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Tinnitus is abnormal perception of sound and has many subtypes. Clinical evaluation, audiometry, and otoscopy should be performed before ordering any imaging, as the choice of imaging will depend on various factors. Type of tinnitus (pulsatile or nonpulsatile) and otoscopy findings of a vascular retrotympanic lesion are key determinants to guide the choice of imaging studies. High-resolution CT temporal bone is an excellent tool to detect glomus tumors, abnormal course of vessels, and some other abnormalities when a vascular retrotympanic lesion is seen on otoscopy. CTA or a combination of MR and MRA/MRV are used to evaluate arterial or venous abnormalities like dural arteriovenous fistula, arteriovenous malformation, carotid stenosis, dural sinus stenosis, and bony abnormalities like sigmoid sinus wall abnormalities in cases of pulsatile tinnitus without a vascular retrotympanic lesion. MR of the brain is excellent in detecting mass lesions such as vestibular schwannomas in cases of unilateral nonpulsatile tinnitus. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation. [ABSTRACT FROM AUTHOR]

Objectives: While there is growing evidence of an association between depressive symptoms and postoperative delirium, the underlying pathophysiological mechanisms remain unknown. The goal of this study was to explore the association between depression and postoperative delirium in hip fracture patients, and to examine Alzheimer's disease (AD) pathology as a potential underlying mechanism linking depressive symptoms and delirium.Methods: Patients 65 years old or older (N = 199) who were undergoing hip fracture repair and enrolled in the study "A Strategy to Reduce the Incidence of Postoperative Delirium in Elderly Patients" completed the 15-item Geriatric Depression Scale (GDS-15) preoperatively. Cerebrospinal fluid (CSF) was obtained during spinal anesthesia and assayed for amyloid-beta (Aβ) 40, 42, total tau (t-tau), and phosphorylated tau (p-tau)181.Results: For every one point increase in GDS-15, there was a 13% increase in odds of postoperative delirium, adjusted for baseline cognition (MMSE), age, sex, race, education and CSF AD biomarkers (OR = 1.13, 95%CI = 1.02-1.25). Both CSF Aβ42/t-tau (β = -1.52, 95%CI = -2.1 to -0.05) and Aβ42/p-tau181 (β = -0.29, 95%CI = -0.48 to -0.09) were inversely associated with higher GDS-15 scores, where lower ratios indicate greater AD pathology. In an analysis to identify the strongest predictors of delirium out of 18 variables, GDS-15 had the highest classification accuracy for postoperative delirium and was a stronger predictor of delirium than both cognition and AD biomarkers.Conclusions: In older adults undergoing hip fracture repair, depressive symptoms were associated with underlying AD pathology and postoperative delirium. Mild baseline depressive symptoms were the strongest predictor of postoperative delirium, and may represent a dementia prodrome. [ABSTRACT FROM AUTHOR]

Neuropsychiatric symptoms (NPS) in persons with dementia (PWD) are common and can lead to poor outcomes, such as institutionalization and mortality, and may be exacerbated by sensory loss. Hearing loss is also highly prevalent among older adults, including PWD.Objective: This study investigated the association between hearing loss and NPS among community- dwelling patients from a tertiary memory care center.Design, Setting, and Participants: Participants of this cross-sectional study were patients followed at the Johns Hopkins Memory and Alzheimer's Treatment Center who underwent audiometric testing during routine clinical practice between October 2014 and January 2017.Outcome Measurements: Included measures were scores on the Neuropsychiatric Inventory-Questionnaire and the Cornell Scale for Depression in Dementia.Results: Participants (n = 101) were on average 76 years old, mostly female and white, and had a mean Mini-Mental State Examination score of 23. We observed a positive association between audiometric hearing loss and the number of NPS (b = 0.7 per 10 dB; 95% confidence interval [CI]: 0.2, 1.1; t = 2.86; p = 0.01; df = 85), NPS severity (b = 1.3 per 10 dB; 95% CI: 0.4, 2.5; t = 2.13; p = 0.04; df = 80), and depressive symptom severity (b = 1.5 per 10 dB; 95% CI: 0.4, 2.5; t = 2.83; p = 0.01; df = 89) after adjustment for demographic and clinical characteristics. Additionally, the use of hearing aids was inversely associated with the number of NPS (b = -2.09; 95% CI -3.44, -0.75; t = -3.10; p = 0.003; df = 85), NPS severity (b = -3.82; 95% CI -7.19, -0.45; t = -2.26; p = 0.03; df = 80), and depressive symptom severity (b = -2.94; 95% CI: -5.93, 0.06; t = 1.70; p = 0.05; df = 89).Conclusion: Among patients at a memory clinic, increasing severity of hearing loss was associated with a greater number of NPS, more severe NPS, and more severe depressive symptoms, while hearing aid use was associated with fewer NPS, lower severity, and less severe depressive symptoms. Identifying and addressing hearing loss may be a promising, low-risk, non-pharmacological intervention in preventing and treating NPS. [ABSTRACT FROM AUTHOR]

Objectives: Postoperative delirium, associated with negative consequences including longer hospital stays and worse cognitive and physical outcomes, is frequently accompanied by sleep-wake disturbance. Our objective was to evaluate the efficacy and short-term safety of ramelteon, a melatonin receptor agonist, for the prevention of postoperative delirium in older patients undergoing orthopedic surgery.Design: A quadruple-masked randomized placebo-controlled trial (Clinical Trials.gov NCT02324153) conducted from March 2017 to June 2019.Setting: Tertiary academic medical center.Participants: Patients aged 65 years or older, undergoing elective primary or revision hip or knee replacement.Intervention: Ramelteon (8 mg) or placebo MEASUREMENTS: Eighty participants were randomized to an oral gel cap of ramelteon or placebo for 3 consecutive nights starting the night before surgery. Trained research staff conducted delirium assessments for 3 consecutive days starting on postoperative day (POD) 0, after recovery from anesthesia, and on to POD2. A delirium diagnosis was based upon DSM-5 criteria determined by expert panel consensus.Results: Of 80 participants, five withdrew consent (one placebo, four ramelteon) and four were excluded (four ramelteon) after randomization. Delirium incidence during the 2 days following surgery was 7% (5 of 71) with no difference between the ramelteon versus placebo: 9% (3 of 33) and 5% (2 of 38), respectively. The adjusted odds ratio for postoperative delirium as a function of assignment to the ramelteon treatment arm was 1.28 (95% confidence interval: 0.21-7.93; z-value 0.27; p-value = 0.79). Adverse events were similar between the two groups.Conclusion: In older patients undergoing elective primary or revision hip or knee replacement, ramelteon was not efficacious in preventing postoperative delirium. [ABSTRACT FROM AUTHOR]

The author offers insights on the risk of dementia and cognitive decline in older people that have undergone surgical procedures.

Objectives: We evaluated whether delirium after hip fracture repair modifies the relationship between baseline dementia and one-year mortality after surgery.Methods: Patients age 65 years and older undergoing hip fracture repair surgery at John Hopkins Bayview Medical Center between 1999 and 2009 were eligible for this prospective cohort study. Baseline probable dementia was defined as either preoperatively diagnosed dementia per geriatrician or score less than 24 on the Mini-Mental State Examination. Delirium was assessed using the Confusion Assessment Method. Four cognitive groups were defined: 1) neither probable dementia nor delirium (NDD), 2) probable dementia only, 3) delirium only, or 4) delirium superimposed on dementia (DSD). Primary outcome of mortality was obtained through hospital records, obituaries, the National Death Index, and Social Security Death Index.Results: The current sample comprises 466 subjects (average age: 80.8 ± 7.0 years; 73.6% female). Of these, 77 (17%) were categorized as DSD, 68 (15%) probable dementia only, 73 (16%) delirium only, and 248 (53%) NDD. Cox regression revealed that DSD subjects had a significantly higher hazard of one-year mortality than NDD subjects (hazard ratio [HR]: 1.71, 95% CI: 1.06, 2.77) after adjusting for age, sex, medical comorbidity, and surgery duration. Trends toward greater mortality for probable-dementia and delirium only subjects were not significant (HR: 1.42 [95% CI: 0.80, 2.52] and 1.12 [95% CI: 0.64, 1.95], respectively).Conclusions: Delirium after hip fracture repair surgery in patients with preoperative dementia modifies the risk of mortality over the first postoperative year. Patients with DSD have a nearly two-fold greater odds of one-year mortality than those without dementia or delirium. [ABSTRACT FROM AUTHOR]

Objective: Hearing loss is a commonly unmet need among adults with dementia that may exacerbate common dementia-related behavioral symptoms. Accessing traditional audiology services for hearing loss is a challenge because of high cost and time commitment. To improve accessibility and affordability of hearing treatment for persons with dementia, there is a need for unique service delivery models. The purpose of this study is to test a novel hearing intervention for persons with dementia and family caregivers delivered in outpatient settings.Methods: The Memory-HEARS pilot study delivered a 2-hour in-person intervention in an outpatient setting. A trained interventionist provided hearing screening, communication strategies, and provision of and instruction using a simple over-the-counter amplification device. Caregivers (N = 20) responded to questionnaires related to depression, neuropsychiatric symptoms, and caregiver burden at baseline and 1-month postintervention.Results: Overall, caregivers believed the intervention was beneficial, and most participants with dementia wore the amplification device daily. For the depression and neuropsychiatric outcome measures, participants with high symptom burden at baseline showed improvement at 1-month postintervention. The intervention had no effect on caregiver burden. Qualitative responses from caregivers described improved engagement for their loved ones, such as laughing more, telling more stories, asking more questions, and having more patience.Conclusion: The Memory-HEARS intervention is a low-cost, low-risk, nonpharmacologic approach to addressing hearing loss and behavioral symptoms in patients with dementia. Improved communication has the potential to reduce symptom burden and improve quality of life. [ABSTRACT FROM AUTHOR]

Objective: Postoperative delirium, occurring days after surgery, is associated with both short- and long-term adverse events. Postanesthesia care unit (PACU) delirium, immediately after recovery from anesthesia, is associated with continued delirium in the succeeding days and adverse cognitive outcomes at discharge. Longer-term consequences are unclear. The objective was to evaluate 18-month outcomes of patients with versus without delirium in the PACU after surgery with general anesthesia.Methods: In a prospective, observational, cohort study, 91 consecutive English-speaking patients, aged at least 70 years and capable of independently providing informed consent before surgery, were followed after admission for a surgical procedure in one teaching hospital. Patients completed cognitive testing before surgery. After recovery from general anesthesia, they were evaluated for a DSM-IV diagnosis of delirium. Participants or proxies were evaluated, at a median of 19 months after surgery (interquartile range: 18-20 months), for survival, cognitive and physical functioning, and healthcare utilization outcomes.Results: All 91 patients or proxies (41 with delirium [45%]) were contacted at follow-up, with 7 deaths (8%) and 3 declining further participation (3%); 81 (96% of survivors) completed follow-up evaluations, demonstrating no significant cognitive or functional decline from baseline, with 75% of the cohort living independently in the community, and no differences in any outcomes between patients with versus without PACU delirium.Conclusion: In a small cohort of older patients evaluated 18 months after surgery, we could not detect an association of delirium diagnosed in the PACU with patient survival, cognitive/physical functioning, and healthcare utilization. [ABSTRACT FROM AUTHOR]

The article presents research in geriatric psychiatry, with a focus on an investigation of whether neuropsychiatric symptoms were associated with increased risk of incident dementia and Alzheimer's disease in patients with mild cognitive impairment (MCI). Topics include data from a longitudinal cohort study, use of the Neuropsychiatric Inventory Questionnaire (NPI-Q) and Mini-Mental State Examination (MMSE), and Cox proportional-hazards models.

Purpose: To assess the association between the visible presence of third molars and the severity of periodontal pathologic findings on teeth more anterior in the mouth. Patients and Methods: The present analysis included dentate participants, 52 to 74 years old, from the Dental Atherosclerosis Risk in Communities study who had undergone an oral examination that included periodontal probing depths (PDs) on all visible teeth, including any third molars. A PD of 4 mm or more and a clinical attachment level of 3 mm or greater were indicator variables for periodontal pathologic features. Explanatory variables were the presence or absence of visible third molars. The covariates included gender, ethnicity, age, income level, education, and smoking status. The outcome variables for periodontal pathologic features were the mean PD, extent (percentage of probing sites) of PDs of 4 mm or more, and the extent (percentage of probing sites) of a clinical attachment level of 3 mm or more. The outcomes between those with and without visible third molars were compared using descriptive statistics and chi-square tests, with significance set at P = .05. Multivariate modeling was performed using Statistical Analysis Systems SAS Proc GLM (SAS Institute, Cary, NC) to calculate the least squared means, adjusting for the study outcome variables and covariates. Results: The Dental Atherosclerosis Risk in Communities study sample included 6,793 subjects; 80% were white and 19% were black. Most (53%) were 62 to 74 years old and female (54%). Of the 6,793 participants, 2,035 (30%) had at least 1 visible third molar. The presence of a visible third molar was significantly associated with male gender, black race, age younger than the mean of 62.4 years, greater income, and never smoking (all P < .01). A greater mean PD for the first and second molars, the extent of PD of 4 mm or more at the first and second molars, and the extent of a clinical attachment level of 3 mm or more at the first and second molars were all significantly associated with the presence of a visible third molar in the unadjusted and adjusted models. Conclusions: In these middle-age and older Americans, the presence of a visible third molar was significantly associated with more severe periodontal disease on teeth more anterior in the mouth compared with those subjects with no visible third molars. [Copyright &y& Elsevier]

Abstract: The amyloid precursor protein (APP) is the source of β-amyloid, a pivotal peptide in the pathogenesis of Alzheimer''s disease (AD). This study examines the possible effect of APP transgene expression on neuronal size by measuring the volumes of cortical neurons (μm3) in transgenic mouse models with familial AD Swedish mutation (APPswe), with or without mutated presenilin1 (PS1dE9), as well as in mice carrying wild-type APP (APPwt). Overexpression of APPswe and APPwt protein, but not of PS1dE9 alone, resulted in a greater percentage of medium-sized neurons and a proportionate decrease in the percentage of small-sized neurons. Our observations indicate that the overexpression of mutant (APPswe) or wild-type APP in transgenic mice is necessary and sufficient for hypertrophy of cortical neurons. This is highly suggestive of a neurotrophic effect and also raises the possibility that the lack of neuronal loss in transgenic mouse models of AD may be attributed to overexpression of APP. [Copyright &y& Elsevier]

Background & Aims: Accurate disease staging in chronic hepatitis C (CHC) infection helps guide treatment and may provide prognostic information. Liver biopsies are invasive, costly, and associated with morbidity. We hypothesized that a noninvasive test of liver fibrosis can accurately stage liver fibrosis. We prospectively evaluated the FIBROSpect II (FSII) biomarker panel versus pathology assessment and a quantitative measure of fibrosis. Methods: Liver biopsy specimens and serum were obtained from 252 CHC patients, including 50 posttransplant, from 3 tertiary centers. Biopsy specimens were scored centrally and independently at each site, along with central quantification of fibrosis by digitized morphometry. Serum tests were performed blinded to clinical or histologic evaluation. Results: The mean biopsy specimen length was 1.95 ± 0.87 cm; prevalence of stage F2 through F4 fibrosis was 77%. Agreement between central and site readings for individual stages was modest (k = 0.674), with concordant readings in 106 of 248 (43%) biopsy specimens. The area under the receiver operating characteristic curve for FSII and morphometry for stages F2 through F4 for concordant biopsy specimens were 0.823 and 0.728, respectively. Sensitivity and specificity for FSII were 83.5% and 66.7%, respectively, with an accuracy of 80.2%. The aspartate aminotransferase to platelet ratio index sensitivity and specificity for predicting F2 through F4 were 30.4% and 100%, respectively, the indeterminate rate was 40.4%, and the accuracy rate was 48.4%. The accuracy of FSII in concordant biopsy specimens in the posttransplant cohort was 73%. Conclusions: Serum biomarkers can differentiate mild from moderate-to-severe fibrosis. This prospective study validates the performance characteristics of FSII in CHC patients and a posttransplant cohort. Assessing the diagnostic utility of biomarkers is limited by variability in methods to quantify fibrosis and poor interobserver agreement for histologic staging. [Copyright &y& Elsevier]

Purpose: Early detection of oral cancer is crucial in improving survival rate. To improve early detection, the use of a dilute acetic acid rinse and observation under a chemiluminescent light (ViziLite; Zila Pharmaceuticals, Phoenix, AZ) has been recommended. However, to date, the contributions of the individual components of the system have not been studied. The present study was done to investigate the efficacy of the individual components of the ViziLite system in providing improved visualization of early oral mucosal lesions. Patients and Methods: A total of 100 patients, 39 males and 61 females, age 18 to 93 years (mean age, 44 years), who presented to the Virginia Commonwealth University School of Dentistry for dental screening were examined. There were 58 Caucasians, 29 African-Americans, 5 Hispanics, 6 Asians, and 2 of mixed ethnicity. Thirty-five patients smoked, 53 used alcohol, and 25 both smoked and drank. After written consent, the oral cavity was examined under incandescent light for soft tissue abnormalities. After 1-minute rinse with 1% acetic acid, the mouth was re-examined for additional mucosal abnormalities. Then, the mouth was examined once again using the ViziLite system’s chemiluminescent light. Any lesions detected by these 3 examinations that were clinically undiagnosable were brush biopsied (Oral CDx) for determination of cellular representation. Results: In the original examination of the 100 patients, 57 clinically diagnosable benign lesions (eg, linea alba, leukoedema) and 29 clinically undiagnosable lesions were detected. After the rinse, 6 additional diagnosable lesions (linea alba) and 3 undiagnosable lesions were found. No additional lesions were detected with the chemiluminescent light. Of the 32 undiagnosable lesions that were brush biopsied, 2 were positive for atypical cellular characterization and warranted further investigation with a scalpel biopsy. Neither of these lesions was found to be premalignant or malignant. Conclusion: Although the acid rinse accentuated some lesions, the overall detection rate was not significantly improved. The chemiluminescent light produced reflections that made visualization more difficult and thus was not beneficial. [Copyright &y& Elsevier]

Cognitive recovery after anaesthesia and surgery is a concern for older adults, their families, and caregivers. Reports of patients who were 'never the same' prompted a scientific inquiry into the nature of what patients have experienced. In June 2018, the ASA Brain Health Initiative held a summit to discuss the state of the science on perioperative cognition, and to create an implementation plan for patients and providers leveraging the current evidence. This group included representatives from the AARP (formerly the American Association of Retired Persons), American College of Surgeons, American Heart Association, and Alzheimer's Association Perioperative Cognition and Delirium Professional Interest Area. This paper summarises the state of the relevant clinical science, including risk factors, identification and diagnosis, prognosis, disparities, outcomes, and treatment of perioperative neurocognitive disorders. Finally, we discuss gaps in current knowledge with suggestions for future directions and opportunities for clinical and translational projects. [ABSTRACT FROM AUTHOR]

Background: The Strategy to Reduce the Incidence of Postoperative Delirium in the Elderly trial tested the hypothesis that limiting sedation during spinal anaesthesia decreases in-hospital postoperative delirium after hip fracture repair. This manuscript reports the secondary outcomes of this trial, including mortality and function.Methods: Two hundred patients (≥65 yr) undergoing hip fracture repair with spinal anaesthesia were randomised to heavier [modified Observer's Assessment of Alertness/Sedation score (OAA/S) 0-2] or lighter (OAA/S 3-5) sedation, and were assessed for postoperative delirium. Secondary outcomes included mortality and return to pre-fracture ambulation level at 1 yr. Kaplan-Meier analysis, multivariable Cox proportional hazard model, and logistic regression were used to evaluate intervention effects on mortality and odds of ambulation return.Results: One-year mortality was 14% in both groups (log rank P=0.96). Independent risk factors for 1-yr mortality included: Charlson comorbidity index [hazard ratio (HR)=1.23, 95% confidence interval (CI), 1.02-1.49; P=0.03], instrumental activities of daily living [HR=0.74, 95% CI, 0.60-0.91; P=0.005], BMI [HR=0.91, 95% CI 0.84-0.998; P=0.04], and delirium severity [HR=1.20, 95% CI, 1.03-1.41; P=0.02]. Ambulation returned to pre-fracture levels, worsened, or was not obtained in 64%, 30%, and 6% of 1 yr survivors, respectively. Lighter sedation did not improve odds of ambulation return at 1 yr [odds ratio (OR)=0.76, 95% CI, 0.24-2.4; P=0.63]. Independent risk factors for ambulation return included Charlson comorbidity index [OR=0.71, 95% CI, 0.53-0.97; P=0.03] and delirium [OR=0.32, 95% CI, 0.10-0.97; P=0.04].Conclusions: This study found that in elderly patients having hip fracture surgery with spinal anaesthesia supplemented with propofol sedation, heavier intraoperative sedation was not associated with significant differences in mortality or return to pre-fracture ambulation up to 1 yr after surgery.Clinical Trial Registration: ClinicalTrials.gov NCT00590707. [ABSTRACT FROM AUTHOR]

Objectives To identify which clinical specialties are most central for care of people with dementia in the community and long-term care (LTC) settings. Design Cross-sectional analysis. Participants Fee-for-service Medicare beneficiaries aged ≥65 years with dementia. Measurements Specialty, categorized into primary care (internal or family medicine, geriatrics, or nurse practitioners [NPs]) versus other specialties, of the predominant provider of care (PPC) for each patient, defined by providing the most ambulatory visits. Results Among 2,598,719 beneficiaries with dementia, 74% lived in the community and 80% had a PPC in primary care. In LTC, 91% had primary care as their PPC compared with 77% in the community ( P < .001). Cardiology and neurology were the most frequent specialties. NPs were PPCs for 19% of dementia patients in LTC versus 7% in the community ( P < .001). Conclusion It is unknown whether specialists are aware of their central role for many dementia patients’ care needs. In LTC, NPs play the lead role as PPCs. [ABSTRACT FROM AUTHOR]

An increasing reliance on telemedicine for older adults with cognitive impairment requires a better understanding of the barriers and facilitators for this unique patient population. The study team queried PubMed, Embase, the Cochrane Library, PsycINFO, CINAHL, Scopus, and ClinicalTrials.gov on May 1, 2020, for studies in English published from January 2010 to May 2020. We conducted a systematic review of articles investigating the use of telemedicine among older adults with Alzheimer's disease and related dementia (ADRD) or mild cognitive impairment (MCI) that focused on the patient and care partner perspectives. Telemedicine encounter purpose, technological requirements, and findings regarding sensory needs were extracted. The Cochrane Collaboration's Risk of Bias Tool was applied for quality assessment. The search yielded 3551 abstracts, from which 90 articles were reviewed and 17 were included. The purpose of telemedicine encounters included routine care, cognitive assessment, and telerehabilitation. All studies reported successful implementation of telemedicine, supported by patient and care partner satisfaction, similar results on cognitive assessment and diagnosis compared to in-person visits, and improvement in outcome measures following rehabilitation. Sixteen studies relied on staff and care partners to navigate technologies. Six studies reported participants reporting difficulty hearing the provider during the telemedicine visits. Five studies excluded participants with visual or hearing impairment because of the potential difficulty of using telemedicine technology. No studies reported technological adaptations to account for sensory impairment. Telemedicine is well received among patients and care partners, but successful delivery incorporates support staff and the care partners to navigate technologies. The exclusion of older adults with sensory impairment, especially given that it is highly prevalent, in developing telemedicine systems may further exacerbate access to care in this population. Adapting technologies for sensory needs is critical to the advancement of accessible dementia care through telemedicine. [ABSTRACT FROM AUTHOR]