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Background: Recently, the Ultra-Brief Confusion Assessment Method (UB-CAM), designed to help physicians and nurses to recognize delirium, showed high, but imperfect, accuracy compared with Research Reference Standard Delirium Assessments (RRSDAs). The aim of this study is to identify factors associated with disagreement between clinicians' app-based UB-CAM assessments and RRSDAs., Methods: This is a secondary analysis of a prospective diagnostic test study. The study was conducted at two hospitals and included 527 inpatients (≥70 years old) and 289 clinicians (53 physicians, 236 nurses). Trained research associates performed RRSDAs and determined delirium presence using the CAM. Clinicians administered the UB-CAM using an iPad app. Disagreement factors considered were clinician, patient, and delirium characteristics. We report odds ratios and 95% confidence intervals., Results: One thousand seven hundred and ninety-five clinician UB-CAM assessments paired with RRSDAs were administered. The prevalence of delirium was 17%. The rate of disagreement between clinician UB-CAM assessments and RRSDAs was 12%. Significant factors associated with disagreement between clinician UB-CAM assessments and RRSDAs (OR [95% CI]) included: presence of dementia (2.7 [1.8-4.1]), patient education high school or less (1.9 [1.3-2.9]), psychomotor retardation (2.5 [1.4-4.2]), and the presence of mild delirium or subsyndromal delirium (5.5 [3.5-8.7]). Significant risk factors for false negatives were patient age less than 80 (2.2 [1.1-4.3]) and mild delirium (3.5 [1.6-7.4]). Significant risk factors for false positives were presence of dementia (4.0 [2.3-7.0]), subsyndromal delirium (5.1 [2.9-9.1]), and patient education high school or less (2.0 [1.2-3.6]). Clinician characteristics were not significantly associated with disagreement., Conclusions: The strongest factors associated with disagreement between clinician UB-CAM screens and RRSDAs were the presence of dementia and subsyndromal delirium as risk factors for false positives, and mild delirium and younger age as a risk factor for false negatives. These disagreement factors contrast with previous studies of risk factors for incorrect clinician delirium screening, and better align screening results with patient outcomes., (© 2023 The American Geriatrics Society.)

Background/objectives: An effective and efficient protocol for delirium identification is needed to improve health outcomes for older adults and reduce healthcare costs. This study describes the barriers and facilitators related to the implementation of the ultra-brief confusion assessment method (UB-CAM), a rapid two-step delirium identification protocol (ultra-brief screen, followed by CAM in positives), field tested with hospitalized older adults (70+)., Design: A qualitative descriptive design using observational data collection and brief semi-structured interviews., Settings: An urban academic medical center and a community teaching hospital., Participants: Participants included 50 physician hospitalists, 189 registered nurses, and 83 nursing assistants (NAs)., Measurements: Field researchers guided by a modified multi-level implementation framework, collected observational data as participants administered the UB-CAM (n = 767). Thematic analysis was conducted on five observational categories: structural, organizational, patient, clinician, and innovation. Field notes and brief semi-structured interviews (n = 231) with clinicians, explored the utility, acceptability, and feasibility of the protocol, and supplemented the observations., Results: The UB-CAM was generally positively received by all three clinician types. Six themes describe barriers and/or facilitators to implementing the UB-CAM: (1) physical setting and milieu; (2) practice environment; (3) integrating into role; (4) adaptive techniques; (5) patient responses; and (6) systematic assessment. The composition and interaction of the six themes determined if the theme was expressed as a barrier or facilitator, affirming the importance of context when implementing system-level delirium screening., Conclusion: This is one of the first studies to test a two-step process for delirium identification, and to involve NAs in screening, and the findings demonstrate overall support from clinicians for delirium identification, and describe the need for a multifaceted, contextualized, and systemic approach to implementation and evaluation of delirium screening., (© 2021 The American Geriatrics Society.)

Background/objectives: Systematic screening can improve detection of delirium, but lack of time is often cited as why such screening is not performed. We investigated the time required to implement four screening protocols that use the Ultra-Brief two-item screener for delirium (UB-2) and the 3-Minute Diagnostic Interview for Confusion Assessment Method (CAM)-defined Delirium (3D-CAM), with and without a skip pattern that can further shorten the assessment. Our objective was to compare the sensitivity, specificity, and time required to complete four protocols: (1) full 3D-CAM on all patients, (2) 3D-CAM with skip on all patients, (3) UB-2, followed by the full 3D-CAM in "positives," and (4) UB-2, followed by the 3D-CAM with skip in "positives.", Design: Comparative efficiency simulation study using secondary data., Setting: Two studies (3D-CAM and Researching Efficient Approaches to Delirium Identification (READI)) conducted at a large academic medical center (3D-CAM and READI) and a small community hospital (READI only)., Participants: General medicine inpatients, aged 70 years and older (3D-CAM, n = 201; READI, n = 330)., Measurements: We used 3D-CAM data to simulate the items administered under each protocol and READI data to calculate median administration time per item. We calculated sensitivity, specificity, and total administration time for each of the four protocols., Results: The 3D-CAM and READI samples had similar characteristics, and all four protocols had similar simulated sensitivity and specificity. Mean administration times were 3 minutes 13 seconds for 3D-CAM, 2 minutes 19 seconds for 3D-CAM with skip, 1 minute 52 seconds for UB-2 + 3D-CAM in positives, and 1 minute 14 seconds for UB-2 + 3D-CAM with skip in positives, which was 1 minute 59 seconds faster than the 3D-CAM (P < .001)., Conclusion: The UB-CAM, consisting of the UB-2, followed in positives by the 3D-CAM with skip pattern, is a time-efficient delirium screening protocol that holds promise for increasing systematic screening for delirium in hospitalized older adults., (© 2020 The American Geriatrics Society.)

Objectives: Prior studies in outpatient and long-term care settings demonstrated increased risk for sudden death with typical and atypical antipsychotics. To date, no studies have investigated this association in a general hospitalized population. We sought to evaluate the risk of death or nonfatal cardiopulmonary arrest in hospitalized adults exposed to antipsychotics., Design: Retrospective cohort study., Setting: Large academic medical center in Boston, Massachusetts., Participants: All hospitalizations between 2010 and 2016 were eligible for inclusion. We excluded those admitted directly to the intensive care unit (ICU), obstetric and gynecologic or psychiatric services, or with a diagnosis of a psychotic disorder., Intervention: Typical and atypical antipsychotic administration, defined by pharmacy charges., Measurements: The primary outcome was death or nonfatal cardiopulmonary arrest during hospitalization (composite)., Results: Of 150 948 hospitalizations in our cohort, there were 691 total events (515 deaths, 176 cardiopulmonary arrests). After controlling for comorbidities, ICU time, demographics, admission type, and other medication exposures, typical antipsychotics were associated with the primary outcome (hazard ratio [HR] = 1.6; 95% confidence interval [CI] = 1.1-2.4; P = .02), whereas atypical antipsychotics were not (HR = 1.1; 95% CI = .8-1.4; P = .5). When focusing on adults age 65 years and older, however, both typical and atypical antipsychotics were associated with increased risk of death or cardiopulmonary arrest (HR = 1.8; 95% CI = 1.1-2.9; and HR = 1.4; 95% CI = 1.1-2.0, respectively). Sensitivity analyses using a propensity score approach and a cohort of only patients with delirium both yielded similar results., Conclusion: In hospitalized adults, typical antipsychotics were associated with increased mortality or cardiopulmonary arrest, whereas atypical antipsychotics were only associated with increased risk among adults age 65 years and older. Providers should be thoughtful when prescribing antipsychotic medications, especially to older adults in settings where data regarding benefit are lacking. J Am Geriatr Soc 68:544-550, 2020., (© 2019 The American Geriatrics Society.)

Objectives: To apply the Frailty Phenotype (FP) and Frailty Index (FI) before major elective orthopedic surgery to categorize frailty status and assess associations with postoperative outcomes., Design: Prospective cohort study., Setting: Two tertiary hospitals in Boston, Massachusetts., Participants: Individuals aged 70 and older undergoing scheduled orthopedic surgery enrolled in the Successful Aging after Elective Surgery (SAGES) Study (N = 415)., Measurements: Preoperative evaluation included assessment of frailty using the FP and FI. The weighted kappa statistic was used to determine concordance between the two frailty measures and multivariable modeling to determine associations between each measure and postoperative complications, postoperative length of stay (LOS) of longer than 5 days, discharge to postacute institutional care (PAC), and 300 day readmission., Results: Frailty was highly prevalent (FP, 35%; FI, 41%). There was moderate concordance between the FP and FI (κ = 0.42, 95% confidence interval (CI) 0.36-0.49). When using the FP, being prefrail predicted greater risk of complications (relative risk (RR) = 1.6, 95% CI = 1.1-2.1) and discharge to PAC (RR = 1.8, 95% CI = 1.2-2.9) than being robust, and being frail predicted more complications (RR = 1.7, 95% CI = 1.1-2.1), LOS longer than 5 days (RR = 3.1, 95% CI = 1.1-8.8), and discharge to PAC (RR = 2.3 95% CI = 1.4-3.7). When using FI, being prefrail predicted LOS longer than 5 days (RR = 2.1, 95% CI = 1.0-4.8) and discharge to PAC (RR = 1.5, 95% CI = 1.4-2.1), as did being frail (RR = 1.9, 95% CI = 1.4-2.5; RR = 3.1, 95% CI = 1.4-6.8, respectively). The other outcomes were not significantly associated with frailty status., Conclusion: FP and FI predict postoperative outcomes after major elective orthopedic surgery and should be considered for preoperative risk stratification., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

Objectives: To derive and validate a method for scoring delirium severity using a recently validated, brief, structured diagnostic interview for Confusion Assessment Method (CAM)-defined delirium (3D-CAM) and to demonstrate its agreement with the CAM Severity short form (CAM-S SF) as the reference standard., Design: Derivation and validation analysis in a prospective cohort study., Setting: Two academic medical centers., Participants: Individuals aged 70 and older enrolled in the Successful Aging after Elective Surgery Study undergoing major elective noncardiac surgery (N = 566)., Measurements: The sample was randomly divided into a derivation dataset (n = 377) and an independent validation dataset (n = 189). These datasets were used to develop a severity scoring method using the 3D-CAM based on the four-item CAM-S SF (3D-CAM-S) and evaluate agreement between the 3D-CAM-S and the traditional CAM-S SF using weighted kappa statistics., Results: A method for scoring severity using 3D-CAM items was developed that achieved good agreement with the CAM-S SF in the derivation dataset (κ = 0.94, 95% confidence interval (CI) = 0.93-0.95). The 3D-CAM-S achieved nearly identical agreement in the independent validation dataset (κ = 0.93, 95% CI = 0.92-0.95), and 100% of 3D-CAM-S scores were within 1 point of the CAM-S SF score in both datasets. The 3D-CAM-S also strongly predicts clinical outcomes., Conclusion: A newly developed method for scoring delirium severity using the 3D-CAM (the 3D-CAM-S) has excellent agreement with the CAM-S SF. This new methodology enables clinicians and researchers using the 3D-CAM for surveillance to measure delirium severity and monitor its course simultaneously by tracking changes over time. The 3D-CAM-S expands the utility of the 3D-CAM as an important tool for delirium recognition and management., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

Objectives: To establish Montreal Cognitive Assessment (MoCA) scores that correspond to well-established cut-points on the Mini-Mental State Examination (MMSE)., Design: Cross-sectional observational study., Setting: General medical service of a large teaching hospital., Participants: Individuals aged 75 and older (N = 199; mean age 84, 63% female)., Measurements: The MoCA (range 0-30) and the MMSE (range 0-30) were administered within 2 hours of each other. The Abbreviated MoCA (A-MoCA; range 0-22) was calculated from the full MoCA. Scores from the three tests were analyzed using equipercentile equating, a statistical method for determining comparable scores on different tests of a similar construct by estimating percentile equivalents., Results: MoCA scores were lower (mean 19.3 ± 5.8) than MMSE scored (mean 24.1 ± 6.6). Traditional MMSE cut-points of 27 for mild cognitive impairment and 23 for dementia corresponded to MoCA scores of 23 and 17, respectively., Conclusion: Scores on the full and abbreviated versions of the MoCA can be linked directly to the MMSE. The MoCA may be more sensitive to changes in cognitive performance at higher levels of functioning., (© 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.)

Objectives: To determine the extent to which bodily pain mediates the effect of obesity on disability and physical function., Design: Cross-sectional analysis., Setting: Population-based sample of residents in the greater Boston area., Participants: Community-dwelling adults aged 70 and older (N=736)., Measurements: Body mass index (BMI), obtained from measured height and weight, was categorized as normal weight (19.0-24.9 kg/m2), overweight (25.0-29.9 kg/m2), or obese (≥30.0 kg/m2). Main outcome measures were the Physical Component Summary of the Medical Outcomes Study 12-item Short-Form Survey (PCS), activity of daily living (ADL) disability, and Short Physical Performance Battery (SPPB) score. Chronic pain was assessed according to the number of weight-bearing joint sites that had pain (hips, knees, feet and pain all over)., Results: Older obese adults had greater ADL disability and lower SPPB and PCS scores than their nonobese counterparts, although in sex-stratified adjusted analyses, obesity was adversely associated with outcomes only in women. Obesity was associated with greater number of pain sites; and more pain sites were associated with greater odds of disability. Mediation analysis suggests that pain is a significant mediator (22-44%) of the adverse effect of obesity on disability and physical function in women., Conclusion: Bodily pain may be an important treatable mediator of the adverse effect of obesity on disability and physical function in women., (© 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.)

Clinical studies often face the difficult problem of how to account for participants who die without experiencing the study outcome of interest. In a geriatric population with considerable comorbidities, the competing risk of death is especially high. Traditional approaches to describe risk of disease include Kaplan-Meier survival analysis and Cox proportional hazards regression, but these methods can overestimate risk of disease by failing to account for the competing risk of death. This report discusses traditional survival analysis and competing risk analysis as used to estimate risk of disease in geriatric studies. Furthermore, it illustrates a competing risk approach to estimate risk of second hip fracture in the Framingham Osteoporosis Study and compares the results with traditional survival analysis. In this example, survival analysis overestimated the 5-year risk of second hip fracture by 37% and the 10-year risk by 75% compared with competing risk estimates. In studies of older individuals in which a substantial number of participants die during a long follow-up, the cumulative incidence competing risk estimate and competing risk regression should be used to determine incidence and effect estimates. Use of a competing risk approach is critical to accurately determining disease risk for elderly individuals and therefore best inform clinical decision-making.

Objectives: To determine the incidence and predictors of subsequent fracture in nursing home residents with a hip fracture, accounting for the competing risk of death., Design: Dynamic cohort study., Setting: Hebrew Rehabilitation Center, a 725-bed, long-term care facility in Boston, Massachusetts., Participants: Long-term care residents with a surgically repaired hip fracture (1999-2006) followed through June 30, 2007, for the occurrence of subsequent fracture at any skeletal site., Measurements: Information on age, sex, anatomic location, type of repair, body mass index (BMI), comorbidities, functional status, cognitive status, and medication use were evaluated as potential risk factors for subsequent fracture., Results: The study included 184 residents with a baseline hip fracture. Thirty-nine residents (7 men, 32 women) experienced a subsequent fracture over a median follow-up of 1.1 years. After the baseline hip fracture, 6% of residents experienced a subsequent fracture within 6 months, 12% within 1 year, and 21% within 5 years. In addition, 23% of residents died within 6 months, 31% within 1 year, and 60% within 5 years. High functional status was associated with a five times greater risk of subsequent fracture (high vs low functional status, hazard ratio=5.10, P<.005). Age, sex, BMI, comorbidities, cognitive status, and medication use were not associated with subsequent fracture., Conclusion: Hip fractures are a sentinel event in nursing home residents, with a high incidence of subsequent fracture and death occurring within 1 year. Identification of prefracture characteristics and postfracture complications associated with mortality should help guide secondary prevention efforts in nursing home residents.

A 40-year-old man with a left frontotemporal grade II oligodendroglioma developed seizures that were refractory to 14 antiepileptic medications, the ketogenic diet, and epilepsy surgery. With temozolomide therapy, his seizure frequency gradually changed from 30 partial seizures per day to a single simple partial seizure in 6 months. No additional therapeutic measures were introduced during this time. This reduction in seizure frequency appears attributable solely to temozolomide therapy.