concept of a "therapeutic" fall may help patients and providers take a more balanced and nuanced approach to promoting safety while maximising independence.Rehabilitation is the right environment to support shared decision-making about risk that better prepares patients and families for the often challenging transition back to community living.This works represents a shift in philosophy in how we classify, communicate and learn from falls, and joins the growing literature in which falls are not something to be avoided at all costs, but can instead be part of the journey to recovery.

Predictive Strategies to Reduce the Risk of Rehospitalization with a Focus on Frail Older Adults: A Narrative Review

Frailty is a geriatric syndrome that has physical, cognitive, psychological, social, and environmental components and is characterized by a decrease in physiological reserves. Frailty is associated with several adverse health outcomes such as an increase in rehospitalization rates, falls, delirium, incontinence, dependency on daily living activities, morbidity, and mortality. Older adults may become frailer with each hospitalization; thus, it is beneficial to develop and implement preventive strategies. The present review aims to highlight the epidemiological importance of frailty in rehospitalization and to compile predictive strategies and related interventions to prevent hospitalizations. Firstly, it is important to identify pre-frail and frail older adults using an instrument with high validity and reliability, which can be a practically applicable screening tool. Comprehensive geriatric assessment-based care is an important strategy known to reduce morbidity, mortality, and rehospitalization in older adults and aims to meet the needs of frail patients with a multidisciplinary approach and intervention that includes physiological, psychological, and social domains. Moreover, effective multimorbidity management, physical activity, nutritional support, preventing cognitive frailty, avoiding polypharmacy and anticholinergic drug burden, immunization, social support, and reducing the caregiver burden are other recommended predictive strategies to prevent post-discharge rehospitalization in frail older adults.

Establishing and sustaining an acute care for elders unit: An incremental journey to success

Acute Care for Elders (ACE) units reduce hospital-associated delirium, functional decline, and lengths of stay. However, establishing and sustaining such units have proven difficult. There are only 43 ACE units among the >3500 hospitals in the United States. This study describes an iterative quality improvement process, which allowed us to establish and sustain an ACE unit care model in a modern academic hospital. This continuous process was centered on implementing the key principles of the ACE unit model of care: patient-centered care assessments, medical care review, specialized prepared environment, early mobilization, physical therapy, and early planning for discharge to home. Quality of care and patient outcomes data for older adults admitted to our ACE unit includes mortality index (observed/expected) consistently <1 (FY22 = 0.86), 30-day readmission rate of <10% (FY22 9.31%), and length of stay index of ~1 (FY22 1.07). We describe how work on our ACE unit has led to hospital-wide initiatives, including dementia-friendly hospital certification. Our hope is that others can use this process to enhance the dissemination of the ACE unit model of care.

The Thalamus in Perioperative Neurocognitive Disorders

Thalamus function and structure are known predictors of individual differences in the risk of age-related neurocognitive disorders (NCD), such as dementia. However, to date, little is known about their role in the perioperative setting. Here, we provide a narrative review of brain-imaging studies of preoperative and postoperative thalamus scanning parameters associated with risks of developing perioperative NCD, such as postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) during the postoperative phase. These findings are discussed in light of the concept of reserve capacity.

Nurses' perceptions of using volunteer support in health care settings: A systematic scoping review

AIMS

To understand nurses' perceptions of volunteer support in health care settings.

BACKGROUND

Increasingly, volunteers provide specialised support to health care service users, requiring volunteers and nurses to work closely together. However, little is known about nurses' perceptions of volunteer support.

METHODS

A scoping review was conducted following the PRISMA-ScR checklist. A mixed-methods convergent integrative approach was taken guided by the JBI framework. Quantitative data were transformed into qualitative data for synthesis and descriptive thematic analysis. Six databases were searched (CINHAL+, EMBASE, PubMed, Scopus, PsycInfo, ProQuest Health and Medical Collection) on 24 January 2022 using terms related to nurses, perceptions, volunteers and care settings, followed by a manual search. The search was limited to English language articles published during 2000-2022. Studies were included if they reported nurses' perceptions of volunteers supporting care within any health care setting.

RESULTS

Of the 943 records identified, 12 met the inclusion criteria. All 12 were included in the review following critical appraisal. Five themes were identified: perceived benefits for patients, volunteers providing support for nursing staff, nurses' valuing volunteer support, nurses' understanding of the volunteer role and nurses' understanding of recruitment and training of volunteers.

CONCLUSION

Nurses generally viewed volunteer support positively and perceived that it benefitted patients and assisted nurses. Some nurses raised concerns about the burden of additional supervision of volunteers and lacked knowledge of the volunteer role, recruitment and training. Emerging innovative models of nurse-led volunteer support can maximise the contribution of volunteers and help overcome barriers to volunteer acceptance.

IMPLICATIONS

These findings will inform volunteer policies and provide guidance in developing volunteer support programs.

Hip fractures in the older adult: orthopaedic and geriatric shared care model in Southland, New Zealand-a 5-year follow-up study

BACKGROUND

Neck of femur fractures are common with associated high morbidity and mortality rates. National standards include provision of orthogeriatric care to any patient with a hip fracture. This study assessed the outcomes at 5 years following implementation of a collaborative orthogeriatric service at Southland Hospital in 2012.

METHODS

Retrospective data were collected for patients aged 65 years and older admitted with a fragility hip fracture. Data were collated for 2011 (preimplementation) and 2017 (postimplementation). Demographic data and American Society of Anesthesiologists (ASA) scores were recorded to ensure comparability of the patient groups. Length of stay, postoperative complications and 30-day and 1-year mortality were assessed.

RESULTS

74 admissions with mean age at surgery of 84.2 years in 2011 and 107 admissions with mean age of 82.6 years in 2017. There was a higher proportion of ASA 2 and ASA 3 patients in 2017 compared with 2011 (p=0.036). The median length of stay in the orthopaedic ward was unchanged in the two cohorts but there was a shorter median length of stay by 6.5 days and mean length of stay by 11 days in 2017 in the rehabilitation ward (p<0.001 for both median and mean). Through logistic regression controlling for age, sex and ASA score, there was a reduction in the odds of having a complication by 12% (p<0.001). The study was too small to undertake statistical testing to calculate significant difference in overall 30-day and 1-year mortality between the groups.

CONCLUSION

The orthogeriatric service has reduced the frequency of complications and length of stay on the rehabilitation ward 5 years following implementation.

Update on Perioperative Delirium

A strong association between frailty and in-hospital delirium in nonsurgical patients has been shown. Physical and cognitive frailties have been associated with decline and dysfunction in the frontal cognitive domains. Risk factors for frailty are similar to risk factors for postoperative delirium (POD). Frailty can be screened and diagnosed by various tools and instruments. Different anesthetic techniques have been studied to decrease the incidence of POD. However, no anesthetic technique has been conclusively proven to decrease the risk of POD. Patients with dementia develop delirium more often, and delirium is associated with accelerated cognitive decline.

Psoas Muscle Index as a Predictor of Perioperative Outcomes in Geriatric Patients Undergoing Spine Surgery

STUDY DESIGN

Single-center retrospective study.

OBJECTIVE

The objective of this study was to evaluate the association of psoas muscle mass defined sarcopenia with perioperative outcomes in geriatric patients undergoing elective spine surgery.

METHODS

We included geriatric patients undergoing thoracolumbar spinal surgery. Total psoas surface area (TPA) was measured on preoperative axial computerized tomography or magnetic resonance imaging at the L3 vertebra and normalized to the L3 vertebral body area. Patients were divided into quartiles by normalized TPA, and the fourth quartile (Q4) was compared to quartiles 1-3 (Q1-3). Outcomes included perioperative transfusions, length of stay (LOS), delirium, pseudoarthrosis, readmission, discharge disposition, revision surgery, and mortality.

RESULTS

Of the patients who met inclusion criteria (n = 196), the average age was 73.4 y, with 48 patients in Q4 and 148 patients in Q1-3. Q4 normalized TPA cut-off was <1.05. Differences in Q4 preoperative characteristics included significantly lower body mass index, baseline creatinine, and a greater proportion of females (Table 1). Q4 patients received significantly more postoperative red blood cell and platelet transfusions and had longer ICU LOS (P < .05; Table 2). There was no difference in intraoperative transfusion volumes, delirium, initiation of walking, discharge disposition, readmission, pseudoarthrosis, or revision surgery (Tables 2 and 3). Mortality during follow-up was higher in Q4 but was not statistically significant (P = .075).

CONCLUSION

Preoperative TPA in geriatric patients undergoing elective spine surgery is associated with increased need for intensive care and postoperative blood transfusion. Preoperative normalized TPA is a convenient measurement and could be included in geriatric preoperative risk assessment algorithms.